Contract

Contract Data Page

CONTRACT DATA PAGE

 

Contract Number:  [P9999999999]    Contract Date:  [May 2, 2014]

 

Owner:  [JOHN DOE]    [Date of Birth:  [March 1, 1976]    Age at Issue:  [38]]
[Owner:  [JANE DOE]    Date of Birth:  [June 10, 1976]    Age at Issue:  [37]]
Annuitant:  [JOHN DOE]    Date of Birth:  [March 1, 1976]    Age at Issue:  [38]
[Annuitant:  [JANE DOE]    Date of Birth:  [June 10, 1976]    Age at Issue:  [37]]

Beneficiary: As named by You

Initial Purchase Payment: [$25,000.00]

Maximum Purchase Payment Without Our Approval:  [$1,000,000]

Purchase Payment Age Limit:  [Prior to the 86th birthday]

Minimum Subsequent Purchase Payment: [$500]

Fixed Account Option(s) Minimum Guaranteed Interest Rate:  [1.0% - 3.0%]

Minimum Partial Withdrawal Amount:  [$1,000]

Maximum Penalty-Free Withdrawal Percentage:  [10%]

Minimum Systematic Withdrawal Amount:  [$100]

Minimum Amount Remaining After Any Partial Withdrawal:  [$2,500]

Withdrawal Charge Schedule:

 

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See Page [11] for Withdrawal Provisions.

 

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CONTRACT DATA PAGE (Cont’d.)

[Premium Tax: None]

Minimum Transfer Amount:  [$100]

Separate Account Charge  [(including guaranteed death benefit risk charge of [0.10%])]:

 

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Annual Contract Maintenance Fee:  [$50]

Transfer Fee:  [$25]

Earliest Annuity Date After the Contract Date:  [Two years]

Latest Annuity Date:  [1st day of the month following Your 95th Birthday]

Separate Account:  [Variable Separate Account]

 

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