EXHIBIT 4(c)
GOLDEN
AMERICAN DEFERRED VARIABLE
LIFE INSURANCE ANNUITY CONTRACT
COMPANY
GOLDEN AMERICAN IS A STOCK COMPANY DOMICILED IN WILMINGTON, DELAWARE.
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Annuitant Owner
[XXXXXX X. XXX] [XXXX X. XXX]
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Initial Premium Annuity Option Annuity Commencement Date
[$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026]
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Separate Account(s) Contract Number
[SEPARATE ACCOUNT B] [123456]
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This is a legal Contract between its Owner and us. PLEASE READ IT CAREFULLY.
In this contract YOU or YOUR refers to the Owner shown above. WE, OUR or US
refers to Golden American Life Insurance Company. You may allocate this
Contract's Accumulation Value among the Divisions of the Variable Separate
Account and the General Account shown in the Schedule.
If this Contract is in force, we will make income payments to you starting on
the Annuity Commencement Date. If the Owner dies prior to the Annuity
Commencement Date, we will pay a death benefit to the Beneficiary. The amount
of such benefits is subject to the terms of this Contract.
ALL PAYMENTS AND VALUES, WHEN BASED ON THE INVESTMENT EXPERIENCE OF A VARIABLE
SEPARATE ACCOUNT, MAY INCREASE OR DECREASE, DEPENDING ON THE CONTRACT'S
INVESTMENT RESULTS.
RIGHT TO EXAMINE THIS CONTRACT: YOU MAY RETURN THIS CONTRACT TO US OR THE
AGENT THROUGH WHOM YOU PURCHASED IT WITHIN 10 DAYS AFTER YOU RECEIVE IT. IF
SO RETURNED, WE WILL TREAT THE CONTRACT AS THOUGH IT WERE NEVER ISSUED. UPON
RECEIPT WE WILL PROMPTLY REFUND THE ACCUMULATION VALUE, MINUS ANY CREDIT, PLUS
ANY CHARGES WE HAVE DEDUCTED AS OF THE DATE THE RETURNED CONTRACT IS RECEIVED
BY US.
Customer Service Center Secretary:
0000 Xxxxxxxxx Xxxxxx, Xxxxx 000
Xxxxxxxxxx, Xxxxxxxx 00000
President:
DEFERRED VARIABLE ANNUITY CONTRACT - NO DIVIDENDS
Variable Cash Surrender Values while the Annuitant and Owner are living and
prior to the Annuity Commencement Date. Death benefit subject to guaranteed
minimum. Additional Premium Payment Option. Partial Withdrawal Option. Non-
participating. Investment results reflected in values.
GA-IA-1037-02/97
CONTRACT CONTENTS
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THE SCHEDULE YOUR CONTRACT BENEFITS............ 14
PAYMENT AND INVESTMENT INFORMATION.3A CASH VALUE BENEFIT
THE VARIABLE SEPARATE ACCOUNTS.....3B PARTIAL WITHDRAWAL OPTION
THE GENERAL ACCOUNT................3C PROCEEDS PAYABLE TO THE BENEFICIARY
CONTRACT FACTS.....................3D
CHARGES AND FEES...................3E
INCOME PLAN FACTORS................3F
CHOOSING AN INCOME PLAN........... 16
IMPORTANT TERMS .................... 4
INTRODUCTION TO THIS CONTRACT....... 6 ANNUITY BENEFITS
ANNUITY COMMENCEMENT DATE SELECTION
THE CONTRACT FREQUENCY SELECTION
THE OWNER THE INCOME PLAN
THE ANNUITANT THE ANNUITY OPTIONS
THE BENEFICIARY PAYMENT WHEN NAMED PERSON DIES
CHANGE OF OWNER OR BENEFICIARY
OTHER IMPORTANT INFORMATION....... 18
PREMIUM PAYMENTS AND ALLOCATION
CHANGES........................... 8
SENDING NOTICE TO US
INITIAL PREMIUM PAYMENT REPORTS TO OWNER
ADDITIONAL PREMIUM PAYMENT OPTION ASSIGNMENT - USING THIS CONTRACT AS
YOUR RIGHT TO CHANGE ALLOCATION OF COLLATERAL SECURITY
ACCUMULATION VALUE CHANGING THIS CONTRACT
WHAT HAPPENS IF A VARIABLE SEPARATE CONTRACT CHANGES-APPLICABLE TAX LAW
ACCOUNT DIVISION IS NOT AVAILABLE MISSTATEMENT OF AGE OR SEX
NON-PARTICIPATING
HOW WE MEASURE THE CONTRACT'S PAYMENTS WE MAY DEFER
ACCUMULATION VALUE................. 9 AUTHORITY TO MAKE AGREEMENTS
REQUIRED NOTE ON OUR COMPUTATIONS
THE VARIABLE SEPARATE ACCOUNTS
THE GENERAL ACCOUNT
VALUATION PERIOD
ACCUMULATION VALUE
ACCUMULATION VALUE IN EACH DIVISION
MEASUREMENT OF INVESTMENT EXPERIENCE
CHARGES DEDUCTED FROM ACCUMULATION
VALUE ON EACH CONTRACT PROCESSING
DATE
Copies of any application and any additional Riders and Endorsements are at
the back of this Contract.
THE SCHEDULE
The Schedule gives specific facts about this Contract and its coverage.
Please refer to the Schedule while reading this Contract.
2
THE SCHEDULE
PAYMENT AND INVESTMENT INFORMATION
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Annuitant Owner
[XXXXXX X. XXX] [XXXX X. XXX]
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Annuitant's Issue Age Annuitant's Sex Owner's Issue Age
[55] [MALE] [35]
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Initial Premium Annuity Option Annuity Commencement Date
[$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026]
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Contract Date Issue Date Residence Status
[JANUARY 1, 1996] [JANUARY 1, 1996] [DELAWARE]
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Separate Account(s) Contract Number
[SEPARATE ACCOUNT B] [123456]
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INITIAL INVESTMENT
Initial Premium Payment received: [$10,000]
Your initial Accumulation Value has been invested as follows:
PERCENTAGE OF
DIVISIONS ACCUMULATION VALUE
--------- ------------------
[Multiple Allocation 10%
Fully Managed 10%
Capital Appreciation 10%
Rising Dividends 10%
All-Growth 10%
Real Estate 10%
Value Equity 10%
Hard Assets 5%
Emerging Markets 5%
Managed Global 5%
Limited Maturity Bond 5%
Liquid Asset 5%
Strategic Equity 5%
------------------------- ---
Total 100%
===== ====
ADDITIONAL PREMIUM PAYMENT INFORMATION
[We will accept additional Premium Payments until either the Annuitant or
Owner reaches the Attained Age of 85. The minimum additional payment which
may be made is [$500.00].]
[In no event may you contribute to your XXX for the taxable year in which you
attain age 70 1/2 and thereafter (except for rollover contributions). The
minimum additional payment which may be added is [$250.00].]
3A1
THE SCHEDULE
PAYMENT AND INVESTMENT INFORMATION(continued)
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Annuitant Owner
[XXXXXX X. XXX] [XXXX X. XXX]
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Annuitant's Issue Age Annuitant's Sex Owner's Issue Age
[55] [MALE] [35]
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Initial Premium Annuity Option Annuity Commencement Date
[$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026]
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Contract Date Issue Date Residence Status
[JANUARY 1, 1996] [JANUARY 1, 1996] [DELAWARE]
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Separate Account(s) Contract Number
[SEPARATE ACCOUNT B] [123456]
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ACCUMULATION VALUE ALLOCATION RULES
The maximum number of Divisions in which you may be invested at any one time
is[ sixteen]. You are allowed unlimited allocation changes per Contract Year
without charge. We reserve the right to impose a charge for any allocation
change in excess of [twelve] per Contract Year. The Excess Allocation Charge
is shown in the Schedule. Allocations into and out of the Guaranteed
Interest Divisions are subject to restrictions (see General Account).
ALLOCATION CHANGES BY TELEPHONE
You may request allocation changes by telephone during our telephone request
business hours. You may call our Customer Service Center at 1-800-366-0066
to make allocation changes by using the personal identification number you
will receive. You may also mail any notice or request for allocation changes
to our Customer Service Center at the address shown on the cover page.
3A2
THE SCHEDULE
THE VARIABLE SEPARATE ACCOUNTS
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Annuitant Owner
[XXXXXX X. XXX] [XXXX X. XXX]
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Initial Premium Annuity Option Annuity Commencement Date
[$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026]
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Separate Account(s) Contract Number
[SEPARATE ACCOUNT B] [123456]
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DIVISIONS INVESTING IN SHARES OF A MUTUAL FUND
Separate Account B (the "Account") is a unit investment trust Separate
Account, organized in and governed by the laws of the State of Delaware, our
state of domicile. The Account is divided into Divisions. Each Division
listed below invests in shares of the mutual fund portfolio (the "Series")
designated. Each portfolio is a part of The GCG Trust managed by Directed
Services, Inc.
SERIES SERIES
------ ------
[Multiple Allocation Real Estate
Fully Managed Hard Assets
Value Equity Emerging Markets
Small Cap Limited Maturity Bond
Capital Appreciation Liquid Assets
Rising Dividend Strategic Equity
All-Growth Managed Global]
Each division listed below invests in shares of the mutual fund portfolio
(the "Portfolio") designated. Each portfolio is a part of the Equi-Select
Series Trust managed by Equitable Investment Services, Inc.
PORTFOLIO
---------
[OTC
Growth & Income
Value + Growth
Research
Total Return]
The division listed below invests in shares of the mutual fund portfolio (the
"Portfolio") designated. The portfolio is a part of the Warburg Pincus Trust
managed by Warburg, Xxxxxx Counselors, Inc.
PORTFOLIO
---------
[International Equity]
3B
THE SCHEDULE
THE GENERAL ACCOUNT
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Annuitant Owner
[XXXXXX X. XXX] [XXXX X. XXX]
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Initial Premium Annuity Option Annuity Commencement Date
[$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026]
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Separate Account(s) Contract Number
[SEPARATE ACCOUNT B] [123456]
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GENERAL ACCOUNT
[GUARANTEED INTEREST DIVISION
A Guaranteed Interest Division provides an annual minimum interest rate of
3%. At our sole discretion, we may periodically declare higher interest
rates for specific Guarantee Periods. Such rates will apply to periods
following the date of declaration. Any declaration will be by class and will
be based on our future expectations.
LIMITATIONS OF ALLOCATIONS
We reserve the right to restrict allocations into and out of the General
Account. Such limits may be dollar restrictions on allocations into the
General Account or we may restrict reallocations into the General Account.
GUARANTEE PERIODS
Each allocation to a Guaranteed Interest Division will be guaranteed an
interest rate for the entire Initial Guarantee Period elected. We currently
offer Initial Guarantee Periods of one, two, three, five, seven and ten
years. The Initial Guarantee Period starts on the day an allocation is made
to a Guaranteed Interest Division and ends on the last day of the calendar
month following one, two, three, five, seven or ten year(s) as appropriate,
the Maturity Date.
At the end of a Guarantee Period, you may transfer the Accumulation Value in
such Guarantee Period to the Variable Separate Account Divisions or to a
Guarantee Period we then offer. If we do not receive notification by the
Maturity Date, your Accumulation Value in the maturing Guarantee Period will
automatically be transferred to a one-year Guarantee Period. Upon such
automatic transfer you will have thirty days to reallocate any of your
Accumulation Value to the Divisions.
DEDUCTION FOR CHARGES
We do not deduct the Mortality and Expense Risk Charge and the Asset-Based
Administrative Charge with respect to the amount of the Accumulation Value
allocated to a Guaranteed Interest Division while such Accumulation Value
remains allocated to a Guaranteed Interest Division.
TRANSFERS FROM A GUARANTEED INTEREST DIVISION
On a Maturity Date, 100% of the Accumulation Value in the maturing Guarantee
Period may be transferred.
We currently require that an amount allocated to a Guarantee Period not be
transferred until the Maturity Date, except pursuant to our published rules.
We reserve the right not to allow amounts previously transferred from a
Guaranteed Interest Division to the Variable Separate Account Divisions to be
transferred back to the Guaranteed Interest Division for a period of at least
six months from the date of transfer. We reserve the right to reduce the
amount otherwise available for transfer from a Guaranteed Interest Division
by any amounts previously withdrawn from that Guaranteed Interest Division.]
3C
THE SCHEDULE
CONTRACT FACTS
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Annuitant Owner
[XXXXXX X. XXX] [XXXX X. XXX]
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Initial Premium Annuity Option Annuity Commencement Date
[$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026]
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Separate Account(s) Contract Number
[SEPARATE ACCOUNT B] [123456]
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CONTRACT FACTS
CONTRACT PROCESSING DATE
The Contract Processing Date for your Contract is [January 1] of each year.
SPECIALLY DESIGNATED DIVISIONS
When a distribution is made from an investment portfolio underlying a
Separate Account Division in which reinvestment is not available, we will
allocate the amount of the distribution to the [Liquid Asset Division] unless
you specify otherwise.
PARTIAL WITHDRAWALS
The maximum amount that can be withdrawn each Contract Year without being
considered an Excess Partial Withdrawal is 10% of the Accumulation Value as
of the date of the withdrawal. We will collect a Surrender Charge for Excess
Partial Withdrawals and a charge for any unrecovered Premium Tax. In no
event may a Partial Withdrawal exceed 90% of the Cash Surrender Value. After
a Partial Withdrawal, the remaining Accumulation Value must be at least $100
to keep the Contract in force.
CONVENTIONAL PARTIAL WITHDRAWALS
Minimum Withdrawal Amount: $1,000.
SYSTEMATIC PARTIAL WITHDRAWALS
Systematic Partial Withdrawals may be taken on a monthly, quarterly or annual
basis. You select the day withdrawals will be made, but no later than the
28th day of the month.
Minimum Withdrawal Amount: $100.
Maximum Withdrawal Amount:
Variable Separate Account Divisions: 0.83% monthly, 2.50% quarterly or 10%
annually of Accumulation Value.
Guaranteed Interest Divisions: Interest earned on a Guaranteed
Interest Division for the prior month,
quarter or year (depending on the
frequency selected).
[XXX PARTIAL WITHDRAWALS FOR QUALIFIED PLANS ONLY
XXX Partial Withdrawals may be taken on a monthly, quarterly or annual basis.
A minimum withdrawal of $100.00 is required. You select the day the
withdrawals will be made, but no later than the 28th day of the month. If
you do not elect a day, the Contract Date will be used. Systematic Partial
Withdrawals and Conventional Partial Withdrawals are not allowed when XXX
Partial Withdrawals are being taken.]
3D1
THE SCHEDULE
CONTRACT FACTS (continued)
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Annuitant Owner
[XXXXXX X. XXX] [XXXX X. XXX]
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Initial Premium Annuity Option Annuity Commencement Date
[$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026]
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Separate Account(s) Contract Number
[SEPARATE ACCOUNT B] [123456]
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DEATH BENEFITS
[IF DEATHBEN = "1": The Death Benefit is the greatest of (i) the
Accumulation Value less an amount equal to all Credits applied within twelve
months prior to date of death, (ii) the Guaranteed Death Benefit less an
amount equal to all Credits applied within twelve months prior to date of
death, (iii) the Cash Surrender Value less an amount equal to all Credits
applied within twelve months prior to date of death, and (iv) the sum of
premiums paid, less any Partial Withdrawals.
IF DEATHBEN = "2": The Death Benefit is the greatest of (i) the Accumulation
Value less an amount equal to all Credits applied within twelve months prior
to date of death, (ii) the Guaranteed Death Benefit less an amount equal to
all Credits applied within twelve months prior to date of death, (iii) the
Cash Surrender Value less an amount equal to all Credits applied within
twelve months prior to date of death, and (iv) the sum of premiums paid, less
any Partial Withdrawals.
IF DEATHBEN = "3": The Death Benefit is the greatest of (i) the Cash
Surrender Value less an amount equal to all Credits applied within twelve
months prior to date of death, (ii) the Accumulation Value less an amount
equal to all Credits applied within twelve months prior to date of death,
(iii) the sum of the premiums paid, less any Partial Withdrawals.]
GUARANTEED DEATH BENEFIT
On the Contract Date, the Guaranteed Death Benefit is the initial premium
plus any Credits. On subsequent Valuation Dates, the Guaranteed Death
Benefit is calculated as follows:
[IF DEATHBEN = "1": OPTION 1:
(1) Start with the Guaranteed Death Benefit from the prior Valuation
Date;
(2) Calculate interest on (1) for the current Valuation Period at the
Guaranteed Death Benefit Interest Rate;
(3) Add (1) and (2);
(4) Add any additional premiums paid and Credits during the current
Valuation Period to (3);
(5) Subtract Partial Withdrawals made during the current Valuation
Period from (4);
Each accumulated initial or additional Premium Payment and Credits, reduced
by any Partial Withdrawals (including any Surrender Charge incurred)
allocated to such premium, will continue to grow at the Guaranteed Death
Benefit Interest Rate until reaching its Maximum Guaranteed Death Benefit.
GUARANTEED DEATH BENEFIT INTEREST RATE
The Guaranteed Death Benefit is accumulated at a rate of 7% compounded
annually, except:
(1) Amounts in the Liquid Asset Division are accumulated at the net rate
of return for the Liquid Asset Division during the current Valuation
Period if less than 7%; and
(2) Amounts in the Limited Maturity Bond Division are accumulated at the
net rate of return for the Limited Maturity Bond Division during the
current Valuation Period if less than 7%; and
(3) Amounts in a Guaranteed Interest Division of the General Account are
accumulated at the interest rate being credited to such Guaranteed
Interest Division during the current Valuation Period if less than
7%.
3D2
THE SCHEDULE
CONTRACT FACTS (continued)
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Annuitant Owner
[XXXXXX X. XXX] [XXXX X. XXX]
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Initial Premium Annuity Option Annuity Commencement Date
[$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026]
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Separate Account(s) Contract Number
[SEPARATE ACCOUNT B] [123456]
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THE MAXIMUM GUARANTEED DEATH BENEFITS
The Maximum Guaranteed Death Benefit equals two times the cumulative premiums
paid, plus two times
cumulative Credits applied, less an adjustment to reflect Partial
Withdrawals. Each Partial Withdrawal reduces the maximum Guaranteed Death
Benefit as follows: First, the Maximum Guaranteed Death Benefit is reduced by
any Partial Withdrawals of earnings; second, the Maximum Guaranteed Death
Benefit is reduced in proportion to the reduction in Accumulation Values for
other Partial Withdrawals (in each case, including any associated Surrender
Charge incurred). To the extent that Partial Withdrawals in a contract year
do not exceed 7% of cumulative Premiums and did not exceed 7% of the
cumulative premiums in any prior contract year, such withdrawals will be
treated as earnings for the purposes of calculating the Maximum Guaranteed
Death Benefit. Once Partial Withdrawals exceed 7% of the cumulative premiums
in any Contract Year, Partial Withdrawals will be treated as Other Partial
Withdrawals.
[IF DEATHBEN = "2": OPTION 2:
(1) Start with Guaranteed Death Benefit from the prior Valuation Date;
(2) Add to (1) any additional premium paid and any Credits since the
prior Valuation Date and subtract from (1) any Partial Withdrawals
taken prior to the Valuation Date.
(3) On all other Valuation Dates that occurs on or prior to the onwer's
attained age 80, which is also a Contract Anniversary, we set the
Guaranteed Death Benefit equal to the greater of (2) or the
Accumulation Value as of such date.
On all other Valuation Dates, the Guaranteed Death Benefit is equal to (2)]
[IF DEATHBEN = "3": Option 3:
(1) Start with the Guaranteed Death Benefit from the prior Valuation
Date;
(2) Add any additional premiums paid and any Credits during the current
Valuation Period to (1);
(3) Subtract any Partial Withdrawals made during the current Valuation
Period from (2).]
CHANGE OF OWNER
A change of Owner will result in recalculation of the death benefit and
Guaranteed Death Benefit. As of the date of change, we will use the
Accumulation Value of the Contract, for the purpose of such recalculation
only, as the initial premium to determine a new Guaranteed Death Benefit for
this Contract. The new Owner's age at the time of the change will be used as
the basis for this calculation. The new Owner's death will determine when a
death benefit is payable.
[IF DEATHBEN = "1": If the new Owner's age is less than or equal to 75, the
Guaranteed Death Benefit Option in effect prior to the change of Owner will
remain in effect. If the new Owner's age is greater than 75, the Guaranteed
Death Benefit will be zero and the Death Benefit will be the greater of the
Cash Surrender Value, the Accumulation Value less an amount equal to all
Credits applied within twelve months prior to date of death, and the sum of
the premiums paid, less any Partial Withdrawals.
IF DEATHBEN = "2": If the new Owner's age is less than or equal to 79, the
Guaranteed Death Benefit Option in effect prior to the change of Owner will
remain in effect. If the new Owner's age is greater than 79, the Guaranteed
Death Benefit will be zero and the Death Benefit will be the greater of the
Cash Surrender Value, the Accumulation Value less an amount equal to all
Credits applied within twelve months prior to date of death, and the sum of
the premiums paid, less any Partial Withdrawals.
IF DEATHBEN = "3": The Guaranteed Death Benefit Option after the change of
Owner will remain the same as before the change.]
3D3
THE SCHEDULE
CONTRACT FACTS (continued)
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Annuitant Owner
[XXXXXX X. XXX] [XXXX X. XXX]
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Initial Premium Annuity Option Annuity Commencement Date
[$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026]
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Separate Account(s) Contract Number
[SEPARATE ACCOUNT B] [123456]
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CHOOSING AN INCOME PLAN
REQUIRED DATE OF ANNUITY COMMENCEMENT
[Distributions from a Contract funding a qualified plan must commence no
later than [April 1st] of the calendar year following the calendar year in
which the Owner attains age 70 1/2.]
The Annuity Commencement Date is required to be the same date as the Contract
Processing Date in the month following the Annuitant's 90th birthday. If, on
the Annuity Commencement Date, a Surrender Charge remains, your elected
Annuity Option must include a period certain of at least five years duration.
In applying the Accumulation Value, we may first collect any Premium Taxes
due us.
MINIMUM ANNUITY INCOME PAYMENT
The minimum monthly annuity income payment that we will make is [$20].
OPTIONAL BENEFIT RIDERS - [None.]
ATTAINED AGE
The Issue Age of the Annuitant or Owner plus the number of full years elapsed
since the Contract Date.
CREDIT ADDED TO PREMIUM
A Credit will be added to each Premium Payment applied to the Accumulation
Value. The Credit will be applied, PRO RATA into each Variable Separate
Account Division or Guaranteed Interest Division. The Credit is equal to
[4%] of the Premium Payment applied to the Accumulation Value. In the
following the same ratio as the applicable Premium Payment circumstances the
Credit may not be payable:
(1) When the Contract is returned under the Right To Examine Contract
provision, any Credit will be deducted from the refund amount.
(2) If a death benefit becomes payable, any Credit based on premium
received within one year prior to the date of death of the Owner (or
Annuitant if the Owner is not an individual) may reduce the death
benefit payable.
(3) If any Surrender Charges are waived under the Waiver of Surrender
Charge Rider: 1)The Accumulated Value will be reduced for all
Credits applied within one year prior to the date such surrender
charges are waived; 2)No credits will be applied to payments
received after the earliest date in which any surrender charges are
waived.
3D4
THE SCHEDULE
CHARGES AND FEES
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Annuitant Owner
[XXXXXX X. XXX] [XXXX X. XXX]
------------------------------------------------------------------------------
Initial Premium Annuity Option Annuity Commencement Date
[$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026]
------------------------------------------------------------------------------
Separate Account(s) Contract Number
[SEPARATE ACCOUNT B] [123456]
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DEDUCTIONS FROM PREMIUMS
[None.]
DEDUCTIONS FROM ACCUMULATION VALUE
INITIAL ADMINISTRATIVE CHARGE
[None.]
ADMINISTRATIVE CHARGE
We charge [$40] to cover a portion of our ongoing administrative expenses for
each Contract Processing Period. The charge is incurred at the beginning of
the Contract Processing Period and deducted on the Contract Processing Date
at the end of the period. At the time of deduction, this charge will be
waived if:
(1) The Accumulation Value is at least $100,000 ; or
(2) The sum of premiums paid to date is at least $100,000.
EXCESS ALLOCATION CHARGE
Currently none, however, we reserve the right to charge ]$25[ for a change if
you make more than [twelve] allocation changes per Contract Year. Any charge
will be deducted in proportion to the amount being transferred from each
Division.
SURRENDER CHARGE
A Surrender Charge is imposed as a percentage of premium if the Contract is
surrendered or an Excess Partial Withdrawal is taken. The percentage imposed
at time of surrender or Excess Partial Withdrawal depends on the number of
complete years that have elapsed since a Premium Payment was made. The
Surrender charge expressed as a percentage of each Premium Payment is as
follows:
Complete Years Elapsed Surrender
Since Premium Payment Charges
---------------------- ---------
[0 8%
1 8%
2 8%
3 8%
4 7%
5 6%
6 5%
7 3%
8 1%]
9+ 0%]
For the purpose of calculating the Surrender Charge for an Excess Partial
Withdrawal: a) we treat premiums as being withdrawn on a first-in, first-out
basis; and b) amounts withdrawn which are not considered an Excess Partial
Withdrawal are not considered a withdrawal of any Premium Payments.
3E1
THE SCHEDULE
CHARGES AND FEES
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Annuitant Owner
[XXXXXX X. XXX] [XXXX X. XXX]
------------------------------------------------------------------------------
Initial Premium Annuity Option Annuity Commencement Date
[$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026]
------------------------------------------------------------------------------
Separate Account(s) Contract Number
[SEPARATE ACCOUNT B] [123456]
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[PREMIUM TAXES
We deduct the amount of any premium or other state and local taxes levied by
any state or governmental entity when such taxes are incurred.
We reserve the right to defer collection of Premium Taxes until surrender or
until application of Accumulation Value to an Annuity Option. We reserve the
right to change the amount we charge for Premium Tax charges on future
Premium Payments to conform with changes in the law or if the Owner changes
state of residence.]
DEDUCTIONS FROM THE DIVISIONS
MORTALITY AND EXPENSE RISK CHARGE - We deduct [IF DEATHBEN = "1": .004280% IF
DEATHBEN = "2": .003863% IF DEATHBEN = "3": .003446%] of the assets in each
Variable Separate Account Division on a daily basis (equivalent to an annual
rate of [IF DEATHBEN = "1": 1.55% IF DEATHBEN = "2": 1.40% IF DEATHBEN
= "3": 1.25%]) for mortality and expense risks. This charge is not deducted
from the General Account values.
ASSET BASED ADMINISTRATIVE CHARGE - We deduct [0.000411%] of the assets in
each Variable Separate Account Division on a daily basis (equivalent to an
annual rate of [0.15%]) to compensate us for a portion of our ongoing
administrative expenses. This charge is not deducted from the General
Account values.
CHARGE DEDUCTION DIVISION
All charges against the Accumulation Value in this Contract will be deducted
from the [Liquid Asset Division].
3E2
THE SCHEDULE
INCOME PLAN FACTORS
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Annuitant Owner
[XXXXXX X. XXX] [XXXX X. XXX]
------------------------------------------------------------------------------
Initial Premium Annuity Option Annuity Commencement Date
[$10,000] [LIFE 10-YEAR CERTAIN] [JANUARY 1, 2026]
------------------------------------------------------------------------------
Separate Account(s) Contract Number
[SEPARATE ACCOUNT B] [123456]
------------------------------------------------------------------------------
Values for other payment periods, ages or joint life combinations are
available on request. Monthly payments are shown for each $1,000 applied.
TABLE FOR INCOME FOR A FIXED PERIOD
Fixed Period Monthly Fixed Period Monthly Fixed Period Monthly
of Years Income of Years Income of Years Income
------------ ------- ------------ ------- ------------ -------
[5 17.95 14 7.28 23 5.00
6 15.18 15 6.89 24 4.85
7 13.20 16 6.54 25 4.72
8 11.71 17 6.24 26 4.60
9 10.56 18 5.98 27 4.49
10 9.64 19 5.74 28 4.38
11 8.88 20 5.53 29 4.28
12 8.26 21 5.33 30 4.19]
13 7.73 22 5.16
TABLE FOR INCOME FOR LIFE
Male/Female Male/Female Male/Female
Age 10 Years Certain 20 Years Certain Refund Certain
--- ---------------- ---------------- --------------
[50 $4.06/3.83 $3.96/3.77 $3.93/3.75
55 4.43/4.14 4.25/4.05 4.25/4.03
60 4.90/4.56 4.57/4.37 4.66/4.40
65 5.51/5.10 4.90/4.73 5.12/4.83
70 6.26/5.81 5.18/5.07 5.76/5.42
75 7.11/6.70 5.38/5.33 6.58/6.19
80 7.99/7.70 5.48/5.46 7.69/7.21
85 8.72/8.59 5.52/5.51 8.72/8.59
90 9.23/9.18 5.53/5.53 10.63/10.53]
3F
IMPORTANT TERMS
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ACCUMULATION VALUE - The amount that a Contract provides for investment at any
time. Initially, this amount is equal to the premium paid.
ANNUITANT - The person designated by the Owner to be the measuring life in
determining Annuity Payments.
ANNUITY COMMENCEMENT DATE - For each Contract, the date on which Annuity
Payments begin.
ANNUITY OPTIONS - Options the Owner selects that determine the form and amount
of annuity payments.
ANNUITY PAYMENT - The periodic payment an Owner receives. It may be either a
fixed or a variable amount based on the Annuity Option chosen.
ATTAINED AGE - The Issue Age of the Annuitant or Owner plus the number of full
years elapsed since the Contract Date.
BENEFICIARY - The person designated to receive benefits in the case of the
death of the Owner.
BUSINESS DAY - Any day the New York Stock Exchange ("NYSE") is open for
trading, exclusive of federal holidays, or any day on which the Securities
and Exchange Commission ("SEC") requires that mutual funds, unit investment
trusts or other investment portfolios be valued.
CASH SURRENDER VALUE - The amount the Owner receives upon surrender of the
Contract.
CHARGE DEDUCTION DIVISION - The Division from which all charges are deducted
if so designated or elected by the Owner.
CONTINGENT ANNUITANT - The person designated by the Owner who, upon the
Annuitant's death prior to the Annuity Commencement Date, becomes the
Annuitant.
CONTRACT ANNIVERSARY - The anniversary of the Contract Date.
CONTRACT DATE - The date we received the initial premium and upon which we
begin determining the Contract values. It may not be the same as the
Contract Issue Date. This date is used to determine Contract months,
processing dates, years, and anniversaries.
CONTRACT ISSUE DATE - The date the Contract is issued at our Customer Service
Center.
CONTRACT PROCESSING DATES - The days when we deduct certain charges from the
Accumulation Value. If the Contract Processing Date is not a Valuation
Date, it will be on the next succeeding Valuation date. The Contract
Processing Date will be on the Contract Anniversary of each year.
CONTRACT PROCESSING PERIOD - The period between successive Contract Processing
Dates unless it is the first Contract Processing Period. In that case, it
is the period from the Contract Date to the first Contract Processing Date.
CONTRACT YEAR - The period between Contract Anniversaries.
CREDIT - An amount added to the Contract's Accumulation Value at the time a
Premium Payment is made.
4
IMPORTANT TERMS (continued)
------------------------------------------------------------------------------
EXPERIENCE FACTOR - The factor which reflects the investment experience of the
portfolio in which a Variable Separate Account Division invests and also
reflects the charges assessed against the Division for a Valuation Period.
GUARANTEE PERIOD - The period of years a rate of interest is guaranteed to be
credited to a Guaranteed Interest Division.
GUARANTEED DEATH BENEFIT INTEREST RATE - The annual rate at which the
Guaranteed Death Benefit is calculated.
GUARANTEED INTEREST DIVISION - An investment option available in the General
Account, an account which contains all of our assets other than those held
in our Variable Separate Accounts.
GUARANTEED INTEREST RATE - The effective annual interest rate which we will
credit for a specified Guarantee Period.
GUARANTEED MINIMUM INTEREST RATE - The minimum interest rate which can be
declared by us for allocations to a Guaranteed Interest Division.
INDEX OF INVESTMENT EXPERIENCE - The index that measures the performance of a
Variable Separate Account Division.
INITIAL PREMIUM - The payment amount required to put each Contract in effect.
ISSUE AGE - The Annuitant's or Owner's age on the last birthday on or before
the Contract Date.
MATURITY DATE - The date on which a Guarantee Period matures.
OWNER - The person who owns a Contract and is entitled to exercise all rights
of the Contract. This person's death also initiates payment of the death
benefit.
RIDERS - Riders add provisions or change the terms of the Contract.
SPECIALLY DESIGNATED DIVISION - Distributions from a portfolio underlying a
Division in which reinvestment is not available will be allocated to this
Division unless you specify otherwise.
VALUATION DATE - The day at the end of a Valuation Period when each Division
is valued.
VALUATION PERIOD - Each business day together with any non-business days
before it.
VARIABLE SEPARATE ACCOUNT DIVISION - An investment option available in the
Variable Separate Account shown on the Schedule.
5
INTRODUCTION TO THIS CONTRACT
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THE CONTRACT
This is a legal contract between you and us. We provide benefits as stated
in this Contract. In return, you supply us with the Initial Premium Payment
required to put this Contract in effect.
This Contract, together with any Riders or Endorsements, constitutes the
entire Contract. Riders and Endorsements add provisions or change the terms
of the basic Contract.
THE OWNER
You are the Owner of this Contract. You are also the Annuitant unless
another Annuitant has been named by you and is shown in the Schedule. You
have the rights and options described in this Contract, including but not
limited to the right to receive the Annuity Benefits on the Annuity
Commencement Date.
One or more people may own this Contract. If there are multiple Owners
named, the age of the oldest Owner will be used to determine the applicable
death benefit. In the case of a sole Owner who dies prior to the Annuity
Commencement Date, we will pay the Beneficiary the death benefit then due.
If the sole Owner is not an individual, we will treat the Annuitant as Owner
for the purpose of determining when the Owner dies under the death benefit
provision (if there is no Contingent Annuitant), and the Annuitant's age will
determine the applicable death benefit payable to the Beneficiary. The sole
Owner's estate will be the Beneficiary if no Beneficiary designation is in
effect, or if the designated Beneficiary has predeceased the Owner. In the
case of a joint Owner of the Contract dying prior to the Annuity Commencement
Date, the surviving Owner(s) will be deemed as the Beneficiary(ies).
THE ANNUITANT
The Annuitant is the measuring life of the Annuity Benefits provided under
this Contract. You may name a Contingent Annuitant. The Annuitant may not
be changed during the Annuitant's lifetime.
If the Annuitant dies before the Annuity Commencement Date, the Contingent
Annuitant becomes the Annuitant. You will be the Contingent Annuitant unless
you name someone else. The Annuitant must be a natural person. If the
Annuitant dies and no Contingent Annuitant has been named, we will allow you
sixty days to designate someone other than yourself as an Annuitant. If all
Owners are not individuals and, through the operation of this provision, an
Owner becomes Annuitant, we will pay the death proceeds to the Beneficiary.
If there are joint Owners, we will treat the youngest of the Owners as the
Contingent Annuitant designated, unless you elect otherwise.
THE BENEFICIARY
The Beneficiary is the person to whom we pay death proceeds if any Owner dies
prior to the Annuity Commencement Date. See Proceeds Payable to the
Beneficiary for more information. We pay death proceeds to the primary
Beneficiary (unless there are joint Owners in which case the death benefit
proceeds are payable to the surviving Owner). If the primary Beneficiary
dies before the Owner, the death proceeds are paid to the Contingent
Beneficiary, if any. If there is no surviving Beneficiary, we pay the death
proceeds to the Owner's estate.
6
INTRODUCTION TO THIS CONTRACT (continued)
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One or more persons may be named as primary Beneficiary or contingent
Beneficiary. In the case of more than one Beneficiary, we will assume any
death proceeds are to be paid in equal shares to the surviving Beneficiaries.
You can specify other than equal shares.
You have the right to change Beneficiaries, unless you designate the primary
Beneficiary irrevocable. When an irrevocable Beneficiary has been
designated, you and the irrevocable Beneficiary may have to act together to
exercise the rights and options under this Contract.
CHANGE OF OWNER OR BENEFICIARY
During your lifetime and while this Contract is in effect you can transfer
ownership of this Contract or change the Beneficiary. To make any of these
changes, you must send us written notice of the change in a form satisfactory
to us. The change will take effect as of the day the notice is signed. The
change will not affect any payment made or action taken by us before
recording the change at our Customer Service Center. A Change of Owner may
affect the amount of death benefit payable under this Contract. See Proceeds
Payable to Beneficiary.
7
PREMIUM PAYMENTS AND ALLOCATION CHARGES
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INITIAL PREMIUM PAYMENT
The Initial Premium Payment is required to put this Contract in effect. The
amount of the Initial Premium Payment is shown in the Schedule.
ADDITIONAL PREMIUM PAYMENT OPTION
You may make additional Premium Payments under this Contract after the end of
the Right to Examine period. Restrictions on additional Premium Payments,
such as the Attained Age of the Annuitant or Owner and the timing and amount
of each payment, are shown in the Schedule. We reserve the right to defer
acceptance of or to return any additional Premium Payments.
As of the date we receive and accept your additional Premium Payment:
(1) The Accumulation Value will increase by the amount of the Premium
Payment plus any Credit less any premium deductions as shown in the
Schedule.
(2) The increase in the Accumulation Value will be allocated among the
Divisions of the Variable Separate Account and General Account in
accordance with your instructions. If you do not provide such
instructions, allocation will be among the Divisions of the Variable
Separate Account and General Account in proportion to the amount of
Accumulation Value in each Division.
WHERE TO MAKE PAYMENTS
Remit the Premium Payments to our Customer Service Center at the address
shown on the cover page. On request we will give you a receipt signed by our
treasurer.
YOUR RIGHT TO CHANGE ALLOCATION OF ACCUMULATION VALUE
You may change the allocation of the Accumulation Value among the Divisions
after the end of the Right to Examine period. The number of free allocation
changes each year that we will allow is shown in the Schedule. To make an
allocation change, you must provide us with satisfactory notice at our
Customer Service Center. The change will take effect when we receive the
notice. Restrictions for reallocation into and out of Divisions of the
Variable Separate Account and General Account are shown in the Schedule.
WHAT HAPPENS IF A VARIABLE SEPARATE ACCOUNT DIVISION IS NOT AVAILABLE
When a distribution is made from an investment portfolio supporting a unit
investment trust Separate Account Division in which reinvestment is not
available, we will allocate the distribution to the Specially Designated
Division shown in the Schedule unless you specify otherwise.
Such a distribution may occur when an investment portfolio or Division
matures, when distribution from a portfolio or Division cannot be reinvested
in the portfolio or Division due to the unavailability of securities, or for
other reasons. When this occurs because of maturity, we will send written
notice to you thirty days in advance of such date. To elect an allocation to
other than the Specially Designated Division shown in the Schedule, you must
provide satisfactory notice to us at least seven days prior to the date the
investment matures. Such allocations will not be counted as an allocation
change of the Accumulation Value for purposes of the number of free
allocations permitted.
8
HOW WE MEASURE THE CONTRACT'S ACCUMULATION VALUE
------------------------------------------------------------------------------
The variable Annuity Benefits under this Contract are provided through
investments which may be made in our Separate Accounts.
THE VARIABLE SEPARATE ACCOUNTS
These accounts, which are designated in the Schedule, are kept separate from
our General Account and any other Separate Accounts we may have. They are
used to support Variable Annuity Contracts and may be used for other purposes
permitted by applicable laws and regulations. We own the assets in the
Separate Accounts. Assets equal to the reserves and other liabilities of the
accounts will not be charged with liabilities that arise from any other
business we conduct; but, we may transfer to our General Account assets which
exceed the reserves and other liabilities of the Variable Separate Accounts.
Income and realized and unrealized gains or losses from assets in these
Variable Separate Accounts are credited to or charged against the account
without regard to other income, gains or losses in our other investment
accounts.
The Variable Separate Account will invest in mutual funds, unit investment
trusts and other investment portfolios which we determine to be suitable for
this Contract's purposes. The Variable Separate Account is treated as a unit
investment trust under Federal securities laws. It is registered with the
Securities and Exchange Commission ("SEC") under the Investment Company Act
of 1940. The Variable Separate Account is also governed by state law as
designated in the Schedule. The trusts may offer non-registered series.
VARIABLE SEPARATE ACCOUNT DIVISIONS
A unit investment trust Separate Account includes Divisions, each investing
in a designated investment portfolio. The Divisions and the investment
portfolios designated may be managed by a separate investment adviser. Such
adviser may be registered under the Investment Advisers Act of 1940.
CHANGES WITHIN THE VARIABLE SEPARATE ACCOUNTS
We may, from time to time, make additional Variable Separate Account
Divisions available to you. These Divisions will invest in investment
portfolios we find suitable for this Contract. We also have the right to
eliminate Divisions from a Variable Separate Account, to combine two or more
Divisions or to substitute a new portfolio for the portfolio in which a
Division invests. A substitution may become necessary if, in our judgment, a
portfolio or Division no longer suits the purpose of this Contract. This may
happen due to a change in laws or regulations, or a change in a portfolio's
investment objectives or restrictions, or because the portfolio or Division
is no longer available for investment, or for some other reason. We may get
prior approval from the insurance department of our state of domicile before
making such a substitution. We will also get any required approval from the
SEC and any other required approvals before making such a substitution.
Subject to any required regulatory approvals, we reserve the right to
transfer assets of the Variable Separate Account which we determine to be
associated with the class of contracts to which this Contract belongs, to
another Variable Separate Account or Division.
When permitted by law, we reserve the right to:
(1) deregister a Variable Separate Account under the Investment Company
Act of 1940;
(2) operate a Variable Separate Account as a management company under
the Investment Company Act of 1940, if it is operating as a unit
investment trust;
(3) operate a Variable Separate Account as a unit investment trust under
the Investment Company Act of 1940, if it is operating as a managed
Variable Separate Account;
(4) restrict or eliminate any voting rights of Owners, or other persons
who have voting rights to a Variable Separate Account; and,
(5) combine a Variable Separate Account with other Variable Separate
Accounts.
9
HOW WE MEASURE THE CONTRACT'S ACCUMULATION VALUE (continued)
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THE GENERAL ACCOUNT
The General Account contains all assets of the Company other than those in
the Separate Accounts we establish. The Guaranteed Interest Divisions
available for investment are shown in the Schedule. We may, from time to
time, offer other Divisions where assets are held in our General Account.
VALUATION PERIOD
Each Division will be valued at the end of each Valuation Period on a
Valuation Date. A Valuation Period is each Business Day together with any
non-Business Days before it. A Business Day is any day the New York Stock
Exchange (NYSE) is open for trading, and the SEC requires mutual funds, unit
investment trusts, or other investment portfolios to value their securities.
ACCUMULATION VALUE
The Accumulation Value of this Contract is the sum of the amounts in each of
the Divisions of the Variable Separate Account and General Account. You
select the Divisions of the Variable Separate Account and General Account to
which to allocate the Accumulation Value. The maximum number of Divisions to
which the Accumulation Value may be allocated at any one time is shown in the
Schedule.
ACCUMULATION VALUE IN EACH DIVISION
ON THE CONTRACT DATE
On the Contract Date, the Accumulation Value is allocated to each Division as
elected by you, subject to certain terms and conditions imposed by us. We
reserve the right to allocate premium to the Specially Designated Division
during any Right to Examine contract period. After such time, allocation
will be made proportionately in accordance with the initial allocation(s) as
elected by you.
ON EACH VALUATION DATE
At the end of each subsequent Valuation Period, the amount of Accumulation
Value in each Division will be calculated as follows:
(1) We take the Accumulation Value in the Division or at the end of the
preceding Valuation Period.
(2) We multiply (1) by the Variable Separate Account Division's Net Rate
of Return for the current Valuation Period or we calculate interest
to be credited to a Guaranteed Interest Division for the current
Valuation Period.
(3) We add (1) and (2).
(4) We add to (3) any additional Premium Payments plus Credits (less any
premium deductions as shown in the Schedule) allocated to the
Division during the current Valuation Period.
(5) We add or subtract allocations to or from that Division during the
current Valuation Period.
(6) We subtract from (5) any Partial Withdrawals which are allocated to
the Division during the current Valuation Period.
(7) We subtract from (6) the amounts allocated to that Division for:
(a) any charges due for the Optional Benefit Riders as shown in the
Schedule;
(b) any deductions from Accumulation Value as shown in the
Schedule.
All amounts in (7) are allocated to each Division in the proportion that (6)
bears to the Accumulation Value unless the Charge Deduction Division has been
specified (see the Schedule).
10
HOW WE MEASURE THE CONTRACT'S ACCUMULATION VALUE (continued)
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MEASUREMENT OF INVESTMENT EXPERIENCE
INDEX OF INVESTMENT EXPERIENCE
The Investment Experience of a Variable Separate Account Division is
determined on each Valuation Date. We use an Index to measure changes in
each Division's experience during a Valuation Period. We set the Index at
$10 when the first investments in a Division are made. The Index for a
current Valuation Period equals the Index for the preceding Valuation Period
multiplied by the Experience Factor for the current Valuation Period.
HOW WE DETERMINE THE EXPERIENCE FACTOR
For Divisions of a unit investment trust Separate Account the Experience
Factor reflects the Investment Experience of the portfolio in which the
Division invests as well as the charges assessed against the Division for a
Valuation Period. The factor is calculated as follows:
(1) We take the net asset value of the portfolio in which the Division
invests at the end of the current Valuation Period.
(2) We add to (1) the amount of any dividend or capital gains
distribution declared for the investment portfolio and reinvested in
such portfolio during the current Valuation Period. We subtract
from that amount a charge for our taxes, if any.
(3) We divide (2) by the net asset value of the portfolio at the end of
the preceding Valuation Period.
(4) We subtract the daily Mortality and Expense Risk Charge for each
Division shown in the Schedule for each day in the Valuation Period.
(5) We subtract the daily Asset Based Administrative Charge shown in the
Schedule for each day in the Valuation Period.
Calculations for Divisions investing in unit investment trusts are on a per
unit basis.
NET RATE OF RETURN FOR A VARIABLE SEPARATE ACCOUNT DIVISION
The Net Rate of Return for a Variable Separate Account Division during a
Valuation Period is the Experience Factor for that Valuation Period minus
one.
INTEREST CREDITED TO A GUARANTEED INTEREST DIVISION
Accumulation Value allocated to a Guaranteed Interest Division will be
credited with the Guaranteed Interest Rate for the Guarantee Period in effect
on the date the premium or reallocation is applied. Once applied, such rate
will be guaranteed until the Maturity Date of that Guarantee Period.
Interest will be credited daily at a rate to yield the declared annual
Guaranteed Interest Rate. No Guaranteed Interest Rate will be less than the
Minimum Interest Rate shown in the Schedule
CHARGES DEDUCTED FROM ACCUMULATION VALUE ON EACH CONTRACT PROCESSING DATE
Expense charges and fees are shown in the Schedule.
CHARGE DEDUCTION DIVISION OPTION
We will deduct all charges against the Accumulation Value of this Contract
from the Charge Deduction Division if you elected this option on the
application (see the Schedule). If you did not elect this Option or if the
charges are greater than the amount in the Charge Deduction Division, the
charges against the Accumulation Value will be deducted as follows:
(1) If these charges are less than the Accumulation Value in the
Variable Separate Account Divisions, they will be deducted
proportionately from all Divisions.
(2) If these charges exceed the Accumulation Value in the Variable
Separate Account Divisions, any excess over such value will be
deducted proportionately from the Guaranteed Interest Divisions.
Any charges taken from the General Account will be taken from the Guaranteed
Interest Division starting with the Guarantee Period nearest its Maturity
Date until such charges have been paid.
At any time while this Contract is in effect, you may change your election of
this Option. To do this you must send us a written request to our Customer
Service Center. Any change will take effect within seven days of the date we
receive your request.
11
YOUR CONTRACT BENEFITS
------------------------------------------------------------------------------
While this Contract is in effect, there are important rights and benefits
that are available to you. We discuss these rights and benefits in this
section.
CASH VALUE BENEFIT
CASH SURRENDER VALUE
The Cash Surrender Value, while the Annuitant is living and before the
Annuity Commencement Date, is determined as follows:
(1) We take the Contract's Accumulation Value;
(2) We deduct any Surrender Charge;
(3) We deduct any charges shown in the Schedule that have been incurred
but not yet deducted, including;
(a) any administrative fee that has not yet been deducted;
(b) the pro rata part of any charges for Optional Benefit Riders;
and
(c) any applicable premium or other tax.
CANCELLING TO RECEIVE THE CASH SURRENDER VALUE
At any time while the Annuitant is living and before the Annuity Commencement
Date, you may surrender this Contract to us. To do this, you must return
this Contract with a signed request for cancellation to our Customer Service
Center.
The Cash Surrender Value will vary daily. We will determine the Cash
Surrender Value as of the date we receive the Contract and your signed
request in our Customer Service Center. All benefits under this Contract
will then end.
We will usually pay the Cash Surrender Value within seven days; but, we may
delay payment as described in the Payments We May Defer provision.
PARTIAL WITHDRAWAL OPTION
After the Contract Date, you may make Partial Withdrawals. The minimum
amount that may be withdrawn is shown in the Schedule. For purposes of
calculating any Surrender Charge, any Partial Withdrawal you take will not be
considered premium, unless it is an Excess Partial Withdrawal. To take a
Partial Withdrawal, you must provide us satisfactory notice at our Customer
Service Center.
PROCEEDS PAYABLE TO THE BENEFICIARY
PRIOR TO THE ANNUITY COMMENCEMENT DATE
If the sole Owner dies prior to the Annuity Commencement Date, we will pay
the Beneficiary the death benefit. If there are joint Owners and any Owner
dies, we will pay the surviving Owners the death benefit. We will pay the
amount on receipt of due proof of the Owner's death at our Customer Service
Center. Such amount may be received in a single lump sum or applied to any
of the Annuity Options (see Choosing an Income Plan). When the Owner (or all
Owners where there are joint Owners) is not an individual, the death benefit
will become payable on the death of the Annuitant prior to the Annuity
Commencement Date (unless a Contingent Annuitant survived the Annuitant).
Only one death benefit is payable under this Contract. In all events,
distributions under the Contract must be made as required by applicable law.
HOW TO CLAIM PAYMENTS TO BENEFICIARY
We must receive proof of the Owner's (or the Annuitant's) death before we
will make any payments to the Beneficiary. We will calculate the death
benefit as of the date we receive due proof of death. The Beneficiary should
contact our Customer Service Center for instructions.
12
CHOOSING AN INCOME PLAN
------------------------------------------------------------------------------
ANNUITY BENEFITS
If the Annuitant and Owner are living on the Annuity Commencement Date, we
will begin making payments to the Owner. We will make these payment under
the Annuity Option (or Options) as chosen in the application or as
subsequently selected. You may choose or change an Annuity Option by making
a written request at least 30 days prior to the Annuity Commencement Date.
Unless you have chosen otherwise, Option 2 on a 10-year period certain basis
will become effective. The amounts of the payments will be determined by
applying the Accumulation Value on the Annuity Commencement Date in
accordance with the Annuity Options section below (see Payments We Defer).
Before we pay any Annuity Benefits, we require the return of this Contract.
If this Contract has been lost, we require the applicable lost Contract form.
ANNUITY COMMENCEMENT DATE SELECTION
You select the Annuity Commencement Date. You may select any date following
the fifth Contract Anniversary but before the required date of Annuity
Commencement as shown in the Schedule. If you do not select a date, the
Annuity Commencement Date will be in the month following the required date of
Annuity Commencement.
FREQUENCY SELECTION
You may choose the frequency of the Annuity Payments. They may be monthly,
quarterly, semi-annually or annually. If we do not receive written notice
from you, the payments will be made monthly.
THE INCOME PLAN
While this Contract is in effect and before the Annuity Commencement Date,
you may chose one or more Annuity Options for the payment of death benefits
proceeds. If, at the time of the Owner's death, no Option has been chosen
for paying the death benefit proceeds, the Beneficiary may choose an Option
within one year. You may also elect an Annuity Option on surrender of the
Contract for its Cash Surrender Value. For each Option we will issue a
separate written agreement putting the Option into effect.
Our approval is needed for any Option where:
(1) the person named to receive payment is other than the Owner or
Beneficiary; or
(2) the person named is not a natural person, such as a corporation; or
(3) any income payment would be less than the minimum annuity income
payment shown in the Schedule.
THE ANNUITY OPTIONS
There are four Options to choose from. They are:
OPTION 1. INCOME FOR A FIXED PERIOD
Payment is made in equal installments for a fixed number of years. We
guarantee each monthly payment will be at least the Income for Fixed Period
amount shown in the Schedule. Values for annual, semiannual or quarterly
payments are available on request.
13
CHOOSING AN INCOME PLAN (continued)
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OPTION 2. INCOME FOR LIFE
Payment is made to the person named in equal monthly installments and
guaranteed for at least a period certain. The period certain can be 10 or 20
years. Other periods certain are available on request. A refund certain may
be chosen instead. Under this arrangement, income is guaranteed until
payments equal the amount applied. If the person named lives beyond the
Guarantee Period, payments continue until his or her death.
We guarantee each payment will be at least the amount shown in the Schedule.
By age, we mean the named person's age on his or her last birthday before the
Option's effective date. Amounts for ages not shown are available on
request.
OPTION 3. JOINT LIFE INCOME
This Option is available if there are two persons named to receive payments.
At least one of the persons named must be either the Owner of Beneficiary of
this Contract. Monthly payments are guaranteed and are made as long as at
least one of the named persons is living. The monthly payment amounts are
available upon request. Such amounts are guaranteed and will be calculated
on the same basis as the Table for Income for Life, however, the amounts will
be based on two lives.
OPTION 4. ANNUITY PLAN
An amount can be used to buy any single premium immediate annuity we offer
for the Option's effective date.
The minimum rates for Option 1 are based on 3% interest, compounded annually.
The minimum rates for Options 2 and 3 are based on 3% interest, compounded
annually, and the Annuity 2000 Mortality Table. We may pay a higher rate at
our discretion.
PAYMENT WHEN NAMED PERSON DIES
When the person named to receive payment dies, we will pay any amounts still
due as provided by the Option agreement. The amounts still due are
determined as follows:
(1) For Option 1 or for any remaining guaranteed payments in Option 2,
payments will be continued.
(2) For Option 3, no amounts are payable after both named persons have
died.
(3) For Option 4, the annuity agreement will state the amount due, if
any.
14
OTHER IMPORTANT INFORMATION
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SENDING NOTICE TO US
Whenever written notice is required, send it to our Customer Service Center.
The address of our Customer Service Center is shown on the cover page.
Please include your Contract number in all correspondence.
REPORTS TO OWNER
We will send you a report at least once during each Contract Year. The
report will show the Accumulation Value and the Cash Surrender Value as of
the end of the Contract Processing Period. The report will also show the
allocation of the Accumulation Value as of such date and the amounts deducted
from or added to the Accumulation Value since the last report. The report
will also include any information that may be currently required by the
insurance supervisory official of the jurisdiction in which the Contract is
delivered.
We will also send you copies of any shareholder reports of the portfolios in
which the Divisions of the Variable Separate Account invest, as well as any
other reports, notices or documents required by law to be furnished to
Owners.
ASSIGNMENT - USING THIS CONTRACT AS COLLATERAL SECURITY
You can assign this Contract as collateral security for a loan or other
obligation. This does not change the ownership. Your rights and any
Beneficiary's right are subject to the terms of the assignment. To make or
release an assignment, we must receive written notice satisfactory to us, at
our Customer Service Center. We are not responsible for the validity of any
assignment.
CHANGING THIS CONTRACT
This Contract or any additional benefit riders may be changed to another
annuity plan according to our rules at the time of the change.
CONTRACT CHANGES - APPLICABLE TAX LAW
We reserve the right to make changes in this Contract or its Riders to the
extent we deem it necessary to continue to qualify this Contract as an
annuity. Any such changes will apply uniformly to all Contracts that are
affected. You will be given advance written notice of such changes.
MISSTATEMENT OF AGE OR SEX
If an age or sex has been misstated, the amounts payable or benefits provided
by this Contract will be those that the Premium Payment made would have
bought at the correct age or sex.
NON-PARTICIPATING
This Contract does not participate in the divisible surplus of Golden
American Life Insurance Company.
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OTHER IMPORTANT INFORMATION (continued)
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PAYMENTS WE MAY DEFER
We may not be able to determine the value of the assets of the Variable
Separate Account Divisions because:
(1) The NYSE is closed for trading;
(2) the SEC determines that a state of emergency exists;
(3) an order or pronouncement of the SEC permits a delay for the
protection of Owners; or
(4) the check used to pay the premium has not cleared through the
banking system. This may take up to 15 days.
During such times, as to amounts allocated to the Divisions of the Variable
Separate Account, we may delay;
(1) determination and payment of the Cash Surrender Value;
(2) determination and payment of any death benefit if death occurs
before the Annuity Commencement Date;
(3) allocation changes of the Accumulation Value; or,
(4) application of the Accumulation Value under an income plan.
As to the amounts allocated to a Guaranteed Interest Division in the General
Account, we may, at any time, defer payment of the Cash Surrender Value for
up to six months after we receive a request for it. We will allow interest
of at least 3.00% a year on any Cash Surrender Value payment derived from the
Guaranteed Interest Divisions that we defer 30 days or more.
AUTHORITY TO MAKE AGREEMENTS
All agreements made by us must be signed by one of our officers. No other
person, including an insurance agent or broker, can:
(1) change any of this Contract's terms;
(2) extend the time for Premium Payments; or
(3) make any agreement binding on us.
REQUIRED NOTE ON OUR COMPUTATIONS
We have filed a detailed statement of our computations with the insurance
supervisory official in the jurisdiction where this Contract is delivered.
The values are not less than those required by the law of that state or
jurisdiction. Any benefit provided by an attached Optional Benefit Rider
will not increase these values unless otherwise stated in that Rider.
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DEFERRED VARIABLE ANNUITY CONTRACT - NO DIVIDENDS
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Variable Cash Surrender Values while the Annuitant and Owner are living and
prior to the Annuity Commencement Date. Death benefit subject to guaranteed
minimum. Additional Premium Payment Option. Partial Withdrawal Option. Non-
participating. Investment results reflected in values.
