.
.
.
24(b)(4)(a)
XXXX XXXXXXX LIFE INSURANCE COMPANY OF NEW YORK [XXXX XXXXXXX LOGO]
OVERNIGHT MAILING ADDRESS: ANNUITIES SERVICE CENTER: HOME OFFICE
000 Xxxxxxxxx Xxxxx P.O. Box 9505 000 Xxxxxx Xxxx Xxxxx, 0xx Xxxxx
Xxxxxxxxxx, XX 00000-0000 Xxxxxxxxxx, XX 00000-9505 Valhalla, NY 10595
0-000-000-0000
THIS IS A LEGAL CONTRACT - READ IT CAREFULLY.
WE AGREE to pay the benefits of this Contract in accordance with its terms.
THIS CONTRACT is issued in consideration of the Payments.
Xxxx Xxxxxxx Life Insurance Company of New York agrees to pay a guaranteed
withdrawal amount beginning on the Lifetime Income Date and continuing for the
life of the Annuitant. We will pay an annuity benefit beginning on the Maturity
Date to the Annuitant, if living, unless otherwise directed by the Owner, in
accordance with the Annuity Payments provision of this Contract. If the
Annuitant dies while this Contract is in effect prior to the date Annuity
Payments begin, we will pay the Contract Value to the Beneficiary upon receipt
at our Annuities Service Center of all required claim forms and proof of the
Annuitant's death.
Contract Asset Fee Charge: No greater than 1.20%
RIGHT TO REVIEW
YOU HAVE 10 DAYS AFTER YOU RECEIVE THE CONTRACT TO EXAMINE IT. DURING THAT 10
DAY PERIOD YOU MAY CANCEL THE CONTRACT BY RETURNING IT TO OUR ANNUITIES SERVICE
CENTER OR THE REGISTERED REPRESENTATIVE WHO SOLD IT TO YOU. WE WILL THEN REFUND
TO YOU THE SUM OF YOUR PAYMENT(S), INCREASED OR DECREASED BY THE INVESTMENT
PERFORMANCE OF THE CONTRACT.
IF YOUR CONTRACT IS ISSUED AS AN INDIVIDUAL RETIREMENT ANNUITY, AND YOU RETURN
IT WITHIN 7 DAYS AFTER YOU RECEIVE IT, WE WILL REFUND TO YOU THE SUM OF ALL
PAYMENT(S) IF THAT AMOUNT IS GREATER THAN THE REFUND AMOUNT DESCRIBED ABOVE. IF
YOU RETURN THE CONTRACT TO US AFTER THE FIRST 7 DAYS AND BEFORE THE 10 DAY
PERIOD HAS ELAPSED, WE WILL REFUND THE SUM OF YOUR PAYMENT(S), INCREASED OR
DECREASED BY THE INVESTMENT PERFORMANCE OF THE CONTRACT.
THE REFUND AMOUNT WILL BE DETERMINED AT THE END OF THE VALUATION PERIOD DURING
WHICH THE CONTRACT IS DELIVERED TO US. WE WILL PROCESS THE REFUND WITHIN 7 DAYS
OF DELIVERY OF THE CONTRACT BY US.
SIGNED FOR THE COMPANY at its Home Office, Valhalla, New York, on the Contract
Date.
DETAILS OF VARIABLE ACCOUNT PROVISIONS ON PAGE 5.1
/s/ Xxxxx X. Xxxxxxxxx /s/ Xxxxxxx Xxxxx
President Secretary
MODIFIED SINGLE PAYMENT DEFERRED VARIABLE ANNUITY
GUARANTEED LIFETIME WITHDRAWAL BENEFIT
NON-PARTICIPATING
DEATH BENEFITS, SURRENDER VALUES, AND OTHER VALUES PROVIDED BY THIS CONTRACT
WHEN BASED ON THE INVESTMENT EXPERIENCE OF A SEPARATE ACCOUNT ARE VARIABLE, MAY
INCREASE OR DECREASE IN ACCORDANCE WITH THE FLUCTUATIONS IN THE NET INVESTMENT
FACTOR, AS APPLICABLE AND NOT GUARANTEED AS TO FIXED DOLLAR AMOUNT.
VENTURE-MSP.A.09-NY NATIONAL
INTRODUCTION
This is a modified single payment deferred variable annuity contract. This
Contract provides that, prior to the Maturity Date, the Contract Value will
accumulate on a variable basis. If you limit withdrawals to the amounts
described in the Lifetime Income Benefits provision, we guarantee that the
Lifetime Income Amount will be available for withdrawal each Contract Year after
the Lifetime Income Date and during the life of the Annuitant. Subject to the
provisions of the Contract, you may take withdrawals of any amount up to the
Contract Value. Withdrawals that are not part of our Systematic Withdrawal
Program may reduce the guaranteed Lifetime Income Amount. After the Maturity
Date, Annuity Payments will be fixed in amount.
The Contract Value will vary with the investment performance of your Investment
Option.
TABLE OF CONTENTS PAGE
------------------------------------ ----
SPECIFICATIONS PAGES S.1
PART 1 - DEFINITIONS 1.1
PART 2 - OWNER, BENEFICIARY 2.1
PART 3 - PAYMENTS 3.1
PART 4 - FEES AND DEDUCTIONS 4.1
PART 5 - VARIABLE ACCOUNT PROVISIONS 5.1
PART 6 - WITHDRAWALS 6.1
PART 7 - SETTLEMENT PHASE 7.1
PART 8 - DISTRIBUTIONS AFTER DEATH 8.1
PART 9 - ANNUITY PAYMENTS 9.1
PART 10 - ANNUITY OPTIONS 10.1
PART 11 - GENERAL PROVISIONS 11.1
NATIONAL
SPECIFICATIONS PAGE
TYPE OF CONTRACT: QUALIFIED CONTRACT DATE: 5/1/2009
INITIAL PAYMENT: $25,000.00 CONTRACT NUMBER: 000000005
OWNER: XXXX X. XXXXX GOVERNING LAW: NY
ANNUITANT: XXXX X. XXXXX ANNUITANT'S AGE 55
CO-OWNER:
PLAN AnnuityNote 1
FEES AND CHARGES
CONTRACT ASSET FEE 1.20%
SALES CHARGES 3%
LIFETIME INCOME BENEFIT
LIFETIME INCOME PERCENTAGE 5.0%
LIFETIME INCOME DATE 5/1/2014
PAYMENT LIMITS
PAYMENT LIMITS The initial Payment is shown above. We will not accept any Payment, without our prior approval that
(a) exceeds $1,000,000, or
(b) causes the total of all Payments received to
exceed $1,000,000, or
(c) is received more than 9 months after the Contract
Date.
S.1
AVAILABLE INVESTMENT OPTION
VARIABLE ACCOUNT: XXXX XXXXXXX LIFE INSURANCE COMPANY OF NEW YORK SEPARATE
ACCOUNT A
VARIABLE INVESTMENT OPTION: Core Strategy Portfolio
ANNUITY BENEFITS
MATURITY DATE: 5/1/2049
ANNUITY OPTION Life Annuity with Cash Refund
ANNUITY PAYMENTS - GENERAL INFORMATION The rates for Annuity Payments are determined based on:
- Mortality Table: Annuity 2000 Table projected at Scale G to the terminal age of
the Table
- Fixed Annuity Payment Interest Rate: 1.50% interest per year
The amount of each Annuity Payment will depend upon the age of the Annuitant.
BENEFICIARY INFORMATION
Xxxx Xxxxx
THIS PLAN IS INTENDED TO QUALIFY UNDER THE INTERNAL REVENUE CODE FOR TAX-FAVORED
STATUS. LANGUAGE CONTAINED IN THIS CONTRACT REFERRING TO FEDERAL TAX STATUS OR
RULES IS INFORMATIONAL AND INSTRUCTIONAL. PLEASE SEEK THE ADVICE OF YOUR OWN TAX
ADVISOR REGARDING YOUR INDIVIDUAL TAX TREATMENT.
S.2
PART 1 DEFINITIONS
------------------------ --------------------------------------------------------------------
WE AND YOU "We", "us" and "our" means the Company. "You" or "your" means the
Owner of this Contract.
ACCUMULATION UNIT A unit of measure that is used to calculate the value of the
Variable Account of this Contract before the Maturity Date.
ANNUITANT The person whose age and life is used to determine the duration of
the Lifetime Income Benefit and the amount and duration of Annuity
Payments. The Annuitant is as designated on the Specifications Page.
ANNUITY OPTION The method selected by you for Annuity Payments made by us.
ANNUITY PAYMENT(S) Payment(s) by us to you on or after the Maturity Date under the
terms of this Contract.
ANNUITIES SERVICE CENTER Any office designated by us for the receipt of Payments and
processing of Owner requests.
BENEFICIARY The person, persons or entity to whom benefits are payable following
the death of an Owner or Annuitant. For purposes of section 72(s) of
the Internal Revenue Code, the "designated beneficiary" under the
Contract shall be the individual who is entitled to receive the
amounts payable on death of an Owner, or if any Owner is not an
individual, on any change in, or death of, an Annuitant.
COMPANY The insurance company named on the first page of this Contract (or
any successor insurance company named by endorsement to this
Contract) that will pay benefits in accordance with this Contract.
CONTRACT ANNIVERSARY The annual anniversary of the Contract beginning twelve months from
the Contract Date and each year thereafter.
CONTRACT DATE The date of issue of this Contract as designated on the
Specifications Page.
CONTRACT VALUE The total of your Investment Account Values at any time before
Annuity Payments begin.
CONTRACT YEAR The period of time measured twelve consecutive months from the
Contract Date or any Contract Anniversary thereafter.
CONTINGENT BENEFICIARY The person, persons or entity who becomes entitled to receive the
Contract proceeds if all Beneficiaries die before the Owner dies.
ENDORSEMENT An Endorsement modifies the contract to which it is attached.
Endorsements must be signed by an officer of the Company in order to
be effective.
FIXED ANNUITY An Annuity Option with payments which are predetermined and
guaranteed as to dollar amount.
GENERAL ACCOUNT All the assets of the Company other than assets in separate
accounts.
INTERNAL REVENUE CODE The Internal Revenue Code of 1986, as amended from time to time, and
(IRC) any successor statute of similar purposes.
INVESTMENT ACCOUNT VALUE The value of your investment in an Investment Option.
INVESTMENT OPTION The Sub-Account of the Variable Account to which You allocate your
Contract Value. The Investment Option initially available under this
Contract is shown on the Specifications Page. The Sub-Account of the
Variable Account invests in a corresponding Portfolio.
1.1
LIFETIME INCOME AMOUNT (LIA) The Lifetime Income Amount is the amount that is guaranteed to be
available for systematic withdrawal each Contract Year after the
Lifetime Income Date and during the life of the Annuitant while this
Contract is in effect.
LIFETIME INCOME DATE The Lifetime Income Date is the date on which the initial LIA is
calculated.
LIFETIME INCOME PERCENTAGE The percentage used to determine your Lifetime Income Amount.
MATURITY DATE The latest date on which Annuity Payments may commence. It is the
date specified on the Specifications Page, unless changed. The
maximum Maturity Date will be the later of age 95 or the end of the
10th Contract Year. Any extension of the Maturity Date will be
subject to the laws and regulations then in effect and our prior
approval.
NET PAYMENT The Payment less the amount of Sales Charge and premium tax, if any,
deducted from the Payment.
OWNER The person, persons or entity entitled to the ownership rights under
this Contract. The Owner is as designated on the Specifications
Page, unless changed.
PORTFOLIO The investment choice(s) available to the Variable Account.
PAYMENT An amount You pay to Us as consideration for the benefits provided
by this Contract.
QUALIFIED CONTRACTS Contracts issued under Qualified Plans.
QUALIFIED PLANS Retirement plans which receive favorable tax treatment under
sections 401 or 408 of the Internal Revenue Code of 1986, as
amended.
SEPARATE ACCOUNT A segregated account of the Company that is not commingled with our
general assets and obligations.
SUB-ACCOUNT(S) The Variable Account is divided into Sub-Accounts. Each Sub-Account
is invested in shares of a different Portfolio.
SURRENDER VALUE The Contract Value on any Valuation Date, less, if applicable, any
deduction for premium taxes or similar taxes.
SYSTEMATIC WITHDRAWAL PROGRAM A program for the automatic distribution of scheduled withdrawals.
VALUATION DATE Any date on which the New York Stock Exchange is open for business
and the net asset value of a Portfolio is determined.
VALUATION PERIOD Any period from one Valuation Date to the next, measured from the
time on each such date that the net asset value of each Portfolio is
determined.
VARIABLE ACCOUNT The Company's Separate Account as shown in the Specifications Page.
WITHDRAWAL AMOUNT The amount deducted from the Contract Value as the result of a
withdrawal. This amount is the total of the amount paid to you plus
any deduction for premium taxes or similar taxes, and any income
taxes resulting from the withdrawal and withheld by us. The
Withdrawal Amount may not exceed the Contract Value.
1.2
PART 2 OWNER, BENEFICIARY
------------------------ --------------------------------------------------------------------
GENERAL Before the Maturity Date, the Owner of this Contract shall be the
person, persons or entity designated on the Specifications Page or
the latest change filed with us. On the Maturity Date, the Annuitant
becomes the Owner of this Contract.
OWNER The Owner must be a natural person who is primary Owner of the
Contract and the Annuitant, a custodian, or a Trust established for
the exclusive benefit of the Annuitant or his or her Beneficiaries.
This Contract is established for the exclusive benefit of the
Annuitant or his or her beneficiaries. In the event a co-Owner is
also named, the primary Owner/Annuitant is the covered life for
purposes of the benefits provided by this Contract.
BENEFICIARY The Beneficiary is as designated on the Specifications Page, unless
changed. If there is a surviving Owner, that person will be treated
as the Beneficiary. If no such Beneficiary is living, the
Beneficiary is the Contingent Beneficiary. If no Beneficiary or
Contingent Beneficiary is living, the Beneficiary is the estate of
the deceased Annuitant.
CHANGE OF OWNER, Subject to the right of an irrevocable Beneficiary, you may change
ANNUITANT, BENEFICIARY the Owner or Beneficiary by written request in a form acceptable to
us and which is received at our Annuities Service Center.
The substitution or addition of any Owner is subject to our
underwriting rules in effect at the time of the request and may
result in the elimination of the Lifetime Income Amount guarantee as
of the date of such change.
If approved, any change of Beneficiary will take effect on the date
the request is signed.
You may not change the Annuitant unless the change is pursuant to a
court order. Any change in Annuitant will result in the elimination
of the Lifetime Income Amount guarantee. If any Annuitant is changed
and any Owner is not an individual, the entire interest in the
Contract must be distributed to the Owner within five years of the
change.
You need not send us the Contract unless we request it. We will not
be liable for any payments or actions we take before any change is
approved.
2.1
PART 3 PAYMENTS
-------------------------- --------------------------------------------------------------------
GENERAL The Contract is not effective until Payment is received by us at our
Annuities Service Center. Generally, the Contract will be purchased
with a single payment. If Payments will be paid from different
sources, we will accept multiple Payments subject to the Payment
Limits identified in the Specifications Page. All Payments under
this Contract are payable at our Annuities Service Center. Payment
Limits are identified on the Specifications Page.
ALLOCATION OF NET PAYMENTS When we receive Payments, the Net Payments will be allocated among
the Investment Option(s). If we offer more than one Investment
Option, we will allocate the Net Payment among the Investment
Options in accordance with the instructions you provide. You may
change the allocation of subsequent Net Payments at any time,
without charge, by giving us notice in a form acceptable to us.
3.1
PART 4 FEES AND DEDUCTIONS
------------------------ --------------------------------------------------------------------
CONTRACT ASSET FEE We assess a Contract Asset Fee to compensate us for assuming certain
administration expenses, expense risks and mortality risks. We
deduct the fee from the variable Investment Option(s) each Valuation
Period at an annual rate shown in the Specifications Page. A portion
of this Contract Asset Fee may also be used to reimburse us for
distribution expenses. This fee is reflected in the Net Investment
Factor used to determine the value of Accumulation Units and Annuity
Units of the Contract.
SALES CHARGE We assess a Sales Charge to compensate us for assuming certain
distribution expenses. The Sales Charge is equal to the applicable
Sales Charge Percentage shown in the Specifications Page multiplied
by the Payment. We deduct a Sales Charge from each Payment. The Net
Payment will be applied to your Investment Account as described in
the Allocation of Net Payments provision in the Payments section.
TAXES Certain taxes may be charged against your Payments (either at the
time of payment or liquidation), Contract Value, payment of Death
Benefit, withdrawals, or Annuity Payments, as appropriate. Such
taxes may include premium taxes or other taxes levied by any
government entity which we determine have resulted from the
establishment or maintenance of the Variable Account, or from the
receipt by us of Payments, or from the issuance of this Contract, or
from the commencement or continuance of Annuity Payments under this
Contract.
4.1
PART 5 VARIABLE ACCOUNT PROVISIONS
-------------------------- --------------------------------------------------------------------
INVESTMENT ACCOUNT VALUE The Investment Account Value of an Investment Option is determined
by multiplying (a) times (b) where:
(a) equals the number of Accumulation Units credited to the
Investment Option; and,
(b) equals the appropriate Accumulation Unit Value.
ACCUMULATION UNITS We will credit Net Payments to your Investment Options in the form
of Accumulation Units. The number of Accumulation Units we will
credit to the Investment Option(s) will be determined by dividing
the Net Payment allocated to that Investment Option by the
Accumulation Unit Value for that Investment Option.
Accumulation Units will be adjusted for any transfers and will be
canceled on payment of a death benefit, withdrawal, maturity or
assessment of certain charges based on their value for the Valuation
Period in which such transaction occurs.
ACCUMULATION UNIT VALUE We will determine the Accumulation Unit Value for a particular
Investment Option for any Valuation Period by multiplying the
Accumulation Unit Value for the immediately preceding Valuation
Period by the net investment factor for the corresponding
Sub-Account for the Valuation Period for which the value is being
determined. The Accumulation Unit Value may increase, decrease or
remain the same from one Valuation Period to the next.
NET INVESTMENT FACTOR The net investment factor is an index that measures the investment
performance of a Sub-Account from one Valuation Period to the next.
The net investment factor for any Valuation Period is determined by
dividing (a) by (b) and subtracting (c) from the result where:
(a) is the net result of:
1) the net asset value per share of a Portfolio share
held in the Sub-Account determined as of the end
of the current Valuation Period, plus:
2) the per share amount of any dividend or capital
gain distributions made by the Portfolio on shares
held in the Sub-Account if the ex-dividend date
occurs during the current Valuation Period, and
(b) is the net asset value per share of a Portfolio share held in
the Sub-Account determined as of the end of the immediately
preceding Valuation Period, and
(c) is the Contract Asset Fee shown on the Specifications Page.
The net investment factor may be greater or less than, or equal to,
one.
TRANSFERS Before the Maturity Date (or the date Annuity Payments begin, if
earlier), if we offer more than one Investment Option you may
transfer amounts among such Investment Options. Amounts will be
canceled from the Investment Option(s) from which amounts are
transferred and credited to the Investment Option(s) to which
amounts are transferred. We will effect such transfers so that the
Contract Value on the date of transfer will not be affected by the
transfer.
We may defer, modify or terminate the transfer privilege at any
time. Transfer limitations are identified in the Suspension of
Payments provision.
5.1
SUSPENSION OF PAYMENTS We may defer the right of withdrawal from, or postpone the date of
payments or transfers from, the variable Investment Option(s) for
any period when:
(a) the New York Stock Exchange is closed (other than
customary weekend and holiday closings);
(b) trading on the New York Stock Exchange is restricted;
(c) an emergency exists as a result of which disposal of
securities held in the Variable Account is not
reasonably practicable or it is not reasonably
practicable to determine the value of the Variable
Account's net assets; or
(d) the Securities and Exchange Commission, by order,
permits such deferral or postponement for the protection
of security holders.
Applicable rules and regulations of the Securities and Exchange
Commission shall govern whether the conditions described in (b) and
(c) exist.
5.2
PART 6 WITHDRAWALS
----------------------------------- --------------------------------------------------------------------
GENERAL This Contract guarantees that each Contract Year after the Lifetime
Income Date and during the life of the Annuitant we will
automatically pay you an amount equal to the Lifetime Income Amount
(LIA), even if your Contract Value reduces to zero. The LIA is
described below in the Lifetime Income Amount (LIA) provision. The
Lifetime Income Amount will be paid on a scheduled monthly basis
under our Systematic Withdrawal Program.
The Lifetime Income Date is shown on the Specifications Page
You may notify us to defer the start of LIA payments or to stop LIA
payments after they have begun. If you later request that LIA
payments be made to you, the LIA will be calculated as described
below.
LIFETIME INCOME AMOUNT (LIA) If you do not take any withdrawals prior to the Lifetime Income
Date, the initial LIA is equal to the Lifetime Income Percentage
(shown on the Specifications Page) multiplied by the greater of the
gross Payments or the Contract Value on the Lifetime Income Date. If
you take a withdrawal prior to the Lifetime Income Date, the initial
LIA is equal to the Lifetime Income Percentage multiplied by the
Contract Value on the Lifetime Income Date.
After the Lifetime Income Date, any unscheduled withdrawal you
request will cause the scheduled LIA payments to be suspended. After
suspension, you may request that LIA payments be resumed. However,
the scheduled monthly LIA payments thereafter may be reset to equal
the lesser of (a) the LIA payment prior to the withdrawal or (b) the
Lifetime Income Percentage multiplied by the Contract Value
immediately after the withdrawal.
If the Contract is issued under a Qualified Plan, unless we are
directed otherwise, we will automatically pay the greater of the LIA
or the required minimum distribution. Payments will be made on a
monthly basis under the Systematic Withdrawal Program.
PAYMENT OF UNSCHEDULED WITHDRAWALS You may request an unscheduled withdrawal of part or all of the
Surrender Value, at any time before the earlier of the death of the
Annuitant, the date Annuity Payments begin or the Maturity Date, by
sending us a written request. We will pay all unscheduled
withdrawals within seven days of receipt of the request at the
Annuities Service Center subject to postponement in certain
circumstances, as specified in the Suspension of Payments provision
above.
- TOTAL WITHDRAWAL Upon receipt of your request to withdraw the entire Contract Value,
we will terminate the Contract and pay you the Surrender Value.
- PARTIAL WITHDRAWAL If you request to withdraw an amount less than the Surrender Value,
we will pay you the amount requested and deduct the Withdrawal
Amount from the Contract Value. Unless you specify the amount to be
withdrawn from each Investment Option, the Withdrawal Amount will be
withdrawn from each Investment Option on a pro rata basis.
You may make as many unscheduled partial withdrawals as you wish.
IMPACT OF WITHDRAWALS Any withdrawals prior to the Lifetime Income Date, or unscheduled
ON OTHER BENEFITS withdrawals after the Lifetime Income Date may reduce or eliminate
the Lifetime Income Benefit. All withdrawals and LIA payments will
reduce the Contract Value and Death Benefit.
6.1
PART 7 SETTLEMENT PHASE
------------------------ --------------------------------------------------------------------
BENEFITS DURING THE The Contract will enter its Settlement Phase if
SETTLEMENT PHASE
(a) the Contract Value reduces to zero, and
(b) there were no unscheduled withdrawals during the
Contract Year.
When the Contract enters its Settlement Phase the Lifetime Income
Benefit will continue, however all other rights and benefits under
the Contract, including Death Benefits, will terminate.
You will automatically receive settlement payments equal to the LIA
each Contract Year of the Settlement Phase during the life of the
Annuitant. If the Settlement Phase is entered prior to the Lifetime
Income Date, then settlement payments will begin on or after the
Lifetime Income Date. The settlement payments will be paid on a
scheduled monthly basis under our Systematic Withdrawal Program.
If the Annuitant dies during the Settlement Phase, then the Lifetime
Income Benefit terminates and no additional settlement payments will
be paid.
7.1
PART 8 DISTRIBUTIONS AFTER DEATH
------------------------ --------------------------------------------------------------------
DEATH BEFORE MATURITY If any Owner dies prior to the Maturity Date (or date Annuity
DATE Payments begin, if earlier) the Death Benefit will equal to the
Contract Value.
Upon death of the Owner who is also the Annuitant, we will pay the
Death Benefit in one sum to the Beneficiary.
If the co-Owner predeceases the Owner, the Owner will be treated as
the Beneficiary. The Beneficiary may continue the Contract as the
Owner, subject to the requirements of Section 72(s) of the Internal
Revenue Code. If the Contract can not continue under Section 72(s),
or if the Beneficiary elects not to continue the Contract, the Death
Benefit will be distributed in one sum. The Contract will terminate
if the Death Benefit is taken in one sum.
Written notice and proof of death and all required claim forms must
be received at the Company's Annuities Service Center prior to any
distribution.
DEATH BENEFIT ON OR On or after the date Annuity Payments begin, if the Annuitant dies,
AFTER MATURITY DATE the Death Benefit will depend on the Annuity Option selected in
accordance with Part 10 (Annuity Payments).
PROOF OF DEATH We will require Proof of death upon the death of the Annuitant or
the Owner. Proof of death is one of the following received at the
Annuities Service Center:
(a) A certified copy of a death certificate.
(b) A certified copy of a decree of a court of competent
jurisdiction as to the finding of death.
(c) Any other proof satisfactory to us.
8.1
PART 9 ANNUITY PAYMENTS
------------------------ --------------------------------------------------------------------
GENERAL Benefits payable under this Contract may be applied in accordance
with one or more of the Annuity Options described below, subject to
any restrictions of Internal Revenue Code sections 72(s) (or section
401(a)(9) and 408(b)(3) if this Contract is issued in a Qualified
Plan). Once Annuity Payments commence, the Annuity Option may not be
changed. The "Life Annuity with Cash Refund" option described in
Part 10 is the default Annuity Option unless you rquest another
option prior to the Annuity Payments begin or unless otherwise
required by the Internal Revenue code. If you are receiving
distributions that comply with the minimum distribution requirements
of the Internal Revenue Code, you do not need to annuitize the
Contract Value.
We will send you information about Annuity Options before the
Maturity Date. If by the Maturity Date, you do not choose an Annuity
Option, make a total Withdrawal of the Surrender Value, or ask us to
change the Maturity Date, we will automatically pay you Annuity
Payments under the Annuity Option shown in the Specifications Page.
You can change the Annuity Option at any time before Annuity
Payments begin.
We will provide Fixed Annuity payments. The method used to calculate
the amount of the Fixed Annuity payments is described below.
If the monthly Annuity Payment is less than $20, we may pay the
greater of the Contract Value or the commuted value of the Lifetime
Income Benefit in one lump sum on the Maturity Date, or the date
Annuity Payments would begin, if earlier.
FIXED ANNUITY PAYMENTS We will determine the amount of each Fixed Annuity payment by
applying the Contract Value as of a date not more than 10 business
days prior to the date Annuity Payments begin (minus any applicable
premium taxes) to the Annuity Option elected based on the mortality
table and interest rate shown on the Specifications Page.
Fixed Annuity payments, at the time of their commencement will not
be less than those that would be provided by the application of an
amount to purchase any single consideration immediate annuity
contract offered at the time, to the same class of annuitants. Since
no such annuity contract currently exists, a comparable contract in
an affiliated company will be used. Such an amount would be equal to
the greater of:
(a) the Contract Value less applicable Withdrawal Charges; or
(b) 95% of the Contract Value.
We guarantee the dollar amount of Fixed Annuity payments.
9.1
PART 10 ANNUITY OPTIONS
------------------------ --------------------------------------------------------------------
DESCRIPTION OF ANNUITY Life Annuity with Cash Refund: We will make payments during the
OPTIONS lifetime of the Annuitant. After the death of the Annuitant, we will
pay the Beneficiary a lump sum amount equal to the excess, if any,
of the Contract Value at the election of this option over the sum of
the Annuity Payments made under this option.
The annual amount of the annuity payments will equal the greater of
(a) the Lifetime Income Amount, or
(b) the annual amount determined by applying the Contract
Value to a Cash Refund Annuity Option based on the
Mortality Table and Fixed Annuity Payment Interest Rate
listed in the Specifications.
ALTERNATE ANNUITY Instead of settlement in accordance with the Annuity Option
OPTIONS described above, you may choose an alternate form of settlement
acceptable to us. Once Annuity Payments commence, the form of
settlement may not be changed.
10.1
PART 11 GENERAL PROVISIONS
------------------------ --------------------------------------------------------------------
ENTIRE CONTRACT The entire Contract consists of this Contract and Endorsements, if
any, and the application, if one is attached to this Contract.
BENEFITS AND VALUES The benefits and values available under this Contract are not less
than the minimum required by any statute of the state in which this
Contract is delivered.
MODIFICATION Only the President, a Vice President, or the Secretary of the
Company has authority to change or waive the provisions of this
Contract. Any change or waiver must be in writing and signed by one
of these officers of the Company. We will not change this Contract
without your consent unless the change is required to make it
conform to any applicable law or regulation or any ruling issued by
a government agency.
CHANGE IN MATURITY DATE Prior to the Maturity Date, you may request a change of the Maturity
Date. Any extension of the Maturity Date will be subject to our
prior approval and any applicable law or regulation then in effect.
ASSIGNMENT You may assign this Contract prior to the Maturity Date. No
assignment will be binding on us unless it is written in a form
acceptable to us, received at our Annuities Service Center and
approved by us under our underwriting rules in effect at the time of
the request. An assignment may result in the elimination of the
Lifetime Income Amount guarantee as of the date of such change. We
will not be liable for any payments made or actions taken before the
assignment is received by us. An absolute assignment will revoke the
interest of any revocable Beneficiary. We will not be responsible
for the validity of any assignment.
CLAIMS OF CREDITORS All benefits and payments under this Contract shall be exempt from
the claims of creditors to the extent permitted by law.
MISSTATEMENT AND PROOF We may require proof of age or survival of any person upon whose age
OF AGE OR SURVIVAL or survival any Lifetime Income Benefit, Annuity Payments or other
benefits provided by this Contract or any Endorsement attached
thereto depend. If the age of the Annuitant has been misstated, the
benefits will be those which would have been provided for the
correct age. If we have made incorrect benefit payments, we will
immediately pay the amount of any underpayment adjusted with
interest at 3% per annum. We will deduct the amount of any
overpayment from future benefit payments without adjustment for
interest.
ADDITION, DELETION OR We may:
SUBSTITUTION OF
INVESTMENT OPTIONS (a) add, delete or substitute Portfolio shares held or
purchased by the Variable Account;
(b) eliminate shares of one Portfolio and substitute shares
of another Portfolio;
(c) establish additional Sub-Accounts to invest in a new
Portfolio, eliminate or combine existing Sub-Accounts or
transfer Sub-Account assets to another Separate Account
of the Company or an affiliated company.
We will obtain prior approval required from the Securities and
Exchange Commission and the New York Superintendent of Insurance
before making these changes. We will provide you with notice of
these substitutions or changes.
If deemed by us to be in the best interests of persons having voting
rights under the Contracts, the Variable Account may be operated as
a management company under the Investment Company Act of 1940 or it
may be de-registered under such Act in the event such registration
is no longer required.
11.1
NON-PARTICIPATING Your Contract is non-participating. This means the Contract will not
share in our profits or surplus earnings. We will pay no dividends
on your Contract.
REPORTS We will send you annual reports without charge, containing the value
of the Investment Account(s) and the Contract Value. The report will
include the number of Accumulation Units credited to the Variable
Account, the Accumulation Unit value and the dollar value of the
Accumulation Unit of the Variable Account no more than 4 months
prior to the date of the mailing of the report. We will provide
annual calendar year reports concerning the status of the Contract
and such information concerning required minimum distributions as is
prescribed by the Commissioner of Internal Revenue.
INSULATION The assets of the Variable Account equal to the reserves and other
contract liabilities applicable to that account are not chargeable with
liabilities from any other business we may conduct. Moreover, the income,
gains and losses, realized or unrealized, applicable to the assets of the
Variable Account shall be applied to that account regardless of our other
income, gains or losses.
SEPARATE ACCOUNT ASSETS We will maintain, in the Separate Account, assets with a value at
least equal to the amounts accumulated in accordance with the terms
of the applicable agreements with respect to the Separate Account,
and the reserves for annuities, in the course of payment that may
vary with the investment experience of the Separate Account.
CURRENCY AND PLACE OF All payments made to or by us shall be made in the lawful
PAYMENTS currency of the United States of America at the Annuities Service
Center or elsewhere if we consent.
NOTICES AND ELECTIONS Notices and elections are any form of communication that provides
information needed by us to process your request. A notice or
election may be provided to us in a written and signed format or in
another manner that we approve in advance. All notices and elections
you make under this Contract must be received by us at the Annuities
Service Center. All notices, requests and elections will be
effective when signed. . We will not be liable for any payments made
or actions taken before the notice or election is received by us.
GOVERNING LAW This Contract will be governed by the laws of the jurisdiction
indicated on the Specifications Page.
SECTION 72(s) The provisions of this Contract shall be interpreted so as to comply
with the requirements of Section 72(s) of the Internal Revenue Code.
11.2
--------------------------------------------------------------------------------
XXXX XXXXXXX LIFE INSURANCE COMPANY OF NEW YORK [XXXX XXXXXXX LOGO]
--------------------------------------------------------------------------------
