EXHIBIT (4)(c)
GOLDEN
AMERICAN
[LOGO] LIFE INSURANCE DEFERRED VARIABLE
COMPANY ANNUITY CONTRACT
Golden American is a stock Company domiciled in Wilmington, Delaware
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Annuitant Owner
[Xxxxxx X. Xxx] [Xxxx X. Public]
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Initial Premium Annuity Option Annuity Commencement Date
[$10,000] [Life 10 Year Certain] [January 1, 2053]
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Separate Account(s) Contract Number
[Separate Account B ] [123456]
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This is a legal Contract between its Owner and us. Please read it
carefully. In this Contract you or your refers to the Owner shown above.
We, our or us refers to Golden American Life Insurance Company. You may
allocate this Contract's Accumulation Value among the Separate Account
Divisions shown in the Schedule.
If this Contract is in force, we will make income payments to you starting
on the Annuity Commencement Date. If the Owner dies prior to the Annuity
Commencement Date, we will pay a death benefit to the Beneficiary. The
amount of such benefits are subject to the terms of this Contract.
ALL PAYMENTS AND VALUES, WHEN BASED ON THE INVESTMENT EXPERIENCE OF A
SEPARATE ACCOUNT, MAY INCREASE OR DECREASE, DEPENDING ON THE CONTRACT'S
INVESTMENT RESULTS.
RIGHT TO EXAMINE THIS CONTRACT: You may return this Contract to us or the
agent through whom you purchased it within 10 days after you receive it. If
so returned, we will treat the Contract as though it were never issued.
Upon receipt we will promptly refund the Accumulation Value plus any
charges we have deducted as of the date the returned Contract is received
by us.
Customer Service Center Secretary:
0000 Xxxxxxxx Xxxxx
Xxxx Xxxxxxx, XX 00000-1478
President:
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DEFERRED VARIABLE ANNUITY CONTRACT - NO DIVIDENDS
Variable Cash Surrender Values while the Annuitant and Owner is living and
prior to the Annuity Commencement Date. Death benefit subject to guaranteed
minimum. Additional Premium Payment Option. Partial Withdrawal Option.
Non-participating. Investment results reflected in values.
GA-IA-1008-04/95
CONTRACT CONTENTS
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SPECIFICATION PAGES
Payment and Investment Information ................ 3A
The Separate Accounts ............................. 3B
The General Account ............................... 3C
Contract Facts .................................... 3D
Charges and Fees................................... 3E
Income Plan Factors ............................... 3F
INTRODUCTION TO THIS CONTRACT ....................... 4
The Contract
The Owner
The Annuitant
The Beneficiary
Change of Owner or Beneficiary
PREMIUM PAYMENTS AND ALLOCATION CHANGES ............. 6
Initial Premium Payment
Additional Premium Payment Option
Your Right to Change Allocation of
Accumulation Value
What Happens if a Separate Account Division
is Not Available
HOW WE MEASURE THE CONTRACT'S
ACCUMULATION VALUE ................................. 7
The Separate Accounts
The General Account
Valuation Period
Accumulation Value
Accumulation Value in each Division
Measurement of Investment Experience
Charges Deducted from Accumulation Value on
each Contract Processing Date
YOUR CONTRACT BENEFITS .............................. 11
Cash Value Benefit
Partial Withdrawal Option
Proceeds Payable to the Beneficiary
CHOOSING AN INCOME PLAN ............................. 13
Annuity Benefits
Annuity Commencement Date Selection
Frequency Selection
The Income Plan
The Annuity Options
Payments When Named Person Dies
OTHER IMPORTANT INFORMATION ......................... 15
Sending Notice to Us
Reports to Owner
Assignment - Using this Contract as
Collateral Security
Changing this Contract
Contract Changes - Applicable Tax Law
Misstatement of Age or Sex
Non-Participating
Payments We May Defer
Authority to Make Agreements
Required Note on Our Computations
A copy of any application and any additional Riders and Endorsements
are at the back of this Contract.
SPECIFICATION PAGES
The Specification Pages give specific facts about this Contract and its
coverage. Please refer to them while reading this Contract.
GA-IA-1008-04/95 2
THE SCHEDULE
PAYMENT AND INVESTMENT INFORMATION
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Annuitant Owner
[Xxxxxx X. Xxx] [Xxxx X. Public]
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Annuitant's Issue Age Annuitant's Sex Owner's Issue Age
[35] [Male] [55]
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Initial Premium Annuity Option Annuity Commencement Date
[$10,000] [Life 10 Year Certain] [January 1, 2053]
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Contract Date Issue Date Residence State
[January 1, 1994] [January 1, 1994] [Delaware]
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Separate Account(s) Contract Number
[Separate Account B ] [123456]
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Initial Investment
Initial Premium Payment received: [$10,000]
As requested in the application, your Accumulation Value has been invested
as follows:
Percentage of
Division Accumulation Value
-------- ------------------
[Multiple Allocation 10%
Fully Managed 10%
Capital Appreciation 10%
Rising Dividends 10%
All-Growth 10%
Real Estate 5%
Natural Resources 5%
Emerging Markets 5%
The Managed Global Account 5%
Limited Maturity Bond 5%
Liquid Asset 5%
Value Equity 5%
Fixed Interest 5%
1-Year Guarantee Period 5%
3-Year Guarantee Period 5%
--------
Total 100%
GA-IA-1008-04/95 3A1
THE SCHEDULE
PAYMENT AND INVESTMENT INFORMATION (continued)
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Annuitant Owner
[Xxxxxx X. Xxx] [Xxxx X. Public]
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Annuitant's Issue Age Annuitant's Sex Owner's Issue Age
[35] [Male] [55]
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Initial Premium Annuity Option Annuity Commencement Date
[$10,000] [Life 10 Year Certain] [January 1, 2053]
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Contract Date Issue Date Residence State
[January 1, 1994] [January 1, 1994] [Delaware]
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Separate Account(s) Contract Number
[Separate Account B ] [123456]
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ADDITIONAL PREMIUM PAYMENT INFORMATION
We will accept additional premium payments until either the Annuitant or
the Owner reaches the Attained Age of [85]. The minimum additional payment
which may be made is [$500.00].
ACCUMULATION VALUE ALLOCATION RULES
The maximum number of Divisions in which you may be invested at any one
time is [twelve]. You are allowed unlimited allocation changes per Contract
Year without charge. We reserve the right to impose a charge for any
allocation change in excess of [twelve] per Contract Year. The Excess
Allocation Charge is shown in the Schedule.
ALLOCATION CHANGES BY TELEPHONE
You may request allocation changes by telephone during our telephone
request business hours. You may call our Customer Service Center at
1-800-366-0066 to make allocation changes by using the personal
identification number you will receive. You may also mail any notice or
request for allocation changes to our Customer Service Center at the
address shown on the cover page.
GA-IA-1008-04/95 3A2
THE SCHEDULE
THE SEPARATE ACCOUNTS
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Annuitant Owner
[Xxxxxx X. Xxx] [Xxxx X. Public]
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Initial Premium Annuity Option Annuity Commencement Date
[$10,000] [Life 10 Year Certain] [January 1, 2053]
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Separate Account(s) Contract Number
[Separate Account B ] [123456]
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DIVISIONS INVESTING IN SHARES OF A MUTUAL FUND
Separate Account B (the "Account") is a unit investment trust Separate
Account, organized in and governed by the laws of the State of Delaware,
our state of domicile. The Account is divided into Divisions.
Each Division listed below invests in shares of the mutual fund portfolio
(the "Series") designated. Each portfolio is a part of The GCG Trust (the
"Trust") managed by Directed Services, Inc.
ALL-GROWTH ALL-GROWTH SERIES
DIVISION Portfolio Manager - Pilgrim Xxxxxx & Associates, Ltd.
CAPITAL CAPITAL APPRECIATION SERIES
APPRECIATION Portfolio Manager - INVESCO (NY), Inc.
DIVISION
DEVELOPING DEVELOPING WORLD SERIES
WORLD DIVISION Portfolio Manager - Baring International Investment
Limited
GROWTH GROWTH OPPORTUNITIES SERIES
OPPORTUNITIES Portfolio Manager - Xxxxxxxxxx Asset Management, LLC
DIVISION
FULLY FULLY MANAGED SERIES
MANAGED Portfolio Manager - X. Xxxx Price Associates, Inc.
DIVISION
MULTIPLE MULTIPLE ALLOCATION SERIS
ALLOCATION Portfolio Manager - Xxxxx Advisors Inc.
DIVISION
RISING RISING DIVIDENDS SERIES
DIVIDENDS Portfolio Manager - Xxxxx Xxxxxxxx Investment
DIVISION Management, LLC
STRATEGIC STRATEGIC EQUITY SERIES
EQUITY Portfolio Manager - Xxxxx Advisors Inc.
DIVISION
VALUE VALUE EQUITY SERIES
EQUITY Portfolio Manager - Eagle Asset Management, Inc.
DIVISION
GA-IA-1008-04/95 3Bl
THE SCHEDULE
THE SEPARATE ACCOUNTS
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Annuitant Owner
[Xxxxxx X. Xxx] [Xxxx X. Public]
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Initial Premium Annuity Option Annuity Commencement Date
[$10,000] [Life 10 Year Certain] [January 1, 2053]
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Separate Account(s) Contract Number
[Separate Account B ] [123456]
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EMERGING EMERGING MARKETS SERIES
MARKETS Portfolio Manager - X. X. Xxxxxx Investment Management Inc.
DIVISION
GLOBAL GLOBAL FIXED INCOME PORTFOLIO
FIXED Portfolio Manager - Baring Investment Limited International
INCOME
DIVISION
GROWTH AND GROWTH AND INCOME PORTFOLIO
INCOME Portfolio Manager - Xxxxxxxxx, Xxxxxxxx & Company Investment
DIVISION Manager, L. P.
HARD HARD ASSETS SERIES
ASSETS Portfolio Manager - Xxx Xxx Associates Corporation
DIVISION
LIMITED LIMITED MATURITY BOND SERIES
MATURITY Portfolio Manager - ING Investment Management, LLC
BOND
DIVISION
LIQUID LIQUID ASSET SERIES
ASSET Portfolio Manager - ING Investment Management, LLC
DIVISION
MANAGED MANAGED GLOBAL SERIES
GLOBAL Portfolio Manager - Xxxxxx Investment Management, Inc.
DIVISION
MID-CAP MID-CAP GROWTH SERIES
GROWTH Portfolio Manager - Massachusetts Financial Services Co.
DIVISION
REAL REAL ESTATE SERIES
ESTATE Portfolio Manager - EII Realty Securities, Inc.
DIVISION
RESEARCH RESEARCH PORTFOLIO
DIVISION Portfolio Manager - Massachusetts Financial Services Co.
SMALL SMALL CAP SERIES
CAP Portfolio Manager - Xxxx Xxxxx Management, Inc.
DIVISION
GA-IA-1008-04/95 3B2
THE SCHEDULE
THE SEPARATE ACCOUNTS
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Annuitant Owner
[Xxxxxx X. Xxx] [Xxxx X. Public]
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Initial Premium Annuity Option Annuity Commencement Date
[$10,000] [Life 10 Year Certain] [January 1, 2053]
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Separate Account(s) Contract Number
[Separate Account B ] [123456]
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TOTAL TOTAL RETURN PORTFOLIO
RETURN Portfolio Manager - Massachusetts Financial Services Co.
DIVISION
VALUE + VALUE + GROWTH PORTFOLIO
GROWTH Portfolio Manager - Xxxxxxxxx, Xxxxxxxx & Company
DIVISION Investment Management, L. P.
NOTE: PLEASE REFER TO THE PROSPECTUSES FOR THE CONTRACT AND THE GCG
TRUST FOR MORE DETAILS.
Each Division below invests in shares of the mutual fund portfolio (the
"Portfolio") designated. Each portfolio is a part of the PIMCO Trust
managed by Pacific Investment Management Company ("PIMCO").
HIGH YIELD HIGH YIELD BOND PORTFOLIO
BOND Portfolio Manager - PIMCO.
DIVISION
STOCKSPLUS STOCKSPLUS GROWTH AND INCOME PORTFOLIO
GROWTH AND Portfolio Manager - PIMCO
INCOME
DIVISION
GA-IA-1008-04/95 3B3
THE SCHEDULE
THE GENERAL ACCOUNT
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Annuitant Owner
[Xxxxxx X. Xxx] [Xxxx X. Public]
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Initial Premium Annuity Option Annuity Commencement Date
[$10,000] [Life 10 Year Certain] [January 1, 2053]
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Separate Account(s) Contract Number
[Separate Account B ] [123456]
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GUARANTEED DIVISION
[Fixed Interest Division
The Fixed Interest Division provides a minimum of 3% annual interest rate.
At our sole discretion, we may periodically declare higher interest rates.
Such rates will apply to periods following the date of declaration. Any
such declaration will be by class and will be based on our future
expectations.
Limitations on Allocations
We reserve the right to restrict allocations into the General Account. Such
limits may be dollar restrictions on allocations into the General Account
or we may restrict reallocations into the General Account.
Guarantee Periods
Each allocation to the Fixed Interest Division will be guaranteed an
interest rate for the entire Initial Guaranteed Period elected. We
currently offer Initial Guarantee Periods of one, three, five, seven and
ten years. The Initial Guarantee Period starts on the day an allocation is
made to the Fixed Interest Division and ends on the last day of the
calendar month following one, three, five, seven or ten years as
appropriate, the Maturity Date.
At the end of a Guarantee Period, you may transfer the Accumulation Value
in such Guarantee Period to the Divisions or to a Guarantee Period we then
offer. If we do not receive notification by the Maturity Date, your
Accumulation Value in the maturing Guarantee Period will automatically be
transferred to a one year Guarantee Period. Upon such automatic transfer
you will have thirty days to reallocate any of your Accumulation Value to
the Divisions.
Deductions for Charges
We do not deduct the Mortality and Expense Charge and the Asset-Based
Administrative Charge with respect to that amount of Accumulation Value
allocated to the Fixed Interest Division while such Accumulation Value
remains allocated to the Fixed Interest Division.
Transfers from the Fixed Interest Division
You may transfer your Accumulation Value from a Guarantee Period to the
Divisions of Separate Account B or Separate Account D (the "Divisions"), or
to a different Guarantee Period, subject to the following restrictions:
The maximum amount which may be transferred from the Fixed Interest
Division during a Contract Year is 15% of the Accumulation Value in your
Fixed Interest Division. In addition, no more than 15% of the Accumulation
Value allocated to a particular Guarantee Period may be transferred during
any one year period beginning on the date such allocation was initially
allocated or transferred to such Guarantee Period. On a Maturity Date, 100%
of the Accumulation Value in the maturing Guarantee Period may be
transferred.]
GA-IA-1008-04/95 3C1
THE SCHEDULE
THE GENERAL ACCOUNT (continued)
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Annuitant Owner
[Xxxxxx X. Xxx] [Xxxx X. Public]
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Initial Premium Annuity Option Annuity Commencement Date
[$10,000] [Life 10 Year Certain] [January 1, 2053]
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Separate Account(s) Contract Number
[Separate Account B ] [123456]
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GUARANTEED DIVISION (continued)
[We currently require that an amount allocated to a one year Guarantee
Period not be transferred until held in such Guarantee Period for at least
one year, except pursuant to our published rules. This means that amounts
allocated to a one year Guarantee Period cannot be transferred prior to the
end of the Guarantee Period. We reserve the right to have such a
requirement for other Guarantee Periods as well. We also reserve the right
not to allow amounts previously transferred from the Fixed Interest
Division to the Divisions to be transferred back to the Fixed Interest
Division for a period of at least six months from the date of transfer.
We reserve the right to reduce the amount otherwise available for transfer
from the Fixed Interest Division by any amounts previously withdrawn from
the Fixed Interest Division.
Systematic Withdrawals
Up to the interest earned in the prior month or quarter may be withdrawn
monthly or quarterly, depending whether you have chosen a monthly or
quarterly frequency, respectively.
Conventional Partial Withdrawals
Amounts withdrawn from a Fixed Interest Division may be subject to
surrender charge if such amounts cause the total amount withdrawn from the
Contract in a Contract Year to exceed 15% of the Contract's Accumulation
Value.]
GA-IA-1008-04/95 3C2
THE SCHEDULE
CONTRACT FACTS
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Annuitant Owner
[Xxxxxx X. Xxx] [Xxxx X. Public]
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Initial Premium Annuity Option Annuity Commencement Date
[$10,000] [Life 10 Year Certain] [January 1, 2053]
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Separate Account(s) Contract Number
[Separate Account B ] [123456]
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CONTRACT PROCESSING DATES
The Contract Processing Dates are the days when we deduct charges from the
Accumulation Value. The Contract Processing Date for your Contract is
[April 1] of each year.
CONTRACT PROCESSING PERIODS
The period between successive Contract Processing Dates unless it is the
first Contract Processing Period. In that case, it is the period from the
Contract Date to the first Contract Processing Date.
SPECIALLY DESIGNATED DIVISION
When a distribution is made from an investment portfolio underlying a
Separate Account Division or from a Division of a managed Separate Account
in which reinvestment is not available, we will allocate the amount of the
distribution to the [Liquid Asset Division] unless you specify otherwise.
PARTIAL WITHDRAWALS
[The maximum amount that can be withdrawn in a Contract Year without being
considered an Excess Partial Withdrawal is 15% of the Accumulation Value as
of the date of the withdrawal. We will collect a Surrender Charge for
Excess Partial Withdrawals. In no event may a Partial Withdrawal be greater
than 90% of the Cash Surrender Value.
Conventional Partial Withdrawals
Minimum Withdrawal Amount: $1,000
Systematic Partial Withdrawals
Systematic Partial Withdrawals may be elected to commence after 28 days
from the Contract Issue Date.
Systematic Partial Withdrawals may be taken on a monthly or quarterly
basis. You select the day withdrawals will be made, but no later than the
28th day of the month. If you do not elect a day, the Contract Date will be
used.
Minimum Withdrawal Amount: $100.00
Maximum Percentage: 1.25% Monthly or 3.75% Quarterly]
GA-IA-1008-04/95 3D1
THE SCHEDULE
CONTRACT FACTS (continued)
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Annuitant Owner
[Xxxxxx X. Xxx] [Xxxx X. Public]
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Initial Premium Annuity Option Annuity Commencement Date
[$10,000] [Life 10 Year Certain] [January 1, 2053]
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Separate Account(s) Contract Number
[Separate Account B ] [123456]
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Death Benefit
IF DEATHBEN="1": The Death Benefit is the greatest of (i) the Accumulation
Value, (ii) the Guaranteed Death Benefit, (iii) the Cash Surrender Value, and
(iv) the sum of premiums paid, less any partial withdrawals.
IF DEATHBEN="2": The Death Benefit is the greatest of (i) the Accumulation
Value, (ii) the Guaranteed Death Benefit, (iii) the Cash Surrender Value, and
(iv) the sum of premiums paid, less any partial withdrawals.
IF DEATHBEN="3": The Death Benefit is the greater of (i) the Cash Surrender
Value, (ii) the Accumulation Value, and (iii) the sum of the premiums paid, less
any Partial Withdrawals.
Guaranteed Death Benefit
[On the Contract Date, the Guaranteed Death Benefit is the Initial Premium. On
subsequent Valuation Dates, the Guaranteed Death Benefit is calculated as
follows:
Option 1:
(1) Start with the Guaranteed Death Benefit from the prior Valuation Date;
(2) Calculate interest on (1) if the Owner is living (the Annuitant if
the Owner is not an individual) for the current Valuation Period at the
Guaranteed Death Benefit Interest Rate;
(3) Add (1) and (2);
(4) Add any additional premiums paid during the current Valuation Period to
(3);
(5) Subtract Partial Withdrawals made during the current Valuation Period
from (4);
Each accumulated initial or additional premium payment, reduced by any Partial
Withdrawals (including any associated Market Value Adjustment and Surrender
Charge incurred) allocated to such premium, will continue to grow at the
Guaranteed Death Benefit Interest Rate until reaching its Maximum Guaranteed
Death Benefit.
Guaranteed Death Benefit Interest Rate
The Guaranteed Death Benefit is accumulated at a rate of 7% compounded annually,
except:
(1) Amounts in the Liquid Asset Division are accumulated at the net rate
of return for the Liquid Asset Division during the current Valuation
Period if less than 7%; and
(2) Amounts in Limited Maturity Bond Division are accumulated at the net
rate of return for the Limited Maturity Bond Division during the
current Valuation Period if less than 7%; and
(3) Amounts in a Fixed Allocation are accumulated at the interest rate
being credited to such Fixed Allocation during the current Valuation
Period if less than 7%.
MAXIMUM GUARANTEED DEATH BENEFIT
The Maximum Guaranteed Death Benefit is initially equal to two times the initial
or additional premium paid. Thereafter, the Maximum Guaranteed Death Benefit as
of the effective date of a partial withdrawal is reduced first by the amount of
any partial withdrawal representing earnings and second in proportion to the
reduction in Accumulation Value for any partial withdrawal representing premium
(in each case, including any Surrender Charge). If withdrawals do not exceed
7% of premium paid in a Contract Year, and did not exceed 7% of premiums paid
in any prior Contract Year, the Maximum Guaranteed Death Benefit will be
reduced only by the amount of such withdrawals. Once withdrawals exceed 7% in
a Contract Year all withdrawals of premium will be treated as proportional in
relation to the amount of Accumulation Value for any Partial Withdrawal
(including any Surrender Charge incurred).
GA-IA-1008-04/95 3D2
THE SCHEDULE
CONTRACT FACTS (continued)
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Annuitant Owner
[Xxxxxx X. Xxx] [Xxxx X. Xxxxxx]
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Initial Premium Annuity Option Annuity Commencement Date
[$10,000] [Life 10 Year Certain] [January 1, 2053]
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Separate Account(s) Contract Number
[Separate Account B ] [123456]
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[Option 2:
(1) Start with the Guaranteed Death Benefit from the prior Valuation Date;
(2) Add to (1) any additional premium paid since the prior Valuation Date
and subtract from (1) any Partial Withdrawals taken since the prior
Valuation Date;
(3) On a Valuation Date which occurs through the Certificate Year in which
the Certificateowner's Attained Age is 80 and which is also a
Certificate Anniversary, if the Owner is living (the Annuitant if
the Owner is not an individual), we set the Guaranteed Death Benefit
equal to the greater of (2) or the Accumulation Value as of such date.
On all other Valuation Dates, the Guaranteed Death Benefit is equal
to (2).]
Option 3:
(1) Start with the Guaranteed Death Benefit from the prior Valuation Date;
(2) Add any additional premiums paid during the current Valuation Period
to (1);
(3) Subtract any Partial Withdrawals made during the current Valuation
Period from (2).]
GA-IA-1008-04/95 3D3
THE SCHEDULE
CONTRACT FACTS (continued)
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Annuitant Owner
[Xxxxxx X. Xxx] [Xxxx X. Xxxxxx]
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Initial Premium Annuity Option Annuity Commencement Date
[$10,000] [Life 10 Year Certain] [January 1, 2053]
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Separate Account(s) Contract Number
[Separate Account B ] [123456]
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Change of Owner
[When the ownership changes, the new Owner's age at the time of the change
will be used as the basis for the death benefit. The new Owner's death will
determine when a death benefit is payable.
IF DEATHBEN="1": If the new Contractowner's age is less than or equal to
75, the Guaranteed Death Benefit Option in effect prior to the change of
Contractowner will remain in effect. If the new Contractowner's age is
greater than 75, the Guaranteed Death Benefit will be zero and the Death
Benefit shall be the greatest of the Cash Surrender Value, the Accumulation
Value, and the sum of the premiums paid, less any Partial Withdrawals.
IF DEATHBEN="2": If the new Contractowner's age is less than or equal to
79, the Guaranteed Death Benefit Option in effect prior to the change of
Contractowner will remain in effect. If the new Contractowner's age is
greater than 79, the Guaranteed Death Benefit will be zero and the Death
Benefit shall be the greater of Cash Surrender Value, the Accumulation
Value, and the sum of premiums paid, less any Partial Withdrawals.
IF DEATHBEN="3": The Guaranteed Death Benefit Option after the change of
Contractowner will remain the same as before the change.]
CHOOSING AN INCOME PLAN
Required Date of Annuity Commencement
[The Annuity Commencement Date is required to be the same date as the
Contract Processing Date in the month following the Annuitant's [9Oth]
birthday. If, on the Annuity Commencement Date, a Surrender Charge remains,
your elected Annuity Option must include a period certain of at least five
years duration. In applying the Accumulation Value, we may first collect
any Premium Taxes due us.]
Minimum Annuity Income Payment
The minimum monthly annuity income payment that we will make is [$20].
Optional Benefit Riders - [None.]
ATTAINED AGE
The Issue Age of the Annuitant or Owner plus the number of full years
elapsed since the Contract Date.
GA-IA-1008-04/95 3D4
THE SCHEDULE
CHARGES AND FEES
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Annuitant Owner
[Xxxxxx X. Xxx] [Xxxx X. Xxxxxx]
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Initial Premium Annuity Option Annuity Commencement Date
[$10,000] [Life 10 Year Certain] [January 1, 2053]
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Separate Account(s) Contract Number
[Separate Account B ] [123456]
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DEDUCTIONS FROM PREMIUMS
[None.]
DEDUCTIONS FROM ACCUMULATION VALUE
Initial admistrative Charge
[None.]
Administrative Charge
[We charge [$40] to cover a portion of our ongoing administrative expenses
for each Contract Processing Period. The charge is incurred at the
beginning of the Contract Processing Period and deducted on the Contract
Processing Date at the end of the period. At the time of deduction, this
charge will be waived if:
(1) The Accumulation Value is at least $100,000; or
(2) The sum of premiums paid to date is at least $100,000.]
Excess Allocation Charge
Currently none, however, we reserve the right to charge [$25] for a change
if you make more than [twelve] allocation changes per Contract Year. Any
charge will be deducted in proportion to the amount being transferred from
each Division.
Surrender Charge - A Surrender Charge is imposed as a percentage of premium
if the Contract is surrendered or an Excess Partial Withdrawal is taken.
The percentage imposed at time of surrender or Excess Partial Withdrawal
depends on the number of complete years that have elapsed since a premium
payment was made. The Surrender Charge expressed as a percentage of each
premium payment is as follows:
Complete Years Elapsed Surrender
Since Premium Payment Charges
--------------------- -------
[0 7%
1 7%
2 6%
3 5%
4 4%
5 3%
6 1%
7+ 0%]
For the purpose of calculating the Surrender Charge for an Excess Partial
Withdrawal; a) we treat premiums as being withdrawn on a first-in, first-out
basis, and b) amounts withdrawn which are not considered an Excess Partial
Withdrawal are not considered a withdrawal of any premium payments.
GA-IA-1008-04/95 3E1
THE SCHEDULE
CHARGES AND FEES (continued)
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Annuitant Owner
[Xxxxxx X. Xxx] [Xxxx X. Public]
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Initial Premium Annuity Option Annuity Commencement Date
[$10,000] [Life 10 Year Certain] [January 1, 2053]
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Separate Account(s) Contract Number
[Separate Account B ] [123456]
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[Premium Taxes - We deduct the amount of any premium or other state and
local taxes levied by any state or governmental entity when such taxes are
incurred.
We reserve the right to defer collection of Premium Taxes until surrender
or until application of Accumulation Value to an Annuity Option. An Excess
Partial Withdrawal will result in the deduction of any Premium Tax then due
us on such amount. We reserve the right to change the amount we charge for
Premium Tax charges on future premium payments to conform with changes in
the law or if the Owner changes state of residence.]
Deductions from the Divisions
Mortality and Expense Risk Charge - [We deduct [0.003863%] of the assets in
the Separate Account Division on a daily basis (equivalent to an annual
rate of [1.40%]) for mortality and expense risks. This charge is not
deducted from the Fixed Account values.]
Asset Based Administrative Charge - [We deduct 0.000411% of the assets in
each Separate Account Division on a daily basis (equivalent to an annual
rate of 0.15%) to compensate us for a portion of our ongoing administrative
expenses.]
CHARGE DEDUCTION DIVISION
[All charges against the Accumulation Value in this Contract will be
deducted from the [Liquid Asset Division].]
GA-IA-1008-04/95 3E2
THE SCHEDULE
INCOME PLAN FACTORS
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Annuitant Owner
[Xxxxxx X. Xxx] [Xxxx X. Public]
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Initial Premium Annuity Option Annuity Commencement Date
[$10,000] [Life 10 Year Certain] [January 1, 2053]
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Separate Account(s) Contract Number
[Separate Account B ] [123456]
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[Values for other payment periods, ages, or joint life combinations are
available on request. Monthly payments are shown for each $1,000 applied.
TABLE FOR INCOME FOR A FIXED PERIOD
Fixed Period Monthly Fixed Period Monthly Fixed Period Monthly
of Years Income of Years Income of Years Income
------------ -------- ------------ ------- ------------ -------
11 $8.88 21 $5.33
2 $42.96 12 8.26 22 5.16
3 29.06 13 7.73 23 5.00
4 22.12 14 7.28 24 4.85
5 17.95 15 6.89 25 4.72
6 15.18 16 6.54 26 4.60
7 13.20 17 6.24 27 4.49
8 11.71 18 5.98 28 4.38
9 10.56 19 5.74 29 4.28
10 9.64 20 5.53 30 4.19
TABLE FOR INCOME FOR LIFE
Male/Female Male/Female Male/Female
Age 10 Years Certain 20 Years Certain Refund Certain
- --- ---------------- ---------------- --------------
50 $4.53/4.19 $4.38/4.13 $4.40/4.12
55 4.93/4.52 4.68/4.40 4.74/4.42
60 5.45/4.96 4.99/4.72 5.16/4.79
65 6.11/5.52 5.30/5.07 5.75/5.29
70 6.91/6.26 5.54/5.40 6.52/5.97
75 7.79/7.18 5.68/5.62 7.33/6.74
80 8.61/8.18 5.75/5.73 8.61/7.90
85 & Over 9.24/9.01 5.77/5.76 10.43/9.50]
GA-IA-1008-04/95 3F
INTRODUCTION TO THIS CONTRACT
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THE CONTRACT
This is a legal Contract between you and us. We provide benefits as stated
in this Contract. In return, you supply us with the Initial Premium Payment
required to put this Contract in effect.
This Contract, together with any Riders or Endorsements, constitutes the
entire Contract. Riders and endorsements add provisions or change the terms
of the basic Contract.
THE OWNER
You are the Owner of this Contract. You are also the Annuitant unless
another Annuitant has been named in the application and is shown in the
Schedule. You have the rights and options described in this Contract,
including but not limited to the right to receive the Annuity Benefits on
the Annuity Commencement Date.
One or more people may own this Contract. If there are multiple Owners
named, the age of the oldest Owner shall be used to determine the
applicable death benefit. In the case of a sole Owner who dies prior to the
Annuity Commencement Date, we will pay the Beneficiary the death benefit
then due. If the sole Owner is not an individual, we will treat the
Annuitant as Owner for the purpose of determining when the Owner dies under
the death benefit provision (if there is no Contingent Annuitant), and the
Annuitant's age will determine the applicable death benefit payable to the
Beneficiary. The sole Owner's estate will be the Beneficiary if no
Beneficiary designation is in effect, or if the designated Beneficiary has
predeceased the Owner. In the case of a joint Owner of the Contract dying
prior to the Annuity Commencement Date, the surviving Owner(s) shall be
deemed as the Beneficiary(ies).
THE ANNUITANT
The Annuitant is the measuring life of the Annuity Benefits provided under
this Contract. You may name a Contingent Annuitant. The Annuitant may not
be changed during the Annuitant's lifetime.
If the Annuitant dies before the Annuity Commencement Date, the Contingent
Annuitant becomes the Annuitant. You will be the Contingent Annuitant
unless you name someone else. The Annuitant must be a natural person. If
the Annuitant dies and no Contingent Annuitant has been named, we will
allow you sixty days to designate someone other than yourself as Annuitant.
If all Owners are not individuals and, through the operation of this
provision, an Owner becomes Annuitant, we will pay the death proceeds to
the Beneficiary. If there are joint Owners, we will treat the youngest of
the Owners as the Contingent Annuitant designated, unless you elect
otherwise.
THE BENEFICIARY
The Beneficiary is the person to whom we pay death proceeds if any Owner
dies prior to the Annuity Commencement Date. See Death Benefit Proceeds for
more information. We pay death proceeds to the primary Beneficiary (unless
there are joint Owners in which case death benefit proceeds are payable to
the surviving Owner). If the primary Beneficiary dies before the Owner, the
death proceeds are paid to the contingent Beneficiary, if any. If there is
no surviving Beneficiary, we pay the death proceeds to the Owner's estate.
One or more persons may be named as primary Beneficiary or contingent
Beneficiary. In the case of more than one Beneficiary, we will assume any
death proceeds are to be paid in equal shares to the surviving
Beneficiaries. You can specify other than equal shares.
You have the right to change Beneficiaries, unless you designate the
primary Beneficiary irrevocable. When an irrevocable Beneficiary has been
designated, you and the irrevocable Beneficiary may have to act together to
exercise the rights and options under this Contract.
GA-IA-1008-04/95 4
INTRODUCTION TO THIS CONTRACT (continued)
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CHANGE OF OWNER OR BENEFICIARY
During your lifetime and while this Contract is in effect you can transfer
ownership of this Contract or change the Beneficiary. To make any of these
changes, you must send us written notice of the change in a form
satisfactory to us. The change will take effect as of the day the notice is
signed. The change will not affect any payment made or action taken by us
before recording the change at our Customer Service Center. A Change of
Owner may affect the amount of death benefit payable under this Contract.
See Proceeds Payable to Beneficiary.
GA-IA-1008-04/95 5
PREMIUM PAYMENTS AND ALLOCATION CHARGES
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INITIAL PREMIUM PAYMENT
The Initial Premium Payment is required to put this Contract in effect. The
amount of the Initial Premium Payment is shown in the Schedule.
ADDITIONAL PREMIUM PAYMENT OPTION
You may make additional premium payments under this Contract after the end
of the free look period. Restrictions on additional premium payments, such
as the Attained Age of the Annuitant or Owner and the timing and amount of
each payment, are shown in the Schedule. We reserve the right to defer
acceptance of or to return any additional premium payments.
As of the date we receive and accept your additional premium payment:
(1) The Accumulation Value will increase by the amount of the premium
payment less any premium deductions as shown in the Schedule.
(2) The increase in the Accumulation Value will be allocated among
the Separate and General Account Divisions in accordance with
your instructions. If you do not provide such instructions,
allocation will be among the Separate and General Account
Divisions in proportion to the amount of Accumulation Value in
each Division as of the date we receive and accept your
additional premium payment. Some General Account Divisions may
have restrictions on allocations. See the Schedule.
Where to Make Payments
Remit the premium payments to our Customer Service Center at the address
shown on the cover page. On request we will give you a receipt signed by
our treasurer.
YOUR RIGHT TO CHANGE ALLOCATION OF ACCUMULATION VALUE
You may change the allocation of the Accumulation Value among the Divisions
after the end of the free look period. The number of free allocation
changes each year that we will allow is shown in the Schedule. To make an
allocation change, you must provide us with satisfactory notice at our
Customer Service Center. The change will take effect when we receive the
notice. Some General Account Divisions may have restrictions on
reallocations. See the Schedule.
WHAT HAPPENS IF A SEPARATE ACCOUNT DIVISION IS NOT AVAILABLE
When a distribution is made from an investment portfolio supporting a unit
investment trust Separate Account Division or from a Division of a managed
Separate Account in which reinvestment is not available, we will allocate
the distribution to the Specially Designated Division shown in the Schedule
unless you specify otherwise.
Such a distribution may occur when an investment portfolio or Division
matures, when distribution from a portfolio or Division cannot be
reinvested in the portfolio or Division due to the unavailability of
securities, or for other reasons. When this occurs because of maturity, we
will send written notice to you thirty days in advance of such date. To
elect an allocation to other than the Specially Designated Division shown
in the Schedule, you must provide satisfactory notice to us at least seven
days prior to the date the investment matures. Such allocations will not be
counted as an allocation change of the Accumulation Value for purposes of
the number of free allocations permitted.
GA-IA-1008-04/95 6
HOW WE MEASURE THE CONTRACT'S ACCUMULATION VALUE
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The variable Annuity Benefits under this Contract are provided through
investments which may be made in our Separate Accounts.
THE SEPARATE ACCOUNTS
These accounts, which are designated in the Schedule, are kept separate
from our General Account and any other Separate Accounts we may have. They
are used to support Variable Annuity Contracts and may be used for other
purposes permitted by applicable laws and regulations. We own the assets in
the Separate Accounts. Assets equal to the reserves and other liabilities
of the accounts will not be charged with liabilities that arise from any
other business we conduct; but, we may transfer to our General Account
assets which exceed the reserves and other liabilities of the Separate
Accounts. Xxxxxx and realized and unrealized gains or losses from assets in
these Separate Accounts are credited to or charged against the account
without regard to other income, gains or losses in our other investment
accounts.
One type of Separate Account will invest in mutual funds, unit investment
trusts and other investment portfolios which we determine to be suitable
for this Contract's purposes. This Separate Account is treated as a unit
investment trust under Federal securities laws. It is registered with the
Securities and Exchange Commission ("SEC") under the Investment Company Act
of 1940. This Separate Account is also governed by state law as designated
in the Schedule. The trust may offer non-registered series.
Another type of Separate Account will invest directly in portfolio
securities deemed appropriate by the investment adviser or the committee
managing a Separate Account. This Separate Account is treated as an open
end, diversified management investment company under Federal securities
laws. It is registered with the SEC under the Investment Company Act of
1940. This Separate Account is also governed by state laws as designated in
the Schedule. We may offer certain non-registered Series or Separate
Accounts. Any such Series or Separate Account is shown in the Schedule.
Separate Account Divisions
A unit investment trust Separate Account includes Divisions, each investing
in a designated investment portfolio. The Divisions and the investment
portfolios in which they invest, if applicable, are specified in the
Schedule. Some of the portfolios designated may be managed by a separate
investment adviser. Such adviser may be registered under the Investment
Advisers Act of 1940.
A managed Separate Account includes Divisions, each investing directly in
portfolios of securities designed to meet the objectives of the Division.
The Divisions, if applicable, and their objectives are specified in the
Schedule. Some of the Divisions designated may be managed by a separate
investment adviser. Such adviser may be registered under the Investment
Advisers Act of 1940.
Changes Within the Separate Accounts
We may, from time to time, make additional Separate Account Divisions
available to you. These Divisions will invest in investment portfolios we
find suitable for this Contract. We also have the right to eliminate
Divisions from a Separate Account, to combine two or more Divisions or to
substitute a new portfolio for the portfolio in which a Division invests. A
substitution may become necessary if, in our judgment, a portfolio or
Division no longer suits the purposes of this Contract. This may happen due
to a change in laws or regulations, or a change in a portfolio's investment
objectives or restrictions, or because the portfolio or Division is no
longer available for investment, or for some other reason. We will get
prior approval from the insurance department of our state of domicile
before making such a substitution. This approval process is on file with
the insurance department of the jurisdiction in which this Contract is
delivered. We will also get any required approval from the SEC and any
other required approvals before making such a substitution.
Subject to any required regulatory approvals, we reserve the right to
transfer assets of the Separate Account, which we determine to be
associated with the class of Contracts to which this Contract belongs, to
another Separate Account or Division.
GA-IA-1008-04/95 7
HOW WE MEASURE THE CONTRACT'S ACCUMULATION VALUE (continued)
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When permitted by law, we reserve the right to:
(1) deregister a Separate Account under the Investment Company Act of
1940;
(2) operate a Separate Account as a management company under the
Investment Company Act of 1940, if it is operating as a unit
investment trust;
(3) operate a Separate Account as a unit investment trust under the
Investment Company Act of 1940, if it is operating as a managed
Separate Account;
(4) restrict or eliminate any voting rights of Owners, or other
persons who have voting rights as to a Separate Account; and,
(5) combine a Separate Account with other Separate Accounts.
THE GENERAL ACCOUNT
The General Account contains all assets of the company other than those in
the Separate Accounts we establish. The General Account Divisions available
for investment are shown in the Schedule. We may, from time to time, offer
other Divisions where assets are held in our General Account.
VALUATION PERIOD
Each Division will be valued at the end of each Valuation Period on a
Valuation Date. A Valuation Period is each Business Day together with any
non-Business Days before it. A Business Day is any day the New York Stock
Exchange (NYSE) is open for trading, and the SEC requires mutual funds,
unit investment trusts, or other investment portfolios to value their
securities.
ACCUMULATION VALUE
The Accumulation Value of this Contract is the sum of the amounts in each
of the Separate and General Account Divisions. You select the Separate and
General Account Divisions to which to allocate the Accumulation Value. The
maximum number of Divisions to which the Accumulation Value may be
allocated at any one time is shown in the Schedule.
ACCUMULATION VALUE IN EACH DIVISION
On the Contract Date
On the Contract Date, the Accumulation Value is allocated to each Division
as shown in the Schedule.
On each Valuation Date
At the end of each subsequent Valuation Period, the amount of Accumulation
Value in each Division will be calculated as follows:
(1) We take the Accumulation Value in the Division at the end of the
preceding Valuation Period.
(2) We multiply (1) by the Division's Net Rate of Return for the
current Valuation Period.
(3) We add (1) and (2).
(4) We add to (3) any additional premium payments (less any premium
deductions as shown in the Schedule) allocated to the Division
during the current Valuation Period.
(5) We add or subtract allocations to or from that Division during
the current Valuation Period.
(6) We subtract from (5) any Partial Withdrawals which are allocated
to the Division during the current Valuation Period.
GA-IA-1008-04/95 8
HOW WE MEASURE THE CONTRACT'S ACCUMULATION VALUE (continued)
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(7) We subtract from (6) the amounts allocated to that Division for:
(a) any charges due for Optional Benefit Riders as shown in the
Schedule;
(b) any Contract fees as shown in the Schedule;
All amounts in (7) are allocated to each Division in the proportion that
(6) bears to the Accumulation Value unless the Charge Deduction Division
has been specified (See the Schedule).
MEASUREMENT OF INVESTMENT EXPERIENCE
Index of Investment Experience
The Investment Experience of a Separate Account Division is determined on
each Valuation Date. We use an Index to measure changes in each Division's
experience during a Valuation Period. We set the lndex at $10 when the
first investments in a Division are made. The Index for a current Valuation
Period equals the Index for the preceding Valuation Period multiplied by
the Experience Factor for the current Valuation Period.
How We Determine the Experience Factor
For Divisions of a unit investment trust Separate Account the Experience
Factor reflects the Investment Experience of the portfolio in which the
Division invests as well as the charges assessed against the Division for a
Valuation Period. The factor is calculated as follows:
(1) We take the net asset value of the portfolio in which the
Division invests at the end of the current Valuation Period.
(2) We add to (1) the amount of any dividend or capital gains
distribution declared for the investment portfolio and reinvested
in such portfolio during the current Valuation Period. We
subtract from that amount a charge for our taxes, if any.
(3) We divide (2) by the net asset value of the portfolio at the end
of the preceding Valuation Period.
(4) We subtract the daily Mortality and Expense Risk Charge for each
Division shown in the Schedule for each day in the Valuation
Period.
(5) We subtract the daily Asset Based Administrative Charge shown in
the Schedule for each day in the Valuation Period.
For Divisions of a managed Separate Account which invest directly in
portfolio securities the Experience Factor reflects the Investment
Experience of the Division as well as the charges assessed against the
Division. The factor is calculated as follows:
(1) Take the value of the assets in the Division at the end of the
preceding Valuation Period.
(2) Add to (1) any investment income and capital gains, realized or
unrealized, credited to the assets during the current Valuation
Period.
(3) Subtract from (2) any capital losses, realized or unrealized,
charged against the assets during the current Valuation Period.
(4) Subtract from (3) any amount charged against the Division for any
taxes.
(5) Divide (4) by the value of the assets in the Division at the end
of the preceding Valuation Period.
(6) Subtract from (5) a daily charge for operating expenses actually
incurred.
(7) Subtract from (6) the daily charge for investment advice for each
day in the Valuation Period as shown in the Schedule.
(8) Subtract from (7) the daily charge for mortality and expense
risks for each day in the Valuation Period as shown in the
Schedule.
(9) Subtract from (8) the daily Asset Based Administrative Charge for
each day in the Valuation Period as shown in the Schedule.
Calculations for Divisions investing in mutual fund portfolios are made on
a per share basis. Calculations for Divisions investing in unit investment
trusts are on a per unit basis.
GA-IA-1008-04/95 9
HOW WE MEASURE THE CONTRACT'S ACCUMULATION VALUE (continued)
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Net Rate of Return for a Separate Account Division
The Net Rate of Return for a Separate Account Division during a Valuation
Period is the Experience Factor for that Valuation Period minus one.
Net Rate of Return for a General Account Division
The Net Rate of Return for a General Account Division during a Valuation
Period is the rate for the number of days in the Valuation Period
equivalent to the effective annual rate declared for that Division.
CHARGES DEDUCTED FROM ACCUMULATION VALUE ON EACH CONTRACT PROCESSING DATE
Expense charges and fees are shown in the Schedule.
Charge Deduction Division Option
We will deduct all charges against the Accumulation Value of this Contract
from the Charge Deduction Division if you elected this Option on the
application (see the Schedule) We will deduct these charges proportionately
from all of the Divisions in which you are invested if you did not elect
this Option or if the charges are greater than the amount in the Charge
Deduction Division.
At any time while this Contract is in effect, you may change your election
of this Option. To do this you must send us a written request to our
Customer Service Center. Any change will take effect within seven days of
the date we receive your request.
GA-IA-1008-04/95 10
YOUR CONTRACT BENEFITS
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While this Contract is in effect, there are important rights and benefits
that are available to you. We discuss these rights and benefits in this
section.
CASH VALUE BENEFIT
Cash Surrender Value
The Cash Surrender Value, while the Annuitant is living and before the
Annuity Commencement Date, is determined as follows:
(1) We take the Contract's Accumulation Value;
(2) We deduct any Surrender Charges;
(3) We deduct any charges shown in the Schedule that have been
incurred but not yet deducted, including:
(a) any first year administrative fee that has not yet been
deducted;
(b) any quarterly administrative fee to be deducted on the next
Contract Processing Date;
(c) the pro rata part of any charges for Optional Benefit
Riders; and
(d) any applicable premium or similar tax.
Cancelling to Receive the Cash Surrender Value
At any time while the Annuitant is living and before the Annuity
Commencement Date, you may surrender this Contract to us. To date this, you
must return this Contract with a signed request for cancellation to our
Customer Service Center.
The Cash Surrender Value will vary daily. We will determine the Cash
Surrender Value as of the date we receive the Contract and your signed
request in our Customer Service Center. All benefits under this Contract
will then end.
We will usually pay the Cash Surrender Value within seven days; but, we may
delay payment as described in the Payments We May Defer provision.
PARTIAL WITHDRAWAL OPTION
After the first Contract Anniversary, you may make a Partial Withdrawal
once in each Contract Year without incurring a Partial Withdrawal Charge.
Any additional Partial Withdrawals in a Contract Year are subject to a
Partial Withdrawal Charge. The minimum amount that may be withdrawn is
shown in the Schedule. The maximum amount that may be withdrawn is
determined by multiplying the Cash Surrender Value by the maximum
withdrawal percentage factor shown in the Schedule. Any withdrawal you make
will not be treated as premium only for the purposes of calculating the
deferred charges against the Accumulation Value. To take a Partial
Withdrawal, you must provide us with satisfactory notice at our Customer
Service Center.
PROCEEDS PAYABLE TO THE BENEFICIARY
Prior to the Annuity Commencement Date
If the sole Owner dies prior to the Annuity Commencement Date, we will pay
the Beneficiary the death benefit. If there are joint Owners and any Owner
dies, we will pay the surviving Owners the death benefit. We will pay the
amount on receipt of due proof of the Owner's death at our Customer Service
Center. Such amount may be received in a single ]ump sum or applied to any
of the Annuity Options (see Choosing an Income Plan). When the Owner (or
all Owners where there are joint Owners) is not an individual, the death
benefit will become payable on the death of the Annuitant prior to the
Annuity Commencement Date (unless a Contingent Annuitant survived the
Annuitant). Only one death benefit is payable under this Contract. In all
events, distributions under the Contract must be made as required by
applicable law.
GA-IA-1008-04/95 11
YOUR CONTRACT BENEFITS (continued)
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How to Claim Payments to Beneficiary
We must receive proof of the Owner's (or Annuitant's) death before we will
make any payments to the Beneficiary. We will calculate the death benefit
as of the date we receive due proof of death. The Beneficiary should
contact our Customer Service Center for instructions.
Guaranteed Death Benefit
On the Contract Date the Guaranteed Death Benefit is equal to the premium
paid. On subsequent Valuation Dates, the Guaranteed Death Benefit is
calculated as shown in the Schedule. A Change of Owner will affect the
Guaranteed Death Benefit, as shown in the Schedule.
GA-IA-1008-04/95 12
CHOOSING AN INCOME PLAN
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ANNUITY BENEFITS
If the Annuitant and Owner are living on the Annuity Commencement Date, we
will begin making payments to the Owner. We will make these payments under
the Annuity Option (or Options) as chosen in the application or as
subsequently selected. You may choose or change an Annuity Option by making
a written request at least 30 days prior to the Annuity Commencement Date.
Unless you have chosen otherwise, Option 2 on a 10 year period certain
basis will become effective. The amount of the payments will be determined
by applying the Accumulation Value on the Annuity Commencement Date in
accordance with the Annuity Options section below (See Payments We May
Defer). Before we pay any Annuity Benefits, we require the return of this
Contract. If this Contract has been lost, we require the applicable lost
Contract form.
ANNUITY COMMENCEMENT DATE SELECTION
You select the Annuity Commencement Date. You may select any date following
the third Contract Anniversary but before the required date of Xxxxxxx
Commencement as shown in the Schedule. If you do not select a date, the
Annuity Commencement Date will be in the month following the required date
of Annuity Commencement.
FREQUENCY SELECTION
You choose the frequency of the Annuity Payments. They may be monthly,
quarterly, semi-annually, or annually. If we do not receive written notice
from you, the payments will be made monthly.
THE INCOME PLAN
While this Contract is in effect and before the Annuity Commencement Date,
you may choose one or more Annuity Options for the payment of death benefit
proceeds. If, at the time of the Owner's death, no Option has been chosen
for paying death benefit proceeds, the Beneficiary may choose an Option
within one year. You may also elect an Annuity Option on surrender of the
Contract for its Cash Surrender Value. For each Option we will issue a
separate written agreement putting the Option into effect.
Our approval is needed for any Option where:
(1) the person named to receive payment is other than the Owner or
Beneficiary; or
(2) the person named is not a natural person, such as a corporation;
or
(3) any income payment would be less than the minimum annuity income
payment shown in the Schedule.
THE ANNUITY OPTIONS
There are four Options to choose from. They are:
Option 1. Income for a Fixed Period
Payment is made in equal installments for a fixed number of years. We
guarantee each monthly payment will be at least the Income For Fixed Period
amount shown in the Schedule. Values for annual, semiannual or quarterly
payments are available on request.
Option 2. Income for Life
Payment is made to the person named in equal monthly installments and
guaranteed for at least a period certain. The period certain can be 10 or
20 years. Other periods certain are available on request. A refund certain
may be chosen instead. Under this arrangement, income is guaranteed until
payments equal the amount applied. If the person named lives beyond the
guaranteed period, payments continue until his or her death.
We guarantee each payment will be at least the amount shown in the
Schedule. By age, we mean the named person's age on his or her last
birthday before the Option's effective date. Amounts for ages not shown are
available on request.
GA-IA-1008-04/95 13
CHOOSING AN INCOME PLAN (continued)
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Option 3. Joint Life Income
This Option is available if there are two persons named to receive
payments. At least one of the persons named must be either the Owner or
Beneficiary of this Contract. Monthly payments are guaranteed and are made
as long as at least one of the named persons is living. The monthly payment
amounts are available upon request. Such amounts are guaranteed and will be
calculated on the same basis as the Table for Income for Life, however, the
amounts will be based on two lives.
Option 4. Annuity Plan
An amount can be used to buy any single premium annuity we offer on the
Option's effective date.
PAYMENT WHEN NAMED PERSON DIES
When the person named to receive payment dies, we will pay any amounts
still due as provided by the Option agreement. The amounts still due are
determined as follows:
(1) For Option 1 or for any remaining guaranteed payments in Option
2, payments will be continued. Under Options 1 and 2, the
discounted values of the remaining guaranteed payments may be
paid in a single sum. This means we deduct the amount of the
interest each remaining guaranteed payment would have earned had
it not been paid out early. The discount interest rate is 3.00%
for Option 1 and 3.50% for Option 2. We will however, base the
discount interest rate on the interest rate used to calculate the
payments for Options 1 and 2 if such payments were not based on
the Tables in this Contract.
(2) For Option 3, no amounts are payable after both named persons
have died.
(3) For Option 4, the annuity agreement will state the amount due, if
any.
GA-IA-1008-04/95 14
OTHER IMPORTANT INFORMATION
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SENDING NOTICE TO US
Whenever written notice is required, send it to our Customer Service
Center. The address of our Customer Service Center is shown on the cover
page. Please include your Contract number in all correspondence.
REPORTS TO OWNER
We will send you a report within 31 days of each calendar quarter. The
report will show the Accumulation Value and the Cash Surrender Value as of
the end of the Contract Processing Period. The report will also show the
allocation of the Accumulation Value as of such date and the amounts
deducted from or added to the Accumulation Value since the last report. The
report will also include any other information that may be currently
required by the insurance supervisory official of the jurisdiction in which
this Contract is delivered.
We will also send you copies of any shareholder reports of the portfolios
in which the Divisions of the Separate Accounts invest, as well as any
other reports, notices or documents required by law to be furnished to
Contractowners.
ASSIGNMENT - USING THIS CONTRACT AS COLLATERAL SECURITY
You can assign this Contract as collateral security for a loan or other
obligation. This does not change the ownership. Your rights and any
Beneficiary's rights are subject to the terms of the assignment. To make or
release an assignment, we must receive written notice satisfactory to us,
at our Customer Service Center. We are not responsible for the validity of
any assignment.
CHANGING THIS CONTRACT
This Contract or any additional Benefit Riders may be changed to another
Annuity Plan according to our rules at the time of the change.
CONTRACT CHANGES - APPLICABLE TAX LAW
We reserve the right to make changes in this Contract or its Riders to the
extent we deem it necessary to continue to qualify this Contract as an
annuity. Any such changes will apply uniformly to all Contracts that are
affected. You will be given advance written notice of such changes.
MISSTATEMENT OF AGE OR SEX
If an age or sex has been misstated, the amounts payable or benefits
provided by this Contract shall be those that the premium payment made
would have bought at the correct age or sex.
NON-PARTICIPATING
This Contract does not participate in the divisible surplus of Golden
American Life Insurance Company.
GA-IA-1008-04/95 15
OTHER IMPORTANT INFORMATION (continued)
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PAYMENTS WE MAY DEFER
We may not be able to determine the value of the assets of the Separate
Account Divisions because:
(1) The NYSE is closed for trading;
(2) the SEC determines that a state of emergency exists; or
(3) an order or pronouncement of the SEC permits a delay for the
protection of Contractowners.
(4) the check used to pay the premium has not cleared through the
banking system. This may take up to 15 days.
During such times, as to amounts allocated to the Divisions of the Separate
Account, we may delay:
(1) determination and payment of the Cash Surrender Value;
(2) determination and payment of any death benefit if death occurs
before the Annuity Commencement Date;
(3) allocation changes of the Accumulation Value; or,
(4) application of the Accumulation Value under an income plan.
As to amounts allocated to a General Account Division, we may, at any time,
defer payment of the Cash Surrender Value for up to six months after we
receive a request for it. We will allow interest of at least 3.00% a year
on any Cash Surrender Value payment derived from the General Account
Divisions that we defer 30 days or more.
AUTHORITY TO MAKE AGREEMENTS
All agreements made by us must be signed by one of our officers. No other
person, including an insurance agent or broker, can:
(1) change any of this Contract's terms;
(2) extend the time for premium payments; or
(3) make any agreement binding on us.
REQUIRED NOTE ON OUR COMPUTATIONS
We have filed a detailed statement of our computations with the insurance
supervisory official in the jurisdiction where this Contract is delivered.
The values are not less than those required by the law of that state or
jurisdiction. Any benefit provided by an attached Optional Benefit Rider
will not increase these values unless otherwise stated in that Rider.
GA-IA-1008-04/95 16
GOLDEN
[LOGO] AMERICAN Section 72 Rider
LIFE INSURANCE
COMPANY
A Subsidiary of [LOGO] Bankers Trust Company
Golden American is a stock company domiciled in Wilmington, Delaware
- -----------------------------------------------------------------------------
Required Distribution of Proceeds on Death of Owner
This Rider is required to qualify the Contract to which it is attached as
an annuity contract under Section 72 of the Internal Revenue Code of 1986,
as amended (the "Code"). Where the terms of this Rider are in conflict with
the terms of the Contract, the Rider will control. Golden American Life
Insurance Company reserves the right to amend or administer the Contract
and Rider as necessary to comply with applicable tax requirements. This
Rider and the Contract should be construed so that they comply with
applicable tax requirements.
Death of Owner On Or After Annuity Commencement Date
IF ANY OWNER DIES ON OR AFTER the Annuity Commencement Date but prior to
the time the entire interest in the Contract has been distributed, the
remaining portion will be distributed at least as rapidly as under the
method of distribution being used as of the date of the Owner's death.
Death of Owner Prior to Xxxxxxx Commencement Date
IF ANY OWNER DIES PRIOR TO the Annuity Commencement Date, the entire
interest in the Contract will be distributed within five years of the
Owner's death.
However, this distribution requirement will be considered satisfied as
to any portion of the Owner's interest in the Contract which is payable to
or for the benefit of a Designated Beneficiary and which will be
distributed over the life of such Designated Beneficiary or over a period
not extending beyond the life expectancy of that Designated Beneficiary,
provided such distributions begin within one year of the Owner's death. If
the Designated Beneficiary is the surviving spouse of the decedent, the
Contract may be continued in the name of the spouse as Owner and these
distribution rules are applied by treating the spouse as the Owner.
However, on the death of the surviving spouse, this provision regarding
spouses may not be used again.
If any Owner is not an individual, the death or change (where
permitted) of the Annuitant will be treated as the death of an Owner.
The Designated Beneficiary is the person entitled to ownership rights
under the Contract. Thus, where no death benefit has become payable, the
Designated Beneficiary, for the purposes of applying this Rider, will be
the Owner(s). Where a death benefit has become payable, the Designated
Beneficiary, for the purposes of applying this Rider, is the person(s)
entitled to the death benefit, generally the Beneficiary or surviving
Owners, as appropriate. Upon the death of any Owner, the Designated
Beneficiary will become the Owner and, if an individual, will become the
Annuitant.
* * *
An Owner may notify Golden American as to the manner of payment under this
Rider. If such Owner has not so notified Golden American prior to his or
her death, the Designated Beneficiary under the Contract may so notify
Golden American.
GOLDEN AMERICAN LIFE INSURANCE COMPANY
President /s/Xxxx X. Xxxxxxx Secretary
GA-RA-1001-12/94
GOLDEN
[LOGO] AMERICAN Waiver of Surrender Charge Rider
LIFE INSURANCE
COMPANY
A Subsidiary of [LOGO] Bankers Trust Company
Golden American is a stock company domiciled in Wilmington, Delaware
- -----------------------------------------------------------------------------
Golden American Life Insurance Company ("we" or "us") will waive any
Surrender Charge incurred due to a surrender or Excess Partial Withdrawal
under the Contract in the event the Owner ("you") is subject to Qualified
Extended Medical Care or suffers from a Qualifying Terminal Illness subject
to the terms and conditions stated below:
Extended Medical Care
To qualify for this waiver, you must first begin receiving Qualified
Extended Medical Care on or after the first Contract Anniversary for at
least 45 days during any continuous sixty-day period, and your request for
the surrender or withdrawal, together with proof of such Qualified Extended
Medical Care, must be received at our Customer Service Center during the
term of such care or within ninety days after the last day upon which your
received such care.
"Qualified Extended Medical Care" means confinement in a Qualified
Licensed Hospital or Nursing Care Facility prescribed by a Qualifying
Medical Professional.
"Qualifying Licensed Hospital or Nursing Care Facility" means a
state-licensed hospital or state-licensed skilled or intermediate care
nursing facility at which medical treatment is available on a daily basis;
and daily medical records are kept on each patient. This does not include a
facility whose purpose is to provide accommodations, board or personal care
services to individuals who do not need medical or nursing care; nor a
place mainly for rest.
"Qualifying Medical Professional" means a legally-qualified
practitioner of the healing arts who is acting within the scope of hls or
her license; is not a resident of your household or that of the Annuitant;
and is not related to you or the Annuitant by blood or marriage.
Terminal Illness
To qualify for this waiver, you must be first diagnosed by a
Qualifying Medical Professional, on or after the first Contract
Anniversary, as having a Qualifying Terminal Illness. Written proof of
terminal illness, satisfactory to us, must be received at our Customer
Service Center. We reserve the right to require an examination by a
physician of our choice.
"Qualifying Terminal Illness" means an illness or accident, the result
of which results in a life expectancy of twelve months or less, as measured
from the date of diagnosis.
Claims
Evidence, satisfactory to us, must be submitted to qualify for waiver
of Surrender Charge pursuant to this Rider. This evidence will be in
writing and, where applicable, be attested to by a Qualified Medical
Professional.
This Rider is attached to and becomes part of the Contract to which it
is attached. The provisions of this Rider shall supersede the provisions of
the Contract where applicable.
GOLDEN AMERICAN LIFE INSURANCE COMPANY
President /s/Xxxx X. Xxxxxxx Secretary
GA-RA-1004-12/94
DEFERRED VARIABLE ANNUITY CONTRACT - NO DIVIDENDS
Variable Cash Surrender Values while the Annuitant and Owner are living and
prior to the Annuity Commencement Date. Death benefit subject to guaranteed
minimum. Additional Premium Payment Option. Partial Withdrawal Option.
Non-participating. Investment results reflected in values.
GA-IA-1008-04/95
