RIVERSOURCE LIFE INSURANCE COMPANY
00000 Xxxxxxxxxx Xxxxxxxxx Xxxxxx
Xxxxxxxxxxx, XX 00000
0-000-000-0000
DEFERRED ANNUITY CONTRACT
This is a deferred annuity contract. It is a legal contract between You, as the
Owner, and Us, RiverSource Life Insurance Company, a stock company, Minneapolis,
Minnesota. PLEASE READ YOUR CONTRACT CAREFULLY.
If You are living on the Annuitization Start Date, We will begin to pay You
monthly payments, subject to other provisions of this contract. This date may be
changed as provided in this contract.
We issue this contract in consideration of the payment of the initial purchase
payment.
ACCUMULATION VALUES AND ANNUITY PAYMENTS, WHEN BASED ON THE INVESTMENT RESULTS
OF THE VARIABLE SUBACCOUNTS, ARE VARIABLE AND NOT GUARANTEED AS TO FIXED DOLLAR
AMOUNT. SEE THE ACCOUNTS: FIXED AND VARIABLE SECTION FOR VARIABLE ACCOUNT
PROVISIONS.
OPTIONAL RIDER CHARGES MAY REDUCE THE DEATH BENEFIT AMOUNT TO LESS THAN THE
CONTRACT VALUE. SEE THE PAYMENTS TO BENEFICIARIES PROVISIONS.
NOTICE OF YOUR RIGHT TO EXAMINE THIS CONTRACT FOR TEN DAYS. If for any reason
You are not satisfied with this contract, You may cancel this contract by
returning it to Us or Our agent within ten Days after You receive it.
- If this is not an XXX contract, upon such cancellation We will
refund an amount equal to the sum of: (1) the Contract Value at the
end of the Valuation Period during which We receive the contract;
and (2) any premium tax charges paid.
- If this is an XXX contract, upon such cancellation We will refund
all purchase payments which You have paid.
This contract will then be considered void from its start.
Signed for and issued by RiverSource Life Insurance Company of Minneapolis,
Minnesota, as of the Contract Date.
(-s- Signature) (-s- Signature)
Secretary President
- Flexible Purchase Payments -- Subject to Limitations
- Optional Fixed Dollar or Variable Accumulation Values and Annuity Payments
- Annuity Payments Begin on the Annuitization Start Date
- This Contract is Nonparticipating -- Dividends Are Not Payable
- Surrender Charges May Be Waived under Specified Conditions
411380 Page 1 (04/2013)
GUIDE TO CONTRACT PROVISIONS
CONTRACT DATA........................................................
Important contract specifications, fund allocations,
fees and charges, surrender charge schedule
DEFINITIONS.......................................................... Pages 3-4
Important words and meanings
GENERAL PROVISIONS................................................... Pages 5-6
Entire Contract
Annuity Tax Qualification
Contract Modification
Incontestable
Benefits Based on Incorrect Data
State Laws
Reports to Owner
Evidence of Survival
Protection of Proceeds
Payments by Us
Voting Rights
Termination of the Contract
OWNERSHIP, ANNUITANT AND BENEFICIARY................................. Pages 6-7
Owner Rights
Non-Natural Person and Revocable Trust Ownership
Change of Ownership
Beneficiary
Change of Beneficiary
Change of Annuitant or Contingent Annuitant
Pre-election of an Annuity Payment Plan
Assignment
PAYMENTS TO BENEFICIARIES............................................ Page 8-9
Spouse's Option to Continue Contract
Death Benefit Before the Annuitization Start Date
Payment Options
Amount Payable Before the Annuitization Start Date
Death Benefit After the Annuitization Start Date
PURCHASE PAYMENTS.................................................... Page 10
Purchase Payments
Additional Purchase Payments
Payment Limits
Allocation of Purchase Payments
ACCOUNTS: FIXED AND VARIABLE......................................... Pages 11-12
The Fixed Account
Interest to be Credited
The Variable Account
Investments of the Variable Account
Valuation of Assets
Variable Account Accumulation Units
Variable Account Accumulation Unit Value
Net Investment Factor
Mortality and Expense Risk Charge
Variable Account Administrative Charge
Annuity Unit Value
CONTRACT VALUE....................................................... Pages 13-14
Contract Value
Contract Value in the Variable Account
Contract Value in the Regular Fixed Account
Contract Value in the Special DCA Fixed Account
Contract Administrative Charge
Premium Tax Charges
Transfers of Contract Values
Dollar Cost Averaging
Special DCA Fixed Account
SURRENDER PROVISIONS................................................. Pages 15-17
Surrender of the contract for its surrender value
Rules for Surrender
Surrender Value
Surrender Charge
Purchase Payment Surrender Order
Waiver of Surrender Charges
Suspension or Delay in Payment of Surrender
Waiver of Surrender Charges upon Hospital or Nursing
Home Confinement
Waiver of Surrender Charges upon Terminal Illness
Diagnosis
ANNUITY PROVISIONS................................................... Pages 18-19
Annuity Payment
Change of Annuitization Start Date
Annuity Payment Plans
Plan Selection
Allocation of Contract Values to Provide Fixed and
Variable Payments
Fixed Annuity Payments
Variable Annuity Payments
Determination of the First Variable Annuity Payment
Variable Annuity Payments After the First Payment
Exchange of Annuity Units
TABLES OF ANNUITY PAYOUT RATES....................................... Pages 20-21
Tables showing amount of first Variable Annuity
payment and the guaranteed Fixed Annuity payments for the
various payment plans
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DEFINITIONS
The following words are used often in this contract. When We use these words,
this is what We mean:
ACCUMULATION UNIT
An Accumulation Unit is an accounting unit of measure. It is used to calculate
the Contract Value in the Variable Account prior to the application of amounts
to an annuity payment plan.
ANNUITANT
The Annuitant is the person or persons on whose life periodic annuity payments
depend. If there are joint Annuitants prior to the Annuitization Start Date, the
term Annuitant in this contract is replaced in all instances with the term
Annuitants.
ANNUITIZATION START DATE
The Annuitization Start Date is the date on which annuity payments begin as
described in the Annuity Payment provision. This date is either as shown under
Contract Data or the date as changed as provided in this contract. You will be
notified prior to the Annuitization Start Date.
ANNUITY UNIT
An Annuity Unit is an accounting unit of measure. It is used to calculate the
value of annuity payments from the variable subaccounts on and after the
Annuitization Start Date.
ATTAINED AGE
Attained Age is the number of whole year since birth, which is the same as the
age as of a person's latest birthday, unless born on February 29.
CODE
The Code is the Internal Revenue Code of 1986, as amended, its regulations
thereunder and/or promulgations of the Internal Revenue Service, as applicable.
CONTINGENT ANNUITANT
The Contingent Annuitant is the person who becomes the Annuitant when the
current Annuitant dies prior to the Annuitization Start Date.
CONTRACT ANNIVERSARY
The Contract Anniversary is the same Day and month as the Contract Date each
year that the contract remains in force.
CONTRACT DATE
The Contract Date is the date from which Contract Anniversaries, contract years,
and contract months are determined. Your Contract Date is shown under Contract
Data.
CONTRACT VALUE
The Contract Value is the sum of the Contract Value in the Regular Fixed
Account, Contract Value in the Special DCA Fixed Account and Contract Value in
the Variable Account.
DAY
Unless specified otherwise, a Day is a calendar day.
FIXED ACCOUNT
The Fixed Account is made up of all Our assets other than those in any separate
account.
FIXED ANNUITY
A Fixed Annuity is an annuity with payments which are guaranteed by Us as to
dollar amount during the annuity payment period.
NONQUALIFIED CONTRACT
A Nonqualified Contract is a contract used primarily for retirement purposes
that is not intended to qualify as a Tax Qualified Contract.
OWNER, YOU, YOUR
"Owner," "You" and "Your" refer to the owner or owners of this contract. Any
contract provisions based on the age of the Owner will be based on the age of
the oldest Owner. Any ownership change, including continuation of the contract
by Your spouse under the Spouse's Option to Continue Contract provision,
redefines "Owner," "You" and "Your" as the new owner.
REGULAR FIXED ACCOUNT
The Regular Fixed Account is an option available within the Fixed Account to
which You may allocate purchase payments and Contract Values. Amounts allocated
to the Regular Fixed Account will earn a specified rate of interest.
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SPECIAL DCA FIXED ACCOUNT
The Special DCA Fixed Account is an option within the Fixed Account to which You
may allocate purchase payments. Purchase payment amounts You allocate to the
Special DCA Fixed Account must be transferred within a specified period of time
to selected variable subaccounts. The amounts allocated to the Special DCA Fixed
Account earn a specified rate of interest until transferred out of the Special
DCA Fixed Account.
TAX QUALIFIED CONTRACT
A Tax Qualified Contract is a contract that is intended to qualify as part of a
tax-advantaged retirement plan such as individual retirement annuities,
tax-sheltered savings annuities or other tax-advantaged retirement plans.
VALUATION DATE
A Valuation Date is each Day the New York Stock Exchange is open for trading. At
the New York Stock Exchange close of business, the next Valuation Date begins.
Whenever Your Contract Anniversary is not a Valuation Date, Your Contract Value
for that Contract Anniversary will be based on close of business values on the
next Valuation Date.
VALUATION PERIOD
A Valuation Period is the interval of time commencing at the New York Stock
Exchange close of business on each Valuation Date and ending at the close of
business on the next Valuation Date.
VARIABLE ACCOUNT
The Variable Account consists of separate variable subaccounts to which You may
allocate Contract Values including purchase payments. Each subaccount invests in
shares of one fund. The variable subaccounts available on the Contract Date are
shown under Contract Data. The value of Your investment in each variable
subaccount changes with the performance of the particular fund.
VARIABLE ANNUITY
A Variable Annuity is an annuity with payments which are not predetermined or
guaranteed as to dollar amount and vary in amount with the investment experience
of one or more of the variable subaccounts.
WE, US, OUR
Any reference to "We," "Us" or "Our" means RiverSource Life Insurance Company.
WRITTEN REQUEST
A Written Request is a request in writing, on a form acceptable to Us, signed by
You and delivered to Us at Our corporate office.
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GENERAL PROVISIONS
ENTIRE CONTRACT
This contract form and any attached endorsements or riders are the entire
contract between You and Us.
No one except one of Our corporate officers (President, Vice President,
Secretary or Assistant Secretary) can change or waive any of Our rights or
requirements under this contract. That person must do so in writing. None of Our
other representatives or other persons has the authority to change or waive any
of Our rights or requirements under this contract.
ANNUITY TAX QUALIFICATION
This contract is intended to qualify as an annuity contract under Section 72 and
other relevant sections of the Code for Federal income tax purposes. To that
end, the provisions of this contract are to be interpreted to ensure or maintain
such tax-qualification, despite any other provisions to the contrary. We reserve
the right to unilaterally amend this contract to reflect any clarifications that
may be needed or are appropriate to maintain such tax qualification, subject to
any necessary regulatory approval. We will send You a copy of any such
amendments.
CONTRACT MODIFICATION
This contract may be modified at any time by written agreement between You and
Us. The modification must be signed by one of Our corporate officers (President,
Vice President, Secretary or Assistant Secretary).
INCONTESTABLE
This contract is incontestable from its Contract Date.
BENEFITS BASED ON INCORRECT DATA
If benefit amounts are determined by incorrect information regarding a person's
age or gender, payments described in this contract will be adjusted. They will
be based on what would have been provided using the correct birth date and/or
correct gender. Any underpayments made by Us will be made up promptly without
interest. We reserve the right to recover any amounts overpaid from You or Your
estate. If there are any future payments under this contract, overpayments made
by Us will be subtracted, without interest, and/or as otherwise legally
permissible.
STATE LAWS
This contract is governed by the law of the state in which it is delivered. The
values and benefits of this contract are at least equal to those required by
such state. Any paid up annuity, cash surrender or death benefits available
under the contract are not less than the minimum benefits required by any law of
the state in which the contract is delivered.
REPORTS TO OWNER
At least once a year as of a date not more than four months previous to the date
of mailing, We will send You, without charge, a statement showing (1) the
Contract Value as of the beginning and end dates of the period, (2) the
contract's surrender value and any outstanding loan value as of the end date of
the period, and (3) amounts credited or debited during the period, identified by
type. This statement will also show any other information required under state
or federal law.
We will also send You, without charge, notice of current or other values upon
Your request.
EVIDENCE OF SURVIVAL
Where any payments under this contract depend on the recipient or Annuitant
being alive on a certain date, We may require proof satisfactory to Us that such
condition has been met. Such proof may be required prior to making the payments.
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PROTECTION OF PROCEEDS
Payments under this contract are not assignable by any beneficiary prior to the
time they are due. To the extent allowed by law, payments are not subject to the
claims of creditors or to legal process.
PAYMENTS BY US
All sums payable by Us are payable at Our corporate office. Any payment or
surrender from a variable subaccount is based on the variable subaccount value.
VOTING RIGHTS
If federal law requires, We will give certain voting rights to contract owners.
If You have voting rights, We will send You a notice telling You the time and
place of a shareholder meeting. The notice will also explain matters to be voted
upon and how many votes to which You are entitled.
TERMINATION OF THE CONTRACT
The contract will be terminated under the following conditions:
1. After the death benefit is paid, the contract will terminate.
2. Reduction of the Contract Value to zero will terminate the contract unless
benefits are payable under the terms of certain optional withdrawal
benefit or accumulation benefit riders, if any, attached to this contract.
3. Your Written Request for a full surrender will terminate the contract.
OWNERSHIP, ANNUITANT AND BENEFICIARY
OWNER RIGHTS
Unless otherwise stated in this contract, You may exercise all rights and
privileges provided in this contract or allowed by Us.
If two Owners jointly own this contract, each Owner may independently exercise
transfers among the various account options and designate purchase payment
allocations. Unless agreed to by Us, all other terms, conditions, rights and
requirements that apply to an Owner under this contract shall apply jointly to
each joint Owner named.
NON-NATURAL PERSON AND REVOCABLE TRUST OWNERSHIP
The Owner may be a non-natural person (e.g. irrevocable trust or corporation) or
a revocable trust if We agree. If the Owner or any joint Owner is a non-natural
person or a revocable trust, the Annuitant will be deemed to be the Owner for
any provision or benefit using the age or life of the Owner. These include
Payments to Beneficiaries provisions, the XXXX Benefit Age, Hospitalization/
Nursing Home Waiver Benefit Age, TI Waiver Benefit Age and Maximum Purchase
Payments shown under Contract Data, the Waiver of Surrender Charge upon Hospital
or Nursing Home Confinement provision, and the Waiver of Surrender Charge upon
Terminal Illness Diagnosis provision. If the Owner or any joint Owner is a
non-natural person or revocable trust, the Annuitant may not be changed.
CHANGE OF OWNERSHIP
You may change the ownership of this contract by Written Request or other method
agreed to by Us. Once We receive the change, it will take effect as of the date
of Your request, subject to any action taken or payment made by Us before the
receipt.
A change of ownership may result in tax consequences.
See any attached tax qualified endorsement for ownership change limitations.
BENEFICIARY
Except as otherwise provided in the contract, beneficiaries are those You
designate to receive the death benefit of this contract if You die while this
contract is in force. We will not be bound by any such designation unless made
by Written Request or other method agreed to by Us and recorded by Us. Any
beneficiary designation takes effect as of the date of Your request. However, We
are not liable for any payment made by Us before the recording.
For joint spousal ownership with right of survivorship, the surviving spouse is
deemed the sole beneficiary superseding any other beneficiary designation. This
permits the surviving spouse to use the Spouse's Option to Continue Contract
provision in the Payments to Beneficiaries section of the contract. (The deemed
surviving spouse sole beneficiary designation may only be overridden if
specifically requested in writing and signed by both joint spousal Owners.)
411380 Page 6 (04/2013)
Only those beneficiaries who are living as of the date of death may share in the
benefits, if any. Benefits will be paid to all primary beneficiaries surviving
You, in accordance with Your last beneficiary designation on file. If none
survive, proceeds will be paid to all surviving contingent beneficiaries. If
there is no valid beneficiary designation or if no beneficiary survives, We will
pay the benefits as follows:
- if there are joint Owners, We will pay the surviving Owner(s),
otherwise;
- if the Owner is a non-natural person or revocable trust, We will pay
the Owner, otherwise;
- to Your spouse, if living;
- if no spouse is living, to Your lawful children per stirpes;
- if You have no spouse or direct descendents, to Your parents equally
or the survivor, if living, otherwise to Your estate.
CHANGE OF BENEFICIARY
BY OWNER: You may change the beneficiary at any time by Written Request or other
method agreed to by Us. Once We receive the change, it will take effect as of
the date of Your request. However, We are not liable for any payment made by Us
before the receipt.
BY BENEFICIARY: If the death benefit under this contract becomes payable to a
beneficiary (recipient) under an annuity payment plan, that recipient shall have
the right to name, or later change, their own beneficiary by Written Request. If
there is no valid beneficiary designation or if no beneficiary survives the
recipient, We will pay any benefits due under the annuity payment plan following
the death of the original beneficiary as follows:
- to the recipient's spouse, if living;
- if no spouse is living, to the recipient's lawful children per
stirpes;
- if the recipient has no spouse or direct descendents, to the
recipient's parents equally or the survivor, if living, otherwise to
the recipient's estate.
CHANGE OF ANNUITANT OR CONTINGENT ANNUITANT
If:
1. this is a Nonqualified Contract, and
2. You are a natural person, and
3. You are not a revocable trust, and
4. it is prior to the Annuitization Start Date;
then You may change the Annuitant or Contingent Annuitant by Written Request or
other method agreed to by Us. Once We receive the request and We record the
change, it will take effect as of the date of Your request, subject to any
action taken or payment made by Us before the recording.
In addition, if the Annuitant is not an Owner and the Annuitant dies before the
Annuitization Start Date, the Owner becomes the Annuitant unless a Contingent
Annuitant has been previously selected. The contract continues in force, and no
death benefit is payable.
If the Annuitant is an Owner and the Annuitant dies before the Annuitization
Start Date, the death benefit is payable.
In the case of joint ownership, one Owner must be named as Contingent Annuitant.
PRE-ELECTION OF AN ANNUITY PAYMENT PLAN
If this is a Nonqualified Contract, You may elect how the death benefit
described in this contract is to be paid in the event of Your death before the
Annuitization Start Date. You must make the election by Written Request or other
method agreed to by Us. In this event the death benefit shall be payable as so
elected by You, rather than as requested by the beneficiary. If for any reason
such election does not satisfy Section 72 of the Code or related distribution
requirements, the election will be void and the beneficiary will then be
permitted to elect payment pursuant to the provisions of the contract. This
provision is available for Tax Qualified Contracts if agreed to by Us.
ASSIGNMENT
If this is a Nonqualified Contract, You can assign this contract or any interest
in it. Your interest and the interest of any beneficiary are subject to the
interest of the assignee. An assignment is not a change of ownership and an
assignee is not an Owner as these terms are used in this contract. Any amounts
payable to the assignee will be paid in a single sum.
A copy of any assignment must be submitted to Us at Our corporate office. Unless
otherwise specified by You, assignments shall be effective on the date the
assignment notice is signed, subject to any action taken or payment made by Us
before the assignment was received at Our corporate office. We are not
responsible for the validity or effect, tax or otherwise, of any assignment.
411380 Page 7 (04/2013)
PAYMENTS TO BENEFICIARIES
SPOUSE'S OPTION TO CONTINUE CONTRACT
If You die before the Annuitization Start Date and Your spouse is the sole
primary beneficiary or a joint tenant with right of survivorship, Your spouse
may accept payment of the death benefit under options described below or keep
the contract in force as Owner, including any associated riders in force,
subject to rider continuation rules in effect. If the Owner was also the
Annuitant, then the spouse becomes the Annuitant as well.
Election by the spouse to continue the contract must be made by Written Request,
or other method agreed to by Us, at the time We receive due proof of death. Upon
spousal continuation the Contract Value shall be equal to the death benefit that
would otherwise have been paid but with no reduction for rider charges on riders
that remain in-force. The spouse may make additional purchase payments to the
contract. Surrender charges under the continued contract shall only apply to
purchase payments made after the election by the spouse to continue the
contract.
DEATH BENEFIT BEFORE THE ANNUITIZATION START DATE
A death benefit is payable to the beneficiary if You die when the Contract Value
is greater than zero and before the Annuitization Start Date.
If the annuity is jointly owned by non-spousal Owners, then the death benefit
will be paid to the beneficiary at the first death of a joint Owner.
If the annuity is jointly owned by spousal Owners, see Spouse's Option to
Continue Contract above.
PAYMENT OPTIONS
Any amounts payable or applied by Us as described in this section will be based
on the Contract Values as of the Valuation Date on or next following the date on
which We receive due proof of death at Our corporate office. Due proof of death
includes all documents needed to complete a beneficiary's claim.
The death benefit for each beneficiary will be payable in a lump sum on the
Valuation Date We receive due proof of death from that beneficiary. The
beneficiary may elect to receive payment anytime within five years after the
date of death.
In lieu of a lump sum, payments may be made under a payment plan, provided:
- the beneficiary elects the plan at the time We receive due proof of
death; and
- the plan provides payments over a period which does not exceed the
life or over a period not extending beyond the life expectancy of
the beneficiary; and
- payments begin no later than one year after the date of death.
If the beneficiary elects an annuity payment plan, such beneficiary shall be the
Annuitant for purposes of a lifetime payment plan.
AMOUNT PAYABLE BEFORE THE ANNUITIZATION START DATE
If You are the XXXX Benefit Age (shown under Contract Data) or younger on the
later of (1) the Contract Date or (2) the date of the most recent "covered life
change," (if applicable), and if You die prior to the Annuitization Start Date
with a Contract Value greater than zero; then We will pay the beneficiary the
greater of the following amounts:
1. the Contract Value, after any rider charges have been deducted; or
2. the Return of Purchase Payment (XXXX) Value.
If You are older than the XXXX Benefit Age (shown under Contract Data) on the
later of (1) the Contract Date or (2) the date of the most recent "covered life
change" (if applicable), and if You die prior to the Annuitization Start Date
with a Contract Value greater than zero; then We will pay the beneficiary the
Contract Value after any rider charges have been deducted.
COVERED LIFE CHANGE DEFINITION: A "covered life change" is either A)
continuation of the contract by a spouse under the Spouse's Option to Continue
Contract provision or B) an ownership change where an Owner after the ownership
change was not an Owner prior to the change.
RETURN OF PURCHASE PAYMENT (XXXX) VALUE DEFINITION: On the Contract Date the
XXXX value is established as the total purchase payments made to the contract.
Adjustments are made to the XXXX value in the following circumstances:
1. Additional purchase payments will be added to the XXXX value.
2. Partial surrenders will result in "adjustments for partial surrenders"
subtracted from the XXXX value.
3. After a "covered life change" for a spouse who continues the contract, the
XXXX value is reset to the Contract Value on the date of continuation
after any increases to the Contract Value due to
411380 Page 8 (04/2013)
the death benefit that would otherwise have been paid but with no
reduction for rider charges on riders that remain in-force.
4. After a "covered life change" other than for a spouse who continues the
contract:
if the prior Owner was eligible for the XXXX, the XXXX value is reset on
the Valuation Date We receive Your Written Request for the "covered life
change" to the lesser of A or B where:
A = the Contract Value on that date after any rider charges have
been deducted, and
B = the XXXX value on that date (but prior to the reset).
if the prior Owner was not eligible for the XXXX, the XXXX value is reset
on the Valuation Date We receive Your Written Request for the "covered
life change" as the Contract Value on that date, after any rider charges
have been deducted.
ADJUSTMENTS FOR PARTIAL SURRENDERS DEFINITION: "Adjustments for partial
surrenders" are calculated for each partial surrender using the following
formula:
a X b where:
-------
c
a = the amount Your Contract Value is reduced by the partial surrender
b = the XXXX value on the date of (but prior to) the partial surrender
c = the Contract Value on the date of (but prior to) the partial
surrender.
DEATH BENEFIT AFTER THE ANNUITIZATION START DATE
The Owner's death produces a death benefit after the Annuitization Start Date.
The amount payable, if any, will depend on the annuity payment plan then in
effect.
DEATH OF THE OWNER: If the Owner is the Annuitant and dies after the
Annuitization Start Date, payments cease for lifetime only payment plans.
Payments continue to the Owner's beneficiaries for the remainder of any
guarantee period or for the lifetime of a surviving joint Annuitant, if any.
If the Owner is not the Annuitant and dies after the Annuitization Start Date,
payments continue to the beneficiaries according to the payment plan in effect.
DEATH OF THE ANNUITANT OR OF A BENEFICIARY RECEIVING PAYMENTS UNDER AN ANNUITY
PAYMENT PLAN: If the Owner is not the Annuitant and the Annuitant dies after the
Annuitization Start Date, payments cease for lifetime payment plans. Payments
continue to the Owner for the remainder of any guarantee period or for the
lifetime of a surviving joint Annuitant, if any.
If a beneficiary elects an annuity payment plan as provided under the Payment
Options provision above and dies after payments begin, payments continue to
beneficiaries named by the deceased beneficiary as provided under the Change of
Beneficiary provision for the remainder of any guarantee period.
In any event, amounts remaining payable must be paid at least as rapidly as
payments were being made at the time of such death.
411380 Page 9 (04/2013)
PURCHASE PAYMENTS
PURCHASE PAYMENTS
Purchase payments are the payments You make for this contract and the benefits
it provides. Purchase payments must be paid or mailed to Us at Our corporate
office or to an authorized agent. If requested, We'll give You a receipt for
Your purchase payments.
ADDITIONAL PURCHASE PAYMENTS
Subject to the Payment Limits provision below, additional purchase payments may
be made until the earlier of:
1. the date this contract terminates by surrender or otherwise; or
2. the Annuitization Start Date.
Subject to the Payment Limits Provision You may:
1. stop and/or restart purchase payments; or
2. increase or decrease the amount of Your purchase payments; or
3. change the interval of Your purchase payments.
PAYMENT LIMITS
Maximum Purchase Payments - The maximum purchase payments in the first or later
years may not exceed the amounts shown under Contract Data, based on the
contract year and Your Attained Age at the time of payment unless We allow
otherwise on a non-discriminatory basis.
The Maximum Purchase Payments Permitted includes payments to all deferred
annuity contracts We have issued where You are an Owner. We reserve the right to
increase the maximums.
Additional Purchase Payments - Additional purchase payments You make must be at
least the minimum amount shown under Contract Data.
You cannot allocate purchase payments to the Fixed Account for six months
following: (1) a partial surrender from the Fixed Account; (2) a lump sum
transfer from the Regular Fixed Account to another account; or (3) termination
of automated transfers from the Special DCA Fixed Account prior to the end of
the elected Special DCA time period.
We reserve the right to cancel this contract if both of the following conditions
exist at the same time: (1) no purchase payments have been paid for a continuous
period of 24 months; and (2) less than $500 in purchase payments have been paid
under this contract. In this event, We will give You notice of Our intent to
cancel this contract. Upon such cancellation We will pay You the Contract Value,
after any rider charges have been deducted, in one sum. This contract will then
terminate.
ALLOCATION OF PURCHASE PAYMENTS
You instruct Us on how You want Your purchase payments allocated among the
available accounts.
The percentage of any payment which may be allocated to the Regular Fixed
Account is shown under Contract Data. We reserve the right to change this
percentage at any time on a non-discriminatory basis with notification.
We reserve the right to limit the accounts and/or variable subaccounts to which
You can allocate purchase payments or Contract Value at any time. In addition,
allocations to certain accounts or variable subaccounts may be limited or
required under the terms of certain optional benefit riders, if any, attached to
this contract.
Your allocation instructions as of the Contract Date are shown under Contract
Data. Unless any restrictions apply, You may, by Written Request or other method
agreed to by Us, change Your choice of accounts or percentages. If Your current
allocation instructions include a fund to which allocations are restricted and
You do not provide new instructions, We will apply payments pro rata according
to the valid portion of Your allocation instructions. The first purchase payment
will be allocated as of the end of the Valuation Period during which We make an
affirmative decision to issue this contract. Purchase payments after the first
will be allocated as of the end of the Valuation Period during which We receive
the payment at Our corporate office.
411380 Page 10 (04/2013)
ACCOUNTS: FIXED AND VARIABLE
THE FIXED ACCOUNT
The Fixed Account is part of Our general account. It is made up of all Our
assets other than those in:
1. The Variable Account; and
2. Any other segregated asset accounts.
The Fixed Account consists of the Regular Fixed Account and the Special DCA
Fixed Account.
We back the principal and interest guarantees relating to the Fixed Account.
Purchase payments, interest credited and transfers allocated to the Fixed
Account become part of Our general account.
INTEREST TO BE CREDITED
We will credit interest to the Fixed Account daily. We may credit interest to
each Special DCA Fixed Account at promotional rates that are higher than those
We credit to the Regular Fixed Account. All interest rates We quote are
effective annual interest rates - this refers to the rate that results after
interest has been credited and compounded daily for a full year. Interest will
begin to accrue at Our current crediting rate on the date each purchase payment,
which is received in Our corporate office, becomes available to Us for use and
on the date of any transfers to the Fixed Account. Amounts transferred from the
Special DCA Fixed Account to the Regular Fixed Account, through transfers to an
asset allocation model, will begin earning interest at the current crediting
rate for the Regular Fixed Account on the transfer date. The current crediting
rate is determined by Us and at Our discretion but will never be less than the
Fixed Account Minimum Interest Rate shown under Contract Data.
One year after receipt of each purchase payment or transfer, the rate for the
payment or transfer amount, and its accumulated interest, may change. Interest
will accrue at revised rates determined by Us and at Our discretion. These rates
may be based on various factors including, but not limited to, the interest rate
environment, returns earned on investments backing these annuities, the rates
currently in effect for new and existing company annuities, product design,
competition, and the company's revenues and expenses. However, the rate will
never be less than the Fixed Account Minimum Interest Rate shown under Contract
Data. Your interest rate for each purchase payment or transfer will never change
more frequently than annually.
THE VARIABLE ACCOUNT
The Variable Account is a separate investment account of Ours. It consists of
variable subaccounts which are named under Contract Data. We have allocated a
part of Our assets for this and other contracts to the Variable Account. Such
assets remain Our property. However, the portion of the assets which equals the
reserves and other liabilities of the account(s) shall not be charged with
liabilities arising out of any other business in which We may take part. Income,
gains, and losses, whether or not realized from assets allocated to the Variable
Account, are credited or charged to such account without regard to other income,
gains or losses of the company.
INVESTMENTS OF THE VARIABLE ACCOUNT
Purchase payments and transfer amounts applied to the variable subaccounts will
be allocated as specified by You. Each variable subaccount will buy, at net
asset value, shares of the fund for that variable subaccount shown under
Contract Data or as later added or changed as described below.
We may change the funds from which the variable subaccounts buy shares if laws
or regulations change, the existing funds become unavailable or, in Our
judgment, the funds are no longer suitable for the variable subaccounts. We have
the right to substitute any funds for those shown under Contract Data.
We may also:
- add additional variable subaccounts investing in other funds,
- combine any two or more variable subaccounts,
- transfer assets to and from the variable subaccounts or the Variable
Account, and
- eliminate or close any variable subaccounts.
When required, We would first seek approval of the Securities and Exchange
Commission and the insurance regulator of the state where this contract is
delivered.
VALUATION OF ASSETS
Fund shares in the variable subaccounts will be valued at their net asset value.
VARIABLE ACCOUNT ACCUMULATION UNITS
The number of Accumulation Units for variable subaccounts chosen by You is found
by:
1. adding the number of accumulation units resulting from:
a. purchase payments allocated to the variable subaccount; and
b. transfers to the variable subaccount;
2. and subtracting the number of Accumulation Units resulting from:
411380 Page 11 (04/2013)
a. transfers from the variable subaccount; and
b. surrenders (including surrender charges) from the variable
subaccount; and
c. contract administrative charge or any rider charge deductions from
the variable subaccount.
The number of Your Accumulation Units added or subtracted for each of the above
transactions is found by dividing (1) by (2) where:
1. is the amount allocated to or deducted from the variable subaccount; and
2. is the Accumulation Unit value for the variable subaccount for the
respective Valuation Period during which We received the purchase payment
or transfer value, or during which We deducted transfers, surrenders,
surrender charges, rider charges or contract administrative charges.
VARIABLE ACCOUNT ACCUMULATION UNIT VALUE
The value of an Accumulation Unit for each of the variable subaccounts was
arbitrarily set at $1 when the first fund shares were bought. The value for any
later Valuation Period is found as follows:
The Accumulation Unit value for each variable subaccount for the last
prior Valuation Period is multiplied by the net investment factor for the
same variable subaccount for the next following Valuation Period for which
the Accumulation Unit value is being calculated. The result is the
Accumulation Unit value.
NET INVESTMENT FACTOR
The net investment factor is an index applied to measure the investment
performance of a variable subaccount from one Valuation Period to the next. The
net investment factor may be greater or less than one; therefore, the value of
an accumulation or Annuity Unit may increase or decrease.
The net investment factor for any such variable subaccount for any Valuation
Period is determined by: dividing (1) by (2) and subtracting (3) and (4) from
the result. This is done where:
1. is the sum of:
a. the net asset value per share of the fund held in the variable
subaccount determined at the end of the current Valuation Period;
plus
b. the per share amount of any dividend or capital gain distribution
made by the fund held in the variable subaccount, if the
"ex-dividend" date occurs during the current Valuation Period; and
2. is the net asset value per share of the fund held in the variable
subaccount, determined at the end of the last prior Valuation Period; and
3. is a factor representing the mortality and expense risk charge; and
4. is a factor representing the variable account administrative charge
described below.
MORTALITY AND EXPENSE RISK CHARGE
In calculating unit values We will deduct a mortality and expense risk charge
from the variable subaccounts which is equal, on an annual basis, to a
percentage of the daily net asset value. This percentage is the Annual Mortality
and Expense Risk Fee shown under Contract Data. The deduction is made to
compensate Us for assuming the mortality and expense risks under contracts of
this type. The deduction will be:
1. made from each variable subaccount; and
2. computed on a daily basis.
Fees for certain optional riders and features, if elected, will be added to the
Annual Mortality and Expense Risk Fee.
VARIABLE ACCOUNT ADMINISTRATIVE CHARGE
In calculating unit values, We will deduct a variable account administrative
charge, as shown under Contract Data, from the variable subaccounts. This
deduction is made to compensate Us for certain administrative and operating
expenses for contracts of this type. The deduction will be:
1. made from each of Your variable subaccounts; and
2. computed on a daily basis.
ANNUITY UNIT VALUE
The value of an Annuity Unit for each variable subaccount was arbitrarily set at
$1 when the first fund shares were bought. The value for any later Valuation
Period is found as follows:
1. the Annuity Unit value for each variable subaccount for the last prior
Valuation Period is multiplied by the net investment factor for the same
variable subaccount for the next following Valuation Period for which the
Annuity Unit value is being calculated.
2. the result is multiplied by an interest factor, which on an annualized
basis is equal to .952381. This is done to offset the assumed 5%
investment return which is built into Table A under the Tables of Annuity
Payout Rates section.
411380 Page 12 (04/2013)
CONTRACT VALUE
CONTRACT VALUE
The Contract Value at any time is the sum of:
1. Contract Value in the Variable Account; and
2. Contract Value in the Regular Fixed Account; and
3. Contract Value in the Special DCA Fixed Account.
For surrenders and charges, a number of Accumulation Units and dollar amounts
will be deducted from the above accounts to equal any amounts surrendered or
charges made against the Contract Value.
For surrenders, You may specify from which of the above accounts that the
deduction will be taken. Otherwise, the deduction will be taken from the above
accounts in the same proportion that Your interest in each bears to the total
Contract Value.
CONTRACT VALUE IN THE VARIABLE ACCOUNT
Your Contract Value in the Variable Account at any time will be the total of the
value of the units in any variable subaccount resulting from:
1. purchase payments allocated to a variable subaccount; plus
2. any amounts transferred to a variable subaccount; less
3. any amounts transferred from a variable subaccount; less
4. any amounts deducted from a variable subaccount for surrenders, contract
administrative charges or any rider charges.
CONTRACT VALUE IN THE REGULAR FIXED ACCOUNT
The Contract Value in the Regular Fixed Account at any time will be the total
of:
1. purchase payments allocated to the Regular Fixed Account, plus interest
credited; plus
2. any amounts transferred to the Regular Fixed Account, plus interest
credited; less
3. any amounts transferred from the Regular Fixed Account; less
4. any amounts deducted from the Regular Fixed Account for surrenders,
contract administrative charges or any rider charges.
CONTRACT VALUE IN THE SPECIAL DCA FIXED ACCOUNT
The Contract Value in the Special DCA Fixed Account at any time will be the
total of:
1. purchase payments allocated to the Special DCA Fixed Account, plus
interest credited; less
2. any amounts transferred from the Special DCA Fixed Account; less
3. any amounts deducted from the Special DCA Fixed Account for surrenders,
contract administrative charges or any rider charges.
CONTRACT ADMINISTRATIVE CHARGE
We charge a fee for establishing and maintaining Our records for this contract.
The charge per year is shown under Contract Data and is deducted from the
Contract Value at the end of each contract year or, if earlier, when the
contract is fully surrendered. The charge deducted will be prorated among all
accounts in the same proportion Your interest in each bears to the total
Contract Value.
We reserve the right to adjust this charge after the first Contract Anniversary
but the charge will never exceed the amount shown under Contract Data. We waive
or reduce the annual contract administrative charge for any contract year where
the Contract Value immediately prior to the deduction of the charge equals or
exceeds the amount shown under Contract Data.
If You make a full surrender of this contract, We deduct the full contract
administrative charge at the time of full surrender regardless of Contract
Value.
The charge does not apply to the amount applied to an annuity payment plan or to
the death benefit.
PREMIUM TAX CHARGES
We reserve the right to assess a charge against the Contract Value of this
contract for any premium tax assessed to Us by a federal, state or local
government. This charge could be deducted when You make purchase payments, or
make a full surrender of the Contract Value or on the Annuitization Start Date.
411380 Page 13 (04/2013)
TRANSFERS OF CONTRACT VALUES
While this contract is in force prior to the Annuitization Start Date, transfers
of Contract Values may be made as outlined below unless Contract Values are
required to be allocated to certain accounts or variable subaccounts under the
terms of certain optional benefit riders, if any, attached to this contract.
1. You may transfer all or a part of the values held in one or more of the
variable subaccounts to another one or more of the variable subaccounts.
You may also transfer values held in one or more of the variable
subaccounts to the Regular Fixed Account, subject to items 2 and 4 below.
2. On or within the 30 Days before or after a Contract Anniversary You may
transfer values from the Regular Fixed Account to one or more of the
variable subaccounts. This amount shall not exceed the Regular Fixed
Account transfer limit shown under Contract Data. We reserve the right to
change this percentage at any time on a non-discriminatory basis with
notification. If such a transfer is made, You may not transfer amounts
from any variable subaccount to the Regular Fixed Account for six months
after such a transfer.
3. You may transfer from the Special DCA Fixed Account to the other accounts
as explained in the Special DCA Fixed Account provision, shown below. If
You terminate automated transfers from the Special DCA Fixed Account, You
may not transfer amounts from any variable subaccount to the Regular Fixed
Account for six months after such a transfer. You may not transfer values
from any account into the Special DCA Fixed Account.
4. Amounts transferred to the Regular Fixed account shall not exceed the
limit shown under Contract Data. We reserve the right to change this
percentage at any time on a non-discriminatory basis with notification.
You may make a transfer by Written Request. Telephone transfers may also be made
according to telephone procedures or automated transfer procedures that are then
currently in effect, if any. There is no fee or charge for these transfers.
However, the minimum transfer amount is $250, or if less, the entire value in
the account from which the transfer is being made. Smaller minimums may apply to
automated transfer procedures.
We may suspend or modify Your transfer privileges at any time. The right to
transfer Contract Values among the variable subaccounts and between the variable
subaccounts and other accounts is also subject to modification or restriction if
We determine, at Our sole discretion, that the exercise of that right by You is,
or would be, to the disadvantage of other contract owners. Additionally, We
reserve the right to modify or restrict transfer privileges if required to
comply with the written instructions of a fund. Any modification or restriction
could be applied to transfers to or from some or all of the variable subaccounts
and other accounts.
These modifications could include, but are not limited to:
1. the requirements of a minimum time period between each transfer,
2. not accepting transfer requests of an agent acting under a power of
attorney on behalf of more than one contract owner,
3. suspending or terminating automatic transfer programs, or
4. limiting the dollar amount that You may transfer between the variable
subaccounts and other accounts at any one time.
We may apply these modifications or restrictions in any manner reasonably
designed to prevent any use of the transfer right We consider to be to the
disadvantage of other contract owners.
DOLLAR COST AVERAGING (DCA)
You may authorize the automated transfer of specified amounts, according to the
rules then currently in effect, at the interval You select, from the Regular
Fixed Account (subject to transfer limits shown under Contract Data) or any
variable subaccount, to any other variable subaccount other than the source
account. You may terminate automated transfers at any time.
SPECIAL DCA FIXED ACCOUNT
You may also allocate new purchase payments to the Special DCA Fixed Account.
You may authorize the automatic transfer of amounts on a monthly basis from the
Special DCA Fixed Account to any of the variable subaccount(s) or any asset
allocation model. (Transfers from the Special DCA Fixed account to the Regular
Fixed Account are not allowed.) All amounts allocated to the Special DCA Fixed
Account will be transferred out within the specified Special DCA Fixed Account
time period You elect from the time periods We make available.
If You terminate automated transfers from the Special DCA Fixed Account, the
entire Special DCA Fixed Account balance will immediately be transferred
according to Your Special DCA Fixed Account allocation instructions that are
then in effect. If Your current Special DCA allocation instructions include a
fund to which allocations are restricted and You do not provide new
instructions, We will transfer amounts pro rata according to the valid portion
of Your allocation instructions.
411380 Page 14 (04/2013)
SURRENDER PROVISIONS
SURRENDER
By Written Request or other method agreed to by Us and subject to the rules
below You may:
1. surrender this contract for the full surrender value; or
2. surrender part of this contract for a partial surrender.
RULES FOR SURRENDER
All surrenders will have the following conditions.
1. You must send Us Your Written Request (or other method agreed to by Us):
a. while this contract is in force; and
b. while all Owners are living; and
c. prior to the Annuitization Start Date.
2. Unless We agree otherwise, You must surrender an amount equal to at least
$250. The Contract Value after a partial surrender must be at least $500.
3. For surrenders from the variable subaccounts, the amount surrendered, less
any charges, will be paid to You within seven Days of the receipt of Your
Written Request, unless subject to the Suspension or Delay in Payment of
Surrender provision.
For surrenders from the Fixed Account, the amount surrendered, less any
charges, will normally be paid to You within seven Days of the receipt of
Your Written Request and the return of this contract, if required.
Following any required regulatory approval, We have the right to defer
payment for up to six months from the date We receive Your request. In
such circumstance, We will notify You of the reason for the delay, the
effective date of the surrender, and the surrender value as of the date of
Your request.
4. For partial surrenders, if You do not specify from which account the
surrender is to be made, the surrender will be made from all accounts in
the same proportion as Your interest in each bears to the Contract Value.
5. If You die following a surrender request, payment will be made to Your
estate.
6. Any amounts surrendered, including any related charges, cannot be repaid.
Upon surrender for the full surrender value this contract will terminate. We may
require that You return the contract to Us before We pay the full surrender
value.
SURRENDER VALUE
The full surrender value at any time will be:
1. the Contract Value immediately prior to the surrender;
2. minus the full contract administrative charge and any rider charges that
are deducted for a full surrender;
3. minus any surrender charge.
For a partial surrender, We will determine the amount of Your Contract Value
that needs to be surrendered, which after any surrender charge, will equal the
amount You requested. We pay You the amount You requested.
SURRENDER CHARGE
A surrender charge may apply in the event You surrender some or all of Your
Contract Value. The surrender charge schedule for Your contract is shown under
Contract Data. A surrender charge applies if You surrender purchase payments
received that are still in the surrender charge period. Refer to Waiver of
Surrender Charges for situations when surrender charges are not deducted.
We determine Your surrender charge by multiplying the amount of each purchase
payment surrendered which could be subject to a surrender charge by the
applicable surrender charge percentage, and then totaling the surrender charges.
The amount that represents purchase payments surrendered is calculated using a
prorated formula based on the percentage of Your Contract Value being
surrendered. As a result, the amount that represents purchase payments
surrendered may be greater than Your Contract Value surrendered. We determine
the amount that represents purchase payments surrendered (PPS), purchase
payments not subject to a surrender charge (PPF), and purchase payments which
could be subject to a surrender charge (PPSC) by the following formula:
PPS = PPSC + PPF
PPSC = (PS - FA) X (PP - PPF)
-------
CV - FA
PPF = FA - "contract earnings", but not less than zero
PP = Purchase payments not previously surrendered (total purchase
payments - PPS)
PS = Amount the Contract Value is reduced by the surrender
FA = the "total free amount"
CV = Contract Value prior to the surrender
411380 Page 15 (04/2013)
DEFINITION OF "CONTRACT EARNINGS": With respect to these surrender provisions,
"contract earnings" is defined as the Contract Value, less purchase payments not
previously surrendered, but not less than zero.
With respect to these surrender provisions, "contract earnings" are surrendered
first followed by purchase payments. After calculating the amount of purchase
payments surrendered, We use the surrender order described below to determine
the surrender charge.
DEFINITION OF "TOTAL FREE AMOUNT"*: the greater of:
a. "contract earnings", or
b. the CV Waiver Percentage shown under Contract Data multiplied
by Your prior Contract Anniversary Contract Value, less any
prior surrenders taken in the current contract year.
* During the first contract year, "total free amount" is the greater of:
a. "contract earnings", or
b. the CV Waiver Percentage shown under Contract Data multiplied
by all purchase payments applied prior to Your surrender
request, less any amounts surrendered prior to Your surrender
request that represent the "total free amount".
PURCHASE PAYMENT SURRENDER ORDER
For purposes of determining any surrender charge, purchase payments are
surrendered in the following order.
1. First, purchase payments not subject to a surrender charge (PPF) are
surrendered on a first-in, first-out basis. (No surrender charge).
2. Next, purchase payments that may be subject to a surrender charge (PPSC)
are surrendered from purchase payments beyond the surrender charge period
on a first-in, first-out basis. (No Surrender Charge)
3. Finally, any additional purchase payments that may be subject to a
surrender charge (PPSC) are surrendered from purchase payments still in a
surrender charge period on a first-in, first-out basis to minimize the
surrender charge that applies to these payments.
WAIVER OF SURRENDER CHARGES
Surrender charges are waived for all of the following.
1. In each contract year, the "total free amount" as defined in the Surrender
Charge provision; and
2. death benefit payments made in the event of Your death; and
3. amounts applied to an annuity payment plan; and
4. for Tax Qualified Contracts other than Inherited IRAs, amounts surrendered
to meet applicable minimum distribution requirements under the Code to the
extent they exceed amounts waived under item 1 of this provision (NOTE:
Amounts surrendered under this waiver provision are limited to applicable
required minimum distributions for this contract only and to one time per
year unless We agree otherwise.); and
5. exercise of the Waiver of Surrender Charges upon Hospital or Nursing Home
Confinement provision described below; and
6. exercise of the Waiver of Surrender Charges upon Terminal Illness
Diagnosis provision described below.
Surrender proceeds will not be disbursed until we notify You of any denial of
Your request for waiver of surrender charges and give You the opportunity to
accept or reject surrender proceeds.
SUSPENSION OR DELAY IN PAYMENT OF SURRENDER AMOUNT
We have the right to suspend or delay the date of any surrender payment from the
variable subaccounts for any period:
1. when the New York Stock Exchange is closed; or
2. when trading on the New York Stock Exchange is restricted; or
3. when an emergency exists as a result of which:
a. disposal of securities held in the variable subaccounts is not
reasonably practical; or
b. it is not reasonably practical to fairly determine the value of the
net assets of the variable subaccounts; or
4. during any other period when the Securities and Exchange Commission, by
order, so permits for the protection of security holders.
Rules and regulations of the Securities and Exchange Commission will govern as
to whether the conditions set forth in 2 and 3 exist.
411380 Page 16 (04/2013)
WAIVER OF SURRENDER CHARGES UPON HOSPITAL OR NURSING HOME CONFINEMENT
If You are the Hospitalization/Nursing Home Waiver Benefit Age (shown under
Contract Data) or younger on the Contract Date, surrender charges will be waived
providing the following requirements are met:
1. The amount surrendered is paid directly to You; and
2. We receive satisfactory written proof as described below that You are
confined in a nursing home or hospital; and
3. such confinement has lasted for 60 straight Days or began within 30 Days
following a 60 Day confinement; and
4. such confinement began after the Contract Date of this contract; and
5. We receive Your surrender request no later than 91 Days after the release
from the hospital or nursing home.
To qualify, a letter of proof must:
1. be signed by Your licensed physician or the hospital or nursing home
administrator; and
2. be on appropriate medical letterhead; and
3. specify the confinement dates; and
4. if hospital confinement, specify hospital name, address and that it is
operated pursuant to state and federal law; or
5. if nursing home confinement, specify nursing home name, address and that
it meets the following definition of a nursing home.
DEFINITION OF NURSING HOME: To qualify, the nursing home must be a facility or
distinctly separate part of a hospital or other institution which is licensed by
the appropriate licensing agency to engage primarily in providing nursing care
and related services to inpatients; and:
1. provide 24 hour a day nursing service under a planned program of policies
and procedures which was developed with the advice of, and is periodically
reviewed and executed by, a professional group of at least one doctor and
one nurse; and
2. have a doctor on duty or on call at all times to furnish medical care in
case of emergency; and
3. have at least one nurse who is employed there full time (or at least 24
hours per week if the facility has less than 10 beds); and
4. have a nurse on duty or on call at all times; and
5. maintain clinical records for all patients; and
6. have appropriate methods and procedures for handling and administering
drugs and biologicals.
If an institution or facility has multiple licenses or purposes, a portion,
xxxx, wing or unit thereof will qualify as a nursing home only if it meets all
of the above criteria, is authorized by license to provide nursing care to
inpatients, and is engaged principally in providing such nursing care in
accordance with that license.
DEFINITION OF DOCTOR: A doctor is a physician, as defined in section 1861(r)(1)
of the Federal Social Security Act, acting within the scope of his or her
license in the state of licensure.
DEFINITION OF NURSE: A nurse is a registered professional nurse, acting within
the scope of his or her license in the state of licensure.
WAIVER OF SURRENDER CHARGES UPON TERMINAL ILLNESS DIAGNOSIS
If You are the TI Waiver Benefit Age (shown under Contract Data) or younger on
the Contract Date, surrender charges will be waived providing the following
requirements are met:
1. The amount surrendered is paid directly to You; and
2. We receive satisfactory written proof as described below that You are
diagnosed with a medical condition that with reasonable medical certainty
will result in death within 12 months or less from the date of the
diagnosis; and
3. such diagnosis occurred on or after the first Contract Anniversary.
You must provide Us with a letter of proof when You request the surrender. Your
surrender request may be sent to Us any time after the terminal illness
diagnosis and before a death benefit is payable.
To qualify, the letter of proof must:
1. be signed by Your physician who is legally qualified and licensed to
practice medicine in his/her state of residence and is operating within
the scope of that license; and
2. be on appropriate medical letterhead; and
3. specify the terminal illness, the expected date of death and the date the
terminal illness was initially diagnosed.
411380 Page 17 (04/2013)
ANNUITY PROVISIONS
ANNUITY PAYMENT
The Annuitization Start Date is the date shown under Contract Data. It can be
changed by You as provided below. On the Annuitization Start Date, the amount
applied to an annuity payment plan will be the Contract Value after any rider
charges are deducted.
The first payment will be made as provided by the selected plan. Before the
first payment is sent, We will require satisfactory proof of the Annuitant's age
and that the Annuitant is alive. We may also require that You exchange this
contract for a supplemental contract which provides the annuity payments.
CHANGE OF ANNUITIZATION START DATE
You may change the Annuitization Start Date shown under Contract Data by Written
Request or other method agreed to by Us. If You select a new date, it must be at
least 30 Days after We receive Your request.
The Annuitization Start Date must be on or before the latest of:
1. Your 95th birthday, or
2. the 10th Contract Anniversary, or
3. such other date as agreed upon by Us.
ANNUITY PAYMENT PLANS
Annuity payments may be made on a fixed dollar basis, a variable basis or a
combination of both. You can schedule receipt of annuity payments according to
one of the Plans A through D below or another plan agreed to by Us.
PLAN A -- LIFE INCOME NON-REFUND. This provides monthly annuity payments during
the lifetime of the Annuitant. No payments will be made after the Annuitant
dies.
PLAN B -- LIFE INCOME WITH GUARANTEED PERIOD.
This provides monthly annuity payments during the lifetime of the Annuitant with
a guarantee by Us that payments will be made for at least five, 10 or 15 years
whether or not the Annuitant is living. You must select a guaranteed period, and
the minimum number of years payable is five years.
PLAN C -- LIFE INCOME WITH INSTALLMENT REFUND.
This provides monthly annuity payments during the lifetime of the Annuitant with
a guarantee by Us that payments will be made at least for a certain number of
months whether or not the Annuitant is living. We determine the number of months
by dividing the amount applied under this plan by the amount of the first
monthly annuity payment.
PLAN D -- JOINT AND SURVIVOR LIFE INCOME NON-REFUND. This provides monthly
annuity payments during the lifetime of the Annuitant and joint Annuitant. When
either the Annuitant or the joint Annuitant dies We will continue to make
monthly payments during the lifetime of the survivor. No payments will be made
after the death of both the Annuitant and joint Annuitant.
PLAN SELECTION
You may select the plan by Written Request, or other method agreed to by Us, at
least 30 Days before the Annuitization Start Date. If We have not received Your
Written Request to select a plan, the first annuity payment will be made 30 Days
after the Annuitization Start Date according to Plan B with monthly payments
guaranteed for ten years.
After the Annuitization Start Date, You cannot change to a different plan.
If the amount to be applied to a plan is less than $2,000 or would not provide
an initial monthly payment of at least $20, We have the right to change the
frequency of the payment or to make a lump sum payment of the amount that would
have been applied to a plan.
ALLOCATION OF CONTRACT VALUES TO PROVIDE FIXED AND VARIABLE PAYMENTS
On the Annuitization Start Date, You use the value described under the Annuity
Payment provision above, to provide Fixed Annuity and/or Variable Annuity
payments.
Unless We agree otherwise, You may use a maximum of ten variable subaccounts at
any one time. The Special DCA Fixed Account is not available on and after the
Annuitization Start Date. In addition, certain variable subaccounts may not be
available on and after the Annuitization Start date.
FIXED ANNUITY PAYMENTS
A Fixed Annuity is an annuity with payments which:
1. are guaranteed as to dollar amount; and
2. do not vary in amount based on the investment performance of the variable
subaccounts.
When annuity payments begin, amounts You allocate to provide fixed dollar
payments under Plans A, B, C and D will be applied to the applicable Annuity
Payout Rates Table. This will be done in accordance with the payment plan
chosen. The minimum
411380 Page 18 (04/2013)
amount payable for each $1,000 so applied is shown in Table B under the Tables
of Annuity Payout Rates provision.
VARIABLE ANNUITY PAYMENTS
A Variable Annuity is an annuity with payments which:
1. are not predetermined or guaranteed as to dollar amount; and
2. vary in amount based on the investment performance of the variable
subaccounts.
DETERMINATION OF THE FIRST VARIABLE ANNUITY PAYMENT
When annuity payments begin, the amounts You allocate to provide Variable
Annuity payments will be applied to the applicable Annuity Payout Rates Table.
This will be done:
1. on the Annuitization Start Date; and
2. in accordance with the payment plan chosen. The amount payable for the
first payment for each $1,000 so applied under Plans A, B, C and D is
shown in Table A under the Tables of Annuity Payout Rates provision.
VARIABLE ANNUITY PAYMENTS AFTER THE FIRST PAYMENT
Variable annuity payments after the first payment vary in amount. The amount
changes with the investment performance of the variable subaccounts. The dollar
amount of Variable Annuity payments after the first is not fixed. It may change
from month to month. The dollar amount of such payments is determined as
follows.
1. The dollar amount of the first annuity payment is divided by the value of
an Annuity Unit as of the Valuation Date on or next preceding the seventh
Day before the Annuitization Start Date. This result establishes the fixed
number of Annuity Units for each monthly annuity payment after the first
payment. This number of Annuity Units remains fixed during the annuity
payment period unless exchanged for units of any of the other variable
subaccounts as provided below.
2. The fixed number of Annuity Units is multiplied by the Annuity Unit value
as of the Valuation Date on or next preceding the seventh Day before the
date the payment is due. The result establishes the dollar amount of the
payment.
In order for the dollar amount of variable annuity payments not to decrease, the
assets of the variable account must have a 5% annualized investment return.
We guarantee that the dollar amount of each payment after the first will not be
affected by variations in expenses or mortality experience.
EXCHANGE OF ANNUITY UNITS
After the Annuitization Start Date, Annuity Units of any variable subaccount may
be exchanged for units of any of the other variable subaccounts. This may be
done no more than once in any contract year. Unless We agree otherwise You may
use a maximum of ten variable subaccounts at any one time. No exchanges may be
made to or from any Fixed Annuity after the Annuitization Start Date.
411380 Page 19 (04/2013)
TABLES OF ANNUITY PAYOUT RATES
Table A below shows the amount of the first monthly Variable Annuity payment,
based on a 5% assumed investment return, for each $1,000 of value applied under
Plans A, B, C and D. The amount of the first and all subsequent monthly fixed
dollar annuity payments for each $1,000 of value applied under Plans A, B, C and
D will be based on Our fixed dollar Table of Annuity Payout Rates in effect on
the Annuitization Start Date.
Such rates are guaranteed to be not less than those shown in Table B. The amount
of such annuity payments under Plans A, B and C will depend upon the gender and
Attained Age of the Annuitant on the Annuitization Start Date. The amount of
such annuity payments under Plan D will depend upon the gender and the Attained
Age of the Annuitant and the joint Annuitant on the Annuitization Start Date.
TABLE A - DOLLAR AMOUNT OF FIRST MONTHLY VARIABLE ANNUITY PAYMENT
PER $1,000 APPLIED
PLAN A PLAN B PLAN C PLAN D
------------- ----------------------------------------------- -------------- ----------------
Age Life Income with Life Income Joint & Survivor
at Beginning Life Income Five Years Ten Years Fifteen Years Installment Non-Refund
Annuit- In Non-Refund Certain Certain Certain Refund Male & Female
ization Year Male Female Male Female Male Female Male Female Male Female Same Age
--------- --------- ----- ------ ----- ------ ----- --------- ---- ------ ----- ------ ----------------
Age 65 2015 6.33 5.84 6.28 5.82 6.15 5.76 5.95 5.65 6.00 5.66 5.30
2020 6.24 5.77 6.20 5.75 6.09 5.70 5.90 5.60 5.94 5.61 5.26
2025 6.16 5.71 6.13 5.69 6.02 5.64 5.85 5.55 5.88 5.55 5.21
2030 6.09 5.65 6.05 5.63 5.96 5.59 5.80 5.51 5.82 5.51 5.18
2035 6.01 5.59 5.99 5.58 5.90 5.54 5.75 5.47 5.77 5.46 5.14
2040 5.95 5.54 5.92 5.52 5.84 5.49 5.71 5.42 5.72 5.42 5.11
Age 75 2015 8.34 7.56 8.13 7.45 7.59 7.14 6.91 6.68 7.43 6.97 6.50
2020 8.17 7.41 7.98 7.32 7.49 7.04 6.86 6.62 7.32 6.87 6.40
2025 8.02 7.28 7.84 7.19 7.39 6.94 6.81 6.56 7.22 6.78 6.32
2030 7.87 7.16 7.71 7.08 7.30 6.85 6.75 6.50 7.12 6.69 6.24
2035 7.73 7.04 7.59 6.97 7.21 6.76 6.70 6.45 7.03 6.61 6.16
2040 7.60 6.93 7.47 6.87 7.12 6.68 6.65 6.39 6.94 6.53 6.09
Age 85 2015 12.33 11.39 11.26 10.65 9.29 9.06 7.64 7.58 9.91 9.45 9.09
2020 12.00 11.07 11.04 10.41 9.21 8.96 7.62 7.56 9.74 9.28 8.89
2025 11.70 10.77 10.83 10.19 9.13 8.87 7.60 7.53 9.57 9.11 8.70
2030 11.42 10.50 10.63 9.98 9.04 8.77 7.58 7.51 9.42 8.95 8.53
2035 11.15 10.24 10.44 9.78 8.96 8.67 7.56 7.48 9.28 8.80 8.37
2040 10.90 10.01 10.26 9.59 8.88 8.58 7.55 7.46 9.14 8.67 8.23
Age 95 2015 20.42 19.49 15.45 15.13 10.37 10.34 7.82 7.82 14.49 14.05 14.63
2020 19.94 18.97 15.32 14.97 10.36 10.33 7.82 7.82 14.33 13.87 14.34
2025 19.50 18.48 15.20 14.82 10.36 10.32 7.82 7.81 14.17 13.69 14.07
2030 19.09 18.03 15.08 14.67 10.35 10.31 7.82 7.81 14.03 13.52 13.82
2035 18.70 17.61 14.96 14.53 10.34 10.30 7.82 7.81 13.90 13.37 13.59
2040 18.33 17.22 14.84 14.39 10.34 10.29 7.82 7.81 13.76 13.23 13.38
Age 100 2015 28.93 27.60 17.47 17.28 10.50 10.49 7.82 7.82 18.76 18.14 20.41
2020 28.76 27.41 17.46 17.26 10.50 10.49 7.82 7.82 18.72 18.10 20.31
2025 28.59 27.22 17.45 17.25 10.50 10.49 7.82 7.82 18.69 18.06 20.22
2030 28.42 27.04 17.44 17.24 10.50 10.49 7.82 7.82 18.65 18.02 20.13
2035 28.26 26.86 17.44 17.22 10.50 10.49 7.82 7.82 18.62 17.98 20.04
2040 28.10 26.69 17.43 17.21 10.50 10.49 7.82 7.82 18.58 17.94 19.96
Table A above is based on the "Annuity 2000 Mortality Table" with 100%
Projection Scale G and a 5% assumed investment return. Annuity Payment rates
for any year, age, or any combination of year, age and gender not shown above,
will be calculated on the same basis as those rates shown in the Table above.
Such rates will be furnished by Us upon request.
411380 Page 20 (04/2013)
Fixed Dollar annuity payments under Plans A, B, C and D will not be less than
those shown in Table B. In addition, the amount of such payments will not be
less than that which would be provided if a single payment immediate annuity
contract then offered by Us to Annuitants in the same class were to be purchased
with the surrender value of the contract.
TABLE B - DOLLAR AMOUNT OF EACH MONTHLY FIXED DOLLAR ANNUITY PAYMENT
PER $1,000 APPLIED
PLAN A PLAN B PLAN C PLAN D
------------- ----------------------------------------------- -------------- ----------------
Age Life Income with Life Income Joint & Survivor
at Beginning Life Income Five Years Ten Years Fifteen Years Installment Non-Refund
Annuit- In Non-Refund Certain Certain Certain Refund Male & Female
ization Year Male Female Male Female Male Female Male Female Male Female Same Age
--------- --------- ----- ------ ----- ------ ----- --------- ---- ------ ----- ------ ----------------
Age 65 2015 4.03 3.59 4.01 3.58 3.93 3.55 3.80 3.49 3.36 3.16 3.13
2020 3.95 3.53 3.93 3.52 3.86 3.49 3.74 3.43 3.32 3.13 3.08
2025 3.87 3.47 3.85 3.46 3.80 3.43 3.69 3.38 3.28 3.09 3.04
2030 3.80 3.41 3.78 3.40 3.73 3.38 3.63 3.33 3.24 3.05 3.00
2035 3.73 3.35 3.72 3.35 3.67 3.33 3.58 3.28 3.20 3.02 2.96
2040 3.67 3.30 3.66 3.30 3.61 3.28 3.53 3.24 3.17 2.99 2.93
Age 75 2015 5.99 5.30 5.87 5.24 5.49 5.03 4.92 4.66 4.45 4.19 4.40
2020 5.84 5.16 5.72 5.11 5.38 4.92 4.86 4.60 4.38 4.13 4.31
2025 5.69 5.04 5.59 4.99 5.28 4.83 4.80 4.53 4.31 4.07 4.22
2030 5.55 4.92 5.46 4.88 5.18 4.73 4.74 4.46 4.25 4.01 4.14
2035 5.43 4.82 5.34 4.78 5.09 4.65 4.68 4.40 4.19 3.96 4.07
2040 5.30 4.71 5.23 4.68 5.00 4.56 4.62 4.34 4.14 3.91 4.00
Age 85 2015 9.88 9.02 9.10 8.48 7.39 7.14 5.77 5.71 6.30 6.02 7.00
2020 9.58 8.72 8.88 8.25 7.30 7.04 5.75 5.68 6.19 5.92 6.81
2025 9.30 8.44 8.67 8.03 7.21 6.93 5.73 5.66 6.10 5.83 6.63
2030 9.03 8.19 8.47 7.83 7.12 6.83 5.71 5.63 6.02 5.74 6.47
2035 8.78 7.95 8.28 7.63 7.04 6.73 5.69 5.60 5.94 5.66 6.32
2040 8.55 7.73 8.10 7.45 6.95 6.63 5.67 5.57 5.86 5.59 6.19
Age 95 2015 17.92 17.02 13.57 13.23 8.60 8.56 5.98 5.97 9.82 9.50 12.54
2020 17.48 16.52 13.44 13.07 8.59 8.55 5.98 5.97 9.73 9.41 12.26
2025 17.06 16.06 13.31 12.91 8.59 8.54 5.98 5.97 9.66 9.33 12.01
2030 16.67 15.64 13.19 12.76 8.58 8.53 5.98 5.97 9.59 9.26 11.78
2035 16.31 15.25 13.07 12.62 8.57 8.52 5.98 5.97 9.52 9.19 11.56
2040 15.97 14.89 12.95 12.48 8.56 8.51 5.98 5.97 9.46 9.11 11.36
Age 100 2015 26.42 25.09 15.74 15.53 8.74 8.73 5.98 5.98 13.01 12.56 18.30
2020 26.25 24.91 15.73 15.51 8.74 8.73 5.98 5.98 12.99 12.54 18.21
2025 26.09 24.74 15.72 15.50 8.74 8.73 5.98 5.98 12.97 12.52 18.12
2030 25.94 24.57 15.71 15.48 8.74 8.73 5.98 5.98 12.95 12.50 18.04
2035 25.79 24.40 15.70 15.47 8.74 8.73 5.98 5.98 12.93 12.48 17.95
2040 25.64 24.24 15.69 15.46 8.74 8.73 5.98 5.98 12.92 12.46 17.87
Table B above is based on the "Annuity 2000 Mortality Table" with 100%
Projection Scale G at 1.0% annual effective interest rate. Annuity Payment rates
for any year, age, or any combination of year, age and gender not shown above,
will be calculated on the same basis as those rates shown in the Table above.
Such rates will be furnished by Us upon request.
411380 Page 21 (04/2013)
DEFERRED ANNUITY CONTRACT
RIVERSOURCE LIFE (RIVERSOURCE ANNUITIES LOGO)
INSURANCE COMPANY
Offices:
00000 Xxxxxxxxxx Xxxxxxxxx Xxxxxx
Xxxxxxxxxxx, XX 00000
- Flexible Purchase Payments -- Subject to Limitations
- Optional Fixed Dollar or Variable Accumulation Values and Annuity Payments
- Annuity Payments Begin on the Annuitization Start Date
- This Contract is Nonparticipating -- Dividends Are Not Payable
- Surrender Charges May Be Waived under Specified Conditions
CONTRACT DATA
Deferred Annuity Contract: RIVERSOURCE(R) RAVA 5 ADVANTAGE(R) VARIABLE ANNUITY
Contract Number: 9920-SAMPLE Contract Date: May 1, 2013
Annuitant: Xxxx Xxx Annuitization Start Date: May 1, 2073
Contract Owner: Xxxx Xxx Age at Issue: 35
Application Signed State/Contract Delivery State: state
State Insurance Department: 800-ZZZ-ZZZZ
Initial Purchase Payment: $25,000 Contract Type: Non-Qualified
Scheduled Purchase Payment:
Annual Amount: NA
Maximum Purchase Payments Permitted:
1st Contract Year and Total:
- Under age 86: $1,000,000
- Age 86 or older and under age 91: $ 100,000
- Age 91 or older: $ 0
Each Contract Year thereafter:
- Under age 86: $ 100,000
- Age 86 or older and under age 91: $ 50,000
- Age 91 or older: $ 0
Minimum Additional Purchase Payment: $ 50
Minimum Purchase Payment or Transfer Amount
to any Guarantee Period Account: $ 1,000
Purchase Payment Credits: Not available with this contract
Upon issuance of this contract your purchase payments have been scheduled to be
paid and applied to the Fixed Account, Guarantee Period Accounts and variable
subaccounts investing in funds as shown below. You may change the amount,
frequency and allocations as provided in this contract. Refer to the Purchase
Payments provision.
Payment
Allocation
Allocation Percentage
---------- ----------
FIXED ACCOUNT
Regular Fixed Account ___%
6-month Special DCA Fixed Account ___%
12-month Special DCA Fixed Account ___%
GUARANTEE PERIOD ACCOUNTS (GPA)
1 Year Guarantee Period Account ___%
2 Year Guarantee Period Account ___%
3 Year Guarantee Period Account ___%
4 Year Guarantee Period Account ___%
5 Year Guarantee Period Account ___%
6 Year Guarantee Period Account ___%
7 Year Guarantee Period Account ___%
8 Year Guarantee Period Account ___%
9 Year Guarantee Period Account ___%
10 Year Guarantee Period Account ___%
AIM V.I.
Capital Appreciation Fund, Series II Shares ___%
Capital Development Fund, Series II Shares ___%
Global Health Care Fund, Series II Shares ___%
International Growth Fund, Series II Shares ___%
ALLIANCEBERNSTEIN VPS
Global Technology Portfolio (Class B) ___%
Growth and Income Portfolio (Class B) ___%
International Value Portfolio (Class B) ___%
AMERICAN CENTURY VP
Mid Cap Value, Class II ___%
Ultra(R), Class II ___%
Value, Class II ___%
ICC12 411380-DPRA57 Page 3.0 A(04/2013)
CONTRACT DATA - Continued
Contract Number: 9920-SAMPLE Contract Date: May 1, 2013
Payment
Allocation
Allocation Percentage
-------------------------------------------------- ----------
CAMBRIDGE FUNDS
Cambridge Conservative Fund ___%
Cambridge Moderate Fund ___%
Cambridge Aggressive Fund ___%
COLUMBIA
High Yield Fund, Variable Series, Class B ___%
Xxxxxxx Growth Fund, Variable Series, Class A ___%
Xxxxxxx International Opportunities Fund, Variable
Series, Class B ___%
Small Cap Value Fund, Variable Series, Class B ___%
CREDIT SUISSE TRUST -
Commodity Return Strategy Portfolio ___%
DREYFUS
VIF International Equity Portfolio, Service Shares ___%
VIF International Value Portfolio, Service Shares ___%
XXXXX XXXXX VT
Floating-Rate Income Fund ___%
FIDELITY(R) VIP
Contrafund(R) Portfolio Service Class 2 ___%
Investment Grade Bond Portfolio Service Class 2 ___%
Mid Cap Portfolio Service Class 2 ___%
Overseas Portfolio Service Class 2 ___%
FRANKLIN XXXXXXXXX VIP TRUST
Franklin Income Securities Fund - Class 2 ___%
Xxxxxxxxx Global Income Securities Fund - Class 2 ___%
Xxxxxxxxx Growth Securities Fund - Class 2 ___%
XXXXXXX XXXXX VIT
Mid Cap Value Fund - Institutional Shares ___%
Structured U.S. Equity Fund - Institutional Shares ___%
JANUS ASPEN SERIES
Large Cap Growth Portfolio: Service Shares ___%
XXXX XXXXX PARTNERS VARIABLE
Small Cap Growth Portfolio, Class I ___%
MFS(R)
Total Return Series - Service Class ___%
Utilities Series - Service Class ___%
XXXXXXXXXXX
Capital Appreciation Fund/VA, Service Shares ___%
Global Securities Fund/VA, Service Shares ___%
Main Street Small Cap Fund/VA, Service Shares ___%
Strategic Bond Fund/VA, Service Shares ___%
PIMCO VIT
All Asset Portfolio, Advisor Share Class ___%
RIVERSOURCE VARIABLE SERIES TRUST
DISCIPLINED ASSET ALLOCATION(SM) PORTFOLIOS
Conservative ___%
Moderately Conservative ___%
Moderate ___%
Moderately Aggressive ___%
Aggressive ___%
RIVERSOURCE(R) PARTNERS VP
Fundamental Value Fund ___%
Select Value Fund ___%
Small Cap Value Fund ___%
RIVERSOURCE(R) VP
Cash Management Fund ___%
Diversified Bond Fund ___%
Diversified Equity Income Fund ___%
Global Inflation Protected Securities Fund ___%
Growth Fund ___%
High Yield Bond Fund ___%
Income Opportunities Fund ___%
Large Cap Equity Fund ___%
Mid Cap Value Fund ___%
S&P 500 Index Fund ___%
Short Duration U.S. Government Fund ___%
THREADNEEDLE(R) VP
Emerging Markets Fund ___%
International Opportunity Fund ___%
XXX XXXXXX LIT
Xxxxxxxx Portfolio Class II Shares ___%
XXX XXXXXX UIF
Global Real Estate Portfolio, Class II Shares ___%
Mid Cap Growth Portfolio, Class II Shares ___%
XXXXXX
International ___%
USA ___%
ICC12 411380-DPRA57 Page 3.1 A(04/2013)
CONTRACT DATA - Continued
Contract Number: 9920-SAMPLE Contract Date: May 1, 2013
Fixed Account Minimum Interest Rate: 1.00%
Any purchase payments allocated to the Regular Fixed Account on the
Contract Date will earn interest, for the first year, at the annual
effective rate of 1.00%. New rates may be declared from time to time.
Any purchase payments allocated to the 6-Month Special DCA fixed
account on the Contract Date will earn interest at the annual
effective rate of 1.00%. New rates may be declared from time to time.
Any purchase payments allocated to the 12-Month Special DCA fixed
account on the Contract Date will earn interest at the annual
effective rate of 1.00%. New rates may be declared from time to time.
MVA Risk Factor: 0.001
See Guarantee Period Accounts endorsement, MVA formula.
CV Waiver Percentage: 10%
See the definition of "total free amount" in the Surrender Charge
provision.
Hospitalization/Nursing Home Waiver Benefit Age: 75
See Waiver of Surrender Charges upon Hospital or Nursing Home Confinement
provision.
TI Waiver Benefit Age: 100
See Waiver of Surrender Charges upon Terminal Illness Diagnosis provision.
XXXX Benefit Age: 79
See Payments to Beneficiaries provision.
Schedule of Surrender Charges: If you surrender all or a portion of this
contract, a surrender charge may apply. A surrender charge applies if all or
part of the Contract Value surrendered is from payments received during the
seven years before surrender.
Number of Completed Years from Surrender Charge Percentage
Date of Each Purchase Payment Applied to Each Purchase Payment
------------------------------ --------------------------------
0 7.0%
1 7.0%
2 7.0%
3 6.0%
4 5.0%
5 4.0%
6 2.0%
7 + 0.0%
You may surrender the greater of (1) your prior contract anniversary Contract
Value multiplied by the CV Waiver Percentage shown above or (2) contract
earnings each contract year without incurring a surrender charge. Refer to the
Surrender Provisions.
ICC12 411380-DPRA57 Page 3.2 A(04/2013)
CONTRACT DATA - Continued
Contract Number: 9920-SAMPLE Contract Date: May 1, 2013
Annual Mortality and Expense Risk Fee:
Through the 10th Contract Anniversary(1)(2)
Base Fee + Optional Death Benefit Rider Fee = Total M&E Fee
1.10% + 0% = 1.10% of the daily net asset value
After the 10th Contract Anniversary(1)(2)
Base Fee + Optional Death Benefit Rider Fee = Total M&E Fee
0.95% + 0% = 0.95% of the daily net asset value
(1) If the Annuitization Start Date is prior to or on the 10th Contract
Anniversary, the Base Fee will not decrease after the 10th Contract
Anniversary.
(2) To determine which Base Fee applies, use the Contract Anniversary on the
original Contract Date: XX/XX/XXXX.
Annual Variable Account Administrative Charge: 0% of the daily net asset value
Contract Administrative Charge:
Initial Annual Charge $30
We reserve the right to adjust this charge after the first
contract anniversary, but the charge will never exceed $50.
Initial Annual Charge if contract value equals or exceeds $50,000 $ 0
We reserve the right to charge up to $20 after the first
contract anniversary. See Contract Administrative Charge
provision.
Regular Fixed Account Purchase Payment and Transfer Limits:
1. Payments to the Regular Fixed Account are limited to 100% of each
payment. (There are no limits on payments to the Regular Fixed
Account if the payment is used to establish automated transfers
under a dollar cost averaging arrangement, unless this exception
is terminated on a nondiscriminatory basis with notification.)
2. Transfers to the Regular Fixed Account are limited to transfer
amounts which result in the Regular Fixed Account Contract Value
(after the transfer) being no more than 100% of the total
Contract Value. (There are no limits on transfers to the Regular
Fixed Account if the transfer is used to establish automated
transfers under a dollar cost averaging arrangement, unless this
exception is terminated on a nondiscriminatory basis with
notification.)
3. Transfers from the Regular Fixed Account (including automated
transfers under a dollar cost averaging arrangement) are limited
to the greater of:
a. $10,000; or
b. 30% of the Regular Fixed Account Contract Value at the
beginning of the contract year. All purchase payments
received into the Regular Fixed Account prior to Your
transfer request are considered Your beginning of
contract year value during the first contract year.
ICC12 411380-DPRA57 Page 3.3 A(04/2013)
CONTRACT DATA
Deferred Annuity Contract: RIVERSOURCE(R) RAVA 5 ADVANTAGE(R) VARIABLE ANNUITY
Contract Number: 9920-SAMPLE Contract Date: May 1, 2013
Annuitant: Xxxx Xxx Annuitization Start Date: May 1, 2073
Contract Owner: Xxxx Xxx Age at Issue: 35
Application Signed State/Contract Delivery State: state
State Insurance Department: 800-ZZZ-ZZZZ
Initial Purchase Payment: $25,000 Contract Type: Non-Qualified
Scheduled Purchase Payment:
Annual Amount: NA
Maximum Purchase Payments Permitted:
1st Contract Year and Total:
- Under age 86: $1,000,000
- Age 86 or older and under age 91: $ 100,000
- Age 91 or older: $ 0
Each Contract Year thereafter:
- Under age 86: $ 100,000
- Age 86 or older and under age 91: $ 50,000
- Age 91 or older: $ 0
Minimum Additional Purchase Payment: $ 50
Minimum Purchase Payment or Transfer Amount
to any Guarantee Period Account: $ 1,000
Purchase Payment Credits: Not available with this contract
Upon issuance of this contract your purchase payments have been scheduled to be
paid and applied to the Fixed Account, Guarantee Period Accounts and variable
subaccounts investing in funds as shown below. You may change the amount,
frequency and allocations as provided in this contract. Refer to the Purchase
Payments provision.
Payment
Allocation
Allocation Percentage
---------- -----------
FIXED ACCOUNT
Regular Fixed Account ___%
6-month Special DCA Fixed Account ___%
12-month Special DCA Fixed Account ___%
GUARANTEE PERIOD ACCOUNTS (GPA)
1 Year Guarantee Period Account ___%
2 Year Guarantee Period Account ___%
3 Year Guarantee Period Account ___%
4 Year Guarantee Period Account ___%
5 Year Guarantee Period Account ___%
6 Year Guarantee Period Account ___%
7 Year Guarantee Period Account ___%
8 Year Guarantee Period Account ___%
9 Year Guarantee Period Account ___%
10 Year Guarantee Period Account ___%
AIM V.I.
Capital Appreciation Fund, Series II Shares ___%
Capital Development Fund, Series II Shares ___%
Global Health Care Fund, Series II Shares ___%
International Growth Fund, Series II Shares ___%
ALLIANCEBERNSTEIN VPS
Global Technology Portfolio (Class B) ___%
Growth and Income Portfolio (Class B) ___%
International Value Portfolio (Class B) ___%
AMERICAN CENTURY VP
Mid Cap Value, Class II ___%
Ultra(R), Class II ___%
Value, Class II ___%
ICC12 411380-DPRA510 Page 3.0 A(04/2013)
CONTRACT DATA - Continued
Contract Number: 9920-SAMPLE Contract Date: May 1, 2013
Payment
Allocation
Allocation Percentage
-------------------------------------------------- ----------
CAMBRIDGE FUNDS
Cambridge Conservative Fund ___%
Cambridge Moderate Fund ___%
Cambridge Aggressive Fund ___%
COLUMBIA
High Yield Fund, Variable Series, Class B ___%
Xxxxxxx Growth Fund, Variable Series, Class A ___%
Xxxxxxx International Opportunities Fund, Variable
Series, Class B ___%
Small Cap Value Fund, Variable Series, Class B ___%
CREDIT SUISSE TRUST -
Commodity Return Strategy Portfolio ___%
DREYFUS
VIF International Equity Portfolio, Service Shares ___%
VIF International Value Portfolio, Service Shares ___%
XXXXX XXXXX VT
Floating-Rate Income Fund ___%
FIDELITY(R) VIP
Contrafund(R) Portfolio Service Class 2 ___%
Investment Grade Bond Portfolio Service Class 2 ___%
Mid Cap Portfolio Service Class 2 ___%
Overseas Portfolio Service Class 2 ___%
FRANKLIN XXXXXXXXX VIP TRUST
Franklin Income Securities Fund - Class 2 ___%
Xxxxxxxxx Global Income Securities Fund - Class 2 ___%
Xxxxxxxxx Growth Securities Fund - Class 2 ___%
XXXXXXX XXXXX VIT
Mid Cap Value Fund - Institutional Shares ___%
Structured U.S. Equity Fund - Institutional Shares ___%
JANUS ASPEN SERIES
Large Cap Growth Portfolio: Service Shares ___%
XXXX XXXXX PARTNERS VARIABLE
Small Cap Growth Portfolio, Class I ___%
MFS(R)
Total Return Series - Service Class ___%
Utilities Series - Service Class ___%
XXXXXXXXXXX
Capital Appreciation Fund/VA, Service Shares ___%
Global Securities Fund/VA, Service Shares ___%
Main Street Small Cap Fund/VA, Service Shares ___%
Strategic Bond Fund/VA, Service Shares ___%
PIMCO VIT
All Asset Portfolio, Advisor Share Class ___%
RIVERSOURCE VARIABLE SERIES TRUST
DISCIPLINED ASSET ALLOCATION(SM) PORTFOLIOS
Conservative ___%
Moderately Conservative ___%
Moderate ___%
Moderately Aggressive ___%
Aggressive ___%
RIVERSOURCE(R) PARTNERS VP
Fundamental Value Fund ___%
Select Value Fund ___%
Small Cap Value Fund ___%
RIVERSOURCE(R) VP
Cash Management Fund ___%
Diversified Bond Fund ___%
Diversified Equity Income Fund ___%
Global Inflation Protected Securities Fund ___%
Growth Fund ___%
High Yield Bond Fund ___%
Income Opportunities Fund ___%
Large Cap Equity Fund ___%
Mid Cap Value Fund ___%
S&P 500 Index Fund ___%
Short Duration U.S. Government Fund ___%
THREADNEEDLE(R) VP
Emerging Markets Fund ___%
International Opportunity Fund ___%
XXX XXXXXX LIT
Xxxxxxxx Portfolio Class II Shares ___%
XXX XXXXXX UIF
Global Real Estate Portfolio, Class II Shares ___%
Mid Cap Growth Portfolio, Class II Shares ___%
XXXXXX
International ___%
USA ___%
ICC12 411380-DPRA510 Page 3.1 A(04/2013)
CONTRACT DATA - Continued
Contract Number: 9920-SAMPLE Contract Date: May 1, 2013
Fixed Account Minimum Interest Rate: 1.00%
Any purchase payments allocated to the Regular Fixed Account on the
Contract Date will earn interest, for the first year, at the annual
effective rate of 1.00%. New rates may be declared from time to time.
Any purchase payments allocated to the 6-Month Special DCA fixed account on
the Contract Date will earn interest at the annual effective rate of 1.00%.
New rates may be declared from time to time.
Any purchase payments allocated to the 12-Month Special DCA fixed account
on the Contract Date will earn interest at the annual effective rate of
1.00%. New rates may be declared from time to time.
MVA Risk Factor: 0.001
See Guarantee Period Accounts endorsement, MVA formula.
CV Waiver Percentage: 10%
See the definition of "total free amount" in the Surrender Charge
provision.
Hospitalization/Nursing Home Waiver Benefit Age: 75
See Waiver of Surrender Charges upon Hospital or Nursing Home Confinement
provision.
TI Waiver Benefit Age: 100
See Waiver of Surrender Charges upon Terminal Illness Diagnosis provision.
XXXX Benefit Age: 79
See Payments to Beneficiaries provision.
Schedule of Surrender Charges: If you surrender all or a portion of this
contract, a surrender charge may apply. A surrender charge applies if all or
part of the Contract Value surrendered is from payments received during the ten
years before surrender.
Number of Completed Years from Surrender Charge Percentage
Date of Each Purchase Payment Applied to Each Purchase Payment
------------------------------ --------------------------------
0 8.0%
1 8.0%
2 8.0%
3 7.0%
4 6.0%
5 5.0%
6 4.0%
7 3.0%
8 2.0%
9 1.0%
10 + 0.0%
You may surrender the greater of (1) your prior contract anniversary Contract
Value multiplied by the CV Waiver Percentage shown above or (2) contract
earnings each contract year without incurring a surrender charge. Refer to the
Surrender Provisions.
ICC12 411380-DPRA510 Page 3.2 A(04/2013)
CONTRACT DATA - Continued
Contract Number: 9920-SAMPLE Contract Date: May 1, 2013
Annual Mortality and Expense Risk Fee:
Base Fee + Optional Death Benefit Rider Fee = Total M&E Fee
.95% + 0% = .95% of the daily net asset value
Annual Variable Account Administrative Charge: 0% of the daily net asset value
Contract Administrative Charge:
Initial Annual Charge $30
We reserve the right to adjust this charge after the first contract
anniversary, but the charge will never exceed $50.
Initial Annual Charge if contract value equals or exceeds $50,000 $0
We reserve the right to charge up to $20 after the first contract
anniversary. See Contract Administrative Charge provision.
Regular Fixed Account Purchase Payment and Transfer Limits:
1. Payments to the Regular Fixed Account are limited to 100% of each
payment. (There are no limits on payments to the Regular Fixed Account
if the payment is used to establish automated transfers under a dollar
cost averaging arrangement, unless this exception is terminated on a
nondiscriminatory basis with notification.)
2. Transfers to the Regular Fixed Account are limited to transfer amounts
which result in the Regular Fixed Account Contract Value (after the
transfer) being no more than 100% of the total Contract Value. (There
are no limits on transfers to the Regular Fixed Account if the
transfer is used to establish automated transfers under a dollar cost
averaging arrangement, unless this exception is terminated on a
nondiscriminatory basis with notification.)
3. Transfers from the Regular Fixed Account (including automated
transfers under a dollar cost averaging arrangement) are limited to
the greater of:
a. $10,000; or
b. 30% of the Regular Fixed Account Contract Value at the
beginning of the contract year. All purchase payments
received into the Regular Fixed Account prior to Your
transfer request are considered Your beginning of contract
year value during the first contract year.
ICC12 411380-DPRA510 Page 3.3 A(04/2013)
