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EXHIBIT (4)(a)
PMLIC VIP II
PROVIDENT MUTUAL LIFE
INSURANCE COMPANY OF
PHILADELPHIA
PHILADELPHIA, PENNSYLVANIA
ANNUITANT CONTRACT DATE
CONTRACT NUMBER MATURITY DATE
In this Contract, Provident Mutual Life Insurance Company of Philadelphia will
be referred to as "we," "us" or "our." The Owner ("you," "your") is the
Annuitant, unless another person is named in the application or later becomes
the Owner as allowed by this Contract.
We agree to pay the proceeds as described in this Contract, subject to its
provisions.
PRIOR TO THE MATURITY DATE, ANNUITY PAYMENTS AND OTHER VALUES PROVIDED BY THIS
CONTRACT, INCLUDING ANY DEATH BENEFIT THAT MAY BE PAYABLE, WHEN BASED ON THE
INVESTMENT EXPERIENCE OF THE VARIABLE ACCOUNT MAY INCREASE OR DECREASE DAILY,
DEPENDING UPON THE INVESTMENT PERFORMANCE OF THE FUND PORTFOLIOS IN WHICH YOUR
CHOSEN SUBACCOUNTS ARE INVESTED, AND ARE NOT GUARANTEED AS TO FIXED DOLLAR
AMOUNTS. NO MINIMUM CONTRACT ACCOUNT VALUE IS GUARANTEED, EXCEPT FOR ANY AMOUNTS
IN THE GUARANTEED ACCOUNT. THE AMOUNT OF THE ANNUITY PAYMENTS UNDER THIS
CONTRACT WILL BE DETERMINED ON THE MATURITY DATE AND WILL NOT CHANGE DURING THE
PAYMENT PERIOD.
A MORTALITY AND EXPENSE RISK CHARGE WILL BE DEDUCTED FROM THE ASSETS OF THE
VARIABLE ACCOUNT. THIS CHARGE WILL NOT EXCEED AN ANNUAL RATE OF 1.25% OF SUCH
ASSETS.
PLEASE READ THIS CONTRACT CAREFULLY
It is a legal contract between you and us.
NOTICE OF 10 DAY RIGHT TO EXAMINE CONTRACT
PLEASE EXAMINE THIS CONTRACT CLOSELY. IF FOR ANY REASON YOU ARE NOT SATISFIED
WITH THIS CONTRACT, YOU MAY RETURN IT TO US FOR CANCELLATION BY DELIVERING OR
MAILING IT TO:
1. OUR ADMINISTRATIVE OFFICE, 000 XXXXXXXXXXX XXXXX, XXXXXX,
XXXXXXXX 00000;
2. ONE OF OUR AGENCY OFFICES; OR
3. THE AGENT THROUGH WHOM IT WAS PURCHASED.
THIS CONTRACT MUST BE RETURNED TO US NO LATER THAN 10 DAYS AFTER YOU FIRST
RECEIVE IT. UPON SUCH DELIVERY OR MAILING, THIS CONTRACT WILL BE VOID AS OF THE
CONTRACT DATE. WE WILL RETURN THE SUM OF (1) AND (2) WHERE (1) IS THE DIFFERENCE
BETWEEN PREMIUMS PAID, INCLUDING ANY CHARGES, AND THE AMOUNTS ALLOCATED TO THE
SUBACCOUNTS AND (2) THE PORTION OF THE CONTRACT ACCOUNT VALUE ALLOCATED TO THE
SUBACCOUNT. THE VALUE RETURNED IS AS OF THE DATE OF RECEIPT OF CANCELLATION.
Signed for the Company in Newark, Delaware
Secretary President
FLEXIBLE PREMIUM DEFERRED VARIABLE ANNUITY CONTRACT
Flexible premiums as stated in the
Premiums Provision.
Contract values are variable, except for amounts in the
Guaranteed Account. After the Maturity Date, Payment
Options are on a guaranteed basis. Death benefit payable
upon death of Annuitant before Maturity Date.
Participating but no Dividends are anticipated.
ADMINISTRATIVE OFFICE: NEWARK, DELAWARE
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A GUIDE TO THE PROVISIONS OF THIS CONTRACT
PAGE
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Contract Schedule.....................1
Description of Subaccounts............2
Definitions...........................7
General Provisions....................8
Premiums.............................10
The Variable Account.................10
The Guaranteed Account...............12
Allocations and Transfers............12
Contract Values......................13
Payment of Proceeds..................15
Payment Options......................17
A COPY OF THE APPLICATION AND ANY RIDERS ARE INCLUDED AFTER PAGE 19.
ENDORSEMENTS
(To be made by the Company only)
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CONTRACT SCHEDULE
ANNUITANT XXXX XXX SEPT. 1, 1993 CONTRACT DATE
CONTRACT NUMBER 123,456 SEPT. 1, 2023 MATURITY DATE
Initial Premium Payment: $ 2,000
Minimum Additional Premium Amount: $ 100
$ 50 for Qualified Contracts
Planned Periodic Premium: $ 100 monthly
Minimum Withdrawal Amount: $ 500
Minimum Transfer Amount: $ 500
Minimum Remaining Cash Surrender Value $ 2,000
After Withdrawal:
CHARGES AND FEES
Annual Mortality and Expense Risk Charge: 1.25%
Administrative Charge: 0.15% of assets
Annual Administration Fee: $30.00
Transfer Processing Fee: $25 each after first 12 in Contract
Year
Premium Tax Charge: 2% (See Premium Tax Charge - Page 7)
Surrender Charge* CONTRACT YEAR CHARGE
----------------- ------------- ------
1 6%
2 5%
3 4%
4 3%
5 2%
6 1%
7 0
* For the first Contract Year, applies to amount withdrawn or surrendered;
after the first Contract Year, applies to amount withdrawn or surrendered
during a Contract Year in excess of 10% of Contract Account Value as of the
beginning of such Contract Year. See "Surrender Charge" on page 14 for
details and restrictions. In no event will the Surrender Charge exceed 8.50%
of the total premiums received under the Contract.
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CONTRACT SCHEDULE - CONTINUED
DESCRIPTION OF SUBACCOUNTS OF
PROVIDENT MUTUAL VARIABLE ANNUITY SEPARATE ACCOUNT
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Each of the following Subaccounts invests in shares of its respective Portfolio
of THE MARKET STREET FUND, INC., a series type of mutual fund.
GROWTH SUBACCOUNT. Investments of the Growth Portfolio are primarily common
stocks of companies believed to offer above-average growth potential over both
the intermediate and long term.
AGGRESSIVE GROWTH SUBACCOUNT. Investments of the Aggressive Growth Portfolio are
primarily securities of a diverse group of smaller emerging growth companies
believed to offer a high level of long-term capital appreciation.
BOND SUBACCOUNT. Investments of the Bond Portfolio are primarily a diversified
portfolio of marketable debt securities.
MANAGING SUBACCOUNT. Investments of the Managed Portfolio are those types of
securities that are permissible investments of other portfolios. This portfolio
may be invested solely in common stocks, solely in money market instruments,
solely in bonds or in a combination of these types of investments.
MONEY MARKET SUBACCOUNT. Investments of the Money Market Portfolio are primarily
money market instruments such as: United States (U.S.) Government Securities;
bank obligations and instruments secured thereby; commercial paper and certain
debt obligations; repurchase agreements; and certain other obligations.
INTERNATIONAL SUBACCOUNT. Investments of the International Portfolio are
primarily securities of non-United States companies selected primarily for
long-term capital growth.
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Each of the following Subaccounts invests in shares of its respective Portfolio
of the DREYFUS VARIABLE INVESTMENT FUND or the DREYFUS SOCIALLY RESPONSIBLE
GROWTH FUND, INC., each of which is a series type of mutual fund managed by the
DREYFUS CORPORATION.
DREYFUS GROWTH AND INCOME SUBACCOUNT. The Growth and Income Subaccount invests
primarily in both United States and non-United States common stocks, preferred
stocks and convertible securities which offer long-term capital growth with
reasonable investment risk.
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DESCRIPTION OF SUBACCOUNTS - Continued
XXXXXXX SOCIALLY RESPONSIBLE SUBACCOUNT. The Socially Responsible Portfolio
invests primarily in common stocks and securities convertible into common stock,
including government securities and corporate bonds and other short-term bank
obligations. Such investments will be with companies that meet both traditional
investment standards and which also show a contribution to the enhancement of
the quality of life in the United States.
DREYFUS ZERO COUPON 2000 SUBACCOUNT. The Zero Coupon 2000 Portfolio invests
primarily in debt obligations of the U.S. Treasury that have been stripped of
their unmatured interest coupons, interest coupons that have been stripped from
debt obligations issued by the U.S. Treasury, receipts and certificates for such
stripped debt obligations, and stripped coupons and zero coupon securities by
domestic corporations. This portfolio's assets will consist of primarily of
portfolio securities which will mature on or about December 31, 2000.
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Each of the following Subaccounts invests in shares of its respective Portfolio
of the VARIABLE INSURANCE PRODUCTS FUND (VIP) or the VARIABLE INSURANCE PRODUCTS
FUND II (VIP II), each of which is a series of type of mutual Fund managed by
FIDELITY MANAGEMENT AND RESEARCH COMPANY.
FIDELITY ASSET MANAGEMENT SUBACCOUNT (VIP II). The Asset Manager Portfolio seeks
to obtain high total returns with reduced risk over the long term by allocating
its assets among stocks, bonds, and short-term fixed-income investments.
FIDELITY CONTRAFUND SUBACCOUNT (VIP II). The Contrafund Portfolio invests
primarily in both United States and non-United States common stocks and
securities convertible into common stock. Such investments may be undervalued or
unpopular but may produce capital appreciation over the long term.
FIDELITY EQUITY - INCOME SUBACCOUNT (VIP). The Equity-Income Portfolio invests
primarily in income-producing equity securities. In choosing these securities,
the Portfolio also considers the potential for capital appreciation.
FIDELITY GROWTH SUBACCOUNT (VIP). The Growth Portfolio normally purchases common
stocks but may invest in other types of securities, including bonds and
preferred stocks, which it believes will provide for capital appreciation.
FIDELITY HIGH INCOME SUBACCOUNT (VIP). The High Income Portfolio invests
primarily in high-yielding, lower rated, fixed-income securities to obtain a
high level of current income while also considering growth of capital.
FIDELITY INDEX 500 SUBACCOUNT (VIP II). The Index 500 Portfolio invests
primarily in equity securities of companies which compose the Standard and
Poor's 500 Composite Stock Price Index. The Portfolio is designed as a long-term
investment option.
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DESCRIPTION OF SUBACCOUNTS - Continued
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Each of the following Subaccounts invests in shares of its respective Portfolio
of the INSURANCE MANAGEMENT Series, a series type of mutual fund managed by
Federated Advisers.
FEDERATED U.S. GOVERNMENT BOND FUND SUBACCOUNT. The U.S. Government Bond Fund
Portfolio seeks current income by investing in a professionally managed,
diversified portfolio limited to U.S. government securities.
FEDERATED UTILITY FUND. The Utility Fund Portfolio invests primarily in equity
and debt securities of utility companies in order to achieve high current income
and moderate capital growth.
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Each of the following Subaccounts invests in shares of its respective Portfolio
of the QUEST FOR VALUE ACCUMULATION TRUST, a series type of mutual Fund managed
by QUEST FOR VALUE ADVISORS, a subsidiary of Xxxxxxxxxxx Capital.
QUEST FOR VALUE EQUITY SUBACCOUNT. The Equity Portfolio invests primarily in a
diversified portfolio of equity securities selected on the basis of a
value-oriented approach to investing.
QUEST FOR VALUE MANAGED SUBACCOUNT. The Managed Portfolio invests primarily in a
portfolio consisting of common stocks, bonds, and cash equivalents, the
percentages of which will vary over time based on the investment manager's
assessments of relative investment values.
QUEST FOR VALUE SMALL CAP SUBACCOUNT. The Small Cap Portfolio invests primarily
in a diversified portfolio of equity securities of companies with market
capitalizations of under $1 billion.
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Each of the following Subaccounts invests in shares of its respective Portfolio
of the XXXXXXX VARIABLE LIFE INVESTMENT FUND, a series type of mutual fund
managed by XXXXXXX, XXXXXXX & XXXXX, INC.
XXXXXXX BOND SUBACCOUNT. The Bond Portfolio invests primarily in U.S.
Government, corporate and other notes, and bonds to pursue a policy of investing
for a high level of income consistent with a high-quality portfolio of
securities.
XXXXXXX GROWTH AND INCOME SUBACCOUNT. The Growth and Income Portfolio invests
primarily in common stocks, preferred stocks, and securities convertible into
common stock, including bonds and other securities, which it believes will
provide for long-term capital growth.
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DESCRIPTION OF SUBACCOUNTS - Continued
XXXXXXX INTERNATIONAL SUBACCOUNT. The International Portfolio invests primarily
in securities of non-United States companies selected for long-term capital
growth.
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DEFINITIONS
ADMINISTRATIVE OFFICE. Our office at 000 Xxxxxxxxxxx Xxxxx, Xxxxxx, Xxxxxxxx
00000.
ANNUITANT. The person whose life determines the annuity benefits payable under
this Contract and whose death determines the death benefit.
BENEFICIARY. The person to whom we will pay the proceeds payable on your death
or on the death or on the death of the Annuitant. If the Contract has Joint
Owners, the surviving Joint Owner will be the designated beneficiary.
CASH SURRENDER VALUE. The Contract Account Value less any applicable surrender
charge and any applicable Premium Tax Charge.
CONTRACT ACCOUNT VALUE. The sum of the Variable Account Value and the Guaranteed
Account Value.
CONTRACT YEARS, MONTHS, XXXXXXX- XXXXXX. Are measured from the Contract Dated
shown in the Contract Schedule.
GUARANTEED ACCOUNT. This account is part of our General Account and is not part
of or dependent upon the investment performance of the Variable Account.
HOME OFFICE. Our office, at 0000 Xxxxxx Xxxxxx, Xxxxxxxxxxxx, Xxxxxxxxxxxx,
00000.
JOINT OWNERS. Joint Owners must be husband and wife as of the Contract Date.
MATURITY DATE. The date when the Contract Account Value will be applied under a
Payment Option, unless you have elected to receive a lump sum payment of the
Cash Surrender Value. The latest Maturity Date is the later of: the Contract
Anniversary nearest Annuitant's age 85; or 10 years after the Contract Date.
OWNER. The person entitled to exercise all rights and privileges provided in
this Contract.
PREMIUM TAX CHARGE. A percentage of any amount surrendered, withdrawn,
annuitized or paid as death proceeds. The applicable percentage is shown in the
Contract Schedule.
SUBACCOUNT. The Variable Account has Subaccounts; the assets of each Subaccount
are invested in a corresponding portfolio of a designated fund listed in the
Contract Schedule.
VALUATION DAY. Each day on which valuation of the assets of a Subaccount is
required by applicable law.
VALUATION PERIOD. The period that starts at the close of business on one
Valuation Day and ends at the close of business on the next succeeding Valuation
Day.
VARIABLE ACCOUNT. Provident Mutual Variable Annuity Separate Account which is
not part of our General Account. The Variable Account has Subaccounts each of
which is invested in a corresponding portfolio of a designated fund listed in
the Contract Schedule. Other Subaccounts may be established in the future and
will invest in specified portfolios of designated Funds.
WRITTEN NOTICE. A written request or notice in a form satisfactory to us which
is signed by you and received at our Administrative Office.
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GENERAL PROVISIONS
THE CONTRACT. We have issued this Contract in consideration of your application
and your payment of the Initial Premium. The entire contract is made up of this
Contract and the attached copy of the application. The statements made in the
application are deemed representations and not warranties. We cannot use any
statement in defense to a claim or to void this Contract unless it is contained
in the attached application. Only our President, a Vice President, or Secretary
may modify this Contract or waive any of our rights or requirements. No agent
may bind us by making any promise not contained in this Contract.
INCONTESTABILITY. We will not contest this Contract after it has been in force
during the Annuitant's lifetime for two years from the Contract Date.
OWNER. During the Annuitant's lifetime and before the Maturity Date, you have
all the rights and privileges granted by this Contract. During the Annuitant's
lifetime and before the Maturity Date, you may name a new Owner by giving us
Written Notice. If you are not the Annuitant and you die before the Maturity
Date and before the Annuitant, ownership will pass:
1. to your designated beneficiary, if any (as defined in "Proceeds On
Death of Owner"); otherwise
2. to your estate.
BENEFICIARY. We will pay the Beneficiary any proceeds payable on your death or
the death of the Annuitant. During the Annuitant's lifetime and before the
Maturity Date, you may change the named Beneficiary by giving us Written Notice
of such change.
We will pay the proceeds under the beneficiary designation in effect at
the date of death. The proceeds will be paid to the surviving Beneficiaries
equally unless you have indicated otherwise. If no Beneficiary is living when
the Annuitant dies, or if none has been named, the proceeds will be paid to you
or to your estate. If no Beneficiary is living when you die, any proceeds will
be paid to your estate.
CHANGE OF OWNER OR BENEFICIARY. Written Notice must be signed by you, dated, and
of a form and content acceptable to us. Your Written Notice will not be
effective until we receive and file it at our Administrative Office. However,
the change provided in your Written Notice will then be effective as of the date
you signed such notice:
1. subject to any payments made or other action we take before we
receive and file your Written Notice; and
2. whether or not you or the Annuitant are alive when we receive and
file your Written Notice.
ASSIGNMENT. You may assign this Contract or an interest in it at any time before
the Maturity Date during the lifetime of the Annuitant. An assignment must be in
a Written Notice acceptable to us. It will not be binding on us until we receive
and file it at our Administrative Office. We are not responsible for the
validity or sufficiency of any assignment. Your rights and the rights of any
Beneficiary will be affected by an assignment.
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MISSTATEMENT OF AGE OR SEX. If the age or sex of the Annuitant has been
misstated, we will pay the amount which the proceeds would have purchased at the
correct age and sex.
If we make an overpayment because of an error in age or sex, the
overpayment plus interest at 3% compounded annually will be a debt against this
Contract. If the debt is not repaid, future payments will be reduced
accordingly.
If we make an underpayment because of an error in age or sex, any annuity
payments will be recalculated at the correct age and sex, and future payments
will be adjusted. The underpayment with interest at 3% compounded annually will
be paid in a single sum.
PERIODIC REPORTS. We will mail you a report showing the following items:
1. the number of units credited to this Contract and the dollar value
of a unit;
2. the Contract Account Value and Cash Surrender Value;
3. any premiums paid, withdrawals, and charges made since the last
report; and
4. any other information required by law.
The information in the report will be as of a date not more than two
months before the date of the mailing. We will mail the report to you:
1. at least annually, or more often as required by law; and
2. to your last address known to us.
MODIFICATION. Upon notice to you, we may modify the Contract, but only if such
modification:
1. is necessary to make the Contract or the Variable Account comply
with any law or regulation issued by a governmental agency to which
we are subject; or
2. is necessary to assure continued qualification of the Contract under
the Internal Revenue Code or other federal or state laws relating to
variable annuity contracts; or
3. is necessary to reflect a change in the operation of the Variable
Account; or
4. provides additional variable account and/or fixed accumulation
options.
In the event of any such modification, we may make appropriate endorsement
to the Contract.
DIVIDENDS. A dividend is the share of divisible surplus apportioned to this
Contract. We will determine such share yearly. Since this Contract will probably
not contribute to surplus, we do not expect to credit dividends to it. If a
dividend is credited, we will pay it to you in cash.
PROTECTION OF PROCEEDS. No Beneficiary may commute, encumber or alienate any
payments under this Contract before they are due. No annuity payments shall be
subject to the debts, contract or engagements of any Beneficiary nor to any
judicial process to levy upon or attach the same for payment of such debts.
CREDITOR CLAIMS. To the extent permitted by applicable laws, no right or benefit
under this Contract shall be subject to claims of creditors, except as may be
provided by an Assignment.
DISCHARGE OF LIABILITY. We shall be discharged from all liability to the extent
of any withdrawal, surrender or death benefit paid. Any payments made by us
under any Payment Option shall discharge our liability to the extent of each
such payment.
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PREMIUMS
INITIAL PREMIUM. The Initial Premium is shown in the Contract Schedule, and is
payable on or before the Contract Date.
ADDITIONAL PREMIUMS. You may make additional premium payments at any time during
the Annuitant's lifetime and before the Maturity Date. The amount of additional
premium payments may vary. The minimum additional premium that we will accept is
shown in the Contract Schedule.
THE VARIABLE ACCOUNT
VARIABLE ACCOUNT. We have established the Provident Mutual Variable Annuity
Separate Account (the "Variable Account"). The Variable Account is registered
with the Securities and Exchange Commission as a unit investment trust under the
Investment Company Act of 1940. The Variable Account is also subject to the laws
of the Commonwealth of Pennsylvania and is also subject to the laws of the state
where the Contract is delivered.
Although we own the assets in the Variable Account, these assets are held
separately from our other assets and are not part of our General Account. The
assets in the Variable Account are used to support the operation of and provide
the variable values and benefits for this Contract and similar Contracts.
The portion of the assets of the Variable Account equal to the reserves
and other contract liabilities of the Variable Account will not be charged with
liabilities that arise from any other business that we conduct. We have the
right to transfer to our General Account any assets of the Variable Account
which are in excess of such reserves and other liabilities.
SUBACCOUNTS. The Variable Account currently consists of the Subaccounts listed
in the Contract Schedule and in the current prospectus you received. Each
Subaccount invests in shares of a corresponding series of a designated
investment fund, as shown in the Contract Schedule (each referred to as the
"Fund"). Shares of a series are purchased and redeemed for a Subaccount at their
net asset value. Any amounts of income, dividends and gains distributed from the
shares of a series will be reinvested in additional shares of that series at its
net asset value. The Fund prospectus you received defines the net asset value
and describes each portfolio of the Fund.
The dollar amounts of values and benefits of this Contract provided by the
Variable Account depend on the investment performance of the portfolios of the
Fund in which your selected Subaccounts are invested. We do not guarantee the
investment performance of the portfolios. You bear the full investment risk for
amounts applied to the selected Subaccounts.
VARIABLE ACCOUNT VALUE. This Contract's Variable Account Value for any Valuation
Period before the Maturity Date is determined by multiplying:
1. the amount of units credited to this Contract for each Subaccount as
of the end of the Valuation Period; by
2. the current unit value for each Subaccount.
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The sum of these amounts equals the Variable Account Value.
UNITS. We credit premiums in the form of units. We will credit units for the
Initial Premium on the Contract Date. The number of units of each Subaccount
credited under this contract is determined by dividing:
1. the premium allocated to that Subaccount; by
2. the unit value for that Subaccount at the end of the Valuation
Period during which we receive and accept the premium at our
Administrative Office.
We will adjust the units for any transfers (including any Transfer Fee) in
or out of a Subaccount.
We will cancel the appropriate number of units based on the unit value at
the end of the Valuation Period in which any of the following events occurs:
1. the Annual Administration Fee shown in the Contract Schedule is
assessed;
2. the date we receive and file your Written Notice for a withdrawal or
a cash surrender;
3. the Maturity Date occurs;
4. the date we receive due proof of the Annuitant's death; or 5. the
date the Contract Account Value is distributed upon your death.
UNIT VALUE. The unit value for each Subaccount for its first Valuation Period is
set at $50. The unit value for each subsequent Valuation Period is determined by
multiplying:
1. the unit value at the end of the immediately preceding Valuation
Period; by
2. the net investment factor for the Valuation Period for which the
value is being determined.
The unit value for a Valuation Period applies to each day in that period.
The unit value may increase or decrease from one Valuation Period to the next.
NET INVESTMENT FACTOR. The Net Investment Factor is an index that measures the
investment performance of a Subaccount from one Valuation Period to the next.
Each Subaccount has a Net Investment Factor for each Valuation Period, which may
be greater than or less than one.
The Net Investment Factor for each Subaccount for a Valuation Period
equals 1 plus the fraction obtained by dividing (a) by (b) where:
(a) is the net result of:
1. the investment income, dividends, and capital gains, realized or
unrealized, credited during the current Valuation Period; plus
2. any amount credited or released from reserves for taxes attributable
to the operation of the Subaccount; minus
3. the capital losses, realized or unrealized, charged during the
current Valuation Period; minus
4. any amount charged for taxes or any amount we set aside during the
Valuation Period as a reserve for taxes attributable to the
operation or maintenance of the Subaccount; minus
5. the amount charged for mortality and expense risk for that Valuation
Period as shown in the Contract Schedule; minus
6. the amount charged for administration for that Valuation Period, as
shown in the Contract Schedule; and
(b) is the value of the assets in the Subaccount at the end of the
preceding Valuation Period, adjusted for allocations and transfers to and
withdrawals and transfers from the Subaccount occurring during that
preceding Valuation Period.
RESERVED RIGHTS. When permitted by law, we reserve the right to:
1. create new variable accounts;
2. combine variable accounts, including the Provident Mutual Variable
Annuity Separate Account;
3. remove, combine or add Subaccounts and make the new Subaccounts
available to contract owners at our discretion;
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4. substitute shares of another portfolio of the Fund or shares of
another investment company for those of the Fund;
5. add new portfolios to the Fund;
6. deregister the Variable Account under the Investment Company Act of
1940 if registration is no longer required;
7. make any changes required by the Investment Company Act of 1940; and
8. operate the Variable Account as a managed investment company under
the Investment Company Act of 1940 or any other form permitted by
law.
If a change is made, we will send you a revised prospectus and any notice
required by law.
CHANGE IN INVESTMENT POLICY. The investment policy of a Subaccount may not be
changed unless:
1. the change is approved, if required, by the Pennsylvania Insurance
Department and by the Insurance Department of the state in which the
Contract is delivered; and
2. a statement of such approval is filed, if required, with the
insurance department of the state in which this Contract is
delivered.
THE GUARANTEED ACCOUNT
GUARANTEED ACCOUNT. Amounts in the Guaranteed Account are part of our General
Account. The Guaranteed Account is not part of and does not depend on the
investment performance of the Variable Account.
We credit interest to amounts in the Guaranteed Account at rates we
determine. We guarantee that the effective annual interest rate will not be less
than 3%. We may credit a higher current interest rate. For the amount in the
Guaranteed Account at the beginning of a calendar year, we will determine such
interest rates in advance of each calendar year. Such rates will apply to the
calendar year which follows the date of determination. For amounts allocated or
transferred to the Guaranteed Account during a calendar year, we will determine
interest rates applicable to such amounts in advance of the date such amount is
received or transferred. Such rates will apply to the end of the calendar year
in which the payment is received or the transfer is made.
GUARANTEED ACCOUNT VALUE. This Contract's Guaranteed Account Value for any
Valuation Period before the Maturity Date is:
1. the sum of the premiums allocated to the Guaranteed Account; plus
2. any amounts transferred to the Guaranteed Account from a Subaccount
of the Variable Account; minus
3. any amounts withdrawn or transferred from the Guaranteed Account
together with any associated charges; minus
4. any Annual Administration Fee deducted from the amount in the
Guaranteed Account; plus
5. interest we credit to the amount in the Guaranteed Account.
For the purpose of crediting interest, amounts deducted, transferred and
withdrawn from the Guaranteed Account will be accounted for on a last-in,
first-out basis.
ALLOCATIONS AND TRANSFERS
PREMIUM ALLOCATION. In your application you selected how you wanted your Initial
Premium to be allocated among the Subaccounts and the Guaranteed Account.
We will allocate the Initial Premium to the Subaccounts and the Guaranteed
Account based on the premium allocation schedule in your application.
You may change the allocation schedule by Written Notice. Any additional
premiums will be allocated in accordance with the allocation schedule in effect
when such premium is received, unless at
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the time of payment we receive Written Notice to the contrary. The portion of a
premium to be applied to each elected Subaccount and the Guaranteed Account must
be a whole percentage.
TRANSFER PRIVILEGE. Before the Maturity Date, you may transfer all or part of
the amount in the Subaccount(s) to another Subaccount(s) or to the Guaranteed
Account, or transfer a part of an amount in the Guaranteed Account to the
Subaccount(s), subject to the availability of a Subaccount or shares of a
portfolio and subject to these general restrictions and the additional
restrictions below:
1. the minimum transfer amount is shown in the Contract Schedule (or,
the entire amount in that Subaccount or the Guaranteed Account, if
less); and
2. a transfer request that would reduce the amount in that Subaccount
or the Guaranteed Account below $500 will be treated as a transfer
request for the entire amount in that Subaccount or the Guaranteed
Account.
RESTRICTIONS ON TRANSFERS FROM GUARANTEED ACCOUNT. You may transfer a part of
the amount in the Guaranteed Account to the Subaccount(s) of the Variable
Account, subject to these additional restrictions:
1. we allow only one transfer each year and this transfer must be
within the period that is 30 days before and 30 days after the
Contract Anniversary. An unused transfer option does not carry over
in the next year; and
2. the maximum transfer amount is 25% of the Contract's Guaranteed
Account Value on the date of the transfer, unless the balance after
the transfer is less than $500.
We will make the transfer on the Contract Anniversary if your Written Notice
is received prior to the Contract Anniversary; if your Written Notice is
received after the Contract Anniversary, we will make the transfer as of the
date we receive your request at our Administrative Office.
TRANSFER PROCESSING FEE. There is no limit to the number of transfers that you
can make between the Subaccounts or to the Guaranteed Account. However, we only
allow one transfer each year from the Guaranteed Account (See "Restrictions on
Transfers from Guaranteed Account"). The first twelve transfers during each
Contract Year are free. We will assess a transfer fee for each additional
transfer during that Contract Year. The amount of this fee is shown in the
Contract Schedule. For the purposes of assessing the fee, each Written Notice of
transfer is considered to be one transfer, regardless of the number of
Subaccounts or the Guaranteed Account affected by the transfer. The transfer fee
will be deducted from the amount being transferred.
CONTRACT VALUES
CONTRACT ACCOUNT VALUE. The Contract Account Value is the sum of the Variable
Account Value and the Guaranteed Account Value.
CASH SURRENDER VALUE. The Cash Surrender Value is the Contract Account Value,
less any applicable Surrender Charge and any applicable Premium Tax Charge. The
Cash Surrender Value will be determined on the date we receive your Written
Notice for surrender and this Contract at our Administrative Office.
You may surrender this Contract for its Cash Surrender Value at any time
before the earlier of the death of the Annuitant or the Maturity Date. You may
elect to have the Cash Surrender Value paid in a single sum or under a Payment
Option. This Contract ends when we pay the Cash Surrender Value or apply such
sum under a Payment Option.
WITHDRAWALS. You may withdraw part of the Cash Surrender Value at any time
before the earlier
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of the death of the Annuitant or the Maturity Date, subject to these limits:
1. the minimum withdrawal amount is shown in the Contract Schedule;
2. the maximum withdrawal is the amount that would leave a minimum Cash
Surrender Value of the amount shown in the Contract Schedule; and
3. a withdrawal request which would reduce the amount in a Subaccount
or the Guaranteed Account below $500 will be treated as a request
for a full withdrawal of the amount in that Subaccount or Guaranteed
Account.
On the date we receive your Written Notice for a withdrawal at our
Administrative Office we will withdraw the amount of the withdrawal from the
Contract Account Value. We will then deduct any applicable Surrender Charge and
any applicable Premium Tax Charge shown in the Contract Schedule from the
remaining Contract Account Value. No Surrender Charge will be applied to a
withdrawal made after the first Contract Year if such is the first or second
withdrawal during such Contract Year and the amount of the first withdrawal or
the total amount of the first and second withdrawals is not in excess of 10% of
the Contract Account Value as of the beginning of that Contract Year.
You may specify the amount to be withdrawn from certain Subaccounts or the
Guaranteed Account for your partial withdrawal. If you do not specify this
information to us, or the amount in the designated Subaccounts or Guaranteed
Account is inadequate to comply with your request, we will make the withdrawal
based on the proportion that your Subaccount Values and the Guaranteed Account
Value bear to the Contract Account Value prior to the withdrawal.
SURRENDER CHARGE. The applicable percentage from the Surrender Charge Table in
the Contract Schedule will be deducted upon any withdrawal or surrender and will
be applied as follows:
a. to the entire withdrawal amount if such withdrawal is made during
the first Contract Year;
b. to the entire withdrawal amount if such withdrawal is the third or
subsequent withdrawal in any one Contract Year;
c. to that portion of the total amount of the first and second
withdrawals during a Contract Year which is in excess of 10% of the
Contract Account Value as of the beginning of the Contract Year;
d. for a surrender which occurs during the first Contract Year, to the
entire amount of such surrender paid in a single sum;
e. for a surrender which occurs after the first Contract Year, to the
amount of the surrender paid in a single sum which is in excess of
10% of the Contract Account Value as of the beginning of such
Contract Year, less the amount withdrawn during that Contract Year
without imposition of the Surrender Charge.
If the Contract is being surrendered, the applicable Surrender Charge and
Premium Tax Charge will be deducted from the Contract Account Value in
determining the Cash Surrender Value. For a partial withdrawal, any applicable
Surrender Charge will be deducted from the amount withdrawn, unless you request,
in advance, that such charges be deducted from the remaining Contract Account
Value.
In no event will the Surrender Charge exceed 8.5% of the total premiums
received under the Contract.
ANNUAL ADMINISTRATION FEE. We will assess the Annual Administration Fee shown in
the Contract Schedule:
1. for the prior Contract Year, on the Contract Anniversary; or
2. for the current Contract Year on the date this Contract is
surrendered for its Cash Surrender Value or on the Maturity Date
(unless the Contract is surrendered on a
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Contract Anniversary or the Maturity Date is a Contract Anniversary
and the fee is assessed under 1 above).
The fee will be assessed against the Subaccount(s) and Guaranteed Account
based on the proportion that your Subaccount Values and the Guaranteed Account
Value bear to the Contract Account Value.
If the fee is obtained from the Subaccounts, we will cancel the
appropriate number of units credited to this Contract based on the Unit Value at
the end of the Valuation Period when the fee is assessed. If the fee is obtained
from the Guaranteed Account, we will reduce this Contract's Guaranteed Account
Value by the amount of the fee.
MATURITY DATE. No Surrender Charge will be applied to the Contract Account Value
on the Maturity Date if the proceeds are applied under a Payment Option. If the
proceeds are paid in a lump sum on the Maturity Date, the proceeds will equal
the Cash Surrender Value on such date.
You may change the Maturity Date, subject to these limitations:
1. we must receive your Written Notice at our Administrative Office at
least 30 days before the current Maturity Date;
2. the requested Maturity Date must be a date that is at least 30 days
after we receive your Written Notice; and
3. the requested Maturity Date must be not later than the Annuitant's
85th birthday, or any earlier date required by law.
TERMINATION. We may pay you the Contract Account Value and end this Contract if,
before the Maturity Date, all of these events simultaneously exist:
1. you have not paid any premiums for at least three years;
2. the Contract Account Value is less than $2,000; and
3. the total premiums paid, less any partial withdrawals, is less than
$2,000.
We will mail you a notice of our intention to end this Contract at least
six months in advance. This Contract will automatically terminate on the date
specified in the notice, unless we receive an additional premium payment before
the termination date specified in the notice. This additional premium payment
must be for at least the minimum additional premium amount specified in the
Contract Schedule.
BASIS OF VALUES. Any paid-up annuity, cash surrender or death benefits that may
be available are at least equal to the minimum required by law in the state in
which this Contract is delivered. A detailed statement of the method used to
compute the minimum value has been filed, where required, with the insurance
officials of the jurisdiction in which the Contract is delivered.
PAYMENT OF PROCEEDS
PROCEEDS. Proceeds means the amount we will pay when the first of the following
events occurs: the Maturity Date; the Contract is surrendered; or we receive due
proof of death of the Annuitant or the Owner. This Contract ends when we pay the
proceeds.
"Due Proof of Death" is proof of death that is satisfactory to us. Such
proof may consist of:
1. a certified copy of the death certificate; and/or
2. a certified copy of the decree of a court of competent jurisdiction
as to the finding of death.
We will deduct the applicable Premium Tax Charge shown in the Contract
Schedule from the proceeds described below.
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PROCEEDS ON MATURITY DATE. If you have not elected to receive the proceeds in a
lump sum, the proceeds we will pay is the Contract Account Value, which we will
apply under a Payment Option on the Maturity Date. (See the "Maturity Date"
provision and the "Payment Options" section.) If the proceeds are paid in a lump
sum, we will pay the Cash Surrender Value.
PROCEEDS ON SURRENDER. If you surrender this Contract before the earlier of the
death of the Annuitant or the Maturity Date, the proceeds we will pay is the
Cash Surrender Value. (See the "Maturity Date" provision concerning changing the
Maturity Date and having the Contract Account Value applied under a Payment
Option.)
PROCEEDS ON DEATH OF ANNUITANT BEFORE MATURITY DATE. If the Annuitant dies
before the Maturity Date, the proceeds we will pay to the Beneficiary is the
death benefit.
If the Annuitant dies before the end of the sixth Contract Year, the death
benefit will equal the greater of:
1. the premiums paid, less any withdrawals including the applicable
Surrender Charge and Premium Tax Charge; or
2. the Contract Account Value on the date we receive due proof of the
Annuitant's death.
If the Annuitant dies after the end of the sixth Contract Year, the death
benefit will equal the greatest of:
1. the Contract Account Value as of the end of the sixth Contract Year
less any subsequent withdrawals including the applicable Premium Tax
Charge; or
2. the Contract Account Value on the date we receive due proof of the
Annuitant's death; or
3. the premiums paid less any withdrawals including the applicable
Surrender Charge and Premium Tax Charge.
The proceeds will be paid in a lump sum or under a Payment Option. If you
are the Annuitant, the proceeds must be distributed in accordance with the rules
set forth in "Proceeds on Death of an Owner" for an Owner's death before the
Maturity Date. No death benefit is payable if this Contract is surrendered
before the Annuitant's death.
PROCEEDS ON DEATH OF AN OWNER. If any Owner dies before the Maturity Date, the
Contract Account Value (or if the deceased Owner is the Annuitant, the proceeds
payable on the Annuitant's death) must be distributed to the Beneficiary within
five years after the date of such death.
If any Owner dies on or after the Maturity Date, any remaining payments
must be distributed at least as rapidly as under the Payment Option in effect on
the date of such death.
These distribution requirements will be considered satisfied as to any
portion of the proceeds:
1. payable to or for the benefit of a designated beneficiary; and
2. which is distributed over the life (or period not exceeding the life
expectancy) of that Beneficiary, provided that such distributions
begin within one year of the Owner's death.
The designated beneficiary is the person designated by the Owner as
Beneficiary and to whom the ownership of the Contract passes by reason of an
Owner's death and must be a natural person. However, if the owner's spouse is
the designated beneficiary, the Contract may be continued with the surviving
spouse as the new Owner. If the contract has Joint Owners, the surviving Joint
Owner will be the designated beneficiary.
If you are not an individual, the Annuitant as determined in accordance
with section 72(s) of the Internal Revenue Code (i.e. the individual the events
in the life of whom are of primary importance in effecting the timing or amount
of the payout under the Contract) will be treated as Owner for purposes of these
distribution requirements, and any change in the Annuitant will be treated as
the death of the Owner.
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PAYMENTS. We will usually pay any proceeds, withdrawals, or cash surrenders
within seven business days after:
1. we receive and file your Written Notice for a withdrawal or a cash
surrender; or
2. we receive and file due proof of death of the Owner or Annuitant.
However, we can postpone the payment of proceeds, withdrawals, or cash
surrenders or the transfer of amounts between Subaccounts if:
1. the New York Stock Exchange is closed, other than customary weekend
and holiday closings, or trading on the exchange is restricted as
determined by the Securities and Exchange Commission; or
2. the Securities and Exchange Commission permits by an order the
postponement for the protection of Contract holders; or
3. the Securities and Exchange Commission determines that an emergency
exists that would make the disposal of securities held in the
Variable Account or the determination of their value not reasonably
practicable; or
4. the Fund is permitted by law or regulation to postpone payment of
proceeds.
If a recent check or draft has been submitted, we have the right to defer
payment of the Contract Account Value, Cash Surrender Value or Death Benefit
until such check or draft has been honored.
We have the right to defer payment of any withdrawal, transfer or Cash
Surrender Value from the Guaranteed Account for up to six months from the date
we receive your Written Notice for a withdrawal or surrender.
INTEREST ON PROCEEDS. We will pay interest on proceeds if we do not pay the
proceeds in a single sum or begin paying the proceeds under a Payment Option:
1. within 30 days after the proceeds become payable; or
2. within the time required by the applicable jurisdiction, if less
than 30 days.
This interest will accrue from the date the proceeds become payable to the
date of payment at an annual rate of 3%, or the rate and time required by law,
if greater. The interest rate will always be at least equal to the rate provided
under the interest income Payment Option.
CONFORMITY WITH LAWS. To the extent this Contract conflicts with any applicable
laws or the requirements of the Internal Revenue Service concerning
distributions on death, this Contract will be considered to be amended to
conform with such requirements.
PAYMENT OPTIONS
ELECTION OF OPTION. The following options are available to you during your
lifetime. They are also available to the Beneficiary after your death, if you
have not selected an option for such Beneficiary.
You may elect to have the Cash Surrender Value, Contract Account Value or
Death Benefit paid in accordance with any one of the options described below or
in any other manner acceptable to us and permissible under applicable law. If no
election has been made, the automatic option will be Option B. The amount paid
under these options is fixed and does not depend on the investment performance
of the Variable Account.
OPTION A - LIFE ANNUITY: An income payable during the lifetime of the Payee,
ceasing with the last payment due prior to the death of the Payee, according to
the Option Table, Life Only column.
OPTION B - LIFE ANNUITY WITH 10 YEARS GUARANTEED: An income payable during the
lifetime of the Payee with the guarantee that payments will be made for a period
of not less than
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10 years according to the Option Table, 10 Year Period Certain
column.
Under Option B, if any Payee dies while receiving payment, the present
value of the current dollar amount on the date of death of any remaining
guaranteed payments will be paid in one sum to the executors or administrators
of the Payee unless otherwise provided in writing. Calculation of such present
value will be at 3% which is the rate of interest assumed in computing the
amount of annuity payments. If you die on or after the annuity starting date and
before the interest in the Contract has been distributed, the remaining payments
will be distributed at least as rapidly as under the method of distribution
being used as of the date of your death.
ALTERNATE INCOME OPTION. In lieu of one of the above options you may elect to
settle the Cash Surrender Value, Contract Account Value or Death Benefit under
an alternate income option based on our single premium immediate annuity rates
in effect at the time of settlement. Such rates will be adjusted to a due basis
and the income thus produced will be increased by 4%. In no case will the
resulting income be less than that which would be payable if the amount were
used to purchase a single premium immediate annuity adjusted to a due basis.
GENERAL PROVISIONS. Annuity payments will commence and continue subject to the
following provisions:
A. This contract will be surrendered to us at our Administrative
Office. We will issue a Supplementary Contract stating the terms of
payment under the option elected.
B. Proof satisfactory to us of the identity, birth date and sex of any
person on whose life an annuity depends will be provided to us
before any annuity payments will be made.
C. We will make each annuity payment by check which will be personally
endorsed by the person upon whose life the annuity depends, or other
evidence must be furnished that such person is alive.
D. No election of any option may be made under this Contract for any
Payee unless such election would produce a periodic payment of at
least $50 to that Payee. If at any time payments to be made become
less than $50 each, we will have the right to change the frequency
of payments to such interval as will result in the payment of at
least $50. Subject to this condition, payments may be made annually,
semi-annually, quarterly or monthly.
E. If the Payee is other than you, the election of a Payment Option
will require our consent.
F. We will deduct from the Cash Surrender Value or the Contract Account
Value any Premium Tax Charge at the time income payments commence.
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OPTION TABLE
GUARANTEED AMOUNT OF MONTHLY PAYMENT FOR EACH $1,000 OF
ANNUITY VALUE APPLIED
GUARANTEED MONTHLY PAYMENTS GUARANTEED MONTHLY PAYMENTS
-------------------------------------------------------------------------------------------
Age of Payee 10 Year Age of Payee 10 Year
----------------- Life Only Period -------------- Life Only Period
Male Female (Option A) Certain Male Female (Option A) Certain
(Option B) (Option B)
-------------------------------------------------------------------------------------------
5* $2.70 $2.70 45 50 $3.59 $3.58
------------------------------------------------------------------------------------------
6 2.71 2.71 46 51 3.63 3.62
-------------------------------------------------------------------------------------------
7 2.72 2.72 47 52 3.68 3.67
-------------------------------------------------------------------------------------------
8 2.72 2.73 48 53 3.73 3.72
-------------------------------------------------------------------------------------------
9 2.73 2.73 49 54 3.78 3.76
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
5* 10 2.74 2.74 50 55 3.83 3.82
-------------------------------------------------------------------------------------------
6 11 2.75 2.75 51 56 3.89 3.87
-------------------------------------------------------------------------------------------
7 12 2.76 2.76 52 57 3.95 3.93
-------------------------------------------------------------------------------------------
8 13 2.77 2.77 53 58 4.01 3.99
-------------------------------------------------------------------------------------------
9 14 2.78 2.78 54 59 4.07 4.05
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
10 15 2.79 2.79 55 60 4.14 4.11
-------------------------------------------------------------------------------------------
11 16 2.80 2.80 56 61 4.21 4.18
-------------------------------------------------------------------------------------------
12 17 2.81 2.81 57 62 4.29 4.25
-------------------------------------------------------------------------------------------
13 18 2.82 2.83 58 63 4.37 4.33
-------------------------------------------------------------------------------------------
14 19 2.83 2.84 59 64 4.46 4.41
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
15 20 2.85 2.85 60 65 4.55 4.50
-------------------------------------------------------------------------------------------
16 21 2.86 2.86 61 66 4.64 4.58
-------------------------------------------------------------------------------------------
17 22 2.87 2.88 62 67 4.75 4.68
-------------------------------------------------------------------------------------------
18 23 2.89 2.89 63 68 4.86 4.78
-------------------------------------------------------------------------------------------
19 24 2.90 2.90 64 69 4.97 4.88
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
20 25 2.92 2.92 65 70 5.09 4.99
-------------------------------------------------------------------------------------------
21 26 2.93 2.93 66 71 5.22 5.10
-------------------------------------------------------------------------------------------
22 27 2.95 2.95 67 72 5.36 5.21
-------------------------------------------------------------------------------------------
23 28 2.96 2.97 68 73 5.51 5.34
-------------------------------------------------------------------------------------------
24 29 2.98 2.98 69 74 5.67 5.46
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
25 30 3.00 3.00 70 75 5.83 5.60
-------------------------------------------------------------------------------------------
26 31 3.02 3.02 71 76 6.01 5.73
-------------------------------------------------------------------------------------------
27 32 3.04 3.04 72 77 6.19 5.87
-------------------------------------------------------------------------------------------
28 33 3.06 3.06 73 78 6.39 6.02
-------------------------------------------------------------------------------------------
29 34 3.08 3.08 74 79 6.60 6.17
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
30 35 3.10 3.10 75 80 6.82 6.32
-------------------------------------------------------------------------------------------
31 36 3.13 3.13 76 81 7.06 6.48
-------------------------------------------------------------------------------------------
32 37 3.15 3.15 77 82 7.31 6.64
-------------------------------------------------------------------------------------------
33 38 3.18 3.18 78 83 7.58 6.80
-------------------------------------------------------------------------------------------
34 39 3.20 3.20 79 84 7.87 6.97
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
35 40 3.23 3.23 80 85** 8.17 7.13
-------------------------------------------------------------------------------------------
36 41 3.26 3.26 81 8.49 7.29
-------------------------------------------------------------------------------------------
37 42 3.29 3.29 82 8.83 7.45
-------------------------------------------------------------------------------------------
38 43 3.32 3.32 83 9.19 7.61
-------------------------------------------------------------------------------------------
39 44 3.35 3.35 84 9.57 7.77
-------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------
40 45 3.39 3.39 85** 9.96 7.92
-------------------------------------------------------------------------------------------
41 46 3.42 3.42
-------------------------------------------------------------------------------------------
42 47 3.46 3.46
-------------------------------------------------------------------------------------------
43 48 3.50 3.50
-------------------------------------------------------------------------------------------
44 49 3.54 3.54
-------------------------------------------------------------------------------------------
* Payment shown applies to all younger ages.
** Payment shown applies to all older ages.
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FLEXIBLE PREMIUM DEFERRED VARIABLE ANNUITY CONTRACT
Flexible premiums as stated in the Premiums Provision.
Contract values are variable, except for amounts in the Guaranteed Account.
After the Maturity Date, Payment Options are on a guaranteed basis.
Death benefit payable upon death of Annuitant before Maturity Date.
Participating but no Dividends are anticipated.
PROVIDENT MUTUAL LIFE INSURANCE COMPANY OF PHILADELPHIA
0000 Xxxxxx Xxxxxx, Xxxxxxxxxxxx, Xxxxxxxxxxxx 00000
Administrative Office: 000 Xxxxxxxxxxx Xxxxx, Xxxxxx, Xxxxxxxx 00000
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