ailife[LOGO](R) AMERICAN INTERNATIONAL LIFE ASSURANCE
COMPANY OF NEW YORK
HOME OFFICE: 00 XXXX XXXXXX
XXX XXXX, XXX XXXX 00000
(000) 000-0000
--------------------------------------------------------------------------------
This is a legal contract issued in consideration of the payment of the Initial
Premium. We will make annuity payments as set forth in this certificate
beginning on the Annuity Date.
READ YOUR CERTIFICATE CAREFULLY
RIGHT TO CANCEL THIS CERTIFICATE
This certificate may be returned within (a) 10 days after You receive it; or (b)
60 days after You receive it if You have indicated on Your application that this
policy will replace other insurance. It can be mailed or delivered to either Us
or Our agent. Return of this certificate by mail is effective as of the date of
its postmark, properly addressed and postage pre-paid. The returned certificate
will be treated as if We had never issued it. We will promptly refund the
Contract Value and any fees paid for Premium allocated to the Variable Account
(this may be more or less than Premium paid) and Premium plus earnings for
Premium allocated to the Guaranteed Account.
This is a variable annuity certificate. Annuity payments and Contract Value may
increase or decrease depending on the experience of the Variable Account
identified in the Contract Schedule.
The assets of the Variable Account must earn a minimum annual rate of 6.4% so
that the dollar amount of the variable annuity payments will not decrease below
the level shown in the Options On A Variable Basis Table on page 16.
Signed by the Company:
/s/ Xxxxxxxxx X. Xxxx /s/ [ILLEGIBLE]
Secretary President
CERTIFICATE OF COVERAGE
FLEXIBLE PREMIUM DEFERRED VARIABLE ANNUITY
NONPARTICIPATING
TABLE OF CONTENTS
PAGE
CONTRACT SCHEDULE 3
DEFINITIONS 4
GENERAL PROVISIONS 5
OWNERSHIP PROVISIONS 6
BENEFICIARY PROVISIONS 6
PREMIUM PROVISIONS 7
CERTIFICATE CHARGES 7
VARIABLE ACCOUNT 8
GUARANTEED ACCOUNT 8
TRANSFERS 9
DOLLAR COST AVERAGING 10
AUTOMATIC ASSET REBALANCING 10
ANNUITY PROVISIONS 11
ANNUITY OPTIONS 11
DEATH BENEFIT 13
SURRENDER PROVISIONS 14
SYSTEMATIC SURRENDERS 14
DELAY OF PAYMENTS 15
FIXED ANNUITY OPTION TABLES 16
VARIABLE ANNUITY OPTION TABLES 17
2
CONTRACT SCHEDULE
GROUP CONTRACTHOLDER: AIG Life Insurance Company Trust
GROUP CONTRACT NUMBER: 1234 INITIAL PREMIUM: $5,000
CERTIFICATE NUMBER: 5678 MINIMUM SUBSEQUENT PREMIUM: [$1,000]
OWNER: XXXX XXX EFFECTIVE DATE: August 1, 2001
JOINT OWNER: XXXX XXX ANNUITY DATE: August 1, 2031
ANNUITANT: XXXX XXX
CERTIFICATE MAINTENANCE CHARGE: $30.00 each Contract Year. Before the Annuity
Date, this charge will be waived for each year that the Contract Value exceeds
$50,000 on the Contract Anniversary.
ADMINISTRATIVE CHARGE: Equal on an annual basis to 0.15% of the average daily
net assets of the Variable Account.
MORTALITY AND EXPENSE RISK CHARGE: Equal on an annual basis to 1.25% of the
average daily net assets of the Variable Account.
TRANSFER FEE: $ 10.00 per transfer. However, We will not make a charge for the
first 12 transfers in any Contract Year.
[ANNUAL RATCHET RIDER CHARGE: Equal on an annual basis to 0.10% of the net
assets of the Variable Account; this charge will be calculated and deducted
monthly.]
SEPARATE ACCOUNT: Variable Account A
ANNUITY SERVICE OFFICE:
American International Life Assurance Company of New York
c/o Delaware Valley Financial Services
000 Xxxxxx Xxxx
P.O. Box 3031
Berwyn, PA 19312-0031
(000) 000-0000
3
================================================================================
DEFINITIONS
ACCUMULATION UNIT - An accounting unit of measure used to calculate the Contract
Value prior to the Annuity Date.
ADMINISTRATIVE OFFICE - The Annuity Service Office of the Company as designated
on the Contract Schedule.
ANNUITANT - The person designated by the Owner upon whose continuation of life
any annuity payment involving life contingencies depends.
ANNUITY DATE - The date on which annuity payments are to commence.
ANNUITY OPTION - An arrangement under which annuity payments are made under this
certificate.
ANNUITY UNIT - An accounting unit of measure used to calculate annuity payments
after the Annuity Date.
BENEFICIARY - The person(s) who is(are) entitled to the Death Benefit of this
certificate when there is no surviving Owner or the person(s) who is(are)
entitled to receive the remaining annuity payments, if any, when the Annuitant
dies after the Annuity Date.
CONTRACT ANNIVERSARY - An anniversary of the Effective Date of this certificate.
CONTRACT VALUE - The dollar value as of any Valuation Date of all amounts
accumulated under this certificate.
CONTRACT YEAR - Each period of twelve (12) months commencing with the Effective
Date of this certificate.
EFFECTIVE DATE - The date shown on the Contract Schedule on which the first
Contract Year begins for this certificate.
ELIGIBLE INVESTMENT(S) - Those investments available under the certificate.
Eligible Investments, at the time this certificate is issued, are shown in the
application for this Certificate.
GUARANTEED ACCOUNT - A part of Our General Account which earns a Guaranteed Rate
of interest.
JOINT OWNER - The person named as Joint Owner on the application and listed in
the Contract Schedule, unless subsequently changed. The Joint Owner, if any,
possesses an undivided interest in this certificate in conjunction with the
Owner. All references within this certificate to Owner will apply to both the
Owner and the Joint Owner or to either of them.
OWNER - The person named as Owner on the application and listed in the Contract
Schedule, unless subsequently changed. The Owner has all rights under this
certificate.
PREMIUM - Purchase payments are referred to in this certificate as Premiums.
SUBACCOUNT - A division of the Variable Account established to invest in a
particular portfolio of Eligible Investments.
YOU, YOUR - The Owner of this certificate.
VALUATION DATE - Each day that the New York Stock Exchange is open for trading.
VALUATION PERIOD - The period between the close of business of the New York
Stock Exchange on any Valuation Date and the close of business for the next
succeeding Valuation Date.
VARIABLE ACCOUNT - The Separate Account designated on the Contract Schedule.
WE, OUR, US - American International Life Assurance Company of New York.
WRITTEN REQUEST - A request made in a form satisfactory to Us and either signed
by You or confirmed by Us in writing to You. A Written Request takes effect when
received and recorded at Our Administrative Office unless specifically noted as
otherwise within this certificate.
4
================================================================================
GENERAL PROVISIONS
THE CONTRACT - The entire contract consists of the group contract, this
certificate and any attached endorsement(s), rider(s) or application(s). Nothing
in the group contract invalidates or impairs any right granted to You under this
certificate. This certificate may be changed or altered only by Our President or
Secretary. Any change, modification or waiver must be made in writing.
NON-PARTICIPATION IN SURPLUS - This certificate does not share in any
distribution of Our profits or surplus.
INCONTESTABILITY - This certificate is not contestable.
MISSTATEMENT OF AGE OR SEX - We will require proof of age and sex of the
Annuitant before making any life annuity payment provided for by this
certificate. If the age or sex of the Annuitant has been misstated, the amount
payable will be the amount that the Contract Value would have provided at the
correct age or sex.
Once annuity payments have begun, any underpayments will be made up in one sum
including interest at the annual rate of 3%, unless a higher interest rate is
required by the law of the jurisdiction where this certificate is delivered,
with the next annuity payment. Overpayments including interest at the annual
rate of 3%, unless a higher interest rate is required by the law of the
jurisdiction where this certificate is delivered, will be deducted from the
future annuity payments until the total is repaid.
CERTIFICATE SETTLEMENT - This certificate must be returned to Us upon settlement
as a death claim. Prior to any settlement as a death claim, due proof of death
must be submitted to Us.
FACILITY OF PAYMENT - If any recipient is unable to give a valid receipt for a
payment made under this certificate, We may make payments to the person who, in
Our opinion, is caring for that recipient until claim is made by the recipient's
duly appointed guardian or other legal representative.
REPORTS - We will furnish You with a report showing the Contract Value at least
once each calendar year. This report will be sent to Your last known address.
TAXES - Any taxes, if applicable, paid to any governmental entity will be
charged against the Premiums or the Contract Value, depending upon the Owner's
state of residence. We may, at Our sole discretion, pay taxes when due and
deduct that amount from the Contract Value at a later date. Our payment of such
taxes at an earlier date does not waive any right We may have to deduct amounts
at a later date.
EVIDENCE OF SURVIVAL - Where any benefits under this certificate are contingent
upon the recipient being alive on a given date, We will require proof
satisfactory to Us that the condition has been met.
PROTECTION OF PROCEEDS - No payment under this certificate may be commuted or
assigned before it is due. To the extent permitted by law, no payments will be
subject to any creditor claim nor to any judicial process for payment of such
claim.
MODIFICATION OF CERTIFICATE - This certificate may not be modified by Us,
without Your consent except as may be required by applicable law. If the state
insurance laws or regulations, the federal securities or tax laws or
regulations, or any regulations under which this certificate would qualify as an
annuity change, We may amend this certificate to comply with these changes.
MINIMUM BENEFITS - Any paid-up annuity, cash surrender or death benefit that may
be available under this certificate is not less than the minimum benefits
required by statute in the jurisdiction in which this certificate is delivered.
CONTINUATION OF CERTIFICATE COVERAGE - If the group contract under which this
certificate is issued should terminate, coverage may be continued under this
certificate unless it is surrendered or otherwise ends in accordance with its
terms.
5
================================================================================
OWNERSHIP PROVISIONS
OWNER - The Owner and any applicable Joint Owner are named in the Contract
Schedule.
If there is an Owner and Joint Owner for this certificate, then both owners must
agree to any change in this certificate. If one Owner dies, the surviving Owner
retains all rights of this certificate. All references within this certificate
to Owner will apply to both the Owner and Joint Owner or either of them.
The Owner may exercise all the rights of this certificate, subject to the rights
of:
1. any assignee under an assignment filed with Our Administrative Office; and
2. any irrevocably named Beneficiary.
CHANGE OF OWNERSHIP - You may change Ownership of this certificate by submitting
a Written Request to Our Administrative Office. We may require this certificate
for endorsement.
Change of Ownership does not change the Beneficiary. Any change of Ownership is
subject to any payment made by Us before the request is received and recorded at
Our Administrative Office.
ASSIGNMENT - You may assign this certificate while the Annuitant is alive and
before the Annuity Date. A copy of any assignment must be filed with Our
Administrative Office. We are not responsible for the validity of any
assignment. If You assign this certificate, Your rights and those of any
Beneficiary will be subject to the assignment. An assignment will not affect any
payments We may make or actions We may take before such assignment has been
recorded at Our Administrative Office. The assignment will not be recorded until
We have received sufficient direction from the Owner and assignee as to the
proper allocation of rights under this certificate between the Owner and the
assignee.
A change in ownership or an assignment may result in adverse tax consequences.
================================================================================
BENEFICIARY PROVISIONS
BENEFICIARY - The Beneficiary is as stated on the application, unless later
changed by Your Written Request. One or more beneficiaries can be named in the
application. If more than one Beneficiary is named, each can be classed as
primary or contingent. If two or more persons are named in a class, their shares
in the proceeds can be stated. The stated shares in the proceeds will be paid to
any primary beneficiaries. If no primary beneficiaries survive, payment will be
made to any surviving contingent beneficiaries. If You have not made other
arrangements with Us, Beneficiaries who survive in the same class will share the
proceeds equally.
DEATH OF BENEFICIARY - If no named Beneficiary is living at the time a death
benefit becomes payable, We will pay the death benefit to the Owner, or, if no
Owner is alive, to the last surviving Owner's estate.
CHANGE OF BENEFICIARY - To change a Beneficiary, a Written Request for a change
of Beneficiary must be received at Our Administrative Office. If the request is
received at Our Administrative Office after the death of the Owner, it will be
effective only if no payment has been made. After the change is recorded, it
will take effect as of the date the request was signed.
6
================================================================================
PREMIUM PROVISIONS
PREMIUM - The Initial Premium is due on or before the Effective Date.
Thereafter, Premium payments may be made at any time prior to the Annuity Date,
in an amount equal to or greater than the Minimum Subsequent Premium amount,
shown on the Contract Schedule page.
ALLOCATION OF PREMIUM PAYMENTS - Premiums may be allocated to one or more of the
Subaccounts of the Variable Account or to the Guaranteed Account. Whole
percentages must be used. The allocation of the Initial Premium is shown on the
application. You may change the allocation at any time. We will send
confirmation of Your changes. Any subsequent Premium received will be allocated
in accordance with the most recently received allocation instructions.
================================================================================
CERTIFICATE CHARGES
All charges and fees shown on the Contract Schedule are the maximum amounts
which We may charge. We may, however, charge less than the maximum.
MORTALITY AND EXPENSE RISK CHARGE - We deduct a Mortality And Expense Risk
Charge equal, on an annual basis, to the amount shown on the Contract Schedule.
We guarantee that the dollar amount of each annuity payment after the first will
not be affected by variations in mortality or expense experience.
ADMINISTRATIVE CHARGE - We deduct an Administrative Charge equal, on an annual
basis, to the amount shown on the Contract Schedule. The Administrative Charge
compensates Us for some of the costs associated with the administration of this
certificate and the Variable Account.
CERTIFICATE MAINTENANCE CHARGE - We deduct an annual Certificate Maintenance
Charge shown on the Contract Schedule. The Certificate Maintenance Charge will
be deducted from the Contract Value on each Contract Anniversary while this
certificate is in force. Prior to the Annuity Date, the Certificate Maintenance
Charge will be deducted from the Contract Value by canceling Accumulation Units.
The number of Accumulation Units to be canceled from each applicable Subaccount
will be in the ratio that the value of each Subaccount bears to the total
Contract Value.
If this certificate is surrendered for its full Surrender Value on other than a
Contract Anniversary, the full Certificate Maintenance Charge due on the next
Contract Anniversary will be deducted at the time of surrender.
On and after the Annuity Date, the Certificate Maintenance Charge will be
pro-rated and collected on a monthly basis. This amount will be subtracted from
the monthly annuity payments.
7
================================================================================
VARIABLE ACCOUNT
GENERAL DESCRIPTION - The name of the Variable Account is shown in the Contract
Schedule. The assets of the Variable Account and each Subaccount are Our
property but are not chargeable with the liabilities arising out of any other
business We may conduct, except to the extent that Variable Account assets
exceed Variable Account liabilities arising under the contracts or certificates
supported by the Variable Account. The Variable Account and each Subaccount is
separate from Our General Account and any other separate account or Subaccount
We may have.
INVESTMENT ALLOCATIONS TO THE VARIABLE ACCOUNT - The Variable Account consists
of Subaccounts and each Subaccount may invest its assets in a separate class of
shares of a designated investment company or companies.
We have the right to change, add or delete designated investment companies. We
have the right to add or remove Subaccounts. We also have the right to combine
any two or more Subaccounts.
VOTING RIGHTS - To the extent required by law, We will vote the portfolio shares
held in the variable account at shareholder meetings in accordance with
instructions received from persons having a voting interest in the portfolio
VALUATION OF ASSETS - Assets within each Subaccount will be valued at their net
asset value on each Valuation Date.
CONTRACT VALUE - Premiums are allocated among the various Subaccounts within the
Variable Account. For each Subaccount, the Premiums are converted into
Accumulation Units. The number of Accumulation Units credited to the certificate
is determined by dividing the Premiums allocated to the Subaccount by the value
of the Accumulation Unit for the Subaccount. Surrenders will result in the
cancellation of Accumulation Units. The value of the certificate is the sum of
the values for the certificate within each Subaccount and the Guaranteed
Account. The value of each Subaccount is determined by multiplying the number of
Accumulation Units attributable to the Subaccount by the Accumulation Unit value
for the Subaccount, independent of the value of any other Subaccount.
ACCUMULATION UNIT VALUES - The value of an Accumulation Unit will vary in
accordance with the investment experience of the underlying portfolio in which
the Subaccount invests. The value of Accumulation Units is expected to increase
or decrease from Valuation Period to Valuation Period. The value of Accumulation
Units in each Subaccount will change daily to reflect the investment experience
of the corresponding underlying portfolio as well as the daily deduction of the
Certificate Charges. The number of Accumulation Units credited to the
certificate will not change as a result of any fluctuations in the value of an
Accumulation Unit.
================================================================================
GUARANTEED ACCOUNT
GENERAL DESCRIPTION - The Guaranteed Account is a part of Our General Account.
The amount You have in the Guaranteed Account at any time is a result of
Premiums You have allocated to it or any part of Your Contract Value you have
transferred to it.
GUARANTEE PERIODS - The portion of Your Contract Value within the Guaranteed
Account is credited with interest at rates guaranteed by Us for the Guarantee
Period(s) selected. Interest is credited on a daily basis at the then applicable
effective guaranteed interest rate for the applicable Guarantee Period. You may
select from one or more Guarantee Periods which We offer at any particular time.
We reserve the right at any time to add or delete Guarantee Periods. If You have
allocated any part of Your Initial Premium to a Guarantee Period, the amount
allocated, as well as the duration of the Guarantee Period is shown on the
Application.
The guaranteed interest rate applicable to an allocation of Premium or transfer
of Contract Value to a Guarantee Period is the rate in effect for that Guarantee
Period at the time of the allocation or transfer. If You have allocated or
transferred amounts at different times to the Guaranteed Account, each
allocation or transfer may have a unique effective guaranteed interest rate
associated with that amount. We guarantee that the effective annual rate of
interest for the Guaranteed Account,
8
including any of the Guaranteed Periods, will not be less than 3%.
9
================================================================================
TRANSFERS
During the Accumulation Period, or after the Annuity Date, provided a variable
Annuity Option was selected, You may transfer all or part of Your value, in a
Subaccount, or allocated to a Guarantee Period of the Guaranteed Account, to
another Subaccount or Guarantee Period of the Guaranteed Account. However, after
the Annuity Date no transfers may be made between a Subaccount and the
Guaranteed Account. The Transfer Fee is shown on the Contract Schedule.
All transfers are subject to the following:
1. The deduction of any Transfer Fee that may be imposed will be deducted
from the amount which is transferred. However, no Transfer Fee will be
imposed on transfers resulting from the expiration of a Guarantee Period.
2. If We have not received transfer instructions prior to the end of a
Guarantee Period in which You have Contract Value, We will automatically
transfer it to a new Guarantee Period of the same duration and under the
same restrictions as if You had requested such transfer. However, if a new
Guarantee Period of the same duration is not available, then that portion
of Your Contract Value will be transferred to the Guarantee Period next
shortest in duration.
3. The minimum amount which may be transferred is the lesser of (A) $1,000 or
(B) Your entire value in the Subaccount or in the amount allocated to a
Guarantee Period of the Guaranteed Account.
4. No partial transfer will be made if, as a result of such transfer, Your
remaining Contract Value in the Subaccount or in the amount allocated to
the Guarantee Period of the Guaranteed Account would be less than $1,000.
5. Transfers will be effected during the Valuation Period next following
receipt by Us of a Written Request containing all required information.
However, no transfer may be made effective within seven calendar days of
the date on which any annuity payment is due.
6. Any transfer request must clearly specify:
a. the amount which is to be transferred; and
b. the Subaccounts or Guarantee Periods of the Guaranteed Account which
are to be affected.
7. After the Annuity Date, transfers may not take place between a fixed
Annuity Option and a variable Annuity Option.
9
================================================================================
DOLLAR COST AVERAGING
DOLLAR COST AVERAGING - Prior to the Annuity Date, using Our Dollar Cost
Averaging Plan Request Form, You may elect automatic monthly transfers from the
Money Market Subaccount, or from the Guaranteed Account, into one or more
Subaccounts for a specified dollar amount or a specified number of months in
accordance with the following:
1. the allocation to the Subaccounts will be based on instructions provided
by You, or, if You have not specified the allocations, the allocations
will be made in accordance with the Premium allocation that is in effect
at the time of each transfer;
2. We must receive Your authorization for automatic transfers at least 10
days prior to the automatic transfer date;
3. automatic transfers will begin on the first possible transfer date
following Our receipt of Your authorization;
4. automatic transfers will occur on the 15th day of each month, or the
following business day if the 15th is not a business day; and
5. this option may be elected at any time provided there is a minimum balance
of $12,000 in Your Money Market Subaccount or the Guaranteed Account.
If You elect to transfer a specific dollar amount each month, automatic
transfers will continue until Your Money Market Subaccount or Guaranteed Account
is depleted. The last transfer may be a lesser amount. If You elect to transfer
based on a specific number of months, each month We will transfer a fraction of
the balance in Your Money Market Subaccount or Guaranteed Account equal to one
divided by the number of months remaining in the period. For example, if You
elect to transfer over a 12 month period, the first transfer will be 1/12th of
the balance in the Money Market Fund or Guaranteed Account, the second transfer
will be 1/11th of the balance, the third transfer will be 1/10th of the balance,
and so on until the end of the requested period.
Automatic monthly transfers will continue until one of the following conditions
occur:
1. the balance in the Money Market Subaccount or Guaranteed Account is
depleted;
2. We receive Your Written Request to cancel future transfers; or
3. annuity payments begin.
================================================================================
AUTOMATIC ASSET REBALANCING
Prior to the Annuity Date, You may elect to automatically rebalance Your
Contract Value or to rebalance the Contract Value of any Subaccount provided
Your total Contract Value is initially at least $12,000. Asset rebalancing can
be done on a monthly or quarterly basis, in accordance with the following:
1. We must receive a signed Asset Rebalancing request form with instructions
from You;
2. Asset rebalancing will occur on the last business day of the month or
quarter following Our receipt of Your Asset Rebalancing request form in
accordance with the frequency elected, and at the end of each period
thereafter; We must receive Your instructions for asset rebalancing at
least ten days prior to the date the reallocation is to take effect;
3. There is no charge for these transfers.
We will stop processing automatic Asset Rebalancing transfers if one of the
following conditions occur:
1. We receive Your Written Request to cancel future transfers at least ten
days prior to the next scheduled asset rebalancing date; or
2. Annuity payments begin.
10
================================================================================
ANNUITY PROVISIONS
ANNUITY PAYMENTS - Beginning on the Annuity Date, We will make annuity payments
to the Annuitant in accordance with the Annuity Option in effect on that date.
Annuity payments will be made on a monthly basis unless such payments would be
less than $100 per month. In that event, We reserve the right to amend the
frequency of annuity payments to be semi-annual or annual to ensure annuity
payments are at least $100 per payment. If on the Annuity Date the Contract
Value is less than $2,000, or the annuity payment would be less than $20 per
month, We reserve the right to cancel this contact and pay You the Contract
Value in one lump sum
CHANGE IN ANNUITY DATE - You may, upon at least thirty (30) days prior Written
Request, at any time prior to the Annuity Date, change the Annuity Date shown on
the Contract Schedule. The Annuity Date must always be the first day of a
calendar month.
Unless We approve otherwise, the new Annuity Date must be at least one year
after the Effective Date. The latest Annuity Date is the first day of the first
calendar month following the Annuitant's 90th birthday or such earlier date as
may be set by applicable law.
SELECTION OF ANNUITY OPTION - If the Annuitant is alive on the Annuity Date, We
will apply the Contract Value to provide an income on the basis of a life income
with 10 years guaranteed, unless another Annuity Option has been selected. You
may however, upon at least thirty (30) days prior Written Request, at any time
prior to the Annuity Date, select and/or change the Annuity Option.
================================================================================
ANNUITY OPTIONS
ANNUITY OPTION - The Annuity Option you select may be on a fixed or variable
basis, or a combination thereof. If, at the time of election of an Annuity
Option, We are using more favorable rates, they will be used in lieu of those
here guaranteed. We may also make available other income options.
OPTION 1 - LIFE INCOME. Annuity payments are paid during the life of an
Annuitant ceasing with the last Annuity Payment due prior to the Annuitant's
death.
OPTION 2 - LIFE INCOME WITH 10 YEAR GUARANTEE. Annuity payments are paid during
the life of an Annuitant, but at least for a 10 year minimum period.
OPTION 3 - JOINT AND LAST SURVIVOR ANNUITY. Annuity payments are paid during the
joint lifetime of the Annuitant and a designated second person and are paid
thereafter during the remaining lifetime of the survivor ceasing with the last
annuity payment due prior to the survivor's death.
--------------------------------------------------------------------------------
FIXED ANNUITY OPTION
The fixed dollar amount of each fixed annuity payment is determined by
multiplying the available Contract Value (after the deduction of any premium
taxes, if applicable, not previously deducted) by the factor in the Fixed
Annuity Option Table for the option chosen, using the age and sex of the
Annuitant and joint Annuitant, if any, divided by 1,000. The tables are
determined from the Annuity 2000 Table projected with Scale G to the year of
annuitization, with interest at the rate of 3.00% per annum. If, when annuity
payments are elected, We are using tables of annuity rates for these
certificates which result in larger annuity payments, We will use those tables
instead. The annuity payments, determined at the time of their election, will
not be less than payments that would be provided by the application of the
Contract Value to
11
an immediate annuity then offered by Us at the time of election, for the same
class of annuitants.
================================================================================
ANNUITY OPTIONS (Continued)
VARIABLE ANNUITY OPTION
--------------------------------------------------------------------------------
The amount of the first variable annuity payment depends on the Annuity Option
elected and the age and sex of the Annuitant and joint Annuitant, if any. This
certificate contains a Variable Annuity Options Table indicating the dollar
amount of the first monthly payment under each optional annuity form for each
$1,000 of value applied. The tables are determined from the Annuity 2000 Table
projected with Scale G to the year of annuitization, with interest at the rate
of 5.00% per annum. If, when annuity payments are elected, We are using tables
of annuity rates for these certificates which result in larger annuity payments,
We will use those tables instead.
The 5% interest rate assumed in the annuity tables would produce level annuity
payments if the net investment rate remained constant at 5% per year. Subsequent
payments will be less than, equal to, or greater than the first payment
depending upon whether the actual net investment rate is less than, equal to, or
greater than 5%.
The dollar amount of the first variable annuity payment is determined by
applying the available value (after deduction of any premium taxes, if
applicable, not previously deducted) to the table using the age and sex of the
Annuitant and the joint Annuitant, if any. The number of Annuity Units is then
determined by dividing this dollar amount by the then current Annuity Unit
value. Thereafter, the number of Annuity Units remains unchanged during the
period of annuity payments. This determination is made separately for each
Subaccount of the Variable Account. The number of Annuity Units is determined
for each Subaccount and is based upon the available value in each Subaccount as
of the date annuity payments are to begin. The dollar amount determined for each
Subaccount will then be aggregated for purposes of making payments. The dollar
amount of the second and later variable annuity payments is equal to the number
of Annuity Units determined for each Subaccount times the Annuity Unit value for
that Subaccount as of the due date of the payment. This amount may increase or
decrease from month to month. The value of an Annuity Unit for a Subaccount is
determined as shown below, by subtracting item 2. from item 1, dividing that
result by item 3 and multiplying the result by a factor to neutralize the
assumed net investment rate, discussed above, of 5% per annum,
where:
1. is the net result of the assets of the Subaccount attributable to the
Annuity units,
a) plus the cumulative credit; or
b) minus the cumulative charge
for taxes reserved, which credit or charge is determined by Us to have
resulted from the operation of the Subaccount;
2. is the cumulative unpaid amounts for the Mortality and Expense Risk Charge
and for the Administrative Charge, which are shown in the Contract
Schedule; and
3. is the number of Annuity Units outstanding at the end of the Valuation
Period.
The value of an Annuity Unit may increase or decrease from Valuation Period to
Valuation Period.
12
================================================================================
DEATH BENEFIT
DEATH OF THE OWNER - If an Owner dies before the Annuity Date and there is a
surviving Joint Owner, a Death Benefit is payable to the surviving Joint Owner.
If an Owner dies prior to the Annuity Date and there is no surviving Joint
Owner, a Death Benefit is payable to the Beneficiary. The value of the Death
Benefit will be determined as of the date We receive proof of death in a form
acceptable to Us. If there has been a change of Owner, the Death Benefit will be
the Contract Value. Otherwise, We will pay the Death Benefit equal to the
greater of:
1. the total of all Premiums paid, with each premium adjusted for surrenders
as described below; or
2. the Contract Value.
Adjustment for Surrenders. In the determination of the Death Benefit, for each
surrender, a proportionate reduction will be made to each Premium paid prior to
the surrender. The proportion is determined by dividing the amount of the
Contract Value surrendered by the Contract Value immediately prior to each
surrender.
Example for item #1 above:
If the total Premiums paid to the date of a partial surrender request is
$50,000, the Contract Value is $40,000, and a $10,000 partial surrender is
requested, the adjustment in the total Premiums paid as of the date of the
partial surrender would be determined as follows:
$50,000 x [$10,000/$40,000] = $12,500
The adjusted total Premium amount would be:
$50,000 - $12,500 = $37,500
The surviving Joint Owner or Beneficiary may elect the Death Benefit to be paid
as follows:
1. payment of the entire Death Benefit within 5 years of the date of the
Owner's death; or
2. payment over the lifetime of the surviving Joint Owner or designated
Beneficiary based on Tables V and VI of section 1.72-9 of the Income Tax
Regulation with distribution beginning within 1 year of the date of death
of the Owner (see Annuity Options section of this certificate); or
3. if the surviving Joint Owner or designated Beneficiary is a spouse of the
deceased Owner, he/she can continue this certificate in his/her own name.
If no payment option is elected within 60 days of Our receipt of proof of the
Owner's death, a single sum settlement will be made at the end of the sixty (60)
day period following such receipt. Upon payment of the Death Benefit, this
certificate will end.
If the Owner is a person other than the Annuitant, and if the Owner's death
occurs on or after the Annuity Date, no Death Benefit will be payable under this
certificate. Any guaranteed payments remaining unpaid will continue to be paid
to the Annuitant pursuant to the Annuity Option in force at the date of the
Owner's death.
If the Owner is not an individual, any change of Annuitant or death of Annuitant
before the Annuity Date will be treated as if the Owner had died on the date of
such change or death and the Death Benefit will be the Contract Value.
DEATH OF THE ANNUITANT - If the Annuitant is a person other than the Owner and
the Owner is an individual, and if the Annuitant dies before the Annuity Date, a
new Annuitant may be named by the Owner. If no new Annuitant is named within
sixty (60) days of Our receipt of proof of death, the Owner will be the new
Annuitant. If the Annuitant dies after the Annuity Date, the remaining payments,
if any, will be as specified in the Annuity Option elected. We will require
proof of the Annuitant's death. Death benefits, if any, will be paid to the
designated Beneficiary at least as rapidly as under the method of distribution
in effect at the Annuitant's death.
13
================================================================================
SURRENDER PROVISIONS
SURRENDER - While this certificate is in force and before the Annuity Date, We
will, upon Written Request, allow the surrender of all or a portion of this
certificate for its Surrender Value. Surrenders will result in the cancellation
of Accumulation Units from each applicable Subaccount and the Guaranteed Account
in the ratio that the value of each account bears to the total Contract Value.
You must specify by Written Request, in advance, which units are to be canceled
if other than the above described method of cancellation is desired. We will pay
the amount of any surrender within seven (7) days of receipt of a request unless
the "Delay of Payments" provision is in effect.
The Surrender Value will be the Contract Value, as of the date of Our receipt of
Your Written Request for surrender, reduced by the sum of:
1. any applicable premium taxes not previously deducted; plus
2. any applicable Certificate Maintenance Charge.
================================================================================
SYSTEMATIC SURRENDERS
Prior to the Annuity Date, You may request systematic surrenders from the
Contract Value on a monthly, quarterly, semi-annual or annual basis. Systematic
surrenders are subject to the following conditions:
1. We must receive a completed and signed Systematic Withdrawal Request Form
from You at least 10 days prior to the first withdrawal date;
2. the Contract Value must be at least $24,000 as of the date of the first
systematic surrender;
3. the minimum withdrawal amount is $200 per withdrawal;
4. systematic surrenders are subject to the Surrender Provision above;
5. systematic surrenders are subject to a maximum of 10% of Premiums paid;
6. Systematic surrenders will occur on the 10th day of the month, or the
following business day if the 10th is not a business day, in accordance
with the frequency elected;
Systematic Surrenders will continue until one of the following conditions
occurs:
1. We receive your Written Request to cancel future systematic surrenders;
2. Your Contract Value falls below $1,000;
3. We receive notification of the death of the Owner; or
4. Annuity payments begin.
If the systematic surrender program is cancelled, You may not elect to
participate in the program again until the beginning of the next Contract Year.
14
================================================================================
DELAY OF PAYMENTS
DELAY OF PAYMENTS - We will make any payments under this certificate within 7
days (or any shorter period, if required by law) of a request received in good
order. We reserve the right to suspend or postpone any type of payment from the
Variable Account for any period when:
1. the New York Stock Exchange is closed for other than customary weekend and
holiday closings;
2. trading on the Exchange is restricted;
3. an emergency exists as a result of which it is not reasonably practicable
to dispose of securities held in the Variable Account, or to determine
their value; or 4. the Securities and Exchange Commission so permits delay
for the protection of security holders.
The applicable rules of the Securities and Exchange Commission will govern as to
whether the conditions in 2. or 3. exist.
We reserve the right to delay any type of payment from the Guaranteed Account
for up to six (6) months from the date We receive the request for payment.
15
Fixed Annuity Option Tables
------------------------------------------------------------------------------------------------------------
Option 1: Life Income
------------------------------------------------------------------------------------------------------------
Monthly Income per $1,000
------------------------------------------------------------------------------------------------------------
Year of
Annuitization 2010 2020 2030 2040
------------------------------------------------------------------------------------------------------------
Age Male Female Male Female Male Female Male Female
------------------------------------------------------------------------------------------------------------
30 3.16 3.06 3.12 3.03 3.09 3.00 3.06 2.97
------------------------------------------------------------------------------------------------------------
35 3.30 3.18 3.25 3.14 3.21 3.10 3.18 3.07
------------------------------------------------------------------------------------------------------------
40 3.48 3.32 3.42 3.28 3.37 3.23 3.32 3.20
------------------------------------------------------------------------------------------------------------
45 3.70 3.51 3.63 3.45 3.57 3.40 3.51 3.35
------------------------------------------------------------------------------------------------------------
50 3.98 3.74 3.89 3.67 3.82 3.60 3.74 3.54
------------------------------------------------------------------------------------------------------------
55 4.34 4.05 4.23 3.95 4.13 3.87 4.04 3.79
------------------------------------------------------------------------------------------------------------
60 4.82 4.45 4.68 4.33 4.55 4.22 4.43 4.12
------------------------------------------------------------------------------------------------------------
65 5.48 4.99 5.29 4.83 5.12 4.68 4.96 4.55
------------------------------------------------------------------------------------------------------------
70 6.38 5.75 6.13 5.53 5.89 5.33 5.69 5.16
------------------------------------------------------------------------------------------------------------
75 7.62 6.86 7.26 6.54 6.95 6.26 6.66 6.02
------------------------------------------------------------------------------------------------------------
80 9.35 8.48 8.85 8.02 8.41 7.61 8.02 7.26
------------------------------------------------------------------------------------------------------------
85 11.76 10.89 11.08 10.21 10.48 9.62 9.96 9.11
------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------
Option 2: Life Income with 10 year Guarantee
-------------------------------------------------------------------------------------------------------------
Monthly Income per $1,000
-------------------------------------------------------------------------------------------------------------
Year of
Annuitization 2010 2020 2030 2040
-------------------------------------------------------------------------------------------------------------
Age Male Female Male Female Male Female Male Female
-------------------------------------------------------------------------------------------------------------
30 3.16 3.06 3.12 3.03 3.09 3.00 3.06 2.97
-------------------------------------------------------------------------------------------------------------
35 3.30 3.17 3.25 3.14 3.21 3.10 3.17 3.07
-------------------------------------------------------------------------------------------------------------
40 3.47 3.32 3.42 3.27 3.37 3.23 3.32 3.19
-------------------------------------------------------------------------------------------------------------
45 3.69 3.50 3.62 3.44 3.56 3.39 3.50 3.35
-------------------------------------------------------------------------------------------------------------
50 3.96 3.73 3.87 3.66 3.80 3.60 3.73 3.54
-------------------------------------------------------------------------------------------------------------
55 4.30 4.03 4.20 3.94 4.10 3.86 4.02 3.78
-------------------------------------------------------------------------------------------------------------
60 4.74 4.41 4.61 4.29 4.50 4.19 4.39 4.10
-------------------------------------------------------------------------------------------------------------
65 5.31 4.91 5.15 4.76 5.01 4.63 4.87 4.51
-------------------------------------------------------------------------------------------------------------
70 6.02 5.57 5.83 5.39 5.65 5.22 5.48 5.07
-------------------------------------------------------------------------------------------------------------
75 6.85 6.42 6.63 6.19 6.42 5.98 6.23 5.79
-------------------------------------------------------------------------------------------------------------
80 7.73 7.40 7.51 7.16 7.30 6.92 7.10 6.70
-------------------------------------------------------------------------------------------------------------
85 8.52 8.34 8.35 8.13 8.18 7.93 8.02 7.73
-------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------
Option 3: Joint and Last Survivor Annuity (Male and Female)
-------------------------------------------------------------------------------------------------------------
Monthly Income per $1,000
-------------------------------------------------------------------------------------------------------------
Year of
Annuitization 2020 2040
-------------------------------------------------------------------------------------------------------------
Female Age 45 55 65 75 45 55 65 75
-------------------------------------------------------------------------------------------------------------
Male Age
-------------------------------------------------------------------------------------------------------------
45 3.25 3.41 3.52 3.59 3.18 3.32 3.42 3.47
-------------------------------------------------------------------------------------------------------------
55 3.35 3.63 3.90 4.09 3.26 3.52 3.76 3.92
-------------------------------------------------------------------------------------------------------------
65 3.40 3.80 4.30 4.78 3.31 3.67 4.10 4.52
-------------------------------------------------------------------------------------------------------------
75 3.43 3.89 4.59 5.54 3.34 3.74 4.36 5.18
-------------------------------------------------------------------------------------------------------------
The values shown have not been adjusted for the annual certificate maintenance
charge described on Pages 3 and 9.
Values not shown are available from Our Administrative Office on request.
16
Variable Annuity Option Tables
----------------------------------------------------------------------------------------------------------
Option 1: Life Income
----------------------------------------------------------------------------------------------------------
Monthly Income per $1,000
----------------------------------------------------------------------------------------------------------
Year of
Annuitization 2010 2020 2030 2040
----------------------------------------------------------------------------------------------------------
Age Male Female Male Female Male Female Male Female
----------------------------------------------------------------------------------------------------------
30 4.47 4.38 4.44 4.36 4.41 4.34 4.39 4.32
----------------------------------------------------------------------------------------------------------
35 4.58 4.47 4.55 4.44 4.51 4.41 4.48 4.39
----------------------------------------------------------------------------------------------------------
40 4.74 4.60 4.69 4.55 4.64 4.52 4.60 4.49
----------------------------------------------------------------------------------------------------------
45 4.94 4.75 4.88 4.70 4.82 4.65 4.76 4.61
----------------------------------------------------------------------------------------------------------
50 5.20 4.96 5.12 4.90 5.04 4.83 4.97 4.78
----------------------------------------------------------------------------------------------------------
55 5.54 5.24 5.43 5.15 5.34 5.07 5.25 5.00
----------------------------------------------------------------------------------------------------------
60 6.00 5.62 5.86 5.50 5.74 5.40 5.62 5.30
----------------------------------------------------------------------------------------------------------
65 6.65 6.15 6.46 5.99 6.29 5.84 6.14 5.72
----------------------------------------------------------------------------------------------------------
70 7.56 6.90 7.30 6.68 7.07 6.48 6.86 6.30
----------------------------------------------------------------------------------------------------------
75 8.81 8.01 8.45 7.69 8.12 7.41 7.83 7.16
----------------------------------------------------------------------------------------------------------
80 10.55 9.65 10.05 9.18 9.59 8.76 9.19 8.40
----------------------------------------------------------------------------------------------------------
85 12.99 12.09 12.30 11.39 11.68 10.79 11.14 10.26
----------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------
Option 2: Life Income with 10 year Guarantee
----------------------------------------------------------------------------------------------------------
Monthly Income per $1,000
----------------------------------------------------------------------------------------------------------
Year of
Annuitization 2010 2020 2030 2040
----------------------------------------------------------------------------------------------------------
Age Male Female Male Female Male Female Male Female
----------------------------------------------------------------------------------------------------------
30 4.47 4.38 4.44 4.36 4.41 4.34 4.39 4.32
----------------------------------------------------------------------------------------------------------
35 4.58 4.47 4.54 4.44 4.51 4.41 4.48 4.39
----------------------------------------------------------------------------------------------------------
40 4.73 4.59 4.68 4.55 4.64 4.51 4.60 4.48
----------------------------------------------------------------------------------------------------------
45 4.92 4.74 4.86 4.69 4.80 4.65 4.75 4.61
----------------------------------------------------------------------------------------------------------
50 5.16 4.95 5.09 4.88 5.02 4.82 4.95 4.77
----------------------------------------------------------------------------------------------------------
55 5.48 5.21 5.38 5.13 5.30 5.05 5.22 4.99
----------------------------------------------------------------------------------------------------------
60 5.90 5.57 5.77 5.46 5.66 5.36 5.56 5.27
----------------------------------------------------------------------------------------------------------
65 6.44 6.04 6.29 5.90 6.15 5.77 6.02 5.66
----------------------------------------------------------------------------------------------------------
70 7.12 6.67 6.93 6.49 6.76 6.33 6.60 6.18
----------------------------------------------------------------------------------------------------------
75 7.90 7.49 7.69 7.27 7.49 7.06 7.31 6.88
----------------------------------------------------------------------------------------------------------
80 8.73 8.42 8.53 8.18 8.32 7.96 8.13 7.75
----------------------------------------------------------------------------------------------------------
85 9.48 9.31 9.32 9.11 9.16 8.91 9.00 8.72
----------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------
Option 3: Joint and Last Survivor Xxxxxxx (Male and Female)
----------------------------------------------------------------------------------------------------------
Monthly Income per $1,000
----------------------------------------------------------------------------------------------------------
Year of
Annuitization 2020 2040
----------------------------------------------------------------------------------------------------------
Female Age 45 55 65 75 45 55 65 75
----------------------------------------------------------------------------------------------------------
Male Age
----------------------------------------------------------------------------------------------------------
45 4.50 4.64 4.74 4.81 4.45 4.56 4.66 4.71
----------------------------------------------------------------------------------------------------------
55 4.59 4.83 5.07 5.26 4.52 4.73 4.94 5.10
----------------------------------------------------------------------------------------------------------
65 4.65 4.98 5.43 5.90 4.57 4.86 5.25 5.65
----------------------------------------------------------------------------------------------------------
75 4.68 5.08 5.72 6.62 4.59 4.94 5.49 6.27
----------------------------------------------------------------------------------------------------------
The values shown have not been adjusted for the annual certificate maintenance
charge described on Pages 3 and 9.
Values not shown are available from Our Administrative Office on request.
17
ailife[LOGO](R)
AMERICAN INTERNATIONAL LIFE ASSURANCE COMPANY OF NEW YORK
00 XXXX XXXXXX
XXX XXXX, XXX XXXX 00000
CERTIFICATE OF COVERAGE
FLEXIBLE PREMIUM DEFERRED VARIABLE ANNUITY
NONPARTICIPATING
