EXHIBIT 4
[LOGO] TRAVELERS LIFE & ANNUITY
THE TRAVELERS LIFE & ANNUITY COMPANY o [ONE CITYPLACE] o
HARTFORD, CONNECTICUT o [06103-3415]
A STOCK COMPANY
Mailing Address: [Annuity Services
P.O. Box 990009
Hartford, CT
06199-0009]
RIGHT TO EXAMINE THIS CONTRACT
IN ORDER TO CANCEL THIS CONTRACT, YOU MUST PROVIDE A WRITTEN REQUEST
AND THIS CONTRACT TO US AT OUR MAILING ADDRESS OR TO OUR AGENT WITHIN
10 CALENDAR DAYS OR LONGER IF REQUIRED BY APPLICABLE LAW AFTER ITS
DELIVERY TO YOU. WE WILL PAY YOU THE PURCHASE PAYMENT OR THE CASH VALUE
DEPENDING ON THE APPLICABLE STATE LAW OR REGULATION OF YOUR STATE.
AFTER THE CONTRACT IS RETURNED, IT WILL BE CONSIDERED AS NEVER IN
EFFECT.
This Contract is issued in consideration of the Purchase Payment. It is
subject to the terms and conditions stated on the attached pages, all
of which are a part of it.
Executed at Hartford, Connecticut
/s/ ▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇ /s/ ▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇
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President Secretary ]
This is a legal Contract between You and Us.
PLEASE READ YOUR CONTRACT CAREFULLY.
SINGLE PREMIUM INDIVIDUAL DEFERRED MODIFIED GUARANTEED ANNUITY
ELECTIVE OPTIONS NON-PARTICIPATING
THE CASH SURRENDER VALUE MAY INCREASE OR DECREASE IN ACCORDANCE WITH THE MARKET
VALUE ADJUSTMENT FORMULA IN THE CONTRACT SPECIFICATIONS PAGE. THE CASH SURRENDER
VALUE IS AVAILABLE WITHOUT APPLICATION OF THE MARKET VALUE ADJUSTMENT AT THE END
OF A GUARANTEE PERIOD.
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TABLE OF CONTENTS
Contract Specifications Page 3
Definitions Page 5
Ownership Provisions Page 7
Purchase Payment Page 8
Crediting of Interest and Guarantee Periods Page 9
Market Value Adjustment Page 9
Transfer Between Guarantee Periods Page 9
Surrender and Termination Provisions Page 10
Death Benefit Page 10
Settlement Provisions Page 11
General Provisions Page 13
Annuity Tables Page 15
Any Riders or Endorsements follow the Life Annuity Tables.
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CONTRACT SPECIFICATIONS
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CONTRACT NUMBER SPECIMEN
CONTRACT DATE 01-05-2005
MARKETING PROGRAM [Nonqualified]
CONTRACT OWNER ▇▇▇▇ ▇▇▇
[JOINT OWNER ▇▇▇▇▇ ▇▇▇]
ANNUITANT ▇▇▇▇ ▇▇▇
[CONTINGENT ANNUITANT ]
MATURITY DATE 06-01-2026
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PURCHASE PAYMENT:
Minimum Purchase Payment: [$5,000]
Maximum Purchase Payment: [$1,000,000] unless We consent to a larger amount.
SEPARATE ACCOUNT:
[The Travelers Separate Account MGA 2]
INFORMATION ABOUT THE SEPARATE ACCOUNT IS PROVIDED IN THE CONTRACT PROSPECTUS
FOR [THE TRAVELERS SEPARATE ACCOUNT MGA 2]
MARKET VALUE ADJUSTMENT:
A Market Value Adjustment may be applied when a partial or full surrender occurs
prior to the end of a Guarantee Period. The application of a Market Value
Adjustment may adjust your Account Value up or down.
MARKET VALUE ADJUSTMENT FORMULA:
Market Value Adjustment Factor=
[(((1 + strip(G) + OAS(G)) / (1 + strip ( C ) + OAS ( C )))) (t/365) ]
Market Adjusted Value =
[((Contract Value - FI) * Market Value Adjustment Factor) + FI]
FI = the available free interest credited for the previous Contract Year
STRIP(G) = US Treasury strip yield as of the date the guaranteed period is
established
STRIP(C) = US Treasury strip yield, as of the date the Market Value Adjustment
is applied, for a Guaranteed period of "t" days where "t" is the number of days
remaining in the Guaranteed Period adjusted for leap years.
OAS(G) = ▇▇▇▇▇▇ Intermediate US-Credit-Index Option-Adjusted Spread as of the
date the guaranteed period is established
OAS(C) = ▇▇▇▇▇▇ Intermediate US-Credit-Index Option-Adjusted Spread as of the
date the Market Value Adjustment is applied
GUARANTEE PERIOD INTEREST RATES:
The initial and subsequent interest rates applicable to Guarantee Periods
available under this Contract will be earned and credited at an effective annual
rate determined and offered by Us. Guarantee Periods and interest rates offered
by Us may vary through our sales organization channels.
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CONTRACT SPECIFICATIONS
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TERMINATION: We reserve the right to terminate this Contract when the Account
Value is less than [$2,000].
[SURRENDER CHARGE:
This charge is a percentage of the Cash Value being surrendered This charge
applies to full and partial surrenders and varies depending on whether You are
in Your initial Guarantee period or subsequent Guaranteed Period. The charges
are shown below.
INITIAL GUARANTEE PERIOD EACH SUBSEQUENT GUARANTEE PERIOD
------------------------------------------- ------------------------------------------------
YEARS FROM THE BEGINNING OF SURRENDER YEARS FROM THE BEGINNING OF ANY SURRENDER
THE INITIAL GUARANTEE PERIOD CHARGE SUBSEQUENT GUARANTEE PERIOD CHARGE
1 7% 1 5%
2 6% 2 4%
3 5% 3 3%
4 4% 4 2%
5 3% 5 2%
6 2% 6 2%
7 2% 7 2%
8 2% 8 2%
9 2% 9 2%
10 1% 10 1%
There is no surrender charge for full or partial surrender at the end of a
Guarantee Period or during the automatic renewal Guarantee Period. ]
[WE WILL NOT ASSESS A SURRENDER CHARGE FOR:
a) surrenders made during the automatic renewal Guarantee Period;
b) surrenders of interest that have been credited to Your Account Value
during the 12-month period prior to the last anniversary of Your
Contract Date;
c) payment of a death benefit to a beneficiary upon the death of the
Contract owner or the Annuitant;
d) distributions applied to an Annuity option with a minimum designated
period of at least 10 years if elected after the first Contract Year ;
e) Minimum Distributions (as defined by the Internal Revenue Code) taken
under Our managed distribution program then in effect and elected by
Written Request. ]
AUTOMATIC RENEWAL GUARANTEE PERIOD: A one-year Guarantee Period
FREE WITHDRAWAL AMOUNT: [After the first Contract Year,] You may withdraw
interest credited to this Contract in the previous Contract Year without a
Market Value Adjustment or surrender charge.
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DEFINITIONS
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ACCOUNT VALUE - The Purchase Payment plus all interest earned, less the sum of
all partial surrenders, surrender charges, and applicable premium tax deducted
to that date, and reflecting any Market Value Adjustment previously applied.
ANNUITANT - The person on whose life the Contract is issued and on whose life
the annuity payments are made.
BENEFICIARY(IES) - The person(s) entitled to receive benefits after Your death.
CASH VALUE - The Account Value at the end of a Guarantee Period, or at any point
before the end of the Guarantee Period, the Account Value adjusted by the Market
Value Adjustment formula.
CASH SURRENDER VALUE - The Cash Value less surrender charges and any applicable
premium tax.
CONTINGENT ANNUITANT - The person You designate prior to the Contact Date, who,
upon the Annuitant's death prior to the Maturity Date, becomes the Annuitant.
CONTRACT DATE - The date on which the Contract is issued.
CONTRACT YEAR(S) - The twelve-month period(s) beginning with the Contract Date.
DEATH REPORT DATE - The day on which We have received 1) Due Proof of Death and
2) a Written Request for an election of a single sum payment or an alternate
Settlement Option as described in the Contract.
DUE PROOF OF DEATH - 1) a copy of a certified death certificate; 2) a copy of a
certified decree of a court of competent jurisdiction as to the finding of
death; 3) a written statement by a medical doctor who attended the deceased; or
4) any other proof satisfactory to Us.
GUARANTEED INTEREST RATE - The annual effective interest rate credited to a
purchase payment during the Guarantee Period as described in the Crediting of
Interest and Guarantee Periods section.
GUARANTEE PERIOD - The period for which either an initial or subsequent
Guarantee Interest Rate is credited.
MARKET VALUE ADJUSTMENT -The Market Value Adjustment is a formula that we use to
determine the Cash Value before the end of the Guarantee Period. The adjustment
can increase or decrease the Account Value.
MATURITY DATE - The date on which the annuity payments are to begin.
MATURITY VALUE - The accumulated value of a Purchase Payment at the Guaranteed
Interest Rate at the end of the Guarantee Period selected less any surrenders,
surrender charges, and applicable premium tax previously deducted and reflecting
any Market Value Adjustment previously applied.
MINIMUM DISTRIBUTIONS - Minimum amounts that must be distributed each year in
relation to certain qualified plans under the Code.
NONQUALIFIED CONTRACT - A contract other than a Qualified Contract, funded by
after-tax contributions.
OUR OFFICE - The Home Office of The Travelers Life and Annuity Company or any
other office which We may designate for the purpose of administering this
Contract. All correspondence regarding this Contract should be sent to Our
mailing address stated in the cover page of this Contract.
PURCHASE PAYMENT- The premium payment applied to the Contract less applicable
premium tax.
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DEFINITIONS
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QUALIFIED CONTRACT - a Contract used in a retirement plan or program, whereby
the Purchase Payments and any gains are intended to qualify under sections 401,
403, and 408 of the Code.
SEPARATE ACCOUNT(S) - the Separate Account(s) indicated in the Contract
Specifications, which We established for this class of Contracts and certain
other Contracts.
SURRENDER DATE - The date We receive Your Written Request for a surrender or the
date the You request the surrender to be effective, if later.
TERMINATION - Discontinuance of this Contract by Us or by Your Written Request.
WE, US, OUR - The Travelers Life and Annuity Company.
WRITTEN REQUEST - Written information including requests for Contract,
beneficiary, ownership, transfers, surrenders or other changes sent to Us in a
form and content satisfactory to Us and received in good order at Our Office.
Requests for changes are subject to any action taken prior to our receipt of the
written information.
YOU, YOUR - The owner, including any joint owner.
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OWNERSHIP, ANNUITANT AND BENEFICIARY PROVISIONS
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Ownership
This Contract belongs to the owner shown in the Contract Specifications or to
any person subsequently named in a Written Request of "Transfer of Ownership" as
provided below. As owner, You have sole power during the Annuitant's lifetime to
exercise any rights and to receive all benefits given in this Contract, provided
You have not named an irrevocable beneficiary and provided the Contract is not
assigned.
You will be the recipient of all payments while the Annuitant is alive unless
You direct them to an alternate recipient by Written Request. An alternate
recipient does not become the owner. An alternate payment directive is revocable
by You at any time by giving Us 30 days advance notice by Written Request.
Joint Owners
Joint owners may be named in a Written Request prior to the Contract Date. Joint
owners may independently exercise transfers between Guarantee Periods. All other
rights of ownership must be exercised by joint action. Joint owners own equal
shares of any benefits accruing or payments made to them. All rights of a joint
owner end at death if another joint owner survives. The entire interest of the
deceased joint owner in this Contract will pass to the surviving joint owner,
unless the deceased joint owner was also the Annuitant.
If a joint owner dies before payment of an annuity option begins and is survived
by the Annuitant, any surviving joint owner is the "designated beneficiary"
referred to in Section 72(s) of the Code, and his or her rights pre-empt those
of the beneficiary named in a Written Request. Upon the death of a joint owner
who is the Annuitant, the entire interest will pass to the beneficiary(ies).
TRANSFER OF OWNERSHIP
You may transfer ownership by Written Request, subject to Our approval. You may
not revoke any transfer of ownership after We receive the Written Request. It
will take effect subject to any payments made or other actions taken by Us
before the Written Request is received.
Until a new beneficiary is designated, a transfer of ownership does not affect
the interest of any beneficiary designated prior to the effective date of the
transfer.
A transfer of ownership may have tax consequences to You; please consult Your
tax advisor.
ASSIGNMENT
To the extent permitted by law, You may collaterally assign ownership of all or
a portion of this Contract by Written Request without the approval of any
beneficiary unless irrevocably named. We must approve in writing all assignments
that are requested. You may not exercise any rights of ownership while the
assignment remains in effect without the approval of the collateral assignee. We
are not responsible for the validity of any assignment. Once We record the
collateral assignment, it will take effect subject to any payments made or other
actions taken by Us before the Written Request is recorded.
If a claim is made based on an assignment, We may require proof of interest of
the claimant. An assignment takes precedence over any rights of a beneficiary.
Any amounts due under an assignment will be paid in a single sum.
An assignment may have adverse tax consequences to You; please consult Your tax
advisor.
CREDITOR CLAIMS
To the extent permitted by law, no right or benefit of the owner or Beneficiary
under this Contract shall be subject to the claims of creditors or any legal
process except as may be provided by an assignment.
BENEFICIARY
The Beneficiary is the party named by You in a Written Request prior to the
Annuitant's death. If the Beneficiary has been irrevocably designated, the
Beneficiary cannot be changed without such beneficiary's permission.
The Beneficiary has the right to receive any remaining contractual benefits upon
the death of the Annuitant, or under some circumstances, upon the Your death. If
there is more than one Beneficiary surviving, the beneficiaries will share
equally in the benefit unless You have indicated different shares in a Written
Request. When the Annuitant dies, if You have not named a Beneficiary or if the
named Beneficiary is not living, We will pay the death benefit to You or Your
estate.
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If a joint owner dies and is survived by the Annuitant before payment of an
annuity option begins, any surviving joint owner is the "designated beneficiary"
referred to in Section 72(s) of the Code, and his or her rights pre-empt those
of the beneficiary named in a Written Request.
Contingent Annuitant
You may name one individual as a contingent Annuitant by Written Request prior
to the Contract Date, provided the owner is not a trust. A contingent Annuitant
may not be changed, deleted or added to the Contract after the Contract Date.
If the Annuitant (who is not the owner) dies prior to the Maturity Date while
this Contract is in effect and while the contingent Annuitant is living:
a. the death benefit will not be payable upon the Annuitant's death;
b. the contingent Annuitant becomes the Annuitant; and
c. all other rights and benefits provided by this Contract will continue
in effect.
When a contingent Annuitant becomes the Annuitant, the Maturity Date remains the
same as previously in effect, unless otherwise provided.
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PURCHASE PAYMENT
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Purchase Payment
A Purchase Payment is the payment You make to this Contract for the benefits it
provides. A lump sum Purchase Payment must be made and is due and payable before
the Contract becomes effective. The Purchase Payment is payable to Us at Our
Office; the minimum and maximum Purchase Payment amounts are shown in the
Contract Specifications. We reserve the right to reject any Purchase Payment
which does not conform to the requirements in the Contract Specifications or
does not comply with state or federal laws.
A net Purchase Payment is that part of the Purchase Payment applied to the
Contract. A net Purchase Payment is equal to the Purchase Payment less any
applicable Premium Tax charge.
ALLOCATION OF PURCHASE PAYMENT
We will apply the net Purchase Payment to the Guarantee Period selected by You
within two business days following its receipt at Our Office, if the information
received is in good order.
PREMIUM TAX
The premium tax is the amount of tax, if any, charged by the state or
municipality on a Purchase Payment, on the Cash Value upon surrender, or on the
amount applied to elect an annuity option. We will deduct any applicable premium
tax from the Cash Value either upon death, surrender, annuitization or at the
time the Purchase Payment is made, but no earlier than when We have a tax
liability under law.
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CREDITING OF INTEREST AND GUARANTEE PERIODS
The net Purchase Payment will earn interest at the initial Guaranteed Interest
Rate during the initial Guarantee Period. All interest earned will be credited
daily. This compounding effect is reflected in the Guaranteed Interest Rates.
Within 60 days of the end of any Guarantee Period, We will notify You about
selecting a subsequent Guarantee Period. The automatic renewal guarantee period
as stated in the Contract Specifications pages will commence, unless You have:
a) submitted a Written Request for a full surrender which we receive
within 30 days prior to the end of the current Guarantee Period; or
b) elected by Written Request subsequent Guarantee Period from among
those durations offered by Us within 30 days prior to the end of the
current Guarantee Period; or
c) selected a subsequent Guarantee Period that extends beyond the
Maturity Date then in effect. In this case, We will automatically
establish a subsequent Guarantee Period that will end nearest to the
Maturity Date then in effect, unless You elect by Written Request a
subsequent Guarantee Period of shorter duration.
At any time during the automatic renewal Guarantee Period, You may transfer to a
subsequent Guarantee Period without incurring a surrender charge or Market Value
Adjustment.
The Account Value at the beginning of any subsequent Guarantee Period will be
equal to the Account Value at the end of the Guaranteed Period just ending, or
if applicable, the Account Value that is transferred from the automatic renewal
Guarantee Period. The Account Value will earn interest at the subsequent
Guaranteed Interest Rate during the subsequent Guarantee Period. There is no
minimum Guaranteed Interest Rate for renewals .
MARKET VALUE ADJUSTMENT
This Contract contains a Market Value Adjustment formula. The formula may result
in upward or downward adjustments in the amount payable on any full or partial
surrender made prior to the end of any Guarantee Period. Details of the Market
Value Adjustment formula are described in the Contract Specifications pages.
The Market Value Adjustment formula will not be applied when You submit a
Written Request for:
a. a full or partial surrender at the end of any Guarantee Period; or
b. any interest credited during the previous Contract Year.
c. a partial surrender made under our managed distribution program.
The Market Value Adjustment formula will not be applied to full or partial
surrenders made during the automatic renewal Guarantee Period.
TRANSFER BETWEEN GUARANTEE PERIODS
Once each Contract Year after the first Contract Year, You may elect by Written
Request to transfer out of the current Guarantee Period and into a subsequent
Guarantee Period of a different duration. The amount transferred into the new
Guarantee Period will be equal to the Account Value of the old Guarantee Period
on the date of the transfer plus or minus the Market Value Adjustment. There is
no surrender charge for this transfer. The subsequent guarantee period surrender
charges will apply after the transfer.
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SURRENDER AND TERMINATION PROVISIONS
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GENERAL SURRENDERS
Full and partial surrenders may be made under this Contract at any time. A
surrender charge and Market Value Adjustment may be assessed on surrenders as
stated in the Contract Specifications page.
TERMINATION AFTER THE MATURITY DATE
This Contract may not be surrendered after the commencement of annuity payments.
PAYMENT UPON SURRENDER - DEFERRAL OF PAYMENT
We may defer payment of a partial or full surrender request for a period of not
more than six months after We receive Your Written Request. If payment is
deferred for more than 30 days from date the request is received, We will pay
interest of at least 3 1/2% on the amount deferred.
Termination of the Contract
Prior to annuitization, We reserve the right to terminate this Contract if the
Account Value is less than the termination amount shown in the Contract
Specifications page. Termination will not occur until 31 days after We have
mailed notice of termination to the You at Your last known address. If the
Contract is terminated, We will pay You the Cash Surrender Value, if any.
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DEATH BENEFIT
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A death benefit is payable to the Beneficiary upon the death of the Annuitant
before the Maturity Date, unless there is a contingent Annuitant. The death
benefit is equal to the account value as of the Death Report Date. We will pay
the Beneficiary the death benefit, determined as of the Death Report Date, in a
single sum or apply it to a Settlement Option. A beneficiary may request that a
death benefit payable under this Contract be applied to a Settlement Option
subject to the provisions of this Contract and the current tax laws.
Interest on Death Proceeds
Any interest on death proceeds will be paid in accordance with rules in effect
in Your state at the time of death.
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SETTLEMENT PROVISIONS
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MATURITY DATE
The Maturity Date is shown in the Contract Specifications and must be at least
thirteen months after the Contract Date. Annuity payments will begin under this
Contract on the Maturity Date unless the Contract has been fully surrendered or
the proceeds have been paid to the beneficiary prior to that date. We may
require proof that the Annuitant is alive before annuity payments are made. If
no Maturity Date is specified, the automatic Maturity Date will be the greater
of when the Annuitant reaches age 90 or ten years after the Contract Date, or to
a later date with Our consent.
Additionally, to the extent permitted by law, at least 30 days before the
original Maturity Date, You may change the Maturity Date by Written Request to
any time prior to the Annuitant's 90th birthday, or ten years after the Contract
Date, unless You elect a later annuity commencement date, subject to laws and
regulations then in effect and approved by the Company.
ELECTION OF SETTLEMENT OPTIONS
On the Maturity Date, or other agreed upon date, We will pay the amount payable
under this Contract to You in one lump sum or in accordance with an annuity
option elected by You. Once annuity payments have commenced, the Contract has no
Cash Surrender Value and no full or partial surrenders are permitted. While the
annuitant is alive, You may change Your Settlement Option election by Written
request, but only before the Maturity Date. Election of any annuity option must
be made by Written Request and received by Us at least 30 days prior to the date
such election is to become effective. In the absence of such election, the
fourth annuity option providing a joint and last survivor annuity will apply for
qualified contracts. For non-qualified contracts, the Cash Surrender Value will
be applied to the second annuity option, life annuity with 120 monthly payments.
If the Maturity Date coincides with the end of any Guarantee Period, no Market
Value Adjustment will be applied in the determination of the annuity payments.
No surrender charge will be applied upon annuitization if elected after the
first contract year and there is a minimum certain period of at least ten years.
You, or in the event You have not done so, the Beneficiary, may elect, in lieu
of payment in one sum, that any amount due under this Contract be applied under
any of the annuity options described below. The election by the Beneficiary must
be made within one year after Your death by Written Request to Our Office, with
the exception of the sixth annuity option, Annuity Proceeds Settlement Option.
The sixth annuity option (Annuity Proceeds Settlement Option) must be elected at
the time Due Proof of Death is provided to Us.
DEATH OF ANNUITANT
In the event of Your death after annuity payments commence, any amount payable
as a death benefit will be distributed at least as rapidly as under the method
of distribution in effect at the time of Your death or the death of the
Annuitant.
ANNUITY OPTIONS
Subject to the conditions stated in Election of Settlement Options and Minimum
Amounts, the Cash Surrender Value of this Contract may be paid under one or more
of the Annuity Options below. We may offer additional benefits.
OPTION 1. LIFE ANNUITY - NO REFUND
An annuity payable monthly during the lifetime of the Annuitant, ceasing with
the last payment due prior to the death of the Annuitant.
OPTION 2. LIFE ANNUITY WITH 120, 180 OR 240 MONTHLY PAYMENTS ASSURED
An annuity providing monthly income to the Annuitant for a guaranteed period of
120 months, 180 months, or 240 months (as selected), and for as long thereafter
as the Annuitant shall live.
OPTION 3. ▇▇▇▇ REFUND LIFE ANNUITY
An annuity payable monthly during the lifetime of the Annuitant, ceasing with
the last payment due prior to the death of the Annuitant provided that, at the
death of the Annuitant, the Beneficiary will receive an additional payment equal
to the excess, if any, of (a) over (b) where: (a) is the Cash Value applied on
the Maturity Date under this option; and (b) is the dollar amount of annuity
payments already paid.
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OPTION 4. JOINT AND LAST SURVIVOR ANNUITY
An annuity payable monthly during the joint lifetime of the Annuitant and a
secondary payee, and thereafter during the remaining lifetime of the survivor,
ceasing with the last payment prior to the death of the survivor.
OPTION 5. PAYMENTS FOR A DESIGNATED PERIOD
An amount payable monthly for the guaranteed number of years selected which may
be from 5 to 30 years.
OPTION 6. ANNUITY PROCEEDS SETTLEMENT OPTION
Proceeds from the death benefit can be left with Us for a period not to exceed
five years from the date of the Contract Owner's death prior to the Annuity
Commencement Date. The proceeds will remain in the same Guarantee Period and
continue to earn the same Guaranteed Interest Rate in effect at the time of
death as long as this option is elected at the time Due Proof of Death is
provided to Us. If the Guarantee Period ends before the end of the five-year
period, the Beneficiary may elect a new Guarantee Period with a duration not to
exceed the time remaining in the period of five years. from the date of the
death of the Contract Owner. If no election is made, the Contract will
automatically renew for a period of one year, provided that the five-year period
is not exceeded. Full or partial surrenders may be made at any time. A Market
Value Adjustment will be applied to all surrenders except those occurring at the
end of a Guarantee Period or if the previous Contract Year's interest is being
surrendered. This option is only available to Beneficiaries.
ANNUITY TABLES
The attached tables show the dollar amount of the monthly payments for each
$1000 of proceeds applied under an annuity options. Under annuity options 1, 2
or 3, the amount of each payment will depend upon the age of the Annuitant at
the time the first payment is due. Under annuity option 4, the amount of each
payment will depend upon the ages of the Annuitant and the secondary payee at
the time the first payment is due.
BETTERMENT OF RATES
If at the due date of the first annuity payment, We have declared a higher rate
per $1,000 of proceeds applied under an annuity option, then the annuity
payments will be based on the higher rates.
In no event will the annuity benefit, at the time of its commencement, be less
than that which would be provided by applying the greater of the Cash Surrender
Value or 95% of the Cash Value to purchase a single premium immediate annuity
Contract offered by Us or one of Our affiliates at the time to the same class of
annuitants.
MINIMUM AMOUNT
The minimum amount that can be placed under an annuity option is $2,000 unless
We consent to a lesser amount.
MINIMUM PAYMENT
The annuity option elected must result in a payment of at least $100.00. If at
any time payments are less than $100.00, We have the right to change the
frequency to an interval resulting in a payment of at least $100.00. If any
amount due is less than $100.00 per year, We may make other arrangements that
are equitable to the Annuitant.
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DATE OF PAYMENT
The first payment under any annuity option shall be made on the Maturity Date.
Subsequent payments shall be made on the same day of each month in accordance
with the manner of payment selected.
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GENERAL PROVISIONS
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THE CONTRACT
The entire Contract between You and Us consists of the Contract, and any
attached amendments, riders or endorsements.
CONTRACT CHANGES
Upon receiving appropriate state approval, if necessary, We may at any time make
any changes, including retroactive changes to this Contract to the extent that
the change is required to meet the requirements of any federal or state law or
regulation. All Contract changes will be made by a written amendment, rider, or
endorsement and will be signed by Our President, Our Chairman or one of Our home
office authorized officers. Agents do not have authority to alter or modify any
of the terms or conditions of this Contract, or to waive any of its provisions.
Any Contract change will not affect the amount or term of any annuity option
begun prior to the change, unless the change is required to conform the Contract
to any federal or state statute and will not affect the method by which the
Contract value is determined.
Minimum Value
Any paid-up annuity, Cash Surrender Value, or death benefits that are available
under this Contract will not be less that the minimum benefits required by the
statutes of the state in which this Contract is delivered.
MISSTATEMENT
If this Contract is issued as a Nonqualified Contract, and the Annuitant's (or,
if applicable, the owner's) sex or date of birth was misstated, the amount of
the annuity payable by Us will be adjusted based on the correct information
without changing the date of the first payment
If this Contract is issued as a Qualified Contract and the Annuitant's date of
birth was misstated, the amount of the annuity payable by Us will be adjusted
based on the correct information without changing the date of the first payment.
If an underpayment has been made under this Contract due to a misstatement as
described above, We will pay the portion due promptly. If an overpayment has
occurred, the amount due Us will be deducted from subsequent annuity payments,
as necessary. No interest will be credited or charged in the event of an
underpayment or overpayment. Proof of the Annuitant's and owner's Age may be
filed at any time at Our Office.
If the age of the Annuitant or owner has been misstated, the amount of any death
benefit payable will be determined based upon the correct age of the Annuitant
or owner.
INCONTESTABILITY
We will not contest this Contract from its Contract Date
REQUIRED REPORTS
We will furnish a report to the Contract owner as often as required by law, but
at least once annually. The report will also show information required under
state or federal law.
MORTALITY AND EXPENSES
Our actual mortality and expense experience will not affect the amount of any
annuity payments or any other values under the Contract and related Contracts.
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NON-PARTICIPATING
This Contract does not share in Our surplus earnings, so You will not receive
any dividends.
CONFORMITY WITH STATE AND FEDERAL LAWS
This Contract is governed by the law of the state in which it is issued for
delivery. Any paid-up annuity, Cash Surrender Value or death benefit available
under this Contract will not be less than the minimum benefits required by the
statutes of that state.
Upon receiving appropriate state approval, We may at any time make any changes,
including retroactive changes, in this Contract to the extent that the change is
required to meet the requirements of any law or regulation issued by any
governmental agency to which We or You are subject.
RELATION OF THIS CONTRACT TO THE SEPARATE ACCOUNT
We will have exclusive and absolute ownership and control of the assets of Our
Separate Account. That portion of the assets of a Separate Account equal to the
reserves and other Contract liabilities with respect to such Separate Account
shall not be chargeable with liabilities arising out of any other business We
conduct.
Transfers to Other Contracts Issued by Us
Under specific conditions, We may allow You to transfer funds held by You in
this Contract to another Contract issued by Us or one of Our affiliates, without
incurring charges deducted upon surrender as shown in the Contract
Specifications. A market value adjustment may apply on such transfers. Once the
transfer is complete and We have established a new Contract at Your direction,
new withdrawal charges, surrender charges, and market value adjustment may apply
to the new Contract in accordance with the provisions of such Contract.
14
LIFE ANNUITY TABLES
GUARANTEED AMOUNT OF MONTHLY ANNUITY PAYMENTS
PURCHASED WITH EACH $1,000 OF PROCEEDS APPLIED
THIS TABLE WILL BE USED FOR NONQUALIFIED CONTRACTS.
OPTIONS 1, 2 AND 3 - SINGLE LIFE ANNUITIES
FEMALE NUMBER OF MONTHLY PAYMENTS GUARANTEED
ADJUSTED NONE 120 180 240
AGE
45 2.54 2.54 2.53 2.52
46 2.59 2.58 2.58 2.56
47 2.63 2.63 2.62 2.61
48 2.68 2.68 2.67 2.65
49 2.73 2.73 2.72 2.70
50 2.79 2.78 2.77 2.75
51 2.84 2.83 2.82 2.80
52 2.90 2.89 2.88 2.85
53 2.96 2.95 2.93 2.91
54 3.03 3.01 3.00 2.96
55 3.10 3.08 3.06 3.03
56 3.17 3.15 3.13 3.09
57 3.25 3.23 3.20 3.15
58 3.33 3.31 3.27 3.22
59 3.42 3.39 3.35 3.29
60 3.51 3.48 3.43 3.36
61 3.61 3.57 3.52 3.44
62 3.71 3.67 3.61 3.51
63 3.82 3.77 3.70 3.59
64 3.94 3.88 3.80 3.67
65 4.07 4.00 3.90 3.75
66 4.20 4.12 4.01 3.83
67 4.35 4.26 4.12 3.92
68 4.50 4.39 4.24 4.00
69 4.67 4.54 4.36 4.08
70 4.85 4.70 4.48 4.16
71 5.05 4.86 4.60 4.24
72 5.26 5.03 4.73 4.31
73 5.49 5.21 4.85 4.38
74 5.74 5.40 4.98 4.44
75 6.00 5.60 5.10 4.50
Dollar amounts of the monthly annuity payments in the above table
assumes a year 2000 issue, and are based on the Annuity 2000 Table with
mortality improvements based on Projection Scale G. This table assumes
a net investment rate of 1.5% per Annum, assuming a 365-day year.
Calendar Year in which 1st payment is due:
Adjusted Age is Actual Age:
2003-2005 2006-2010 2011-2015 2016-2020
minus 1 minus 2 minus 3 minus 4
2021-2025 2026-2030 2031-2035 2036 AND LATER
minus 5 minus 6 minus 7 minus 8
15
LIFE ANNUITY TABLES
GUARANTEED AMOUNT OF MONTHLY ANNUITY PAYMENTS
PURCHASED WITH EACH $1,000 OF PROCEEDS APPLIED
THIS TABLE WILL BE USED FOR NONQUALIFIED CONTRACTS.
OPTIONS 1, 2 AND 3 - SINGLE LIFE ANNUITIES
MALE NUMBER OF MONTHLY PAYMENTS GUARANTEED
ADJUSTED NONE 120 180 240
AGE
45 2.73 2.72 2.71 2.69
46 2.79 2.78 2.76 2.74
47 2.84 2.83 2.81 2.79
48 2.90 2.88 2.87 2.84
49 2.96 2.94 2.92 2.89
50 3.02 3.00 2.98 2.94
51 3.09 3.07 3.04 3.00
52 3.16 3.14 3.11 3.06
53 3.23 3.21 3.17 3.12
54 3.31 3.28 3.24 3.18
55 3.39 3.36 3.31 3.25
56 3.48 3.44 3.39 3.31
57 3.57 3.53 3.47 3.38
58 3.66 3.62 3.55 3.45
59 3.77 3.71 3.64 3.52
60 3.88 3.82 3.73 3.59
61 3.99 3.92 3.82 3.67
62 4.12 4.04 3.92 3.74
63 4.25 4.16 4.02 3.82
64 4.40 4.28 4.12 3.89
65 4.55 4.41 4.23 3.97
66 4.71 4.55 4.34 4.04
67 4.89 4.70 4.45 4.12
68 5.07 4.85 4.56 4.19
69 5.27 5.00 4.67 4.25
70 5.48 5.16 4.78 4.32
71 5.70 5.33 4.90 4.38
72 5.95 5.51 5.01 4.44
73 6.20 5.68 5.12 4.49
74 6.48 5.87 5.23 4.54
75 6.77 6.05 5.33 4.59
Dollar amounts of the monthly annuity payments in the above table
assumes a year 2000 issue, and are based on the Annuity 2000 Table with
mortality improvements based on Projection Scale G. This table assumes
a net investment rate of 1.5% per Annum, assuming a 365-day year.
Calendar Year in which 1st payment is due:
Adjusted Age is Actual Age:
2003-2005 2006-2010 2011-2015 2016-2020
minus 1 minus 2 minus 3 minus 4
2021-2025 2026-2030 2031-2035 2036 AND LATER
minus 5 minus 6 minus 7 minus 8
16
LIFE ANNUITY TABLES
GUARANTEED AMOUNT OF MONTHLY ANNUITY PAYMENTS
PURCHASED WITH EACH $1,000 OF PROCEEDS APPLIED
THIS TABLE WILL BE USED FOR QUALIFIED CONTRACTS.
OPTIONS 1, 2 AND 3 - SINGLE LIFE ANNUITIES
UNISEX NUMBER OF MONTHLY PAYMENTS GUARANTEED
ADJUSTED NONE 120 180 240
AGE
45 2.64 2.63 2.62 2.61
46 2.68 2.68 2.67 2.65
47 2.73 2.73 2.71 2.70
48 2.79 2.78 2.76 2.74
49 2.84 2.83 2.82 2.79
50 2.90 2.89 2.87 2.85
51 2.96 2.95 2.93 2.90
52 3.03 3.01 2.99 2.95
53 3.09 3.08 3.05 3.01
54 3.17 3.15 3.12 3.07
55 3.24 3.22 3.19 3.14
56 3.32 3.29 3.26 3.20
57 3.40 3.37 3.33 3.27
58 3.49 3.46 3.41 3.34
59 3.59 3.55 3.49 3.41
60 3.69 3.64 3.58 3.48
61 3.80 3.74 3.67 3.55
62 3.91 3.85 3.76 3.63
63 4.03 3.96 3.86 3.71
64 4.16 4.08 3.96 3.78
65 4.30 4.20 4.07 3.86
66 4.45 4.34 4.17 3.94
67 4.61 4.47 4.29 4.02
68 4.78 4.62 4.40 4.10
69 4.96 4.77 4.52 4.17
70 5.16 4.93 4.63 4.24
71 5.37 5.10 4.75 4.31
72 5.59 5.27 4.87 4.38
73 5.84 5.45 4.99 4.44
74 6.10 5.64 5.11 4.50
75 6.38 5.83 5.22 4.55
Dollar amounts of the monthly annuity payments in the above table
assumes a year 2000 issue, and are based upon the Annuity 2000 Table
(blended 50%/50% female/male) with mortality improvements based on
Projection Scale G. This table assumes a net investment rate of 1.5%
per Annum, assuming a 365-day year.
Calendar Year in which 1st payment is due:
Adjusted Age is Actual Age:
2003-2005 2006-2010 2011-2015 2016-2020
minus 1 minus 2 minus 3 minus 4
2021-2025 2026-2030 2031-2035 2036 AND LATER
minus 5 minus 6 minus 7 minus 8
17
LIFE ANNUITY TABLES
GUARANTEED AMOUNT OF MONTHLY ANNUITY PAYMENTS
PURCHASED WITH EACH $1,000 OF PROCEEDS APPLIED
THESE TABLES WILL BE USED FOR NONQUALIFIED CONTRACTS.
OPTION 4 - JOINT AND LAST SURVIVOR LIFE ANNUITY
MALE
ADJUSTED FEMALE ADJUSTED AGE
AGE 45 50 55 60 65 70 75
45 2.34 2.44 2.52 2.59 2.64 2.67 2.70
50 2.40 2.53 2.66 2.76 2.85 2.91 2.96
55 2.45 2.61 2.78 2.94 3.07 3.19 3.27
60 2.48 2.67 2.88 3.10 3.31 3.49 3.64
65 2.51 2.71 2.96 3.23 3.53 3.81 4.06
70 2.52 2.74 3.01 3.33 3.71 4.11 4.51
75 2.53 2.76 3.05 3.40 3.85 4.37 4.94
OPTION 4 - JOINT AND LAST SURVIVOR LIFE ANNUITY
REDUCED BY 50% ON DEATH OF PRIMARY PAYEE
AGE OF PRIMARY MALE DOLLAR AMOUNT
AND SECONDARY FEMALE
45 2.52
50 2.76
55 3.05
60 3.44
65 3.97
70 4.70
75 5.72
Dollar amounts of the monthly annuity payments in the above table and
assumes a year 2000 issue and are based on the Annuity 2000 Table with
mortality improvements based on Projection Scale G. This table assumes
a net investment rate of 1.5% per Annum, assuming a 365-day year.
Calendar Year in which 1st payment is due:
Adjusted Age is Actual Age:
2003-2005 2006-2010 2011-2015 2016-2020
minus 1 minus 2 minus 3 minus 4
2021-2025 2026-2030 2031-2035 2036 AND LATER
minus 5 minus 6 minus 7 minus 8
18
LIFE ANNUITY TABLES
GUARANTEED AMOUNT OF MONTHLY ANNUITY PAYMENTS
PURCHASED WITH EACH $1,000 OF PROCEEDS APPLIED
THESE TABLES WILL BE USED FOR QUALIFIED CONTRACTS.
OPTION 3 - JOINT AND LAST SURVIVOR LIFE ANNUITY
UNISEX
ADJUSTED UNISEX ADJUSTED AGE
AGE 45 50 55 60 65 70 75
45 2.35 2.43 2.49 2.54 2.57 2.60 2.61
50 2.43 2.54 2.64 2.72 2.79 2.83 2.86
55 2.49 2.64 2.79 2.92 3.02 3.10 3.16
60 2.54 2.72 2.92 3.11 3.28 3.42 3.53
65 2.57 2.79 3.02 3.28 3.54 3.77 3.96
70 2.60 2.83 3.10 3.42 3.77 4.13 4.46
75 2.61 2.86 3.16 3.53 3.96 4.46 4.96
OPTION 4 - JOINT AND LAST SURVIVOR LIFE ANNUITY
REDUCED BY 50% ON DEATH OF PRIMARY PAYEE
AGE OF PRIMARY
AND SECONDARY UNISEX DOLLAR AMOUNT
45 2.48
50 2.71
55 3.00
60 3.37
65 3.88
70 4.59
75 5.58
Dollar amounts of the monthly annuity payments in the above table
assumes a year 2000 issue, and are based on the Annuity 2000 Table
(blended 50%/50% female/male) with mortality improvements based on
Projection Scale G. This table assumes a net investment rate of 1.5%
per Annum, assuming a 365-day year.
Calendar Year in which 1st payment is due:
Adjusted Age is Actual Age:
2003-2005 2006-2010 2011-2015 2016-2020
minus 1 minus 2 minus 3 minus 4
2021-2025 2026-2030 2031-2035 2036 AND LATER
minus 5 minus 6 minus 7 minus 8
19
LIFE ANNUITY TABLES FOR FIXED PAYMENTS
GUARANTEED AMOUNT OF MONTHLY ANNUITY PAYMENTS
PURCHASED WITH EACH $1,000 OF PROCEEDS APPLIED
THIS TABLE WILL BE USED FOR NONQUALIFIED AND QUALIFIED CONTRACTS.
OPTION 5 - PAYMENTS FOR A DESIGNATED PERIOD
MONTHLY MONTHLY
NUMBER OF PAYMENT NUMBER OF PAYMENT
YEARS AMOUNT YEARS AMOUNT
5 17.28 18 5.27
6 14.51 19 5.03
7 12.53 20 4.81
8 11.04 21 4.62
9 9.89 22 4.44
10 8.96 23 4.28
11 8.21 24 4.13
12 7.58 25 3.99
13 7.05 26 3.86
14 6.59 27 3.75
15 6.20 28 3.64
16 5.85 29 3.54
17 5.55 30 3.44
The dollar amounts of the monthly annuity payments for the fifth
option are based on a net investment rate of 1.5% per annum,
assuming a 365-day year.
20
THIS PAGE LEFT INTENTIONALLY BLANK.
SINGLE PREMIUM INDIVIDUAL MODIFIED GUARANTEED ANNUITY CONTRACT
ELECTIVE OPTIONS NON-PARTICIPATING
