[First Symetra Letterhead] First Symetra National Life Insurance
Company of New York
[000 Xxxxxxx Xxxxxx, 0xx Xxxxx]
[Xxx Xxxx, XX 00000]
[Mailing Address: PO Box 3882]
[Seattle, WA 98124-3882]
This is a legal Contract between the Owner (referred to in this Contract as
"you" and "your") and First Symetra National Life Insurance Company of New
York (referred to in this Contract as "First Symetra", "our", "us", and "we").
First Symetra is a stock company with its Home Office in [New York, New
York].
This Contract is issued in consideration of the application and payment of the
initial Purchase Payment. First Symetra will make annuity payments,
beginning on the Annuity Date, or pay a death benefit, subject to the terms
of this Contract. First Symetra has executed and attested this Contract as
of the contract date at our Home Office in [New York, New York].
If you have questions, comments, or complaints, please contact First Symetra
at [800-SYMETRA (800-796-3872)].
READ YOUR CONTRACT CAREFULLY
Right to Examine the Contract: If for any reason you are not satisfied with
this Contract, you may return it within 10 days from the date you received it
to First Symetra or to the registered representative who sold you this
Contract. When we receive this contract, we will provide a refund of the
contract value. This may be more or less than your Purchase Payments. The
date of surrender is the date the Contract is mailed to First Symetra or the
date the contract holder actually delivers the contract to the company or its
authorized representative. The contract holder can also surrender the
contract to an authorized sales representative or corporate officer at one
of its regional offices.
Signed for First Symetra National Life Insurance Company of New York by:
/s/Xxxxxx Xxxxx /s/Xxxxxxx X. Xxxxxx
[Xxxxxx Xxxxx] [Xxxxxxx X. Xxxxxx]
Secretary President
INDIVIDUAL FLEXIBLE PREMIUM DEFERRED VARIABLE ANNUITY
NON-PARTICIPATING
THIS IS A VARIABLE ANNUITY CONTRACT. THE CONTRACT VALUE AND VARIABLE ANNUITY
PAYMENTS ARE BASED ON THE INVESTMENT EXPERIENCE OF THE SUB-ACCOUNTS. THE
CONTRACT VALUE OF THE SUB-ACCOUNTS IS BASED ON THE VALUE OF THE SEPARATE
ACCOUNT ASSETS WHICH ARE NOT GUARANTEED AS TO FIXED DOLLAR AMOUNTS AND WILL
INCREASE OR DECREASE IN VALUE BASED UPON INVESTMENT RESULTS. THE SMALLEST
ANNUAL RATE OF INVESTMENT RETURN WHICH WOULD HAVE TO BE EARNED ON THE ASSETS
OF THE SEPARATE ACCOUNT SO THAT THE DOLLAR AMOUNT OF VARIABLE ANNUITY PAYMENTS
WILL NOT DECREASE IS 4%. INCOME, GAINS, AND LOSSES (REALIZED AND UNREALIZED)
RESULTING FROM ASSETS IN THE SEPARATE ACCOUNT ARE CREDITED TO OR CHARGED
AGAINST THE SEPARATE ACCOUNT WITHOUT REGARD TO OTHER INCOME, GAINS OR LOSSES
OF FIRST SYMETRA SURRENDER CHARGES MAY APPLY TO EARLY WITHDRAWALS FROM THE
CONTRACT. TRANSFERS BETWEEN INVESTMENT OPTIONS ARE SUBJECT TO RESTRICTIONS.
THIS CONTRACT CONTAINS A WAIVER OF SURRENDER CHARGE IN CERTAIN CIRCUMSTANCES.
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TABLE OF CONTENTS
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CONTRACT DATA PAGE Insert
DEFINITIONS
Accumulation Phase 1
Accumulation Unit 1
Annuitant 1
Annuity Date 1
Annuity Unit 1
Beneficiary 1
Contract 1
Contract Year 1
Income Phase 1
IRC 1
Owner 1
Portfolios 1
Purchase Payment 1
Separate Account 2
Sub-Account 2
THE ANNUITY CONTRACT
ABOUT THE CONTRACT 3
OWNER 3
ANNUITANT 3
BENEFICIARY 4
Change of Beneficiary 4
PURCHASE PAYMENT PROVISIONS
PURCHASE PAYMENTS 5
ALLOCATION OF PURCHASE PAYMENTS 5
ACCUMULATION UNITS 5
INVESTMENT OPTIONS
Sub-Accounts 7
Substitution of Shares 7
CONTRACT VALUE 7
TRANSFERS 7
Limits on Excessive Transfers 7
CHARGES
INSURANCE CHARGES 8
Mortality and Expense Risk Charge 8
Asset-Related Administration Charge 8
ANNUAL ADMINISTRATION MAINTENANCE
CHARGE 8
SURRENDER CHARGE 8
WAIVER OF SURRENDER CHARGE UPON
CONFINEMENT: PROVISIONS AND
RESTRICTIONS 9
WITHDRAWAL CHARGE 10
TRANSFER CHARGE 10
PREMIUM TAXES 10
INCOME OR OTHER TAXES 10
WITHDRAWAL PROVISIONS
WITHDRAWALS 11
Repetitive Withdrawals 11
ANNUITY PAYMENT PROVISIONS
ANNUITY OPTIONS 12
Life Annuity 12
Life Annuity with Guaranteed Period 12
Joint and Survivor Life Annuity 12
Automatic Option 12
ANNUITY PAYMENTS 13
Fixed Annuity Payments 13
Variable Annuity Payments 13
Changing Sub-Account Elections
after the Annuity Date 14
DEATH BENEFIT PROVISIONS
DEATH OF ANNUITANT Prior to the Annuity Date 15
DEATH OF OWNER Prior to the Annuity Date 15
Guaranteed Minimum Death
Benefit 15
Calculation of Death Benefit 15
Limitation on Death Benefit 16
Payment of Death Benefit 16
DEATH OF ANNUITANT On or After the Annuity
Date 17
DEATH OF OWNER On or After the Annuity
Date 17
GENERAL PROVISIONS
ACCOUNT STATEMENTS 18
ASSIGNMENT OF BENEFITS 18
COMMUNICATIONS 18
ESSENTIAL DATA 18
EVIDENCE OF SURVIVAL 18
INCONTESTABILITY 18
JURISDICTION 18
MISSTATEMENT OF AGE OR SEX 19
NONPARTICIPATION 19
SEPARATE ACCOUNT 19
STATE REQUIRED BENEFITS 19
SUSPENSION OF ANNUITY PAYMENTS,
WITHDRAWALS, OR TRANSFERS 19
TERMINATION OF CONTRACT 19
THE CONTRACT 20
VOTING RIGHTS 20
ANNUITY PURCHASE RATE TABLES
VARIABLE ANNUITY PURCHASE RATE TABLE 21
FIXED ANNUITY PURCHASE RATE TABLE 22
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DEFINITIONS
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Accumulation Phase The period between the date we allocate
your first Purchase Payment and the Annuity
Date.
Accumulation Unit A measurement used to calculate the value
of a Portfolio during the Accumulation Phase.
Annuitant The natural person(s) on whose life/lives
annuity payments are based. You are the
Annuitant unless you designate someone
else before the Annuity Date.
Annuity Date The date annuity payments begin under an
annuity option. For Life Annuity Options, the
Annuity Date must not be less than 12 months
from the contract date shown on the contract
data page. You may elect to commence annuity
payments as early as thirteen months from the
contract date. The Annuity Date must be a date
which is prior to the date on which the
maximum annuitization age shown on the
contract data page is attained.
Annuity Unit A measurement used to calculate variable annuity
payments during the Income Phase.
Beneficiary The person(s) named by the Owner and joint
Owner, if any, to receive any death benefit
payable in accordance with the provisions
of this Contract.
Contract This Flexible Premium Deferred Variable
Annuity.
Contract Year A 12-month period starting on the contract
date shown on your contract data page and
each anniversary of that date.
Income Phase The period beginning on the Annuity Date
during which the payee receives annuity
payments.
IRC The Internal Revenue Code of 1986, as
amended.
Owner The person(s) or entity(ies) named on the
contract application, unless changed. The Owner
has all ownership rights under this Contract.
Portfolios The variable investment options available under
the Separate Account.
Purchase Payment An amount paid to First Symetra for allocation
under this Contract, less any premium tax due
at the time this payment is made.
Separate Account A segregated asset account established under
New York law and shown on the contract data
page.
Sub-account A division of the Separate Account for which
Accumulation Units and Annuity Units are
separately maintained. Each Sub-account
invests exclusively in a particular Portfolio.
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THE ANNUITY CONTRACT
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ABOUT This Contract is an agreement between
THE CONTRACT First Symetra and you, the Owner, where we
promise to pay an income in the form of annuity
payments, beginning on the date you select, or
a death benefit. When you are investing money,
your Contract is in the Accumulation Phase.
Once you begin receiving annuity payments,
your Contract is in the Income Phase.
You purchased this Contract with the initial
Purchase Payment you paid, and the Contract
became effective on the contract date, shown on
your contract data page. The minimum initial
and subsequent Purchase Payments are shown
on the contract data page.
The Contract is called a variable annuity because
you allocate money among Sub-accounts available
within the Separate Account. The investment
performance of the Sub-account(s) you select
may be positive or negative and affects the
value of your Contract and the amount of any
variable annuity payments.
OWNER The Owner is shown on the application, unless
changed. On the contract date, the Owner must
not have been older than the maximum issue
age shown on the contract data page. The
Owner may exercise all ownership rights
under this Contract.
If this Contract is owned by joint Owners, they
must jointly exercise their ownership rights,
unless we are directed otherwise by both joint
Owners in writing. On the contract date, each
joint Owner must not have been older than the
maximum issue age shown on the contract data
page. An Owner who is a non-natural person
(for example, a corporation or a trust) may
not name a joint Owner.
You may change the Owner or joint Owner by
sending us a signed and dated request. If you
designate someone else as Owner, that person
must not have been older than the maximum
issue age on the contract date. Unless you
specify otherwise, a change in ownership is
effective as of the date you signed the notice
of change, subject to any payments made or
actions we may take prior to receipt of the
notice.
ANNUITANT The Annuitant is/are the person(s) on whose
life/lives annuity payments are based. You are
the Annuitant unless you designate someone
else before the Annuity Date. If you designate
someone else as Annuitant, that person must
not be older than the maximum issue age on
the contract date and the maximum
annuitization age when annuity payments begin.
The maximum issue age and the maximum
annuitization age are shown on the contract
data page.
An Owner who is a non-natural person may
not change the Annuitant.
BENEFICIARY The Beneficiary receives any death benefit
payable in accordance with the provisions of
this Contract. You initially name your
Beneficiaries on the contract application.
Change of Beneficiary You may change your Beneficiary designation at
any time by sending us a signed and dated
request. However, if a Beneficiary designation
is irrevocable, that Beneficiary must consent in
writing to any change. A new Beneficiary
designation revokes any prior designation and is
effective when signed by the Owner. We are not
responsible for the validity of any Beneficiary
designation nor for any actions we may take
prior to receiving and recording a Beneficiary
change.
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PURCHASE PAYMENT PROVISIONS
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PURCHASE During the Accumulation Phase, you may make
PAYMENTS additional Purchase Payments. You may change
the amount and frequency of Purchase Payments.
The minimum dollar amounts are shown on the
contract data page. If you stop making Purchase
Payments, all benefits under this Contract continue
until the contract value is completely withdrawn.
Purchase Payments must be in lawful currency of
the United States and submitted to our
Administrative Office at [P.O. Box 3882, Seattle, WA
98124-3882], or in a manner agreed to by First
Symetra.
We reserve the right to reject any application by
an Owner or Annuitant who is ineligible for this
Contract, any incomplete application, any Purchase
Payment which does not meet the minimum
payment amount shown on the contract data
page, and any Purchase Payment in excess of $1
million dollars. If we do not accept a Purchase
Payment, we will return it within five business
days.
ALLOCATION OF Your initial Purchase Payment will be allocated
PURCHASE PAYMENTS according to your instructions on your application.
Unless you tell us otherwise, subsequent
Purchase Payments will be allocated in the same
proportion as your most recent Purchase
Payment (unless that was a Purchase Payment
you directed us to allocate on a one-time-only
basis).
Once we receive your Purchase Payment, the
allocation to the Portfolios is effective and valued
as of the next close of the New York Stock
Exchange (NYSE). If for any reason the NYSE is
closed when we receive your Purchase Payment,
it will be valued as of the close of the NYSE on
its next regular business day.
When we are required to guarantee a return of
Purchase Payments during the Right to Examine
period, we reserve the right to initially apply
amounts to the [Fidelity VIP Money Market Initial
Class] as shown on the cover page of this
Contract. These amounts will then be allocated
in the manner you selected, unless you have
canceled the Contract.
ACCUMULATION When you make Purchase Payments or transfers into a
UNITS Sub-account, we credit your Contract with
Accumulation Units. Similarly, when you request a
withdrawal or a transfer of money from a Sub-
account, Accumulation Units are liquidated. In
either case, the increase or decrease in the
number of your Accumulation Units is
determined by taking the dollar amount of the
Purchase Payment, transfer, or withdrawal
and dividing it by the value of an Accumulation
Unit on the date the transaction occurs.
We calculate the value of an Accumulation Unit
for each Portfolio after the NYSE closes each day.
To determine the current Accumulation Unit
value, we take the prior day's Accumulation Unit
value and multiply it by the Net Investment
Factor for the current day.
The Net Investment Factor is used to measure
the daily change in Accumulation Unit value for
each Sub-account. The Net Investment Factor
equals:
- the net asset value per share of a Sub-
account at the end of the current day
plus the per share amount of any
dividend or income distributions made
by the Sub-account that day; divided
by
- the net asset value per share of a
Sub-account at the end of the prior
day plus the per share amount of any
dividend or income distributions made
by the Sub-account that day; minus
- the daily insurance charges, expressed
as a percentage of the total net assets
of the Sub-account.
The value of an Accumulation Unit will
usually go up or down from day to day.
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INVESTMENT OPTIONS
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SUB-ACCOUNTS You may allocate money to the Sub-accounts
shown on the contract data page.
We reserve the right to add, combine,
restrict, or remove any Sub-account as
an investment option of this Contract.
Sub-accounts have different investment
objectives. The investment performance
of a Sub-account may be positive or
negative.
Substitution of Shares If any shares of the Sub-accounts are
no longer available, or if in our view
no longer meet the purpose of the
Contract, it may be necessary to
substitute shares of another Sub-
account. We will seek prior approval
of the Securities and Exchange
Commission (SEC) to the extent required
by law and give you notice before
doing this.
CONTRACT VALUE Your contract value is the sum of the
values in the Sub-accounts attributable
to your Contract. We calculate this by:
- adding all the Purchase
Payments you invested;
- subtracting the charges which
have been deducted;
- subtracting the withdrawals
you have made;
- adjusting for each Sub-
account's gain or loss;
- subtracting the amounts
withdrawn for an annuity
option; and
- subtracting the amounts
withdrawn to pay the death
benefit.
TRANSFERS During the Accumulation Phase, you can
transfer money among the Portfolios.
The minimum amounts that can be
transferred are shown on the contract
data page. In each Contract Year a
specified number of transfers are free of
charge. Each additional transfer in a
Contract Year may have a transfer
charge. The number of free transfers
and the transfer charge are shown on
the contract data page.
We reserve the right to modify, suspend,
or terminate transfer privileges at any
time if they violate the provisions
outlined in the "Limits on Excessive
Transfers" section of this Contract.
Limits on Excessive We may restrict or eliminate the right
Transfers to make transfers among Sub-accounts
if such rights are executed by you, a
market timing firm, or other third party
authorized to initiate transfers or
exchange transactions on your behalf.
For example, we reserve the right to
reject any transfer request if, in our
judgment, you are engaging in a
pattern of transfer that may
disadvantage other contract owners
or would cause a Portfolio to be
unable to invest effectively in
accordance with its investment
objectives and policies or would
otherwise be potentially adversely
affected. In addition, if we or any
affected Portfolio believes you are
engaging in activity as described
above or similar activity which will
potentially hurt the rights or interests
of other contract owners, we have
the right to restrict the number of
transfers you make.
We will continue to monitor the transfer
activity occurring among the Sub-
accounts and may modify these
transfer restrictions at any time if we
deem it necessary to protect the
interest of all contract owners. These
modifications may include curtailing or
eliminating, without notice, certain
methods to request transfers.
Portfolios offered in this Contract may
have their own market timing policies
and procedures and impose redemption
fees for short-term investments in their
Portfolios. We have the right to deduct
those redemption fees from your
contract value.
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CHARGES
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The following charges apply to your Contract:
INSURANCE CHARGES Each day we make deductions for our
insurance charges. We do this as part
of our calculation of the value of
Accumulation Units and Annuity Units.
The insurance charges are as follows:
Mortality and Expense The mortality and expense risk charge
Risk Charge is equal, on an annual basis, to a
percentage of the average daily net assets of
each Sub-account. The percentage is shown
on the contract data page.
Asset-Related The asset-related administration charge is
Administration Charge equal, on an annual basis, to a percentage
of the average daily net assets of each Sub-
account. The percentages are shown on the
contract data page.
The asset-related administration charge is
determined at the start of each Contract Year.
The contract value at the start of a Contract
Year determines the applicable asset-related
administration charge. The asset-related
administration charge applies for the current
Contract Year. The applicable charge may go
up or down based on market conditions,
deposits, withdrawals, and surrenders. It may
be different for each Contract and each
Contract Year.
ANNUAL ADMINISTRATION The annual administration maintenance charge,
MAINTENANCE CHARGE shown on the contract data page,
will be deducted from your Contract on the last
day of each Contract Year and if you withdraw
the entire contract value. The Sub-account
from which this charge is deducted is
determined by the hierarchical order of the
Sub-accounts shown on the contract data
page.
We will not deduct this charge if your contract
value is at least equal to the amount shown on
the contract data page when the deduction is
to be made. During the Income Phase, we will
not deduct this charge.
SURRENDER CHARGE A surrender charge may be applied to any
withdrawal from the Contract. The surrender
charge is a percentage of the amount withdrawn.
The surrender charge is based on the length of
time each Purchase Payment has been in your
Contract according to the schedule shown on the
contract data page. We treat Purchase Payments
as being withdrawn on a first in, first out basis.
For purposes of applying the surrender charge,
all withdrawals are assumed to come from
Purchase Payments first.
You can withdraw 10% of your contract value
each Contract Year without a surrender charge.
The determination of whether more than 10%
of the contract value has been withdrawn is
made at the time of surrender. If you take more
than one withdrawal in a Contract Year, the
previous withdrawals in the Contract Year are
added to the current contract value to determine
whether more than 10% of the contract value
has been withdrawn in that Contract Year.
Surrender charges will not be assessed on the
following:
- withdrawals, if the total amount
withdrawn during the Contract Year does
not exceed 10% of the contract value;
- withdrawals taken for payment of
the annual administration maintenance
charge, withdrawal charges, transfer
charges, or premium taxes;
- repetitive withdrawals, if the withdrawals
are equal or substantially equal and are
expected to deplete the contract value over
your life expectancy or the joint life
expectancy of you and your joint Owner
(or, if applicable you and your Beneficiary).
If you take additional withdrawals or otherwise
modify or stop the repetitive withdrawals,
however, the repetitive withdrawals taken
during the Contract Year will be included
when determining whether more than 10%
of the contract value has been withdrawn;
- annuity payments; and
- withdrawals taken on account of your
death.
WAIVER OF Surrender charges will also not be assessed on the following:
SURRENDER - withdrawals taken after you have been
CONFINEMENT: confined to a hospital or nursing home for
CHARGES UPON 30 consecutive days if the withdrawal is taken:
PROVISIONS AND - during confinement; or
RESTRICTIONS - within 60 days after confinement ends.
The 30-day period may be satisfied by confinement
in a combination of hospitals, nursing homes, or
home care. Separate periods of confinement
occurring within 6 months of the start of a
previous 30 consecutive day period of
confinement for the same or related condition
will be considered the same confinement.
A new 30 consecutive day period will be applied
for a confinement due to a new or non-related
cause or to a confinement occurring more than
six months from the most recent confinement
for the same or related condition.
If you are confined to a hospital or nursing home
on the contract date, you are not eligible for this
waiver of surrender charges until after the
first Contract Year.
We may require proof of confinement. Proof of
confinement may include a billing statement from
the hospital or nursing home showing the dates
of confinement and service or a certification of
confinement signed by your attending
physician.
Hospital is defined in one of two ways:
(1) a lawfully operated institution that is
licensed as a hospital by the Joint
Commission of Accreditation of
Hospitals; or
(2) a lawfully operated institution that
provides in-patient treatment under
the direction of a staff of physicians
and has 24-hour per day nursing
services.
Nursing home is defined as a facility operated
pursuant to state law that provides convalescent
or chronic care for in-patients who, by reason of
illness or infirmity, are unable to properly care
for themselves.
Physician means a health care practitioner
licensed, board certified or board eligible in the
state of New York, who is qualified to practice
in the area of medicine or in a specialty
appropriate to treat the Owner's condition or
disease. It does not include the Owner, the
Annuitant, or a member of the Owner'(s) or
Annuitant'(s) family.
Home care means the care and treatment of the
Owner who is under the care of a physician but
only if confinement in a hospital or nursing home
would otherwise have been required f home
care was not provided. The plan covering the
home health service must be established and
approved in writing by the attending physician.
WITHDRAWAL CHARGE The withdrawal charge, shown on the contract
data page, is deducted for each withdrawal
after the first withdrawal in a Contract Year.
This charge will be deducted from your
remaining contract value, unless you tell us
otherwise.
We will not deduct this charge for annuity
payments, repetitive withdrawals using electronic
funds transfer (EFT), or if the entire contract
value is withdrawn.
TRANSFER CHARGE The transfer charge is deducted from your Contract
for each transfer in excess of the number of free
transfers allowed in a Contract Year. The transfer
charge and the number of free transfers are shown
on the contract data page.
Scheduled transfers authorized by us as part of an
investment strategy such as dollar cost averaging,
appreciation sweep, Sub-account rebalancing, or
asset allocation programs do not count against
your free transfers.
PREMIUM TAXES The contract data page shows whether or not
premium tax is charged in your state as of the
contract date.
INCOME OR OTHER TAXES Currently we do not pay income or other taxes
on earnings attributable to your Contract.
However, if we ever incur such taxes, we reserve
the right to deduct them from your Contract.
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WITHDRAWAL PROVISIONS
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WITHDRAWALS During the Accumulation Phase, you may withdraw
part or all of your contract value. The minimum
amount that can be withdrawn is shown on the
contract data page.
To take withdrawals, you must send a written
request to our Administrative Office. Unless
you tell us differently, partial withdrawals will be
made pro rata from each Sub-account. Once
we receive your request, withdrawals from the
Sub-accounts will be effective as of the next
close of the NYSE.
A withdrawal may have a surrender charge, a
withdrawal charge, and, if you withdraw the
entire contract value, an annual administration
maintenance charge.
Repetitive Withdrawals You may request repetitive withdrawals of a
predetermined amount on a monthly, quarterly,
or annual basis by completing the appropriate
form.
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ANNUITY PAYMENT PROVISIONS
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ANNUITY OPTIONS The Income Phase will start no later than the
maximum annuitization age shown on the
contract data page, or an earlier date if required
by law. During the Income Phase, the payee
(you or someone you choose) receives regular
annuity payments beginning on the Annuity
Date.
To start the Income Phase, you must notify us
in writing at least 30 days prior to the date that
you want annuity payments to begin. You may
choose annuity payments under an annuity
option described in this Contract or another
annuity option that you want and that we agree
to provide. You cannot start the Income Phase
until the Contract has been in effect for at least
one year. If the amount applied to an annuity
option is less than $2,000, we may make
payment in a lump sum where permitted by
state law. We reserve the right to change the
payment frequency if payment amounts would
be less than $250.
Switching to the Income Phase is irrevocable.
Once you begin receiving annuity payments, you
cannot switch back to the Accumulation Phase.
You cannot add Purchase Payments, change or
add an Annuitant, change the annuity option, or
change between fixed and variable annuity
payments. When the Contract switches to the
Income Phase, the guaranteed minimum death
benefit will no longer be applicable.
The annuity benefits at the time of their
commencement will not be less than those that
are provided by the application of the amount to
purchase any single consideration immediate
annuity contract offered by First Symetra at the
same time to the same class of annuitants.
Annuity payment options based on a life ensure
that the annuitant or annuitants cannot outlive
the annuity payments. The duration of the
annuitant's life or annuitants lives determines
how long payments continue under the following
options:
Life Annuity The payee receives monthly annuity payments
as long as the Annuitant is living. Annuity
payments stop when the Annuitant dies.
Life Annuity with The payee receives monthly annuity payments
Guaranteed Period for the longer of the Annuitant's life or
a guaranteed period of five or more years as
selected by you and agreed to by us. If the
Annuitant dies before all guaranteed payments
have been made, the remaining payments due
will be made to the payee designated by the
Owner. Annuity payments stop the later of the
date the Annuitant dies or the date the last
guaranteed payment is made.
As an alternative to monthly payments, the
Owner may elect to have the present value of
the guaranteed variable annuity payments
remaining as of the date the notice of death is
received by us commuted at the assumed
investment return of 4% and paid in a single
payment.
Joint and Survivor Life The payee receives monthly annuity payments as
Annuity long as the Annuitant is living. After the
Annuitant dies, the payee receives a specified
percentage of each annuity payment as long as
the joint Annuitant is living. You name the joint
Annuitant and payment percentage at the time
you elect this option. Annuity payments stop
the later of the date the Annuitant dies or the
date the joint Annuitant dies.
Automatic Option If you do not choose an annuity option at least 30
days before the latest Annuity Date allowed under
this Contract, we will make variable annuity
payments under the Life Annuity with Guaranteed
Period annuity option. The guaranteed period
will be equal to 10 years, unless otherwise
required by the IRC.
ANNUITY PAYMENTS You can choose whether annuity payments will be
made on a fixed basis, variable basis, or both.
After the Annuity Date, you may not switch
between fixed annuity payments and variable
annuity payments.
Fixed Annuity Payments The dollar amount of each fixed annuity
payment will stay the same. Annuity payments
will be determined by applying the contract
value that you want to use to purchase fixed
annuity payments to the Fixed Annuity Purchase
Rate Table of this Contract, or the current rates
at that time if more favorable to you. If premium
taxes are required by state law, these taxes will
be deducted before the annuity payments are
calculated.
Variable Annuity The dollar amount of each variable annuity
Payments payment will vary depending on the investment
performance of the Sub-accounts that you
selected. Unless we receive different instructions,
variable annuity payments will be based on the
investment allocations in place on the Annuity
Date. Variable annuity payments will be
determined as described below.
First Variable Annuity Payment: The dollar
amount of the first variable annuity payment is
the sum of the payments from each Sub-account
determined by applying the contract value used
to purchase variable annuity payments, as of the
15th day of the preceding month, to the Variable
Annuity Purchase Rate Table of this Contract. If
the NYSE is not open on that date, the calculation
will be made on the next day that the NYSE is
open. If premium taxes are required by state
law, these taxes will be deducted before the
annuity payment is calculated.
Subsequent Variable Annuity Payments: The dollar
amount of each subsequent variable annuity
payment is the sum of the payments from each Sub-
account, which are determined by multiplying the
number of Annuity Units credited for that Portfolio
by the Annuity Unit value of that Sub-account as of
the 15th of the month preceding the annuity payment.
If the NYSE is not open on that date, the calculation
will be made on the next day that the NYSE is open.
Number of Variable Annuity Units: The
number of Annuity Units credited for
each Sub-account is the amount of the
first annuity payment attributable to
that Sub-account divided by the value
of the applicable Annuity Unit for that
Sub-account as of the 15th day of
the month preceding the Annuity Date.
The number of Annuity Units used to
calculate the variable annuity payment
each month remains constant unless
you change Sub-account elections.
Value of Variable Annuity Units: The
value of an Annuity Unit will usually
increase or decrease from one
month to the next. For each month
after the first month, the value of
an Annuity Unit of a particular
Sub-account is:
- the value of that Annuity
Unit as of the 15th day of
the preceding month (or
the next day that the NYSE
is open);
- multiplied by the Net
Investment Factors for that
Sub-account; and
- divided by the Assumed
Investment Factor for
the period.
The Net Investment Factor is a number
that represents the change in the
Accumulation Unit value of a Sub-account
on successive days when the NYSE is
open. The Net Investment Factor for any
Sub-account for any valuation day is
determined by dividing the current
Accumulation Unit value by the prior
day's Accumulation Unit value. The
Net Investment Factor will likely be
different than the Assumed Investment
Factor, and therefore the Annuity Unit
value will usually increase or
decrease.
The Assumed Investment Factor for a
one-day valuation period is 1.00010746.
This factor neutralizes the assumed
investment return of 4% in the
Variable Annuity Purchase Rate
Table.
We guarantee that the dollar amount of each
variable annuity payment made after the first
payment will not be adversely affected by
variations in actual mortality experience or
actual expenses incurred in excess of the expense
deductions provided for in the Contract.
Changing Sub-account If you have selected variable annuity payments,
Elections after after the Annuity Date you may request to change
the Annuity Date Sub-account elections once a month. Changes
will affect the number of units used to calculate
annuity payments.
-----------------------------------------------------------------------
DEATH BENEFIT PROVISIONS
-----------------------------------------------------------------------
DEATH OF ANNUITANT If the Annuitant is not an Owner and the
Prior to the Annuity Annuitant dies before the Annuity Date,
Date you must designate a new Annuitant. If no
designation is made within 30 days after we
are notified of the Annuitant's death, you will
become the Annuitant.
If this Contract is owned by a non-natural person
(for example, a corporation or trust), the death
of the Annuitant will be treated as the death of
the Owner. In this case, all references to "Owner"
and "joint Owner" in these provisions are replaced
by "Annuitant" and "joint Annuitant".
DEATH OF OWNER If any Owner dies before the Annuity Date, we will
Prior to the Annuity pay a death benefit to the:
Date - surviving Owner; or if none, then
- surviving primary Beneficiary(ies); or
if none, then
- surviving contingent Beneficiary(ies);
or if none, then
- the estate of the last Owner to die.
If the death benefit is payable to the Owner's
spouse, the spouse will have the option to
continue the Contract and will then be the
Owner of the Contract.
Guaranteed The guaranteed minimum death benefit is
Minimum Death initially equal to the first Purchase Payment.
Benefit It is immediately increased by additional Purchase
Payments and proportionately reduced for
withdrawals. After such withdrawals, the
guaranteed minimum death benefit will be
recalculated by multiplying the prior guaranteed
minimum death benefit by the ratio of the contract
value after the withdrawal to the contract value
before the withdrawal.
Calculation of If the Owner or older joint Owner is under age
Death Benefit 75 at the time of death, the death benefit on the
calculation date is the sum of:
(1) the contract value; plus
(2) any excess of the guaranteed minimum
death benefit over the contract value.
If the Owner is age 75 or older at the time of
death, the death benefit is the contract value.
The guaranteed minimum death benefit is always
calculated on the life of the oldest original Owner,
as shown on the original application for this Contract.
The amount payable on the death of any Owner
other than the oldest original Owner will be the
current contract value. If the oldest original
Owner ceases to be an Owner of the Contract,
the guaranteed minimum death benefit will be
terminated.
When determining (1) and (2) above, the
calculations are based on the earlier of:
- the date we receive proof of death and the
first election of how to take the death
benefit payment; or
- six months from the date of death.
If we receive due proof of death and the first death
benefit payment election within 6 months of the date
of death: If the guaranteed minimum death benefit
exceeds the contract value, we will add the
difference to the contract value on the date we
receive the required information so that the contract
value will equal the guaranteed minimum death benefit.
This additional amount will be allocated to the Sub-
accounts in the same proportion that Purchase Payments
were last allocated. Thereafter, the contract value
will be subject to investment performance and
applicable charges until the date the death benefit
is paid.
If we receive due proof of death and the first death
benefit payment election more than 6 months after the
date of death: If the guaranteed minimum death benefit
exceeds the contract value on the 6-month anniversary
of the date of death, we will credit the difference
with interest at the currently offered money market
Sub-account rate from the 6-month anniversary until
the date we receive the required information. At that
time we will allocate this additional amount, with
the credited interest, to the Portfolios in the same
proportion that Purchase Payments were last allocated.
Thereafter, the contract value will be subject to
investment performance and applicable contract
charges until the date payment is made.
Limitation on At most, one guaranteed minimum death benefit will
Death Benefit be paid during the life of the Xxxxxxxx.Xx addition,
the maximum amount that we will add to the contract
value is limited to $1 million. This limitation applies
to any amount added to the contract value so that the
contract value equals the guaranteed minimum death
benefit.
Payment of Death To pay the death benefit, we need proof of death
Benefit acceptable to us, such as a certified copy of a death
certificate, plus written direction regarding how to
pay the death benefit payment. If the death benefit
is payable to an Owner's estate, we will pay it in a
single payment.
Upon receiving due proof of death we will credit
interest at the rate required by law.
The death benefit may be paid as:
- a lump sum payment or series of withdrawals
that are completed within five years from
the date of death; or
- annuity payments made over life or life
expectancy. To receive annuity payments,
this election must be made within 60 days
from our receipt of proof of death. Annuity
payments must begin within one year from the
date of death. Once annuity payments begin,
they cannot be changed.
If a person entitled to receive a death benefit dies
before the death benefit is distributed, we will pay
the death benefit to that person's named beneficiary or,
if none, to that person's estate.
DEATH OF ANNUITANT If the Annuitant is not the Owner and dies after the
On or After the Annuity Date, then we will continue paying any remaining
Annuity Date annuity payments to the payee designated by the Owner.
DEATH OF OWNER If the Owner dies after the Annuity Date, any amounts
On or After the paid will depend on the annuity option then in effect.
Annuity Date The right to change the payee for remaining annuity
payments is determined as follows:
- the surviving Owner; or if none, then
- the surviving primary Beneficiary(ies); or if
none, then
- the surviving contingent Beneficiary(ies); or
if none, then
- the estate of the last Owner to die.
-------------------------------------------------------------------------------
GENERAL PROVISIONS
-------------------------------------------------------------------------------
ACCOUNT STATEMENTS At least once each calendar year we will furnish you
with a statement with a date not more than four months
prior to the mailing date showing your contract value
or, if applicable and required by law, your Annuity
Units and the Annuity Unit values.
ASSIGNMENT OF BENEFITS You may assign your rights under this Contract unless
restricted by applicable law. If this Contract is
assigned, we will treat it as a change of ownership and
all rights will be transferred. The new Owner must not
have been older than the maximum issue age on the
contract date. We are not bound by any assignment
unless it is in writing. We are not responsible for
the validity of any assignment. Assignments are
effective on the date the notice of assignment is signed
by the Owner, subject to all payments made and actions
taken by us before a signed copy of the assignment
form is received by us at our Administrative Office.
To the extent allowed by law, payments under this
Contract are not subject to legal process for the
claims of creditors.
COMMUNICATIONS All written communications to you will be addressed to
you at your last known address on file with First
Symetra.
All written communications to First Symetra must be
addressed to First Symetra at its Administrative Office
at [P.O. Box 3882, Seattle, Washington 98124-3882].
ESSENTIAL DATA You and each person entitled to receive benefits under
this Contract must provide us with any information we need
to administer this Contract. We are entitled to rely
exclusively on the completeness and accuracy of data
furnished by you, and we will not be liable with respect
to any omission or inaccuracy.
EVIDENCE OF SURVIVAL When any payments under this Contract depend upon any
person being alive on a given date, we may require
satisfactory proof that the person is living before
making such payments.
INCONTESTABILITY This Contract and any rider(s) or endorsement(s)
presently attached to this Contract are incontestable
as to the material facts of the application for the
Contract and to the representations of the Owner
after such Contract has been in force during the
lifetime of the Owner for two years from its date of
issue. If any rider or endorsement subsequently
attached to this Contract provides supplemental
benefits that the Owner applied for after the Contract
was issued, such rider or endorsement is incontestable
as to the material facts of the application for the
supplemental benefit and to the representations of
the Owner after such rider or endorsement has been in
force during the lifetime of the Owner for two years
from its date of issue.
JURISDICTION In the event of a dispute, the laws of the jurisdiction
in which the Contract is delivered will apply.
MISSTATEMENT OF We may require satisfactory proof of correct age or sex
AGE OR SEX at any time.
- If annuity payments are based on life or life
expectancy and the age or sex of any Annuitant
has been misstated, annuity payments will be
based on the corrected information.
Underpayments will be made up in a lump sum
with the next scheduled payment. Overpayments
will be deducted from future payments until the
total is repaid. We will not credit interest
on underpayments or charge interest on overpayments.
- If the age of any Annuitant or Owner has been
misstated, the amount of any death benefit
payable will be determined based on the correct
age of the Annuitant or Owner.
NONPARTICIPATION This Contract is nonparticipating, which means it
will not share in any distribution of profits, losses,
or surplus of First Symetra.
SEPARATE ACCOUNT The Separate Account holds the assets that underlie
the contract values invested in the Portfolios.
The assets in the Separate Account are the property
of First Symetra. However, assets in the Separate
Account that are attributable to Contracts are not
chargeable with liabilities arising out of any other
business we may conduct. Income, gains and losses
(realized and unrealized), resulting from assets in
the Separate Account are credited to or charged
against the Separate Account without regard to other
income, gains or losses of First Symetra.
STATE REQUIRED The death benefit, contract value and paid up
BENEFITS annuity benefits under this Contact will not be less
than the minimum benefits required by any statute of
any state in which this Contract is delivered.
SUSPENSION OF We may be required to suspend or postpone payment of
ANNUITY PAYMENTS, annuity payments, withdrawals, or transfers from the
WITHDRAWALS, OR Sub-accounts for any period of time when:
TRANSFERS - the NYSE is closed (other than customary
weekend or holiday closings);
- trading on the NYSE is restricted;
- an SEC declared emergency exists such that
disposal of or determination of the value of
the Sub-account shares is not reasonably
practicable; or
- the SEC, by order, so permits for your
protection.
TERMINATION OF This Contract will terminate when First Symetra has
CONTRACT completed all of its duties and obligations under
the Contract.
THE CONTRACT The entire Contract between you and First Symetra
consists of this Contract, contract data page, any
endorsements, amendments or riders, and contract
application, a copy of which is attached to the
Contract.
All statements made by or under the authority of the
applicant for issuance of the contract are deemed to
be representations and not warranties.
The terms and conditions of this Contract may be
amended by written endorsement or amendment and signed
by an authorized officer of First Symetra. Any change
must be in writing. No other person can change any of
the terms or conditions of this Contract. First Symetra
reserves the right to change the provisions of this
Contract to conform to any applicable law, regulation,
or ruling issued by a government agency.
VOTING RIGHTS First Symetra is the legal owner of the Portfolios'
shares. However, when a Portfolio solicits proxies in
connection with a shareholder vote, we are required to
ask you for instructions as to how to vote those shares.
All shares are voted in the same proportion as the
instructions we received. Should we determine that we
are no longer required to comply with the above, we
will vote the shares in our own right. In addition, we
may disregard shareholder voting instructions:
- if required by regulatory officials if such
instructions would require us to vote the
shares so as to cause a change in sub-
classification or investment objectives of
one or more of the Portfolios, or to approve
or disapprove an investment advisory agreement;
- if such instructions would require changes in
the investment objective or investment advisor
of a Portfolio or be inconsistent with the
investment objectives of a Portfolio;
- vary from the general quality and nature of
investments and investment techniques used
by other Portfolios with similar investment
objectives and underlying other variable
contracts offered by First Symetra Life or of
an affiliated insurance company; or
- violate state or federal law.
If we disregard voting instructions, we will notify
contract owners of our actions and of our reasons
for doing so in our next semi-annual report.
-------------------------------------------------------------------------------
ANNUITY PURCHASE RATE TABLES
-------------------------------------------------------------------------------
VARIABLE ANNUITY PURCHASE RATE TABLE
MORTALITY TABLE USED: The rates in the Variable Annuity Purchase Rate Table are based upon the Annuity
2000 Mortality Table projected using a generational approach with an initial projection of 20 years. An age
setback of 1 year will be used if the annuity payments begin in the year 2013-2022, 2 years if the annuity
payments begin in the year 2023-2032, and an additional 1-year setback for each additional 10 years. The
assumed investment return in the table is 4.00%.
Age is to be taken for the exact number of years and completed months. Values for fractional ages are obtained
by simple interpolation. Consideration for ages or combination of lives not shown will be furnished by Symetra
upon request.
Consideration Required to Purchase $1 of Monthly Variable Annuity*
Life Annuity Life Annuity Life Annuity Joint & Survivor**
No Period Certain 5 Years Certain 10 Years Certain 5 Years
Life Certain
Age Male Female Male Female Male Female Annuity and Life
60 $197.53 $212.16 $198.19 $212.54 $200.20 $213.72 $230.94 $230.94
61 193.64 208.52 194.37 208.94 196.57 210.24 227.76 227.76
62 189.65 204.77 190.44 205.23 192.88 206.66 224.45 224.46
63 185.55 200.90 186.42 201.42 189.13 202.98 221.03 221.04
64 181.35 196.93 182.31 197.50 185.33 199.22 217.48 217.50
65 177.06 192.84 178.12 193.47 181.50 195.37 213.81 213.83
66 172.68 188.65 173.87 189.33 177.63 191.43 210.02 210.04
67 168.23 184.34 169.56 185.09 173.76 187.42 206.09 206.12
68 163.72 179.91 165.22 180.74 169.88 183.34 202.05 202.08
69 159.18 175.37 160.85 176.29 166.01 179.20 197.88 197.92
70 154.60 170.71 156.48 171.73 162.17 175.01 193.59 193.64
71 150.02 165.94 152.11 167.08 158.37 170.78 189.18 189.24
72 145.44 161.07 147.76 162.36 154.62 166.52 184.66 184.74
73 140.86 156.11 143.42 157.57 150.93 162.26 180.03 180.13
74 136.27 151.08 139.09 152.73 147.30 158.01 175.30 175.43
75 131.68 145.99 134.77 147.87 143.74 153.79 170.48 170.63
76 127.09 140.88 130.49 143.00 140.26 149.63 165.58 165.76
77 122.51 135.74 126.25 138.13 136.87 145.54 160.59 160.83
78 117.95 130.59 122.05 133.29 133.58 141.54 155.55 155.83
79 113.42 125.44 117.92 128.46 130.42 137.65 150.44 150.79
80 108.93 120.28 113.85 123.67 127.38 133.89 145.29 145.72
81 104.49 115.13 109.87 118.94 124.48 130.28 140.10 140.62
82 100.10 110.01 105.98 114.28 121.74 126.86 134.89 135.53
83 95.78 104.94 102.19 109.72 119.16 123.63 129.67 130.45
84 91.53 99.92 98.50 105.28 116.75 120.62 124.46 125.41
85 87.36 94.99 94.94 100.98 114.50 117.82 119.27 120.42
86 83.26 90.15 91.50 96.85 112.41 115.23 114.12 115.52
87 79.24 85.43 88.21 92.92 110.47 112.85 109.02 110.72
88 75.30 80.83 85.06 89.19 108.68 110.66 103.99 106.04
89 71.50 76.43 82.09 85.70 107.04 108.66 99.07 101.53
90 67.84 72.24 79.28 82.44 105.56 106.88 94.29 97.19
* The consideration shown refers to the net value of the Portfolios used to purchase a variable annuity after
premium taxes or other applicable charges are deducted. For example, if the Annuitant is a 65-year old male,
a Life Annuity initially equivalent to a monthly income of $1,000 will cost $177,060. However, because this is
a variable annuity, the dollar amount of this monthly income is not guaranteed and may increase or decrease.
** Annuitant and joint Annuitant are assumed to be the same age. The rate table for the Joint & Survivor is
calculated based on 100% of annuity payments to the surviving Annuitant.
FIXED ANNUITY PURCHASE RATE TABLE
MORTALITY TABLE USED: The rates in the Fixed Annuity Purchase Rate Table are based upon the Annuity
2000 Mortality Table projected using a generational approach with an initial projection of 20 years. The effective
interest rate assumed in the table is 2.00%.
Age is to be taken for the exact number of years and completed months. Values for fractional ages are obtained
by simple interpolation. Consideration for ages or combination of lives not shown will be furnished by First
Symetra upon request.
Consideration Required to Purchase $1 of Monthly Fixed Annuity*
Life Annuity Life Annuity Life Annuity Joint & Survivor**
No Period Certain 5 Years Certain 10 Years Certain 5 Years
Life Certain
Age Male Female Male Female Male Female Annuity and Life
60 $255.94 $279.92 $256.65 $280.33 $258.98 $281.70 $311.12 $311.13
61 249.36 273.38 250.13 273.83 252.70 275.34 304.87 304.88
62 242.72 266.76 243.56 267.26 246.40 268.91 298.51 298.52
63 236.01 260.05 236.93 260.60 240.09 262.42 292.04 292.05
64 229.25 253.27 230.27 253.88 233.78 255.88 285.46 285.48
65 222.44 246.42 223.57 247.09 227.50 249.29 278.79 278.81
66 215.61 239.50 216.87 240.23 221.25 242.67 272.02 272.04
67 208.76 232.51 210.18 233.31 215.06 236.02 265.15 265.18
68 201.92 225.45 203.52 226.33 208.93 229.36 258.20 258.23
69 195.12 218.32 196.91 219.30 202.90 222.69 251.16 251.21
70 188.37 211.14 190.37 212.22 196.98 216.04 244.06 244.11
71 181.68 203.90 183.91 205.12 191.19 209.41 236.88 236.95
72 175.07 196.62 177.54 198.00 185.53 202.84 229.66 229.74
73 168.55 189.33 171.28 190.88 180.01 196.34 222.38 222.49
74 162.10 182.04 165.10 183.81 174.64 189.94 215.08 215.21
75 155.71 174.78 159.01 176.79 169.43 183.67 207.75 207.91
76 149.41 167.58 153.04 169.85 164.39 177.55 200.41 200.61
77 143.20 160.44 147.18 163.00 159.52 171.61 193.08 193.33
78 137.08 153.39 141.45 156.26 154.85 165.86 185.77 186.08
79 131.07 146.41 135.87 149.64 150.39 160.32 178.49 178.87
80 125.19 139.52 130.43 143.14 146.14 155.02 171.25 171.71
81 119.42 132.74 125.16 136.80 142.13 149.99 164.06 164.63
82 113.80 126.08 120.06 130.63 138.35 145.25 156.95 157.64
83 108.31 119.55 115.13 124.65 134.83 140.82 149.93 150.77
84 102.96 113.18 110.38 118.89 131.56 136.71 143.01 144.03
85 97.76 106.98 105.83 113.37 128.54 132.93 136.21 137.45
86 92.70 100.97 101.48 108.12 125.74 129.45 129.54 131.05
87 87.79 95.16 97.34 103.14 123.18 126.28 123.02 124.85
88 83.02 89.57 93.42 98.48 120.82 123.38 116.67 118.88
89 78.46 84.26 89.74 94.14 118.68 120.77 110.53 113.17
90 74.10 79.24 86.28 90.11 116.76 118.46 104.61 107.73
* The consideration shown refers to the net value used to purchase a fixed annuity after premium taxes or
other applicable charges are deducted. For example, if the Annuitant is a 65-year old male, a Life Annuity
which provides a guaranteed monthly income of $1,000 will cost $222,440.
** Annuitant and joint Annuitant are assumed to be the same age. The rate table for the Joint & Survivor is
calculated based on 100% of annuity payments to the surviving Annuitant.
INDIVIDUAL FLEXIBLE PREMIUM DEFERRED VARIABLE ANNUITY
NON-PARTICIPATING
CONTRACT DATA PAGE
PRODUCT: First Symetra[registered trademark symbol] [Focus] Variable Annuity
OWNER: [Xxxx Xxx] JOINT OWNER: [Xxxx Xxx]
Address: [0000 Xxxx Xx.] Address: [0000 Xxxx Xx.]
[Xxx Xxxx, XX 00000-9999] [Any City, NY 99999-9999]
Date of Birth: [1/01/1970] Date of Birth: [2/01/1970]
Age: [35] Sex: [Male] Age: [35] Sex: [Female]
ANNUITANT: [Xxxx Xxx] JOINT ANNUITANT: [Xxxx Xxx]
Address: [0000 Xxxx Xx.] Address: [0000 Xxxx Xx.]
[Xxx Xxxx, XX 00000-9999] [Any City, NY 99999-9999]
Date of Birth: [1/01/1970] Date of Birth: [2/01/1970]
Age: [35] Sex: [Male] Age: [35] Sex: [Female]
CONTRACT NUMBER: [LP12345678]
CONTRACT DATE: [5/01/2005]
PRODUCT TYPE: [Non-Qualified]
ANNUITY DATE: Not Later Than [12/31/2065]
CAPITAL PRESERVATION RIDER EFFECTIVE DATE: [5/1/2005]
INITIAL PURCHASE PAYMENT: [$50,000]
GUARANTEED MINIMUM DEATH BENEFIT
AGE EXTENSION RIDER: [Yes or No]
CAPITAL PRESERVATION RIDER
7 Year Term [Yes or No]
10 Year Term [Yes or No]
DELIVERED IN THE STATE OF New York AND GOVERNED BY ITS LAWS.
MAXIMUM ISSUE AGE: [85]. The contract date must be prior to the Owner's and Annuitant's (including any
Joint Owner's and Joint Annuitant's) [86th] birthday.
MAXIMUM ANNUITIZATION AGE: [95]. Annuity payments must begin prior to the Annuitant's (including any
Joint Annuitant's) [96th] birthday.
MINIMUM INITIAL PURCHASE PAYMENT: [$10,000]
MINIMUM SUBSEQUENT PURCHASE PAYMENT: [$10,000]
INSURANCE CHARGES:
MORTALITY AND EXPENSE RISK CHARGE: Equal on an annual basis to 1.10% of the average daily net
assets of each Sub-account.
ASSET-RELATED ADMINISTRATION CHARGE: Equal on an annual basis of the average daily net assets of
each Sub-account as follows:
0.40% if contract value is less than $100,000
0.35% if contract value is between $100,000 and $249,999.99
0.25% if contract value is between $250,000 and $499,999.99
0.15% if contract value is between $500,000 and $999,999.99
0.05% if contract value equal or exceeds $1,000,000
The contract value at the start of the current Contract Year will determine the asset-related
administration charge to be applied to the Contract for that Contract Year.
GUARANTEED MINIMUM DEATH BENEFIT AGE EXTENSION RIDER CHARGE: Equal on an annual basis to 0.10%
of the average daily net assets of each Sub-account.
CAPITAL PRESERVATION RIDER CHARGE:
7 YEAR TERM Equal on an annual basis to [0.95%] assessed pro-rata on a quarterly basis from each
Sub-account. The maximum charge for this Rider will never exceed 2.25% of the average daily net
assets of each Sub-account.
10 YEAR TERM Equal on an annual basis to [0.60%] assessed pro-rata on a quarterly basis from each
Sub-account. The maximum charge for this Rider will never exceed 1.75% of the average daily net
assets of each Sub-account.
ANNUAL ADMINISTRATION MAINTENANCE CHARGE: $[40] each Contract Year. The charge may be
changed prior to the Annuity Date, but will never exceed $50 each Contract Year. The charge
will not be deducted if the contract value is $50,000 or more when the charge is to be deducted.
MINIMUM WITHDRAWAL: $500. You must withdraw the entire amount out of an investment option if,
after a withdrawal, the remaining balance in the investment option would be less than $500.
You must withdraw the entire contract value and your Contract will terminate if, after a withdrawal,
the remaining contract value would be less than $5,000.
SURRENDER CHARGE SCHEDULE:
Complete Years Elapsed Since Receipt of Surrender Charge As A Percentage Of
Purchase Payment Purchase Payments Withdrawn
--------------------------------------------------------------------------------------------------------------
0 7%
1 7%
2 7%
3 6%
4 6%
5 5%
6 4%
7 or more 0%
WITHDRAWAL CHARGE: [$25] for each withdrawal after the first withdrawal in a Contract Year. We will
not charge for annuity payments, repetitive withdrawals through electronic funds transfer (EFT), or if
the entire contract value is withdrawn. The maximum withdrawal charge will never exceed $100 for each
withdrawal after the first withdrawal in a Contract Year.
TRANSFERS: The minimum amount you can transfer out of any investment option at one time is $500, or
the entire value of the investment option if less. You must transfer the entire amount of the investment
option if, after a transfer, the remaining balance would be less than $500. The minimum amount you can
transfer into any investment option is $50.
TRANSFER CHARGE: Each Contract Year, 12 transfers are free of charge. For each transfer after the
12th transfer in a Contract Year, the transfer charge is $10 or 2% of the amount transferred, whichever
is less.
PREMIUM TAXES: Do not apply when issued in New York.
SEPARATE ACCOUNT: [First Symetra Separate Account S ]
ELIGIBLE INVESTMENTS:
[0.Xxxxxxxx VIP Money Market -Initial Class]
[0.Xxxxxxxx VIF International Portfolio- Investor Class]
[0.Xxxxxxxx VIF REIT Portfolio- Investor Class]
[0.Xxxxxxxx VIF Mid-Cap Portfolio- Investor Class]
[0.Xxxxxxxx VIF Total Stock Market Portfolio- Investor Class]
[0.Xxxxxxxx VIP Index 500- Initial Class]
[0.Xxxxxxxx VIF High Yield Bond Portfolio-Investor Class]
[0.Xxxxxxxx VIF Total Bond Market Portfolio- Investor Class]
[0.Xxxxxxxx VIF Balanced Portfolio- Investor Class]
[10.DWS Small Cap Index]
[11 Ibbotson Aggressive Growth ETF Asset Allocation- Class I]
[12.Ibbotson Growth ETF Asset Allocation- Class I]
[13.Ibbotson Balanced ETF Asset Allocation- Class I]
[14.Ibbotson Income and Growth ETF Asset Allocation- Class I]
[15.Ibbotson Conservative ETF Asset Allocation- Class I]
ANNUITY SERVICE OFFICE:
Home Office:
First Symetra National Life Insurance Company of New York
[000 Xxxxxxx Xxxxxx, 0xx Xxxxx ]
[Xxx Xxxx, XX 00000]
Mailing Address: Telephone: [800-SYMETRA]
First Symetra National Life
Insurance Company of New York [800-796-3872]
[Retirement Services] Fax: [000-000-0000]
[P.O. Box 3882]
[Seattle, WA 98124-3882]
