24(b)(4)(a)
XXXX XXXXXXX LIFE INSURANCE COMPANY OF NEW YORK (XXXX XXXXXXX(R) LOGO)
OVERNIGHT MAILING ADDRESS: ANNUITIES SERVICE CENTER: HOME OFFICE
[000 Xxxxxxxxx Xxxxx [P.O. Box 9505 000 Xxxxxx Xxxx Xxxxx,
Xxxxxxxxxx, XX 00000-0000] Xxxxxxxxxx, XX 00000-9505] 2nd Floor
[0-000-000-0000] Valhalla, NY 10595
THIS IS A LEGAL CONTRACT - READ IT CAREFULLY.
WE AGREE to pay the benefits of this Contract in accordance with its terms.
THIS CONTRACT is issued in consideration of the Payments.
Xxxx Xxxxxxx Life Insurance Company of New York agrees to pay a guaranteed
withdrawal amount beginning on the Lifetime Income Date and continuing for the
life of the Annuitant. We will pay an annuity benefit beginning on the Maturity
Date to the Annuitant, if living, unless otherwise directed by the Owner, in
accordance with the Annuity Payments provision of this Contract. If the
Annuitant dies while this Contract is in effect prior to the date Annuity
Payments begin, we will pay the Contract Value to the Beneficiary upon receipt
at our Annuities Service Center of all required claim forms and proof of the
Annuitant's death.
Contract Asset Fee Charge: No greater than [1.60%]
RIGHT TO REVIEW
YOU HAVE 10 DAYS AFTER YOU RECEIVE THE CONTRACT TO EXAMINE IT. DURING THAT 10
DAY PERIOD YOU MAY CANCEL THE CONTRACT BY RETURNING IT TO OUR ANNUITIES SERVICE
CENTER OR THE REGISTERED REPRESENTATIVE WHO SOLD IT TO YOU. WE WILL THEN REFUND
TO YOU THE SUM OF YOUR PAYMENT(S), INCREASED OR DECREASED BY THE INVESTMENT
PERFORMANCE OF THE CONTRACT.
IF YOUR CONTRACT IS ISSUED AS AN INDIVIDUAL RETIREMENT ANNUITY, AND YOU RETURN
IT WITHIN 7 DAYS AFTER YOU RECEIVE IT, WE WILL REFUND TO YOU THE SUM OF ALL
PAYMENT(S) IF THAT AMOUNT IS GREATER THAN THE REFUND AMOUNT DESCRIBED ABOVE. IF
YOU RETURN THE CONTRACT TO US AFTER THE FIRST 7 DAYS AND BEFORE THE 10 DAY
PERIOD HAS ELAPSED, WE WILL REFUND THE SUM OF YOUR PAYMENT(S), INCREASED OR
DECREASED BY THE INVESTMENT PERFORMANCE OF THE CONTRACT.
THE REFUND AMOUNT WILL BE DETERMINED AT THE END OF THE VALUATION PERIOD DURING
WHICH THE CONTRACT IS DELIVERED TO US. WE WILL PROCESS THE REFUND WITHIN 7 DAYS
OF RECEIPT OF THE CONTRACT BY US.
SIGNED FOR THE COMPANY at its Home Office, Valhalla, New York,
on the Contract Date.
DETAILS OF VARIABLE ACCOUNT PROVISIONS ON PAGE 5.1
/s/ Xxxxx X. Xxxxxxxxx /s/ Xxxxxxx Xxxxx
------------------------------------- ----------------------------------------
[Xxxxx X. Xxxxxxxxx,] [President] [Xxxxxxx Xxxxx,] [Secretary]
INDIVIDUAL MODIFIED SINGLE PAYMENT DEFERRED VARIABLE ANNUITY
GUARANTEED LIFETIME WITHDRAWAL BENEFIT
NON-PARTICIPATING
DEATH BENEFITS, SURRENDER VALUES, AND OTHER VALUES PROVIDED BY THIS CONTRACT
WHEN BASED ON THE INVESTMENT EXPERIENCE OF A SEPARATE ACCOUNT ARE VARIABLE, MAY
INCREASE OR DECREASE IN ACCORDANCE WITH THE FLUCTUATIONS IN THE INVESTEMENT
RESULTS, AS APPLICABLE AND NOT GUARANTEED AS TO FIXED DOLLAR AMOUNT.
IVA-MSP2.09-NY NY
INTRODUCTION
This is an individual modified single payment deferred variable annuity
contract. This Contract provides that, prior to the Maturity Date, the Contract
Value will accumulate on a variable basis. If you limit withdrawals to the
amounts described in the Lifetime Income Benefits provision, we guarantee that
the Lifetime Income Amount will be available for withdrawal each Contract Year
after the Lifetime Income Date and during the life of the Annuitant. Subject to
the provisions of the Contract, you may take withdrawals of any amount up to the
Surrender Value. Withdrawals that are not part of our Systematic Withdrawal
Program may reduce the guaranteed Lifetime Income Amount. After the Maturity
Date, Annuity Payments will be fixed in amount.
The Contract Value will vary with the investment performance of your Investment
Option.
TABLE OF CONTENTS PAGE
----------------- ----
SPECIFICATIONS PAGES S.1
PART 1 - DEFINITIONS 1.1
PART 2 - OWNER, BENEFICIARY 2.1
PART 3 - PAYMENTS 3.1
PART 4 - FEES AND DEDUCTIONS 4.1
PART 5 - VARIABLE ACCOUNT PROVISIONS 5.1
PART 6 - WITHDRAWALS 6.1
PART 7 - SETTLEMENT PHASE 7.1
PART 8 - DISTRIBUTIONS AFTER DEATH 8.1
PART 9 - ANNUITY PAYMENTS 9.1
PART 10 - ANNUITY OPTIONS 10.1
PART 11 - GENERAL PROVISIONS 11.1
NY
SPECIFICATIONS PAGE
TYPE OF CONTRACT: [QUALIFIED] CONTRACT DATE: [8/1/2009]
INITIAL PAYMENT: [$100,000.00] CONTRACT NUMBER: [000000005]
OWNER: [XXXX X. XXXXX] GOVERNING LAW: NY
ANNUITANT: [XXXX X. XXXXX] ANNUITANT'S AGE [55]
[CO-OWNER:] [__________]
PLAN AnnuityNote Series 2
FEES AND CHARGES
CONTRACT ASSET FEE [1.60%]
WITHDRAWAL CHARGE PERIOD 3 Contract Years
WITHDRAWAL CHARGE
Withdrawal
Charge
Contract Year Percentage
------------- ----------
1 2.00%
2 2.00%
3 1.00%
LIFETIME INCOME BENEFIT
LIFETIME INCOME PERCENTAGE [5.0%]
LIFETIME INCOME DATE [8/1/2014]
PAYMENT LIMITS
PAYMENT LIMITS The initial Payment is shown above. We will not accept any
Payment, without our prior approval that
(a) exceeds $[1,000,000], or
(b) causes the total of all Payments received to exceed
$[1,000,000], or
(c) is received more than [9] months after the Contract
Date.
NY
S.1
AVAILABLE INVESTMENT OPTION
VARIABLE ACCOUNT: [XXXX XXXXXXX LIFE INSURANCE COMPANY OF NEW YORK SEPARATE
ACCOUNT A]
VARIABLE INVESTMENT OPTION: [Core Balanced Strategy]
ANNUITY BENEFITS
MATURITY DATE: [8/1/2049]
ANNUITY OPTION [Life Annuity with Cash Refund]
ANNUITY PAYMENTS - GENERAL The rates for Annuity Payments are determined based
INFORMATION on:
- Mortality Table: Annuity 2000 Table
projected from 2002 to date of
annuitization at Scale G
- Fixed Annuity Payment Interest Rate:
1.50% interest per year
The amount of each Annuity Payment will depend upon
the age of the Annuitant.
AMOUNT OF MONTHLY PAYMENT
PER $1000 OF CONTRACT VALUE
ANNUITANT BORN IN 1954
LIFE ANNUITY WITH CASH REFUND
Age of
Annuitant
---------
55 2.86
60 3.11
65 3.42
70 3.80
75 4.26
80 4.81
85 5.49
90 6.30
95 7.34
Monthly installments for ages not shown and other years of birth will be
furnished on request.
NY
S.2
BENEFICIARY INFORMATION
[Xxxx Xxxxx]
[THIS PLAN IS INTENDED TO QUALIFY UNDER THE INTERNAL REVENUE CODE FOR
TAX-FAVORED STATUS. LANGUAGE CONTAINED IN THIS CONTRACT REFERRING TO FEDERAL TAX
STATUS OR RULES IS INFORMATIONAL AND INSTRUCTIONAL. PLEASE SEEK THE ADVICE OF
YOUR OWN TAX ADVISOR REGARDING YOUR INDIVIDUAL TAX TREATMENT.]
NY
S.3
PART 1 DEFINITIONS
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WE AND YOU "We", "us" and "our" means the Company. "You" or "your" means the
Owner of this Contract.
ACCUMULATION UNIT A unit of measure that is used to calculate the value of the
Variable Account of this Contract before the Maturity Date.
ANNUITANT The person whose age and life is used to determine the duration of
the Lifetime Income Benefit and the amount and duration of Annuity
Payments. The Annuitant is as designated on the Specifications
Page.
ANNUITY OPTION The method selected by you for Annuity Payments made by us.
ANNUITY PAYMENT(S) Payment(s) by us to you on or after the Maturity Date under the
terms of this Contract.
ANNUITIES SERVICE CENTER Any office designated by us for the receipt of Payments and
processing of Owner requests.
BENEFICIARY The person, persons or entity to whom benefits are payable
following the death of an Owner or Annuitant. For purposes of
Section 72(s) of the Internal Revenue Code, the "designated
beneficiary" under the Contract shall be the individual who is
entitled to receive the amounts payable on the death of an Owner,
or if any Owner is not an individual, on any change in or death of,
an Annuitant
COMPANY The insurance company named on the first page of this Contract (or
any successor insurance company named by endorsement to this
Contract) that will pay benefits in accordance with this Contract.
CONTRACT ANNIVERSARY The annual anniversary of the Contract beginning twelve months from
the Contract Date and each year thereafter.
CONTRACT DATE The date of issue of this Contract as designated on the
Specifications Page.
CONTRACT VALUE The total of your Investment Account Values at any time before
Annuity Payments begin.
CONTRACT YEAR The period of time measured twelve consecutive months from the
Contract Date or any Contract Anniversary thereafter.
CONTINGENT BENEFICIARY The person, persons or entity who becomes entitled to receive the
Contract proceeds if all Beneficiaries die before the Owner dies.
ENDORSEMENT An Endorsement modifies the contract to which it is attached.
Endorsements must be signed by an officer of the Company in order
to be effective.
FIXED ANNUITY An Annuity Option with payments which are predetermined and
guaranteed as to dollar amount.
GENERAL ACCOUNT All the assets of the Company other than assets in separate
accounts.
GROSS WITHDRAWAL AMOUNT The amount deducted from the Contract Value as the result of a
withdrawal. This amount is the total of the amount paid to you plus
any deduction for premium taxes or similar taxes, any income taxes
resulting from the withdrawal and withheld by us and any Withdrawal
Charge. The Gross Withdrawal Amount may not exceed the Contract
Value.
INTERNAL REVENUE CODE (IRC) The Internal Revenue Code of 1986, as amended from time to time,
and any successor statute of similar purposes.
INVESTMENT ACCOUNT VALUE The value of your investment in an Investment Option.
NY
1.1
INVESTMENT OPTION The Sub-Account of the Variable Account to which You allocate your
Contract Value. The Investment Option initially available under
this Contract is shown on the Specifications Page. The Sub-Account
of the Variable Account invests in a corresponding Portfolio.
LIFETIME INCOME AMOUNT (LIA) The Lifetime Income Amount is the amount that is guaranteed to be
available for systematic withdrawal each Contract Year after the
Lifetime Income Date and during the life of the Annuitant while
this Contract is in effect.
LIFETIME INCOME DATE The Lifetime Income Date is the date on which the initial LIA is
calculated and made available.
LIFETIME INCOME PERCENTAGE The percentage used to determine your Lifetime Income Amount.
MATURITY DATE The latest date on which Annuity Payments may commence. It is the
date specified on the Specifications Page, unless changed. The
maximum Maturity Date will be age 95. Any extension of the Maturity
Date will be subject to the laws and regulations then in effect and
our prior approval.
NET PAYMENT The Payment less the amount of premium tax, if any, deducted from
the Payment.
NET WITHDRAWAL AMOUNT The Gross Withdrawal Amount less the amount of any premium taxes,
any income tax resulting from the withdrawal and withheld by us and
any Withdrawal Charge. The Net Withdrawal Amount may not exceed the
Surrender Value.
OWNER The person, persons or entity entitled to the ownership rights
under this Contract. The Owner is as designated on the
Specifications Page, unless changed.
PORTFOLIO The investment choice(s) available to the Variable Account.
PAYMENT An amount You pay to Us as consideration for the benefits provided
by this Contract.
QUALIFIED CONTRACTS Contracts issued under Qualified Plans.
QUALIFIED PLANS Retirement plans which receive favorable tax treatment under
sections 401 or 408 of the Internal Revenue Code of 1986, as
amended.
SEPARATE ACCOUNT A segregated account of the Company that is not commingled with our
general assets and obligations.
SUB-ACCOUNT(S) The Variable Account is divided into Sub-Accounts. Each Sub-Account
is invested in shares of a different Portfolio.
SURRENDER VALUE The Contract Value on any Valuation Date, less, if applicable, any
deduction for premium taxes or similar taxes and any Withdrawal
Charge.
SYSTEMATIC WITHDRAWAL PROGRAM A program for the automatic distribution of scheduled withdrawals.
VALUATION DATE Any date on which the New York Stock Exchange is open for business
and the net asset value of a Portfolio is determined.
VALUATION PERIOD Any period from one Valuation Date to the next, measured from the
time on each such date that the net asset value of each Portfolio
is determined.
VARIABLE ACCOUNT The Company's Separate Account as shown in the Specifications Page.
NY
1.2
PART 2 OWNER, BENEFICIARY
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GENERAL Before the Maturity Date, the Owner of this Contract shall be the
person, persons or entity designated on the Specifications Page or
the latest change filed with us. On the Maturity Date, the
Annuitant becomes the Owner of this Contract.
OWNER The Owner must be a natural person who is primary Owner of the
Contract and the Annuitant, a custodian, or a Trust established for
the exclusive benefit of the Annuitant or his or her Beneficiaries.
This Contract is established for the exclusive benefit of the
Annuitant or his or her beneficiaries. In the event a co-Owner is
also named, the primary Owner/Annuitant is the covered life for
purposes of the benefits provided by this Contract.
BENEFICIARY The Beneficiary is as designated on the Specifications Page, unless
changed. If there is a surviving Owner, that person will be treated
as the Beneficiary. If no such Beneficiary is living, the
Beneficiary is the Contingent Beneficiary. If no Beneficiary or
Contingent Beneficiary is living, the Beneficiary is the estate of
the deceased Annuitant.
CHANGE OF OWNER, ANNUITANT, Subject to the right of an irrevocable Beneficiary, you may request
BENEFICIARY to change the Owner or Beneficiary. The request must be in a form
acceptable to us and received at our Annuities Service Center. Any
change will take effect on the date the request is signed.
You may not change the Annuitant unless the change is pursuant to a
court order. Any change in Annuitant will result in the elimination
of the Lifetime Income Amount guarantee. If any Annuitant is
changed and any Owner is not an individual, the entire interest in
the Contract must be distributed to the Owner within five years of
the change.
You need not send us the Contract unless we request it. We will not
be liable for any payments or actions we take before any change is
approved.
NY
2.1
PART 3 PAYMENTS
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GENERAL The Contract is not effective until Payment is received by us at
our Annuities Service Center. Generally, the Contract will be
purchased with a single payment. If Payments will be paid from
different sources, we will accept multiple Payments subject to the
Payment Limits identified in the Specifications Page. All Payments
under this Contract are payable at our Annuities Service Center.
Payment Limits are identified on the Specifications Page.
ALLOCATION OF NET PAYMENTS When we receive Payments, the Net Payments will be allocated among
the Investment Option(s). If we offer more than one Investment
Option, we will allocate the Net Payment among the Investment
Options in accordance with the instructions you provide. You may
change the allocation of subsequent Net Payments at any time,
without charge, by giving us notice in a form acceptable to us.
3.1
PART 4 FEES AND DEDUCTIONS
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CONTRACT ASSET FEE We assess a Contract Asset Fee to compensate us for assuming
certain administration expenses, expense risks and mortality risks.
We deduct the fee from the variable Investment Option(s) each
Valuation Period at an annual rate shown in the Specifications
Page. A portion of this Contract Asset Fee may also be used to
reimburse us for distribution expenses. This fee is reflected in
the Net Investment Factor used to determine the value of
Accumulation Units and Annuity Units of the Contract.
WITHDRAWAL CHARGE A Withdrawal Charge will be assessed on withdrawals during the
Withdrawal Charge Period. The Withdrawal Charge is the Withdrawal
Charge percentage multiplied by the Gross Withdrawal Amount. The
Withdrawal Charge Period and Withdrawal Charge percentage are shown
in the Specifications Page. A Withdrawal Charge will not apply
during the Withdrawal Charge Period if the withdrawal is payment of
the Death Benefit.
TAXES Certain taxes may be charged against your Payments (either at the
time of payment or liquidation), Contract Value, payment of Death
Benefit, withdrawals, or Annuity Payments, as appropriate. Such
taxes may include premium taxes or other taxes levied by any
government entity which we determine have resulted from the
establishment or maintenance of the Variable Account, or from the
receipt by us of Payments, or from the issuance of this Contract,
or from the commencement or continuance of Annuity Payments under
this Contract.
4.1
PART 5 VARIABLE ACCOUNT PROVISIONS
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INVESTMENT ACCOUNT VALUE The Investment Account Value of an Investment Option is determined
by multiplying (a) times (b) where:
(a) equals the number of Accumulation Units credited to the
Investment Option; and,
(b) equals the appropriate Accumulation Unit Value.
ACCUMULATION UNITS We will credit Net Payments to your Investment Options in the form
of Accumulation Units. The number of Accumulation Units we will
credit to the Investment Option(s) will be determined by dividing
the Net Payment allocated to that Investment Option by the
Accumulation Unit Value for that Investment Option.
Accumulation Units will be adjusted for any transfers and will be
canceled on payment of a death benefit, withdrawal, maturity or
assessment of certain charges based on their value for the
Valuation Period in which such transaction occurs.
ACCUMULATION UNIT VALUE We will determine the Accumulation Unit Value for a particular
Investment Option for any Valuation Period by multiplying the
Accumulation Unit Value for the immediately preceding Valuation
Period by the net investment factor for the corresponding
Sub-Account for the Valuation Period for which the value is being
determined. The Accumulation Unit Value may increase, decrease or
remain the same from one Valuation Period to the next.
NET INVESTMENT FACTOR The net investment factor is an index that measures the investment
performance of a Sub-Account from one Valuation Period to the next.
The net investment factor for any Valuation Period is determined by
dividing (a) by (b) and subtracting (c) from the result where:
(a) is the net result of:
1) the net asset value per share of a Portfolio share
held in the Sub-Account determined as of the end of
the current Valuation Period, plus:
2) the per share amount of any dividend or capital gain
distributions made by the Portfolio on shares held
in the Sub-Account if the ex-dividend date occurs
during the current Valuation Period, and
(b) is the net asset value per share of a Portfolio share held in
the Sub-Account determined as of the end of the immediately
preceding Valuation Period, and
(c) is the Contract Asset Fee shown on the Specifications Page.
The net investment factor may be greater or less than, or equal to,
one.
TRANSFERS Before the Maturity Date (or the date Annuity Payments begin, if
earlier), if we offer more than one Investment Option you may
transfer amounts among such Investment Options. Amounts will be
canceled from the Investment Option(s) from which amounts are
transferred and credited to the Investment Option(s) to which
amounts are transferred. We will effect such transfers so that the
Contract Value on the date of transfer will not be affected by the
transfer.
We may defer, modify or terminate the transfer privilege at any
time that we are unable to purchase or redeem shares of the
Portfolios. Transfer limitations are identified in the Suspension
of Payments provision.
NY
5.1
SUSPENSION OF PAYMENTS We may defer the right of withdrawal from, or postpone the date of
payments or transfers from, the variable Investment Option(s) for
any period when:
(a) the New York Stock Exchange is closed (other than
customary weekend and holiday closings);
(b) trading on the New York Stock Exchange is restricted;
(c) an emergency exists as a result of which disposal of
securities held in the Variable Account is not reasonably
practicable or it is not reasonably practicable to
determine the value of the Variable Account's net assets;
or
(d) the Securities and Exchange Commission, by order, permits
such deferral or postponement for the protection of
security holders.
Applicable rules and regulations of the Securities and Exchange
Commission shall govern whether the conditions described in (b) and
(c) exist.
NY
5.2
PART 6 WITHDRAWALS
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GENERAL This Contract guarantees that each Contract Year after the Lifetime
Income Date and during the life of the Annuitant we will
automatically distribute to the Annuitant an amount equal to the
Lifetime Income Amount (LIA), even if your Contract Value reduces
to zero. The LIA is described below in the Lifetime Income Amount
(LIA) provision. The Lifetime Income Amount will be distributed on
a scheduled monthly basis under our Systematic Withdrawal Program.
The Lifetime Income Date is shown on the Specifications Page
You may notify us to defer the start of LIA distributions or to
stop LIA distributions after they have begun. If you later request
that LIA distributions resume, the LIA will be calculated as
described below.
LIFETIME INCOME AMOUNT (LIA) If you do not take any withdrawals prior to the Lifetime Income
Date, the initial LIA is equal to the Lifetime Income Percentage
(shown on the Specifications Page) multiplied by the greater of the
gross Payments or the Contract Value on the Lifetime Income Date.
If you take a withdrawal prior to the Lifetime Income Date, the
initial LIA is equal to the Lifetime Income Percentage multiplied
by the Contract Value on the Lifetime Income Date.
After the Lifetime Income Date, any unscheduled withdrawal you
request will cause the scheduled LIA distributions to be suspended.
After suspension, you may request that LIA distributions be
resumed. However, the scheduled monthly LIA distributions
thereafter may be reset to equal the lesser of (a) the LIA
distribution prior to the withdrawal or (b) the Lifetime Income
Percentage multiplied by the Contract Value immediately after the
withdrawal.
If the Contract is issued under a Qualified Plan, unless we are
directed otherwise, we will automatically pay the greater of the
LIA or the required minimum distribution. Distributions will be
made on a monthly basis under the Systematic Withdrawal Program.
PAYMENT OF UNSCHEDULED You may request an unscheduled withdrawal of part or all of the
WITHDRAWALS Surrender Value, at any time before the earlier of the death of the
Annuitant, the date Annuity Payments begin or the Maturity Date, by
sending us a written request. We will pay all unscheduled
withdrawals within seven days of receipt of the request at the
Annuities Service Center subject to postponement in certain
circumstances, as specified in the Suspension of Payments provision
above.
- TOTAL WITHDRAWAL Upon receipt of your request to withdraw the entire Contract Value,
we will terminate the Contract and pay you the Surrender Value.
- PARTIAL WITHDRAWAL If you request to withdraw an amount less than the Surrender Value,
we will deduct the Gross Withdrawal Amount from your Contract Value
and pay you the Net Withdrawal Amount (as defined in the
Definitions section). If we offer more than one Investment Option,
unless you specify the amount to be withdrawn from each Investment
Option, the Gross Withdrawal Amount will be withdrawn from each
Investment Option on a pro rata basis.
IMPACT OF WITHDRAWALS ON OTHER You may make as many unscheduled partial withdrawals as you wish.
BENEFITS Any withdrawals prior to the Lifetime Income Date, or unscheduled
withdrawals after the Lifetime Income Date may reduce or eliminate
the Lifetime Income Benefit. All withdrawals and LIA distributions
will reduce the Contract Value and Death Benefit.
6.1
PART 7 SETTLEMENT PHASE
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BENEFITS DURING THE SETTLEMENT The Contract will enter its Settlement Phase if
PHASE
(a) the Contract Value reduces to zero, and
(b) there were no unscheduled withdrawals during the Contract
Year.
When the Contract enters its Settlement Phase the Lifetime Income
Benefit will continue, however all other rights and benefits under
the Contract, including Death Benefits, will terminate.
The Annuitant will automatically receive settlement payments equal
to the LIA each Contract Year of the Settlement Phase during the
life of the Annuitant. The settlement payments will be paid on a
scheduled monthly basis under our Systematic Withdrawal Program.
If the Annuitant dies during the Settlement Phase, then the
Lifetime Income Benefit terminates and no additional settlement
payments will be paid.
7.1
PART 8 DISTRIBUTIONS AFTER DEATH
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DEATH BEFORE MATURITY DATE If any Owner dies prior to the Maturity Date (or date Annuity
Payments begin, if earlier) the Death Benefit will equal the
Contract Value.
Upon death of the Owner who is also the Annuitant, we will pay the
Death Benefit in one sum to the Beneficiary.
If the co-Owner predeceases the Owner, the Owner will be treated as
the Beneficiary. The Beneficiary may continue the Contract as the
Owner, subject to the requirements of Section 72(s) of the Internal
Revenue Code. If the Contract can not continue under Section 72(s),
or if the Beneficiary elects not to continue the Contract, the
Death Benefit will be distributed in one sum. The Contract will
terminate if the Death Benefit is taken in one sum.
Written notice and proof of death and all required claim forms must
be received at the Company's Annuities Service Center prior to any
distribution.
DEATH BENEFIT ON OR AFTER On or after the date Annuity Payments begin, if the Annuitant dies,
MATURITY DATE the Death Benefit will depend on the Annuity Option selected in
accordance with Part 10 (Annuity Payments).
PROOF OF DEATH We will require Proof of death upon the death of the Annuitant or
the Owner. Proof of death is one of the following received at the
Annuities Service Center:
(a) A certified copy of a death certificate.
(b) A certified copy of a decree of a court of competent
jurisdiction as to the finding of death.
(c) Any other proof satisfactory to us.
8.1
PART 9 ANNUITY PAYMENTS
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GENERAL Benefits payable under this Contract may be applied in accordance
with one or more of the Annuity Options described below, subject to
any restrictions of Internal Revenue Code sections 72(s) (or
section 401(a)(9) and 408(b)(3) if this Contract is issued in a
Qualified Plan). Once Annuity Payments commence, the Annuity Option
may not be changed. The "Life Annuity with Cash Refund" option
described in Part 10 is the default Annuity Option unless you
request another option prior to the date Annuity Payments begin or
unless otherwise required by the Internal Revenue Code. If you are
receiving distributions that comply with the minimum distribution
requirements of the Internal Revenue Code, you do not need to
annuitize the Contract Value.
We will send you information about Annuity Options before the
Maturity Date. If by the Maturity Date, you do not choose an
Annuity Option, make a total Withdrawal of the Surrender Value, or
ask us to change the Maturity Date, we will automatically pay you
Annuity Payments under the Annuity Option shown in the
Specifications Page. You can change the Annuity Option at any time
before Annuity Payments begin.
We will provide Fixed Annuity payments. The method used to
calculate the amount of the Fixed Annuity payments is described
below.
If the monthly Annuity Payment is less than $20, we may pay the
greater of the Contract Value or the commuted value of the Lifetime
Income Benefit in one lump sum on the Maturity Date, or the date
Annuity Payments would begin, if earlier.
FIXED ANNUITY PAYMENTS We will determine the amount of each Fixed Annuity payment by
applying the Contract Value as of a date not more than 10 business
days prior to the date Annuity Payments begin (minus any applicable
premium taxes) to the Annuity Option elected based on the mortality
table and interest rate shown on the Specifications Page.
Fixed Annuity payments, at the time of their commencement will not
be less than those that would be provided by the application of the
Contract Value to purchase any single consideration immediate
annuity contract offered by the Company at the time, to the same
class of annuitants. Since no such annuity contract currently
exists, a comparable contract in an affiliated company will be
used.
We guarantee the dollar amount of Fixed Annuity payments.
NY
9.1
PART 10 ANNUITY OPTIONS
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DESCRIPTION OF ANNUITY OPTIONS Life Annuity with Cash Refund: We will make payments during the
lifetime of the Annuitant. After the death of the Annuitant, we
will pay the Beneficiary a lump sum amount equal to the excess, if
any, of the Contract Value at the election of this option over the
sum of the Annuity Payments made under this option.
The annual amount of the annuity payments will equal the greater of
(a) the Lifetime Income Amount, or
(b) the annual amount determined by applying the Contract
Value to a Cash Refund Annuity Option based on the
Mortality Table and Fixed Annuity Payment Interest Rate
listed in the Specifications.
ALTERNATE ANNUITY OPTIONS Instead of settlement in accordance with the Annuity Option
described above, you may choose an alternate form of settlement
acceptable to us. Once Annuity Payments commence, the form of
settlement may not be changed.
10.1
PART 11 GENERAL PROVISIONS
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ENTIRE CONTRACT The entire Contract consists of this Contract and Endorsements, if
any, and the application, if one is attached to this Contract.
BENEFITS AND VALUES The benefits and values available under this Contract are not less
than the minimum required by any statute of the state in which this
Contract is delivered.
MODIFICATION Only the President, a Vice President, or the Secretary of the
Company has authority to change or waive the provisions of this
Contract. Any change or waiver must be in writing and signed by one
of these officers of the Company. We will not change this Contract
without prior approval by the New York Superintendent of Insurance.
No change that reduces benefits under this Contract will be made
without your written consent.
CHANGE IN MATURITY DATE Prior to the Maturity Date, you may request a change of the
Maturity Date. Any extension of the Maturity Date will be subject
to our prior approval and any applicable law or regulation then in
effect.
ASSIGNMENT You may assign this Contract prior to the Maturity Date. No
assignment will be binding on us unless it is written in a form
acceptable to us, received at our Annuities Service Center. An
assignment may result in the elimination of the Lifetime Income
Amount guarantee as of the date of such change. We will not be
liable for any payments made or actions taken before the assignment
is received by us. An absolute assignment will revoke the interest
of any revocable Beneficiary. We will not be responsible for the
validity of any assignment.
CLAIMS OF CREDITORS All benefits and payments under this Contract shall be exempt from
the claims of creditors to the extent permitted by law.
MISSTATEMENT AND PROOF OF AGE We may require proof of age or survival of any person upon whose
OR SURVIVAL age or survival any Lifetime Income Benefit, Annuity Payments or
other benefits provided by this Contract or any Endorsement
attached thereto depend. If the age of the Annuitant has been
misstated, the benefits will be those which would have been
provided for the correct age. If we have made incorrect benefit
payments, we will immediately pay the amount of any underpayment
adjusted with interest at 3% per annum. We will deduct the amount
of any overpayment from future benefit payments without adjustment
for interest.
ADDITION, DELETION OR We may:
SUBSTITUTION OF INVESTMENT
OPTIONS (a) add, delete or substitute Portfolio shares held or
purchased by the Variable Account;
(b) eliminate shares of one Portfolio and substitute shares
of another Portfolio;
(c) establish additional Sub-Accounts to invest in a new
Portfolio, eliminate or combine existing Sub-Accounts or
transfer Sub-Account assets to another Separate Account
of the Company or an affiliated company.
We will obtain prior approval required from the Securities and
Exchange Commission and the New York Superintendent of Insurance
before making these changes. We will provide you with notice of
these substitutions or changes.
If deemed by us to be in the best interests of persons having
voting rights under the Contracts, the Variable Account may be
operated as a management company under the Investment Company Act
of 1940 or it may be de-registered under such Act in the event such
registration is no longer required.
NON-PARTICIPATING Your Contract is non-participating. This means the Contract will
not share in our profits or surplus earnings. We will pay no
dividends on your Contract.
NY
11.1
REPORTS We will send you annual reports without charge, containing the
value of the Investment Account(s) and the Contract Value. The
report will include the number of Accumulation Units credited to
the Variable Account, the Accumulation Unit value and the dollar
value of the Accumulation Unit of the Variable Account no more than
4 months prior to the date of the mailing of the report. We will
provide annual calendar year reports concerning the status of the
Contract and such information concerning required minimum
distributions as is prescribed by the Commissioner of Internal
Revenue.
INSULATION The assets of the Variable Account equal to the reserves and other
contract liabilities applicable to that account are not chargeable
with liabilities from any other business we may conduct. Moreover,
the income, gains and losses, realized or unrealized, applicable to
the assets of the Variable Account shall be applied to that account
regardless of our other income, gains or losses.
SEPARATE ACCOUNT ASSETS We will maintain, in the Separate Account, assets with a value at
least equal to the amounts accumulated in accordance with the terms
of the applicable agreements with respect to the Separate Account,
and the reserves for annuities, in the course of payment that may
vary with the investment experience of the Separate Account.
CURRENCY AND PLACE OF PAYMENTS All payments made to or by us shall be made in the lawful currency
of the United States of America at the Annuities Service Center or
elsewhere if we consent.
NOTICES AND ELECTIONS Notices and elections are any form of communication that provides
information needed by us to process your request. A notice or
election may be provided to us in a written and signed format or in
another manner that we approve in advance. All notices and
elections you make under this Contract must be received by us at
the Annuities Service Center. All notices, requests and elections
will be effective when signed. We will not be liable for any
payments made or actions taken before the notice or election is
received by us.
GOVERNING LAW This Contract will be governed by the laws of the jurisdiction
indicated on the Specifications Page.
SECTION 72(S) The provisions of this Contract shall be interpreted so as to
comply with the requirements of Section 72(s) of the Internal
Revenue Code.
NY
11.2
XXXX XXXXXXX LIFE INSURANCE COMPANY OF NEW YORK (XXXX XXXXXXX(R) LOGO)
