Founded in 1867...A Mutual Company...P.O. ▇▇▇ ▇▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇ ▇▇▇▇▇
ANNUITANT: ▇▇▇▇ ▇▇▇
OWNER: ▇▇▇▇ ▇▇▇
CONTRACT NUMBER: 012345678
CONTRACT DATE:
WE PROMISE to pay the benefits of this contract in accordance with its
terms.
LOOK AT THE APPLICATION FORMS. This contract is issued based on payment
of the initial premium and the answers in the application (see copy
attached). If all answers are not true and complete, this contract may
be affected.
PLEASE READ THIS CONTRACT CAREFULLY. This is a legal contract between you
and Union Central.
10 DAY RIGHT TO EXAMINE THE CONTRACT. It is important to Union Central
that you are satisfied with this contract. You have 10 days after you
receive it to review the contract. If you are not satisfied, you may
send it back to us or give it to our agent. In such case, this contract
will be void from the beginning. We will refund, within 7 days after
this contract is returned, any premiums paid.
ALL ACCUMULATION VALUES AND ANNUITY PAYMENTS PROVIDED BY THIS CONTRACT,
WHEN BASED ON THE INVESTMENT EXPERIENCE OF A SEPARATE ACCOUNT, ARE
VARIABLE AND ARE NOT GUARANTEED AS TO FIXED DOLLAR AMOUNTS.
Signed for the Company at Cincinnati, Ohio
/s/ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇▇▇ /s/▇▇▇▇ ▇. ▇▇▇▇▇▇
Secretary President
Flexible Premium Deferred Variable Annuity
Participating
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Licensed Resident Agent
UC 8134
INTRODUCTION
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This is a flexible premium deferred variable annuity. This annuity
contract provides that both the accumulation value and annuity
payments may be either fixed or variable, or a combination of
fixed and variable.
You determine the investment allocation for this annuity. You may
allocate your premiums to either the guaranteed account or the
variable account, or a combination of these accounts. If you select
the guaranteed account, then your accumulation value and annuity
payments will be fixed and guaranteed. If you select the variable
account, your accumulation value and annuity payments will vary with
the investment performance of the separate account's subaccounts.
If you select both the guaranteed and variable accounts, then your
values and payments will be fixed in part, and variable in part.
If you select the variable account, then you must allocate premiums
among one or more subdivisions of the variable account. These sub-
divisions are identified in the contract application and on the
schedule page.
CONTRACT INDEX
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Page
Definitions 4
Ownership 6
Benefits 6
Premiums 8
Variable Account Provisions 8
Guaranteed Account Provisions 11
Transfers 11
Surrender Provisions 12
Charges and Deductions 13
General Provisions 14
Payment of Contract Benefits 16
Schedule Page
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Initial Allocation of Net Premiums: Money Source
Separate Account:
Carillon Account
SUBDIVISIONS OF THE VARIABLE ACCOUNT:
[AIM VI CAP APPRECIATION 0]%
[AIM VI GROWTH 0]
[▇▇▇▇▇ AMERICAN LEVERAGED ALLCAP 0]
[▇▇▇▇▇ AMERICAN MIDCAP GROWTH 0]
[AM CENTURY VP GROWTH & IN 0]
[AM CENTURY VP VALUE 0]
[MFS VIT EMERGING GROWTH 0]
[MFS VIT INVESTORS TRUST 0]
[MFS VIT HIGH INCOME 0]
[MFS VIT NEW DISCOVERY 0]
[MFS VIT TOTAL RETURN 0]
[▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ AMT GUARD 0]
[▇▇▇▇▇▇▇▇▇▇▇ GLOBAL SEC/VA 0]
[▇▇▇▇▇▇▇▇▇▇▇ MAIN ST/VA 0]
[▇▇▇▇▇▇▇ VSI CAP GROWTH 0]
[▇▇▇▇▇▇▇ VSI INTL 0]
[▇▇▇▇▇▇▇ VSI MONEY MARKET 0]
[▇▇▇▇▇▇▇▇ SMALLCAP VALUE CLASS 2 0]
[▇▇▇▇▇▇▇▇ COMM & INFO CLASS 2 0]
[SUMMIT BALANCED INDEX 0]
[SUMMIT BOND 25]
[SUMMIT NASDAQ 100 INDEX 0]
[SUMMIT ▇▇▇▇▇▇▇ 2000 0]
[SUMMIT S&P MID CAP 400 0]
[SUMMIT S&P 500 INDEX 0]
[SUMMIT ZENITH 25]
[FTVIP ▇▇▇▇▇▇▇▇▇ INTL CLASS 2 0]
GUARANTEED ACCOUNT: [50]
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TOTAL: 100%
Transfer Charge:
Current: [$10]
Maximum: $100
Mortality and Expense Charge:
Current: [1.00%]
Maximum: 2.00%
Administration Fee:
Current: [0.25%]
Maximum: 0.25%
Contract Fee for any full or partial year: $30.00
Guaranteed Account Guaranteed Minimum Interest Rate: 3.00%
Annuitant: ▇▇▇▇ ▇▇▇ Contract Number: 012345678
Owner: ▇▇▇▇ ▇▇▇ Maturity Date:
Joint Owner: N/A Contract Date:
UC 8134 - 3 -
Schedule Page
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Surrender Charge:
We impose a surrender charge on certain early surrenders. The amount
of the surrender charge is a percentage of the amount withdrawn and is
set forth below.
Contract Surrender Charge
Year Percentage
[ 1 7% ]
[ 2 7% ]
[ 3 6% ]
[ 4 5% ]
[ 5 4% ]
[ 6 3% ]
[ 7 2% ]
[ 8 1% ]
[ 9 AND ABOVE 0% ]
Partial surrenders totaling not more than 10% of the accumulation value may
be made each contract year without a surrender charge being imposed. In no
event will the cumulative total of all surrender charges exceed 9% of
premiums.
Annuitant: ▇▇▇▇ ▇▇▇ Contract Number: 012345678
Owner: ▇▇▇▇ ▇▇▇ Maturity Date:
Joint Owner: N/A Contract Date:
UC 8134 -3A-
DEFINITIONS
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ACCUMULATION Means the period before the maturity date and during
PERIOD the lifetime of the annuitant.
ACCUMULATION Means a unit of measure that is used to calculate
UNIT the value of your interest in the separate account (SA)
before the maturity date.
ACCUMULATION Means the sum of the values of the guaranteed account and
VALUE the variable account credited to this contract.
ANNUITANT Means the person(s) whose life is used to determine the
duration of any annuity payments involving life
contingencies. The annuitant is named in the application
and on the schedule page.
ANNUITY UNIT Means a unit of measure that is used to calculate
variable annuity payments.
BENEFICIARY Means the person(s) designated by you to receive the
death benefits from this contract upon your death.
CALCULATION DATE Means a date not more than 10 business days prior to the
maturity date.
CONTRACT YEAR Means a period of 12 consecutive months beginning on the
contract date or any anniversary thereafter. The
contract date is shown on the schedule page.
DUE PROOF Means one of the following:
OF DEATH 1. A certified copy of a death certificate;
2. A certified copy of a 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; and
4. Any other proof satisfactory to us.
FIXED ANNUITY Means an annuity with payments fixed throughout the
annuity payment period.
GUARANTEED Means this contract's value which is held by The Union
ACCOUNT Central Life Insurance Company other than those in its
separate accounts (SA).
HOME OFFICE Means the home office of The Union Central Life Insurance
Company which is: ▇▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇ (▇.▇. ▇▇▇ ▇▇▇▇▇),
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MATURITY DATE Means the date on which annuity payments will begin. This
date shall be the annuitant's 95th birthday unless an
earlier date is chosen by you.
NOTICE Means information we have received at our home office
which is written, is signed by you, and is acceptable to
us.
PORTFOLIO OR Means a separate portfolio of one of the mutual funds in
FUND PORTFOLIO which separate account (SA) invests through its
subaccounts, or its successors and assigns.
SCHEDULE PAGE Means the contract schedule page, or the supplemental
contract schedule page most recently sent to you by us.
SEPARATE ACCOUNT Means the Carillon Account of The Union Central Life
("SA") Insurance Company. The separate account is divided into
several subaccounts.
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UC 8134 -4-
SUBACCOUNT(S) Means one or more of the subaccounts of the SA. Each
subaccount is invested in a different fund portfolio.
SUBDIVISION Means the portion of your variable account which is
invested in a specific subaccount.
VARIABLE ACCOUNT Means this contract's value which is invested in one or
more subaccounts of the SA.
VARIABLE ANNUITY Means an annuity with payments which: (1) are not
predetermined or guaranteed as to dollar amount; and
(2) vary in amount in relation to the investment
experience of one or more specified subaccounts.
WE AND YOU "We," "us," or "our" means The Union Central Life
Insurance Company. "You" or "your" means the owner
of this contract.
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UC 8134 -5-
OWNERSHIP
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GENERAL The owner of this contract shall be the person so named
in the application or the latest change filed with us.
CHANGE OF Prior to the maturity date, you may assign the ownership
OWNERSHIP of this contract by providing notice.
CHANGE OF Prior to the maturity date, you may name a new annuitant.
ANNUITANT Such change must be made by written notice in a form
acceptable to us and received at our home office.
BENEFITS
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ANNUITY BENEFITS We will pay an annuity benefit to the annuitant, if
living, on the maturity date. Annuity benefits will
begin on the maturity date and continue while the
annuitant is living, with monthly payments guaranteed
for 10 years, unless you elect a different annuity
option at least 30 days before the maturity date. If
you die after the annuity benefits have begun, the
entire remaining interest will continue to be dis-
tributed to the annuitant, if you are not also the
annuitant, at least as rapidly as under the annuity
option being used as of the date of your death. If you
are the annuitant, we will continue to pay the
beneficiary, if a benefit is payable to a beneficiary.
We may pay the accumulation value on the maturity date
in one lump sum if it is less than $5,000. We may
change the payment frequency to quarterly, semiannually
or annually if the first monthly annuity payment would
be less than $50.
At least 30 days before the maturity date you must
select how the accumulation value will be used to
provide the annuity benefit. Any election must be
written in a form satisfactory to us and received at
our home office. If you do not so select how you
wish settlement to be effected, we will provide a
fixed annuity.
If a variable annuity is used, subsequent annuity
benefit payments will vary based on the investment
experience of the subaccount(s) used to effect the
annuity. The method used to calculate the amount of
subsequent payments is described in the Variable
Annuity Payments provision.
DEATH BENEFITS Notwithstanding any provision to the contrary, death
benefits shall always be made in accordance with the
distribution requirements of the Internal Revenue Code
for annuity contracts.
If the death benefit is paid before the maturity date,
the death benefit will be the greater of : (a) the
accumulation value on the date that due proof of death
is received; or (b) the sum of all premiums paid, less
any amounts deducted in connection with partial
surrenders.
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UC 8134 -6-
Death of Owner. If you are an owner and if you die
before the maturity date, the following will apply:
1. If your spouse is not the beneficiary, the death
benefit will be paid to the named beneficiary:
a. upon written request it may be paid under any
option listed in the Payment of Contract
Benefits section of this contract over a
period not exceeding the beneficiary's life
expectancy. If the death benefit is paid in
installments, the first installment payment
must be made no later than one year after the
date of your death; or
b. in a single sum. The beneficiary has the option
to elect to receive the single sum any time
within five years after the date of your death.
2. If your spouse is the beneficiary, your spouse may
elect, by a written request to us, one of the following
options:
a. to continue this contract as the owner; or
b. to receive the death benefit under any option
listed in the Payment of Contract Benefits
section of this contract over a period not
exceeding the beneficiary's life expectancy.
If the death benefit is paid in installments,
the first installment payment must be made no
later than one year after the date of your
death; or
c. to receive the death benefit in a single sum.
Your spouse may elect to receive the single
sum any time within five years after the date
of your death.
If none of these options is elected by your spouse
within 45 days after we receive due proof of death,
option a. above shall apply.
3. If no beneficiary is living or if no beneficiary
has been named, at the date of your death, the death
benefit will be paid in a single sum to the executor
or administrator of your estate within five years
after the date of your death.
Joint Owners. If this contract is owned jointly,
the death of the first joint owner shall be treated
as the death of the owner.
Death of Annuitant before the Maturity Date. If you,
the owner, are a different person from the annuitant,
and the annuitant dies during your lifetime and before
the maturity date, you will be treated as the annuitant.
If you are not a natural person, and the annuitant dies
before the maturity date, we will pay the death benefit
to you in a single sum. You have the option to elect
to receive the single sum any time within five years of
the death of the annuitant.
Death of Annuitant on or after the Maturity Date. If
the annuitant dies on or after the maturity date, the
death benefit, if any, will depend on the annuity
option in effect on the date of the annuitant's death.
Death of Beneficiary. Unless otherwise provided, if
any beneficiary dies before, at the same time as, or
within 30 days after your death, that beneficiary will
be treated as if their death occurred before yours.
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UC 8134 -7-
PREMIUMS
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GENERAL All premiums under this contract are payable at our home
office or such other place as we may designate.
No premium may be paid under this contract unless it
is at least $50. Premiums may be paid at any time.
The amount of the premium may be increased or
decreased any time subject to the $50 minimum and a
maximum of $10,000 per contract year. We may waive
the $10,000 per year maximum, but waiver in one
instance does not constitute waiver for additional
premiums.
NET PREMIUM The net premium is the premium less any premium tax.
ALLOCATION OF You determine the allocation of the net premiums
NET PREMIUM between the guaranteed account and the variable account.
You may allocate the net premiums totally to the
guaranteed account, totally to the variable account or
partially to both accounts. The minimum amount of any
net premium that you can allocate to the guaranteed
account or any subdivision of the variable account is
$10.
If you allocate a part or all of your premiums to the
variable account, then you will further allocate that
portion of your premiums among one or more subdivisions
of the variable account. To the extent that you
allocate premiums to the variable account, your
accumulation value will be subject to the investment
experience of the SA.
Premiums that you allocate to the guaranteed accoun
will be guaranteed a minimum value. We will credit
interest to amounts allocated to the guaranteed account
at a rate of at least the guaranteed interest rate as
shown on the schedule page, compounded annually. We
may credit a higher rate of interest to such amounts,
but we are not required to do so.
When we receive the premiums, the net premiums will be
allocated in accordance with the net premium allocation
percentages shown in the application or as of the most
recent change of allocation received from you. No
allocation will be made prior to the contract date. You
may change the allocation of subsequent premiums at any
time, without charge, by giving us written notice.
VARIABLE ACCOUNT PROVISIONS
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SEPARATE ACCOUNT The separate account is shown on the schedule page.
It is a unit investment trust registered with the
Securities and Exchange Commission under the Investment
Company Act of 1940. It is established under the laws
of Ohio. The assets in the separate account are kept
separate from our general assets and assets of other
separate accounts.
SUBACCOUNTS The separate account is divided into subaccounts, each
of which invests in a different portfolio.
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UC 8134 -8-
CREDITING OF We will credit net premiums allocated to the
ACCUMULATION variable account in the form of variable accumulation
UNITS units. The number of variable accumulation units to
be credited to this contract for each subdivision of
the variable account will be determined by dividing
the net premium allocated to each subdivision of the
variable account by the accumulation unit value for
the corresponding subaccount as of the end of the
valuation period during which the premium is received.
In the case of the initial premium, accumulation units
will be credited on the later of these dates:
1. the contract date; or
2. the date we receive the premium.
Accumulation units are credited when amounts are
transferred into a subaccount. Accumulation units
are deducted when the charges and deductions are
assessed or when amounts are partially surrendered
or transferred, including transfer charges, out of
a subaccount.
VARIABLE ACCOUNT At any time prior to the maturity date, the variable
account of this contract equals the sum for all
subdivisions of the variable account of (1) times (2)
where:
1. equals the number of accumulation units credited
to a subdivision of the variable account; and
2. equals the value of the appropriate accumulation
unit.
VALUATION DATE A valuation date is any date on which the New York
AND VALUATION Stock Exchange is open for trading and we are open
PERIOD for business. The assets of each subaccount will be
valued on each valuation date. A valuation period
is a period beginning with the close of the New York
Stock Exchange on a valuation date and ending at the
close of the New York Stock Exchange for the next
valuation date.
ACCUMULATION The value of a variable accumulation unit for each
UNIT subaccount was arbitrarily set at $10 when funds were
first credited to the respective subaccount. The
variable accumulation unit value for any subsequent
valuation period is determined by multiplying the
variable accumulation unit value for the immediately
preceding valuation period by the "net investment
factor" for the valuation period for which the value
is being determined. The value of a variable
accumulation unit may increase or decrease from one
valuation period to the next.
NET INVESTMENT The net investment factor is an index that measures
FACTOR the investment performance of a subaccount from one
valuation period to the next. The net investment
factor for each subaccount for any valuation period
is determined by dividing (1) by (2) and subtracting
(3) from the result, where:
1. is the net result of:
a. the net asset value per share of a portfolio
share held in the subaccount determined as of
the end of the current valuation period, plus
b. the per share amount of any dividend or capital
gain distributions made by the portfolio on
shares held in the subaccount if the "exdividend"
date occurs during the current valuation period,
plus or minus
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UC 8134 -9-
c. a per share charge or credit for any taxes
incurred by or reserved for in the subaccount,
which is determined by us to have resulted from
the maintenance of the subaccount; and
2. is the net result of:
a. the net asset value per share of a portfolio
share held in the subaccount determined as of
the end of the immediately preceding valuation
period (adjusted for an "exdividend"), plus or
minus
b. the per share charge or credit for any taxes
reserved for the immediately preceding valuation
period; and
3. is a factor representing the charges deducted from
the subaccounts on a daily basis for administrative
expenses and mortality and expense risks. Such
factor is equal on an annual basis to the amount
shown on the schedule page.
VARIABLE ANNUITY The amount of the first variable annuity payment is
PAYMENT determined by applying the variable account accumulation
value of your contract, measured as of the calculation
date (minus any applicable premium taxes), to the
appropriate Option Table contained in this contract.
This is done separately for each subdivision of the
variable account. We will determine subsequent payments
by dividing the first payment derived from each
subdivision of the variable account by the annuity
unit value determined as of the calculation date. This
number of annuity units is then multiplied by the
annuity unit value for each subsequent determination
date which is a uniformly applied date not more than
10 business days before payment is due.
ANNUITY UNIT The value of an annuity unit for each subaccount was
VALUE arbitrarily set at $10 when funds were first credited
to the respective subaccount. Subsequently, the value
of an annuity unit in each subaccount for any valuation
period is determined as follows:
(a) the net investment factor for each subaccount for
the valuation period for which the annuity unit
value is being calculated is multiplied by the
value of the annuity unit on the preceding
valuation date; and
(b) the result is adjusted to compensate for the
interest rate assumed in the Option Tables used
to determine the first variable annuity payment.
The dollar value of annuity units may change from
one valuation period to the next.
ADDITION, We reserve the right, subject to compliance with
DELETION, OR applicable law, to make additions to, deletions
SUBSTITUTION OF from, or substitution for the portfolio shares that
INVESTMENTS are held by the separate account or that the
separate account may purchase. We reserve the right
to eliminate the shares of any of the eligible
portfolios and to substitute shares of another
portfolio, or of another open-end, registered
investment company, if the shares of an eligible
portfolio are no longer available for investment,
or if in our judgment further investment in any
eligible portfolio should become inappropriate in
view of the purposes of the separate account. We
will not substitute any shares attributable to your
interest in a subaccount without notice to you and
prior approval of the Securities and Exchange
Commission, to the extent required by the Investment
Company Act of 1940. Nothing contained herein shall
prevent the separate account from purchasing other
securities for other series or classes of policies,
or from effecting a conversion between series or
classes of policies on the basis of requests made
by owners.
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UC 8134 -10-
We reserve the right to establish additional
subaccounts, each of which would invest in a new
portfolio, or in shares of another open-end
investment company. We also reserve the right to
eliminate existing subaccounts.
In the event of any such substitution or change, we
may, by appropriate endorsement, make such changes in
this and other policies as may be necessary or
appropriate to reflect such substitution or change.
If deemed by us to be in the best interest of persons
having voting rights under the policies, the separate
account may be operated as a management company under
the Investment Company Act of 1940 or it may be
deregistered under such Act in the event such
registration is no longer required.
The investment contract of the separate account will
not be changed without the approval of the Insurance
Commissioner of the State of Ohio. If required, the
approval process is on file with the Commissioner of
the state in which this contract is issued.
GUARANTEED ACCOUNT PROVISIONS
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GUARANTEED The guaranteed account of your contract at any time
ACCOUNT equals:
1. the total of all net premiums allocated to the
guaranteed account; plus
2. the total of all amounts transferred to the
guaranteed account from the variable account; minus
3. the total of all amounts transferred from the
guaranteed account to the variable account
(including the transfer fee); minus
4. the total of all partial surrenders from the
guaranteed account (including any surrender
charges); plus
5. interest.
GUARANTEED The guaranteed interest rate used in the calculation
ACCOUNT INTEREST of the guaranteed account is found on the schedule
RATE page. Interest in excess of the guaranteed rate may
be used in the calculation of the guaranteed account
at such increased rates and in such a manner as we
may determine.
FIXED ANNUITY We guarantee the amount of fixed annuity payments.
PAYMENTS The payment amount depends only on the annuity option
elected, the age (and possibly sex) of the annuitant,
and the amount applied to purchase the fixed annuity,
in accordance with the Option Tables contained in the
contract.
TRANSFERS
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TRANSFERS BEFORE Before the maturity date you may transfer amounts
MATURITY DATE between the guaranteed account and subdivisions of
the variable account or among subdivisions. Transfers
from subdivisions of the variable account will be
made based on the accumulation unit values at the end
of the valuation period during which we receive the
request for transfer. You must transfer at least
$300 or, if less, the entire amount in the guaranteed
account or a subdivision each time you make a transfer.
If after the transfer the amount remaining in the
guaranteed account or any subdivision of the variable
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UC 8134 -11-
variable account from which the transfer is made is
less than $25, then we will transfer the entire
amount instead of the requested amount. A transfer
charge as shown on the schedule page will be imposed
for each transfer. The charge will be deducted from
the account from which the transfer is made.
TRANSFERS AFTER After annuity payments have been made for at least 12
MATURITY DATE months, you may, no more than once each 12 months,
change all or part of the investment upon which your
annuity payments are based from one subaccount to
another. After your death, the annuitant assumes
this right. To do this, we will convert the number
of annuity units being changed to the number of
annuity units of the subaccount to which you are
changing so as to result in the next annuity payment
being of the same amount that it would have been
without the change. After that, annuity payments
will reflect changes in the values of your new
annuity units. You must give us notice at least
30 days before the due date of the first annuity
payment to which the change will apply.
No transfers may be made with respect to fixed annuity
payments.
SURRENDER PROVISIONS
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PAYMENT OF You may totally or partially surrender the contract
SURRENDERS and receive all of the accumulation value at any time
before the earlier of the death of the annuitant or
the maturity date, by sending us a written request.
We will pay all surrenders from the variable account
within seven days of receipt of the written request,
subject to postponement for any period during which
the New York Stock Exchange is closed for trading
(except for normal holiday closing) or when the
Securities and Exchange Commission has determined
that a state of emergency exists. We reserve the right
to postpone surrenders from the guaranteed account for
up to six months after we receive the request.
TOTAL SURRENDERS If you are totally surrendering the contract, we will
deduct the surrender charge, if applicable, and the
administration fee from the amount paid.
PARTIAL SURRENDER If you are partially surrendering the contract, you
should specify the amounts that should be withdrawn
from the guaranteed account or each subdivision of
the variable account. If you do not so specify, the
requested amount will be withdrawn from the guaranteed
account and each subdivision of the variable account
in which you have an interest, in the same proportion
that your interest therein bears to the accumulation
value. You may pre-authorize periodic surrenders by
entering into a separate agreement with us. Under
this agreement, you may withdraw part of your
accumulation value at a regular interval chosen by
you. You may choose to withdraw a level dollar amount
or a percentage of your accumulation value. If you
choose the latter, the accumulation value for the first
year you choose to make these withdrawals is set on the
date we approve your request. In later years, the
accumulation value is set on the first day of the
contract year. These surrenders may be subject to the
10% federal tax on early withdrawals. We will deduct
the surrender charge, if applicable, from the
accumulation value remaining after the payment of the
requested amount.
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FREQUENCY AND You may make as many partial surrenders as you wish.
AMOUNT OF Any surrender from the guaranteed account or a
SURRENDERS subdivision of the variable account must be at least
$100 or the entire balance of the guaranteed account
or subdivision of the variable account. If, after
the surrender (and deduction of any surrender charge),
the amount remaining in the guaranteed account or a
subdivision is less than $25, then we may consider
the surrender request to be a request for surrender
of the entire amount held in the guaranteed account
or subdivision. If a partial surrender would reduce
the accumulation value to less than $100, then we may
treat the partial surrender request as a total
surrender of the contract.
CHARGES AND DEDUCTIONS
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MORTALITY AND To compensate us for assuming the mortality and
EXPENSE RISK expense risks, we deduct from the variable account
CHARGE a charge each valuation period. The current charge
is shown on the schedule page as is the maximum
effective annual rate that can be charged. We will
deduct the charge from each subdivision of the
variable account in the same proportion that the
value of each subdivision bears to the variable
account.
SURRENDER CHARGE A surrender charge is imposed on total and partial
surrenders other than those made pursuant to the death
of the annuitant or upon annuitization under the
contract. The amount of the charge and the period
for which it will be assessed are shown on the schedule
page.
ADMINISTRATION During the accumulation period we deduct an annual
FEE administration fee of $30 as partial compensation for
the cost of providing and/or purchasing certain
administrative services. The fee is not imposed
during the annuity period.
The administrative fee is deducted on the anniversary
date. It is withdrawn from the guaranteed account or
any subdivision of the variable account in which you
have an interest, in proportion to their value. If the
contract is totally surrendered on any date other than
the last day of any contract year, we will deduct the
full amount of the administrative fee from the amount
paid.
We also deduct from the variable account a charge each
valuation period at an effective annual rate of .25% to
partially defray the expenses of maintaining the
contract.
TAXES We will charge certain taxes against your premiums,
accumulation value, or annuity payments, when incurred.
These taxes include any premium taxes or other taxes
levied by any government entity which we, in our sole
discretion, determine have resulted from:
1. the establishment or maintenance of the variable
account; or
2. from the investment experience of the variable
account; or
3. from the receipt by us of the premium; or
4. from the issuance of this contract, or
5. from the commencement or continuance of annuity
payments under this contract.
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GENERAL PROVISIONS
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ENTIRE CONTRACT This contract is a legal contract that you have
entered into with us. The entire contract consists
of this contract, any endorsements, schedule pages,
amendments, and the attached copy of the application
and supplemental applications. Any change in the
contract must be written and signed by our President,
one of our Vice Presidents, our Secretary or Assistant
Secretary. No agent or person other than the above-
named has the authority to change or modify this
contract or waive any of its provisions. Words that
can be interpreted as singular or plural shall mean
both singular and plural.
BENEFICIARY The primary and any contingent beneficiaries of this
contract are named in the application. If changed,
the beneficiary is as shown in the latest change.
Unless the beneficiary designation provides otherwise,
any death benefits will be divided equally among
beneficiaries of the same class. The contingent
beneficiary will receive the death benefits if no
primary beneficiary is living at the time of the event
giving rise to the benefit payment. Prior to the
maturity date, if no beneficiary survives you, your
estate will be the beneficiary. The interest of any
beneficiary is subject to that of any assignee.
CHANGE OF You may change the beneficiary, unless an irrevocable
BENEFICIARY designation has been made. Any such change must be
made by written notice in a form acceptable to us and
received at our home office. If you die after the
maturity date, the annuitant may change the beneficiary
unless an irrevocable designation has been made.
CHANGE IN Prior to the maturity date, you may change the maturity
MATURITY DATE date by written request at least 30 days before the
previously specified maturity date. After the election,
the new maturity date will become the maturity date.
ASSIGNMENT You may assign this contract. No assignment will be
binding on us unless it is written in a form acceptable
to us and received at our home office. We will not be
responsible for the validity of any assignment. We will
not be liable for any payments we make or actions we take
before we receive notice of an assignment.
CLAIMS OF Any accumulation value, before paid, under this
CREDITORS contract, will not be subject to the claims of a
beneficiary's creditors, except as required by law.
MISSTATEMENT AND We may require proof of age, sex, or survival of any
PROOF OF AGE, SEX person upon whose age, sex, or survival any payments
OR SURVIVAL depend.
If the age or sex of the annuitant has been misstated,
the benefits will be those which the premiums would
have provided for the correct age and sex. If we
have made incorrect annuity payments, we will adjust
future payments. The adjustments will reflect any
overpayment or underpayment.
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DIVIDEND As long as this contract is in force, you will receive
any dividends declared by us. It is anticipated that
no dividends will be declared.
You have these options:
1. take the dividends in cash; or
2. use the dividends to be credited as additional
accumulation units with respect to the variable
account or added to the guaranteed account.
You may choose either option or change options by
notice to us. If none is chosen, the second option
will be used.
REPORTS At least once a year we will send you a report showing:
1. the accumulation unit value as of the beginning date
of the report;
2. the accumulation unit value as of the ending date of
the report;
3. the total number of accumulation units as of the
ending date of the report;
4. the value of the guaranteed account and/or each
subdivision of the variable account on the beginning
date of the report;
5. the value of the guaranteed account and/or each
subdivision of the variable account on the ending
date of the report; and
6. the gain or loss for each subdivision of the
variable account and/or the guaranteed account.
For the column headings within the report, the
accumulation unit is referred to as "unit."
INSULATION The assets of SA are not chargeable with liabilities
arising out of any other business we may conduct.
OWNERSHIP OF We shall have exclusive and absolute ownership and
ASSETS and control of our assets, including the assets of SA.
MODIFICATION We may not modify this contract without your consent
OF CONTRACT except:
1. to make the contract meet the requirements of the
Investment Company Act of 1940;
2. to make the contract comply with any changes in the
Internal Revenue Code; or
3. as required by any other applicable law in order to
continue treatment of the contract as an annuity.
INCONTESTABILITY We cannot contest this contract after it has been in
force during the lifetime of the annuitant for a period
of two years from the date of issue.
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WAIVER OF Notwithstanding the surrender charge described on
SURRENDER the contract schedule page, the surrender charge will
CHARGES be waived in the event (1) or (2) below:
(1) You become confined in a qualified institution for
a period of at least 30 consecutive days after the
contract date, subject to the following:
(a) You must be a natural person (not a Trust,
Corporation, or other legal entity).
(b) You must have been an owner of this contract
continuously since the contract date.
(c) You were not confined in a qualified institution
at any time during the 60 day period just prior
to the contract date.
(d) We receive a written request for a full or partial
surrender along with due proof of confinement
within 12 months following such confinement.
(e) A "qualified institution" means any licensed
hospital or licensed skilled or intermediate care
nursing facility at which:
(i) medical treatment is available on a daily
basis; and
(ii) daily medical records are kept for each
patient.
(2) You acquire a terminal illness after the contract
date, subject to the following:
(a) You must be a natural person (not a Trust,
Corporation, or other legal entity).
(b) You must have been an owner of this contract
continuously since the contract date.
(c) You Must have less than 12 months to live.
(d) We must receive a written statement for full or
partial surrender together with a certificate
from your attending physician stating your life
expectancy and any other proof we may require.
(e) "Physician" means a medical doctor licensed in
the United States who:
(i) is operating within the scope of that
license; and
(ii) is not the owner and is not related to the
owner.
PAYMENT OF CONTRACT BENEFITS
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GENERAL Annuity benefits under this contract are payable in
accordance with the Option Tables given below or under
such other annuity options as we may agree to.
ALTERNATE Instead of an annuity in accordance with the Option
ANNUITY OPTIONS Tables given below, you may choose an alternate type
of fixed annuity payment. Such alternate annuity
option shall be based on rates at least as favorable
as those for fixed dollar single premium immediate
annuities being issued by us on the maturity date.
They may only be elected within 30 days before that date.
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DESCRIPTION OF Option 1: Life Annuity
ANNUITY OPTIONS
(a) Nonrefund. We will make payments during the
lifetime of the annuitant. No payments are due
after the death of the annuitant.
(b) 5-Years Certain. We will make payments for 5
years and after that during the lifetime of the
annuitant. No payments are due after the death
of the annuitant or, if later, the end of the
5-year period certain.
(c) 10-Years Certain. We will make payments for 10
years and after that during the lifetime of the
annuitant. No payments are due after the death
of the annuitant or, if later, the end of the
10-year period certain.
(d) Installment Refund. We will make payments for a
period certain and after that during the lifetime
of the annuitant. No payments are due after the
death of the annuitant or, if later, the end of
the period certain. The number of period certain
payments is equal to the amount applied under this
Installment Refund Option divided by the amount of
the first annuity payment; provided, however, that
the amount of the final period certain payment shall
be multiplied by that part of the preceding quotient
which is not an integer.
Option 2: Joint and Survivor Life Annuity
(a) Joint and Survivor Nonrefund. We will make payments
during the joint lifetime of the annuitant and
contingent annuitant. Payments will then continue
during the remaining lifetime of the survivor of
them. No payments are due after the death of the
last survivor of the annuitant and contingent
annuitant.
(b) Joint and Survivor with 10-Years Certain. We will
make payments for 10 years and after that during the
joint lifetime of the annuitant and contingent
annuitant. Payments will then continue during the
remaining lifetime of the survivor of them. No
payments are due after the death of the survivor of
the annuitant and contingent annuitant or, if later,
the end of the 10-year period certain.
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Flexible Premium Deferred Variable Annuity
Participating
UC 8134
