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First SunAmerica
Life Insurance Company First SunAmerica
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This is an annuity contract on the life of the Annuitant. We will make periodic
annuity payments beginning on the Annuity Date, as set forth in this Contract.
This contract is owned by you, the Contract Owner.
This Contract has been issued in return for the attached application and for the
initial Purchase Payment made.
TEN-DAY FREE LOOK
To be sure that you are satisfied with this Contract, you have a ten-day free
look. Within ten days of the day you receive this Contract, it may be returned
by delivering it or mailing it to us at our Annuity Service Office listed on the
Contract Data Page, or to the agent through whom it was purchased. Within seven
days of receipt of this Contract by us, we will pay you the Contract Value
computed as of the date of surrender. The date of surrender is the date the
Contract Owner transfers possession of the Contract with a written request for
cancellation to the Company or to an authorized representative of the Company.
Signed for the Company.
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Secretary President
INDIVIDUAL FLEXIBLE PURCHASE PAYMENT
DEFERRED VARIABLE ANNUITY CONTRACT
NONPARTICIPATING
NO DIVIDENDS
ANNUITY PAYMENTS AND VALUES PROVIDED BY THIS CONTRACT ARE VARIABLE AND ARE NOT
GUARANTEED AS TO DOLLAR AMOUNT.
PLEASE READ THIS CONTRACT CAREFULLY, IT DEFINES YOUR LEGAL RIGHTS AND IS A
CONVENIENT SOURCE OF INFORMATION AND REFERENCE IN HELPING YOU FULLY UNDERSTAND
AND BENEFIT FROM YOU CONTRACT.
THE VARIABLE PROVISIONS OF THIS CONTRACT
CAN BE FOUND ON PAGES 6 AND 9.
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CONTRACT DATA PAGE
ANNUITANT: CONTRACT NUMBER:
ISSUE DATE: CONTRACT OWNER:
ANNUITY DATE: INITIAL PURCHASE PAYMENT:
NON-QUALIFIED PLAN
ANNUITY SERVICE OFFICE:
FIRST SUNAMERICA
LIFE INSURANCE COMPANY
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MONEY MARKET PORTFOLIO
GOVERNMENT AND QUALITY BOND PORTFOLIO
FIXED INCOME PORTFOLIO
GROWTH PORTFOLIO
HIGH YIELD PORTFOLIO
AGGRESSIVE GROWTH PORTFOLIO
FOREIGN SECURITIES PORTFOLIO
CONVERTIBLE SECURITIES PORTFOLIO
MULTI-ASSET PORTFOLIO
AGGRESSIVE MULTI-ASSET PORTFOLIO
NATURAL RESOURCES PORTFOLIO
TARGET '98 PORTFOLIO
A TOTAL WITHDRAWAL OR A PARTIAL WITHDRAWAL IN EXCESS OF THE WITHDRAWAL WITHOUT
WITHDRAWAL CHARGE AMOUNT WILL BE SUBJECT TO A WITHDRAWAL CHARGE ON PURCHASE
PAYMENTS WITHDRAWN BEFORE THE END OF THE FIFTH CONTRIBUTION YEAR. THE WITHDRAWAL
CHARGE IS 5% IN THE FIRST CONTRIBUTION YEAR AND REDUCES BY 1% EACH FOLLOWING
CONTRIBUTION YEAR, SO THAT THERE IS NO CHARGE IN THE SIXTH AND LATER
CONTRIBUTION YEARS.
ANNUITY PAYMENTS WILL NOT DECREASE AS LONG AS THE INVESTMENT RETURN OF THE
SEPARATE ACCOUNT ASSETS EQUALS OR EXCEEDS 6.40% ON AN ANNUAL BASIS.
FOR USE WITH
VARIABLE ANNUITY ACCOUNT ONE
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TABLE OF CONTENTS
Section Page
Definitions 7
Purchase Payments 7
Accumulation Period 8
Withdrawal Charge Table 9
Death Benefit 10
Death of Owner 10
Annuity Period 10
Table of Monthly Installments Under Option 1 13
Table of Monthly Installments Under Option 2 14
General Provisions 14
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DEFINITIONS
ACCUMULATION PERIOD - The period between the Issue Date of this Contract and the
Annuity Date, the build-up phase of this Contract.
ACCUMULATION UNIT - A unit of measurement which we use to calculate the Contract
Value during the Accumulation Period.
ANNUITANT - The person designated in the Application and shown on the Contract
Data Page to receive or who is actually receiving annuity payments.
ANNUITIZATION - The process by which an Owner converts from the Accumulation
Period to the Annuity Period. That is, you convert your Contract from the
build-up phase to the phase during which the Annuitant receives periodic annuity
payments.
ANNUITY DATE - The date on which annuity payments are to begin.
ANNUITY PERIOD - The period starting on the Annuity Date.
ANNUITY UNIT - A unit of measurement we use to calculate the amount of Variable
Annuity payments.
BENEFICIARY - The person designated to receive any benefits under this Contract
upon the death of the Annuitant during the Accumulation Period. If the Owner
dies during the Accumulation Period, the Beneficiary will, unless the Owner has
elected otherwise, become the Owner of this Contract.
CONTRACT OWNER OR OWNER - You, the person having the privileges of ownership
defined in this Contract. If the Owner dies during the Accumulation Period, the
Beneficiary will, unless the Owner has elected otherwise, become the Owner of
this Contract.
CONTRACT VALUE - The sum of the values of your interest in the Separate Account
Divisions.
CONTRACT YEAR - The period between anniversaries of the Issue Date of this
Contract.
CONTRIBUTION YEAR - Each Contract Year in which a Purchase Payment is made and
each succeeding year measured from the end of the Contract Year during which
such Purchase Payment was made.
DIVISION OR SEPARATE ACCOUNT DIVISION - A Division of the Separate Account
invested wholly in shares of one of the Eligible Portfolios.
ISSUE DATE - The date shown on the Contract Data Page on which the first
Contract Year and first Contribution Year begin.
NON-QUALIFIED PLAN - A retirement plan which does not receive favorable tax
treatment under Section 401, 403(b), 408 or 457 of the Internal Revenue Code.
PORTFOLIOS - One of the Portfolios shown on the Contract Data Page.
PURCHASE PAYMENTS - Amounts you pay to us under this Contract.
QUALIFIED PLAN - A retirement plan which receives favorable tax treatment under
Sections 401, 403(b), 408 or 457 of the Internal Revenue Code.
SEPARATE ACCOUNT OR ACCOUNT - A segregated investment account entitled,
"Variable Annuity Account One", established by us.
VALUATION DATE - Monday through Friday except New Year's Day, President's Day,
Good Friday, Memorial Day, Independence Day, Labor Day, Thanksgiving, and
Christmas Day.
VALUATION PERIOD - The interval between two consecutive Valuation Dates measured
from 5:00 P.M. New York time.
WITHDRAWAL CHARGE - The charge assessed against certain withdrawals or
annuitizations of Accumulation Units in their first five (5) Contribution Years.
WITHDRAWAL VALUE - The Contract Value, less any premium tax payable if the
Contract is being annuitized, minus any applicable Withdrawal Charge.
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PURCHASE PAYMENTS
Purchase Payments are flexible. This means that you, subject to the minimums and
maximums given below, may change the amount and the frequency of timing of
Purchase Payments. The minimum initial Purchase payment we will accept for a
Contract issued pursuant to a Non-Qualified Plan is $1,000. Subsequent Purchase
Payments must be at least $500. The minimum initial Purchase Payment we will
accept for a Contract issued pursuant to a Qualified Plan is $100.
Purchase Payments will be allocated to one or more Separate Account Divisions.
At least $500 must be allocated to each Division selected before an allocation
can be made to an additional Division.
If the Contract Value is less than $500, and no Purchase Payments have been made
during the previous three full calendar years, we reserve the right, after 60
days written notice to you, to terminate this Contract and distribute the
Contract Value to you.
ACCUMULATION PERIOD
PURCHASE PAYMENTS AND CONTRACT VALUE - We will credit a Contract with the number
of Accumulation Units in a Division which results from dividing the Purchase
Payment(s) allocated to that Division, or the amount transferred into the
Division, by the Accumulation Unit Value for that Division at the end of the
Valuation Period next concluding after the allocation or transfer.
The Contract Value for any Valuation Period is determined by multiplying the
number of Accumulation Units credited to each Division by the Accumulation Unit
Value for that Division at the end of the Valuation Period and then adding the
resultant values.
ACCUMULATION UNIT VALUE - The Accumulation Unit Value of a Separate Account
Division for any Valuation Period is calculated by subtracting (2) from (1) and
dividing the result by (3) where:
(1) is the total value of the assets of the Separate Account Division minus
total liabilities;
(2) is the cumulative unpaid charge for assumption or mortality and expense
risks;
(3) is the number of Accumulation Units outstanding at the end of such
Valuation Period.
During the Accumulation Period, each Separate Account Division is assessed with
a daily charge for mortality and expense risks. The charge will equal an
aggregate of 1.25% per annum of the average daily net asset value of each
Division. Net asset value of each Division for any Valuation Period is
calculated by dividing (1) above by (3) above.
The Accumulation Unit Value may increase or decrease from Valuation Period to
Valuation Period.
RECORDS MAINTENANCE CHARGE - During the Accumulation Period, a Records
Maintenance Charge of $30 is assessed each Contract Year against each Contract
in force on the anniversary of the Issue Date. If a total surrender of Contract
Value is made, the charge will be assessed as of the date of surrender. If the
Contract participates in more than one Separate Account Division, an equal share
of the $30 charge will be made against each Division. The number of Accumulation
Units representing your Contract's interest in the affected Separate Account
Divisions will be reduced to reflect the Records Maintenance Charge.
ADMINISTRATIVE EXPENSE CHARGE - During the Accumulation Period, each Separate
Account Division is assessed with a daily charge for administrative expenses.
The charge will equal an aggregate of .15% per annum of the average daily net
asset value of each Division. Net asset value of each Division for any Valuation
Period is calculated dividing (1) by (3) as described in the Accumulation Unit
Value provision. This charge will be reduced to the extent it exceeds that
required for administrative expenses.
TRANSFERS DURING ACCUMULATION PERIOD - You may transfer all or part of the
Contract Value among Separate Account Divisions subject to the following
conditions:
(1) the minimum amount which may be transferred from a Division is $500 or,
the remaining Contract Value in a Separate Account Division if less than
$500;
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(2) no partial transfer can be made if your remaining Contract Value in a
Separate Account Division will be less than $500 after the transfer;
(3) transfers will be honored on the Valuation Date next following receipt
by us of a written direction (containing all required information);
(4) if you make a transfer within 30 days of a prior transfer, or within 30
days of the Issue Date, a transfer fee of $25 ($10 in Pennsylvania and
Texas) will be charged.
We reserve the right to suspend, modify, or terminate the transfer privilege
with notice if there is a cessation of market trading.
The Accumulation Units credited to a Separate Account Division will be reduced
based on the Accumulation Unit Value at the end of the Valuation Period next
following the Valuation Period during which we receive a completely detailed
request for a transfer. Accumulation Units will be credited to the Contract
Value in the Separate Account Division to which the transfer is being made at
the same time.
TOTAL WITHDRAWAL DURING THE ACCUMULATION PERIOD - You may, during the
Accumulation Period, withdraw all the Contract Value remaining after deduction
of the Withdrawal Charge, if any.
An election for total withdrawal must be made in writing to us at our Annuity
Service Office. Payment made by us in honoring an election for total withdrawal
prior to receipt by us of notice of the death of the Annuitant or the Owner will
discharge our obligations under this Contract.
PARTIAL WITHDRAWALS DURING THE ACCUMULATION PERIOD - You may, during the
Accumulation Period, withdraw portions of the Contract Value, subject to the
following conditions:
(1) each partial withdrawal must be for an amount which is not less than
$500 or, if smaller, the remaining value in a Separate Account Division;
(2) the remaining value in each Separate Account Division from which a
partial withdrawal is requested must be at least $500 after the partial
withdrawal is completed;
(3) an election to make a partial withdrawal must be made in writing to us
at our Annuity Service Office;
(4) the election must indicate the amount(s) and the Separate Account
Division(s) from which the partial withdrawal is requested;
(5) the maximum amount of a partial withdrawal will be equal to the Contract
Value in the Division minus the amount of the Withdrawal Charge, if any;
and
(6) you have the right to specify the Division from which a withdrawal is to
be made.
Any payment made by us for partial withdrawal prior to receipt by us of notice
of the death of the Annuitant or the Owner will discharge our obligation under
this Contract to the extent of the payment.
IF A WITHDRAWAL CHARGE IS APPLICABLE. THE REDUCTION IN THE CONTRACT VALUE
REQUIRED TO PRODUCE THE AMOUNT OF THE PARTIAL WITHDRAWAL REQUESTED WILL BE
GREATER THAN THE AMOUNT ACTUALLY PAID BY US TO YOU. THE ACTUAL DOLLAR AMOUNT OF
A PARTIAL WITHDRAWAL REQUESTED WILL BE THE AMOUNT PAID TO YOU.
PARTIAL WITHDRAWAL WITHOUT WITHDRAWAL CHARGE -
(1) all Purchase Payments in a given Contract Year are totalled and are used
separately in calculating applicable Withdrawal Charges.
(2) all withdrawals will be assessed first against Purchase Payments in the
earliest Contract Years.
(3) the amount which may be withdrawn in any Contract Year without a
Withdrawal Charge is 10% of aggregate Purchase Payments made as of the
date of the partial withdrawal, less prior withdrawals. A withdrawal
without withdrawal charges can be made only once per Contract Year and
must be the first withdrawal in that Contract Year. No withdrawal
without withdrawal charges is permitted during the first Contract Year.
(4) any amount withdrawn which exceeds the limitations specified in (3)
above will be subject to a Withdrawal Charge in accordance with the
Withdrawal Charge Table.
WITHDRAWAL CHARGE TABLE
CONTRIBUTION YEAR Rate
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First 5%
Second 4%
Third 3%
Fourth 2%
Fifth 1%
Sixth and later 0%
The Rate applies to Purchase Payments.
WITHDRAWAL PROCEDURES - The Accumulation Units credited to a Contract in a
Separate Account Division will be reduced based on the Accumulation Unit Value
at the end of the Valuation Period during which an election of withdrawal
completely containing all required information is received by us at our Annuity
Service Office. An amount withdrawn will be paid within seven calendar days
after the date proper written election is received by us, except as provided
below.
SUSPENSION OF WITHDRAWAL PRIVILEGES - We may suspend the right of withdrawal
privileges or delay payment more than seven calendar days:
(1) during any period when the New York Stock Exchange is closed (other than
customary weekend and holiday closings);
(2) when trading in the markets the Account or a Portfolio normally utilizes
is restricted or an emergency exists as determined by the Securities and
Exchange Commission so that disposal of the Account's or Portfolio's
investments or determination of Accumulation Unit Value is not
reasonably practicable; or;
(3) for such other periods as the Securities and Exchange Commission by
order may permit for protection of the Contract Owners.
DEATH BENEFIT
The Death Benefit is equal to the greater of:
(1) the Contract Value at the end of the Valuation Period during which Due
Proof of death and an election of the type of payment by the Beneficiary
is received by us at our Annuity Service Office; or
(2) the total dollar amount of Purchase Payments minus the total dollar
amount of partial withdrawals and applicable withdrawal charges; and
(3) after the fifth Contract Year, the Contract Value at the last Contract
Anniversary minus the total dollar amount of partial withdrawals made
since that anniversary.
Payment of Death Benefit may be made in one lump sum or applied under one of the
Annuity Options.
Due Proof of death means a certified copy of a death certificate or a certified
copy of a decree of a court of competent jurisdiction as to a finding of death,
or written statement by a Doctor of Medicine who attended the deceased at time
of death, or any other proof satisfactory to us.
DEATH OF ANNUITANT - The Death Benefit will be payable to the Beneficiary upon
receipt by us of Due Proof of the Annuitant's death during the Accumulation
Period.
DEATH OF OWNER
The following section applies only if this Contract is issued on a non-qualified
basis and if either of the two following conditions exit:
(A) The Owner and the Annuitant are the same individual and that individual
dies during the Accumulation Period; or
(B) The Owner and Annuitant are different persons and the Owner dies during
the Accumulation Period prior to the Annuitant's death.
If either of the above conditions occur, the following provisions apply:
(1) If the Beneficiary is the spouse of the Owner, then the Beneficiary
becomes the Owner and this Contract remains in full force and effect.
(2) If the Beneficiary is a natural person and not the spouse of the Owner,
the Beneficiary becomes the Owner. The Beneficiary can elect to have the
existing Contract Value paid under one of the Annuity Options set forth
in this Contract over a period not extending beyond the life expectancy
of the Beneficiary at the time of the election; however,
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payments under any Annuity Option selected must being not later than one
year after the date of death of the previous Owner.
Alternatively, the Beneficiary may elect to receive a lump sum
distribution of the greater of: (a) the current Contract Value at the
time of election; or (b) the total amount of Purchase Payments made
under the Contract less the aggregate dollar amount of any partial
withdrawals. Under this alternative election, the lump sum must be paid
to the Beneficiary within five years of the previous Owner's death.
(3) If there is no Beneficiary or if the Beneficiary is not a natural
person, then the entire Contract Value must be paid out within five
years of the Owner's death.
ANNUITY PERIOD
ELECTION OF ANNUITY OPTION AND ALLOCATION OF ANNUITY PAYMENTS - Election of an
Annuity Option must be made by written notice to us at our Annuity Service
Office. The election may be made:
(1) by the Owner prior to the Annuity Date and Annuitant's death;
(2) by the Annuitant on the Annuity Date unless the Owner has restricted the
right to make an election; or
(3) by the Beneficiary upon the Annuitant's death unless the Owner has
restricted the right to make an election.
If the Contract Value to be applied is less than $2,000, we may make payment in
one lump sum. If the amount of the first scheduled payment is less than $20, we
may increase the interval between payments to a quarterly, semi-annual or annual
payment to make the first payment at least $20. Payments must be made to a
natural person referred to as the payee.
The amount we use in determining annuity payments under Options 1, 2 and 3,
subject to adjustment for any applicable Withdrawal Charge and premium taxes, is
the Contract Value at the end of the Valuation Period immediately preceding the
Valuation Period which includes the Annuity Date. If Option 1 and 2 is elected,
no Withdrawal Charge will apply.
Payment under Option 3 or in accordance with the Other Settlement Arrangements
section may subject the Contract Value to a Withdrawal Charge. If Option 3 is
elected, the Contract Value may be subject to a Withdrawal Charge in accordance
with the Withdrawal Charge Table.
If no other Annuity Option is elected, the amount payable will be made under
Option 1 with a 10 year period certain.
ANNUITY OPTIONS - The amount payable may be paid under one of the following
options or in any other manner agreed to by us:
OPTION 1 - LIFE ANNUITY WITH INSTALLMENTS GUARANTEED - We will make
monthly payments for the guaranteed period elected and then for the
remaining lifetime of the payee. The period elected may be only 10 or 20
years. If the payee dies before the end of the guaranteed period, the
present value, based on a 5% annual interest rate, of remaining
guaranteed payments will be paid to the payee's estate or the
Beneficiary.
OPTION 2 - JOINT AND SURVIVOR ANNUITY - We will pay the full monthly
income while both payees are living. Upon the death of either payee,
income will continue during the lifetime of the surviving payee at the
percentage of such full amount chosen when this option was elected.
OPTION 3 - INCOME FOR SPECIFIED PERIOD - We will make monthly payments
for the period elected but not less that 5 years or more than 30 years.
The election must be made for full twelve-month periods.
OTHER SETTLEMENT ARRANGEMENTS - Our agreement is necessary for other payment
methods.
VARIABLE ANNUITY - The Contract Value at the end of the Valuation Period
immediately preceding the Valuation Period which includes the Annuity Date will
first be reduced by the dollar amount of any Withdrawal Charge and then by any
applicable premium taxes. The remaining value will be used to calculate the
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first monthly annuity payment. For Annuity Options 1, 2 and 3, the first monthly
annuity payment will be based upon the Annuity Option elected and the
appropriate Annuity Option Table.
With respect to Options 1, 2 and 3, the number of Annuity Units for each
Separate Account Division for purposed of determining subsequent annuity
payments is determined by dividing the amount of the first monthly annuity
payment attributable to the Contract Value in that Separate Account Division by
the Annuity Unit Value for the Division at the end of the Valuation Period
immediately preceding the Valuation Period which includes the Annuity Date. The
number of Annuity Units per payment will remain fixed unless a transfer is made.
The amount of any subsequent annuity payments will be determined by multiplying
the number of Annuity Units per payment in each Separate Account Division by the
Annuity Unit Value for that Division at the end of the Valuation Period
immediately preceding the Valuation Period which includes the date on which
payment is to be made and then adding the resultant values. The Annuity Unit
Value may increase or decrease from Valuation Period to Valuation Period.
We guarantee that the dollar amount of each annuity payment after the first will
not be adversely affected by variations in actual expense or by variations in
mortality experience from the expense and mortality assumptions on which the
first payment is based.
The Annuity Tables are based on the 1983 Table A, projected at Scale G with
interest at the rate of 5% per annum and assume births in year 1942. The amount
of each annuity payment will depend upon the sex and adjusted age of the
Annuitant, the joint annuitant, if any, or other payee. The adjusted age is
determined from the actual age nearest birthday at the time the first monthly
annuity payment is due according to the Table A below.
TABLE A
Adjustment Adjustment
Calendar to Actual Calendar to Actual
Year of Birth Age Year to Birth Age
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1899 - 1905 +6 1946 - 1951 -1
1906 - 1911 +5 1952 - 1958 -2
1912 - 1918 +4 1959 - 1965 -3
1919 - 1925 +3 1966 - 1972 -4
1926 - 1932 +2 1973 - 1979 -5
1933 - 1938 +1 1980 - 1985 -6
1939 - 1945 0
ANNUITY UNIT VALUE - For each Separate Account Division, the value of an Annuity
Unit at the end of any Valuation Period is determined by multiplying the Annuity
Unit Value for the immediately preceding Valuation Period by the net investment
factor for the Valuation Period for which the Annuity Unit Value is being
calculated, and multiplying the result by an interest factor of .999866337 per
calendar day of such Valuation Period to offset the effect of the assumed rate
of 5.00% per annum in the Annuity Option Table.
The net investment factor for each Division for any Valuation Period is
determined by dividing:
(1) the value of an Accumulation Unit of the applicable Division as of the
end of the current Valuation Period; by
(2) the value of an Accumulation Unit of the applicable Division as of the
end of the immediately preceding Valuation Period.
TRANSFERS DURING THE ANNUITY PERIOD - During the Annuity Period, the payee(s)
may transfer the Contract Value in the Separate Account Divisions. To do so,
send a written request to our Annuity Service Office. A transfer may be made
subject to the following:
(1) a transfer may be made once each Contract Year;
(2) a request for a transfer must be received by us at our Annuity Service
Office at least 45 days before the Contract Anniversary as of which the
transfer will take effect;
(3) a transfer will be effected at the next Annuity Unit Value calculated
after we receive the transfer request;
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(4) no transfer may be made during the first year of the Annuity Period;
(5) the entire interest in a Separate Account Division must be
transferred.
The number of Annuity Units per payment attributable to a Separate Account
Division to which a transfer(s) is made, determined as of the effective date of
the transfer, will be equal to the number of Annuity Units per payment in the
Division from which the transfer(s) is being made multiplied by the Annuity Unit
Value for that Division, the amount being divided by the Annuity Unit Value for
the Separate Account Division to which transfer is being made. We reserve the
right without prior notice to any party to terminate, suspend or modify the
transfer privileges described above if there is a cessation of market trading.
SUPPLEMENTARY ANNUITY AGREEMENT - An Annuity Agreement will be issued to reflect
payments to be made under an Annuity Option. If settlement is a result of
Annuitant's death or the Owner's death, the effective date of the Annuity
Agreement will be the date of receipt of Due Proof of death, as defined above.
Otherwise, the effective date will be the date specified in the Annuity
Agreement.
CHANGE OF ANNUITY DATE - You may elect to change the Annuity Date during the
lifetime of the Annuitant. An election to change the Annuity Date must be in
written form received by us at our Annuity Service Office at least 7 days before
the Annuity Date then reflected on our records.
EVIDENCE OF AGE, SEX AND SURVIVAL - We may require satisfactory evidence of:
(1) the age and sex of any person(s) on whose life the annuity payments are
to be based; and
(2) the continued survival of any person(s) on whose life the annuity
payments are based.
DISBURSEMENT OF FUNDS UPON DEATH OF PAYEE - At the payee's death, unless
otherwise provided in the Annuity Agreement, the commuted value, based on 5.00%
interest of any remaining unpaid guaranteed installments, will be paid in one
sum to the Beneficiary. The value (to be commuted) of the remaining installments
will be determined by using (for all payments) the Annuity Unit Value next
determined after Due Proof of death is received by us.
PROTECTION OF BENEFITS - Unless otherwise provided in the Annuity Agreement, the
payee may not commute, anticipate, assign, alienate or otherwise encumber any
payment to be made.
CREDITORS - Proceeds under this Contract and any payment under any of the above
options will be exempt from the claims of creditors and from legal process to
the extent permitted by law.
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TABLES OF MONTHLY INSTALLMENTS UNDER OPTION 1
Monthly installments for ages not shown will be furnished on request.
OPTION 1 Life Annuity with Installments Guaranteed
Guaranteed Period - 10 Years
Adjusted Monthly Installment Adjusted Monthly Installment
Age for each $1,000 of Age for each $1,000 of
------------ Amount Applied ------------ Amount Applied
Male Female Male Female
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40 46 $4.74 58 64 $5.63
41 47 4.77 59 65 5.70
42 48 4.81 60 66 5.79
43 49 4.84 61 67 5.87
44 50 4.88 62 68 5.96
45 51 4.92 63 69 6.06
46 52 4.96 64 70 6.15
47 53 5.00 65 71 6.26
48 54 5.05 66 72 6.36
49 55 5.09 67 73 6.48
50 56 5.14 68 74 6.59
51 57 5.19 69 75 6.71
52 58 5.24 70 6.84
53 59 5.30 71 6.97
54 60 5.36 72 7.10
55 61 5.42 73 7.23
56 62 5.49 74 7.37
57 63 5.56 75 7.51
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OPTION 1 Life Annuity with Installments Guaranteed
Guaranteed Period - 20 Years
Adjusted Monthly Installment Adjusted Monthly Installment
Age for each $1,000 of Age for each $1,000 of
------------ Amount Applied ------------ Amount Applied
Male Female Male Female
---------------------------------- -----------------------------------------
40 46 $4.69 58 64 $5.39
41 47 4.72 59 65 5.44
42 48 4.75 60 66 5.49
43 49 4.78 61 67 5.54
44 50 4.81 62 68 5.59
45 51 4.84 63 69 5.65
46 52 4.87 64 70 5.70
47 53 4.91 65 71 5.75
48 54 4.95 66 72 5.81
49 55 4.98 67 73 5.86
50 56 5.02 68 74 5.91
51 57 5.06 69 75 5.96
52 58 5.11 70 6.01
53 59 5.15 71 6.06
54 60 5.19 72 6.10
55 61 5.24 73 6.15
56 62 5.29 74 6.19
57 63 5.34 75 6.22
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TABLE OF MONTHLY INSTALLMENTS UNDER OPTION 2
Monthly instaLLments for ages or combination of ages not shown
will be furnished on request.
OPTION 2 Joint and Survivor Annuity
Adjusted Age
of Other Payee Adjusted Age of Annuitant
----------------- ----------------------------------------------------------
51 56 58 61 63 66 71
Male Female 57 62 64 67 69 72 77
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50 56 $4.72 $4.80 $4.84 $4.88 $4.91 $4.95 $5.01
55 61 4.81 4.92 4.96 5.03 5.07 5.13 5.23
57 63 4.84 4.97 5.02 5.09 5.14 5.21 5.32
60 66 4.89 5.04 5.10 5.19 5.25 5.34 5.47
62 68 4.93 5.08 5.15 5.25 5.32 5.42 5.58
65 71 4.97 5.15 5.23 5.35 5.43 5.55 5.75
70 76 5.04 5.25 5.35 5.50 5.60 5.77 6.05
TABLE OF MONTHLY INSTALLMENTS UNDER OPTION 3
OPTION 3 income for Specified Period
Monthly Monthly
Specified Installment Specified Installment
Period for each $1,000 of Period for each $1,000 of
(Years) Amount AppLied (Years) Amount AppLied
--------- ------------------ --------- ------------------
5 $18.74 18 $6.94
6 15.99 19 6.71
7 14.02 20 6.51
8 12.56 21 6.33
9 11.42 22 6.17
10 10.51 23 6.02
11 9.77 24 5.88
12 9.16 25 5.76
13 8.64 26 5.65
14 8.20 27 5.54
15 7.82 28 5.45
16 7.49 29 5.36
17 7.20 30 5.28
13
GENERAL PROVISIONS
THE CONTRACT - This Contract and the attached AppLication are the entire
contract between the parties. ALL statements made in the Application are deemed
representations and not warranties. No statement wiLL void this Contract or be
used as a defense to a claim unless it is contained in the AppLication.
MODIFICATION OF CONTRACT - OnLy our President or Secretary may approve a change
or waive the provisions of this Contract. Any change or waiver must be in
writing. No agent has authority to change or waive the provisions of this
Contract.
INCONTESTABILITY - This Contract wiLL not be contestable after it has been in
force for a period of two years from the Issue Date.
MISSTATEMENT OF AGE OR SEX - If a payee's age or sex is misstated, we wiLL
adjust any amount to be paid based upon the corrected age or sex; the date of
the first payfnent wiLL not be changed. Any underpayment ▇▇▇▇ be paid
immediately or accruing at the rate of interest of 6%. Any overpayment wiLL be
deducted from payments subsequently accruing at the rate of interest of 6%.
BENEFICIARY - You may designate a Beneficiary to receive any amount payable on
death. The original Beneficiary wiLL be named in the AppLication. You may change
the Beneficiary by filing a written request with us at our Annuity Service
Office unless an irrevocable Beneficiary designation was previously filed with
us. However, any change will take effect as of the date such request was signed,
except as to any payment made or other action taken by us before the change was
recorded.
If there is more than one Beneficiary, the interest of any Beneficiary who
predeceases the Annuitant will pass to the survivor or survivors, share and
share alike, unless otherwise provided in the Beneficiarydesignation. If no
designated Beneficiary survives the Annuitant, the Beneficiary wiLL be the
Annuitant's estate.
CHANGE OF OWNERSHIP - NOTE: A CHANGE OF OWNERSHIP MAY BE A TAXABLE EVENT.
YOU SHOTJLD FIRST CONSULT WITH YOUR TAX ADVISOR.
OWNERSHIP - If no designated Beneficiary who is a natural person survives the
Owner, the Owner's estate wiLL become the new Owner.
Ownership may be changed at any time during the Annuitant's Lifetime. A change
must be made by written notice from the Owner sent to us at our Annuity Service
office with information sufficient to cLearLy identify the new Owner to us. No
change wiLL take effect until received by us. Upon being received, any change
wiLL take effect as of the date it was signed, except for action taken by us
before the change was received. We reserve the right to require this Contract
for endorsement of a change.
ASSIGNMENT - No assignment of this Contract is binding until received by us at
our Annuity Service office. We assume no responsibility for the validity of any
assignment.
NOTE: AN ASSIGNMENT MAY CONSTITUTE A TAXABLE EVENT. YOU SHOULD FIRST
CONSULT WITH YOUR TAX ADVISOR.
Any claim under an assignment is subject to proof of the extent of interest. If
this Contract is assigned, your rights and the Beneficiary's rights are subject
to the rights of any assignee of record.
OWNERSHIP OF THE SEPARATE ACCOUNT ASSETS - We have exclusive ownership and
control of aLL assets in the Separate Account.
LIABILITIES OF SEPARATE ACCOUNTS - The assets held in the Separate Account wiLL
not be charged with LiabiLities arising out of any other business we may
conduct. The assets are held and applied excLusiveLy for the benefit of Owners,
Annuitants, Beneficiaries or payees of the VariabLe Annuity Contracts.
NONPARTICIPATION IN SURPLUS - This Contract does not share in our profits or
surplus.
SUSPENSION OF PAYMENTS - We may suspend or postpone payments if any of the
foLLowing occur:
(1) during any period when the New York Stock Exchange is closed
(other than customary weekend and holiday closings);
14
(2) when trading in the markets the Account or a portfolio normally
utilizes is restricted, or an emergency exists as determined by
the Securities and Exchange Commission so that disposal of the
Account's or a Portfoliols investments or determination of
AccumuLation Unit VaLue is not reasonably practicable or
(3) for such other periods as the Securities and Exchange Commission
by order may permit for the protection of the Contract Owners.
REPORTS - Once each Contract Year, we wiLL furnish you with an AnnuaL Report of
the Separate Account and a statement showing the Contract VaLue as weLL as the
wording describing any WithdrawaL VaLue and/or any Death Benefit.
ADDITION, SUBSTITUTION AND CONVERSION - Any of the additions, substitutions and
conversions Listed below are subject to the approval of the Superintendent. We
reserve the right to add additional ELigibLe Portfotios from time to time. If
additional ELigible PortfoLios are added, we wiLL notify you in writing.
If shares of a PortfoLio are not available for purchase or if, in our judgment,
further investment in the shares is no longer appropriate in view of the
purposes of the Separate Account, shares of or interests in another investment
portfolio or company may be substituted for PortfoLio shares held or to be
purchased by future Purchase Payments or transfers under this Contract.
CHANGES IN THE LAW - If laws governing this Contract or the taxation of benefits
under this Contract change, we wiLL amend this Contract to comply with these
changes.
15
INDIVIDUAL FLEXIBLE PURCHASE PAYMENT
DEFERRED VARIABLE ANNUITY CONTRACT
NONPARTICIPATING
NO DIVIDENDS
First SunAmerica
Life Insurance Company
FIRST SUNAMERICA
▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇ ▇▇▇▇▇ a SunAmerica Company
▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇ ▇▇▇▇▇
212/888-4540
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16
First SunAmerica
Life Insurance Company FIRST SUNAMERICA
A SunAmerica Company
▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇ ▇▇▇▇▇
▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇ ▇▇▇▇▇
212/888-4540
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JOINT ANNUITANT ENDORSEMENT
This Endorsement is a part of the Annuity Contract to which it is attached.
The Effective Date of this Endorsement is the Issue Date stated in the Contract
Data/Specifications Page.
We agree that persons listed in the Annuity Contract Application have been named
as Joint Annuitants.
The Annuity Contract is changed as follows:
(1) Annuitant means all Joint Annuitants or, after the death of one, the
survivor(s).
(2) While all Annuitants are living, the Annuity Date will be not later than
the 85th birthday of the youngest Annuitant.
(3) The automatic form of annuity will be a Joint and Survivor Income
Option. Income payments will be made to the named Annuitants. A
different Annuity Income Option may be elected by the Annuity Contract
Owner(s) before income payments begin.
(4) The Annuity Value of the Annuity Contract may be applied to provide
Annuity income for each Annuitant. Any part of the Annuity Value may be
used to provide income for one Annuitant. The balance will be used to
provide income to the other Annuitant(s). The incomes may be paid under
the same or different forms of income options.
(5) Unless an Annuitant who dies is also the Annuity Contract Owner, no
settlement will be made upon the death of the first Annuitant to die
before the start of income payments. Such death will not affect the
Annuity Value. The Annuity Date will them be not later than the 85th
birthday of the youngest surviving Annuitant.
Signed for Us:
/s/ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇ /s/ ▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇
----------------------- --------------------------
▇▇▇▇▇ ▇. ▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇
Secretary President
FSA-JtANN-E1
17
First SunAmerica
Life Insurance Company FIRST SUNAMERICA
A SunAmerica Company
▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇ ▇▇▇▇▇
▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇ ▇▇▇▇▇
212/888-4540
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JOINT OWNER ENDORSEMENT
This Endorsement is a part of the Annuity Contract to which it is attached.
The Effective Date of this Endorsement is the Issue Date stated in the Contract
Data/Specifications Page.
We agree that persons listed in the Annuity Contract Application have been named
as Joint Owners, provided they are spouses of each other.
The Annuity Contract is changed as follows:
(1) Owner means all Joint Owners.
(2) Each Joint Owner has an equal ownership interest in the Annuity Contract
unless we are advised otherwise in writing.
(3) Each Joint Owner shall be a Primary Beneficiary. Upon the death of a
Joint Owner, the survivor shall be the Primary Beneficiary.
Signed for Us:
/s/ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇ /s/ ▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇
----------------------- --------------------------
▇▇▇▇▇ ▇. ▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇
Secretary President
FSA-JtOWN-E2
18
First SunAmerica
Life Insurance Company FIRST SUNAMERICA
A SunAmerica Company
▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇ ▇▇▇▇▇
▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇ ▇▇▇▇▇
212/888-4540
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DEATH BENEFIT ENDORSEMENT
This Endorsement is a part of the Annuity Contract to which it is attached.
The DEATH BENEFIT section provisions of the attached Contract are deleted and
replaced by the following:
GENERAL - A Death Benefit will be paid to the Annuitant's Beneficiary upon the
Annuitant's death. The Beneficiary may elect to receive a single sum
distribution or to receive annuity payments. If a single sum payment is
requested, we will pay proceeds attributed to any Separate Account Division
within 7 days of our Annuity Service Office's receipt of the Death Benefit
payment election and due proof of death. If any Annuity Option is desire, an
Option must be elected within sixty (60) days of our receipt of due proof of the
Annuitant's death at our Annuity Service Office; otherwise a single sun payment
will be made at the end of such 60 day period. Funds will remain allocated
pursuant to the last allocation and instructions in effect at the Annuitant's
death until our Annuity Service Office receives new written allocation
instructions:
PROOF OF DEATH - Due proof of death means:
(1) a certified copy of a death certificate; or
(2) a certified copy of a decree of a court of competent jurisdiction as to
the finding of death; or
(3) an attending physician's statement; or
(4) any other proof satisfactory to us.
AMOUNT OF DEATH BENEFIT - The amount of the Death Benefit is equal to the
greater of:
(1) the Contract Value at the end of the Valuation Period during which We
receive at Our Annuity Service Office due proof of the Annuitant's death
and an election of the type of payment to be made; or
(2) the total dollar amount of Purchase Payments minus the dollar amount of
partial withdrawals and applicable withdrawal charges; or
(3) After the fifth Contract Year, the Contract Value at the last Contract
Anniversary minus the total amount of partial withdrawals made since
that anniversary.
Signed for the Company:
/s/ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇ /s/ ▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇
----------------------- --------------------------
▇▇▇▇▇ ▇. ▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇
Secretary President
FSA-JtOWN-E2
19
First SunAmerica
Life Insurance Company
FIRST SUNAMERICA
A SunAmerica Company
▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇ ▇▇▇▇▇
▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇ ▇▇▇▇▇
212/888-4540
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GENERAL ACCOUNT ANNUITY CONTRACT RIDER
The Rider forms part of the Variable Annuity Contract (the "Contract") to which
it is attached. The following provisions add to or modify the Contract.
DEFINITIONS
Contract Value - The Contract Value is the sum of the values of the Owner's
interest in the Separate Account Divisions and the values of the Owner's
interest in the General Account.
Fixed Annuity - A series of payments made during the Annuity Period. These
payments are guaranteed as to dollar amount by the Company and do not vary with
the investment experience of the Separate Account.
General Account - The General Account is the Company's general investment
account. It contains all the assets of the Company except for ICAP Variable
Annuity Account One (the "Separate Account") and other segregated asset
accounts.
General Account Value - The Owner's interest in the General Account.
Separate Account Value - The sum of the Owner's interest in each of the Separate
Account Divisions.
Variable Annuity - A series of payments made during the Annuity Period which
vary in amount based upon the investment experience of the Separate Account
Division.
ACCUMULATION PERIOD
ALLOCATION OF PURCHASE PAYMENTS
Purchase Payments may be allocated to the General Account as elected by the
Owner. A minimum of $500 must be allocated to the General Account before
Purchase Payments or Transfers may be allocated to an additional Separate
Account Division.
GENERAL ACCOUNT VALUE
The General Account Value at any time is equal to:
(1) all Purchase Payments allocated to the General Account plus the
interest credited to those payments; plus
(2) The Separate Account Value transferred to the General Account plus the
interest credited to the transferred values; less
(3) any prior partial withdrawals and withdrawal charges deducted from the
General Account; less
(4) any General Account Value transferred to the Separate Account; less
(5) any prior annuity payments; less (6) Record Maintenance Charge,
Withdrawal Charges and Premium Taxes.
INTEREST TO BE CREDITED
We will credit interest to the General Account during the Accumulation Period at
a rate no less than 4%.
We may declare and credit additional interest at our sole discretion.
Declaration of excess interest is not guaranteed.
We guarantee that the interest rate credited to funds allocated to the General
Account will: (1) not be less than the Interest Rate described above; and (2)
not be modified for one year from the date such funds are allocated to the
General Account.
FSA-▇▇▇▇-R1
20
TRANSFERS DURING THE ACCUMULATION PERIOD
The Transfers During Accumulation Period section of the Contract is modified to
provide, in addition to the language relating to transfers among the Separate
Account Division(s), the following:
The Owner may transfer Contract Values between the General Account and the
Separate Account Division(s) subject to the following:
(1) a request to transfer amounts from a Separate Account Division(s) to the
General Account may be made at any time by written request;
(2) any funds allocated to the General Account must remain in the General
Account one year before being eligible to be transferred out of the
General Account to any Separate Account Division(s). A Contract Owner
may elect to make a transfer of funds out of the General Account to a
Separate Account Division(s) within 30 days of the anniversary of the
allocation of such funds to the General Account. If a Contract Year
Anniversary is not a Valuation Date, the transfer will take effect on
the next Valuation Date following the Contract Year Anniversary;
(3) a request to transfer funds out of the General Account must be in
written form satisfactory to and mailed to us at our Annuity Service
Office.
(4) the minimum amount which may be transferred between the General Account
and a Separate Account Division(s) is $500 or the remaining Contract
Value in the General Account or the Separate Account Division(s) is less
than $500; and
(5) no partial transfer may be made if your remaining Contract Value in the
General Account or Separate Account Division(s) will be less than $500
after the transfer.
CONTRACT CHARGES
The Records Maintenance Charge section of the Contract is $30 whether or not an
Owner elects to have Contract Values allocated to the General Account. There is
no extra charge if the General Account is elected. The Records Maintenance
Charge will also be deducted from the General Account in the same way as for the
Separate Account Divisions.
The Withdrawal Charge section of the Contract also applies to the total or
partial withdrawals of General Account Values in the same way as for the
withdrawals from the Separate Account Divisions.
Premium Taxes, as described in your Contract, are also applicable to any General
Account Values.
The Mortality and Expense Risk Charge, as described in your Contract, does not
apply to General Account Values.
SUSPENSION OF WITHDRAWAL OR TRANSFER
If a withdrawal or transfer is made from the General Account, we may defer
payment for the period permitted by law but not for more than six months after
written election is received by us.
ANNUITY PERIOD
If all of the Contract Value on the seventh calendar day before the Annuity Date
is allocated to: (1) the General Account, the Annuity will be paid as a Fixed
Annuity; (2) the Separate Account, the Annuity will be paid as a Variable
Annuity; (3) both the General Account and the Separate Account, the Annuity will
be paid as combination of a Fixed Annuity and a Variable Annuity to reflect the
allocation between the Accounts. Annuity Payments will reflect the investment
performance of the Separate Account Divisions in accordance with the allocation
of the Contract Value to the Separate Account Divisions on that date.
Thereafter, allocations may not be changed except as provided in the Transfers
During The Annuity Period section.
21
The Withdrawal Charge sections of the Contract also apply to certain
annuitization of the General Account Value just as for certain annuitizations
from the Separate Account Divisions.
FIXED ANNUITY
The General Account Value on the day immediately preceding the Annuity Date will
first be reduced by the dollar amount of any applicable Withdrawal Charge and
then by any applicable premium taxes. The remaining value will be used to
determine the Fixed Annuity monthly payment. For Annuity Options 1, 2 and 3,
monthly annuity payments will be based upon the Annuity Option elected and the
appropriate Annuity Option Table and will remain constant throughout the Annuity
Period. The Annuity Option Tables are contained in the Contract and provide
guaranteed annuity rates. The Company reserves the right, when annuity payments
begin, to use Annuity Option Tables which provide for a greater monthly annuity
payment. The annuity payments at the time of their commencement will not be less
than those that would be provided by purchase of any single consideration
immediate annuity contract offered by the Company at the time to the same class
of annuitants.
TRANSFERS DURING THE ANNUITY PERIOD
The Transfers During The Annuity Period section of your Contract is modified to
provide, in addition to the language relating to transfers among Divisions, the
following:
The payee(s) may transfer, by written request, Contract Values among the
Divisions and/or the General Account subject to the following:
(1) During the Annuity Period, the payee(s) may, by written notice to the
Company: (A) convert Variable Annuity Payments to Fixed Annuity
Payments; or (B) have Variable Annuity Payments reflect the investment
experience of other Separate Account Divisions. The payee(s) may not
convert Fixed Annuity Payments to Variable Annuity Payments.
(2) The amount allocated to the General Account in the event of a transfer
from a Separate Account Division will be equal to the annuity reserve
for the payee's interest in that Separate Account Division. The annuity
reserve is the product of "(a)" multiplied by "(b)" multiplied by "(c)"
where "(a)" is the number of Annuity Units representing the payee's
interest in the Separate Account Division per Annuity payment; "(b)" is
the Annuity Unit Value for the Separate Account Division; and "(c)" is
the present value of $1.00 per payment period as of the Adjusted Age of
the payee attained at time of transfer, determined using the 1983 Table
A, projected at Scale G with interest at the rate of 5% per annum.
Amounts transferred to the General Account will be applied under the
original Annuity Option elected except that adjustment will be made for
the time elapsed since the Annuity Date. All amounts and Annuity Unit
Values will be determined as of the end of the Valuation Period
preceding the effective date of transfer.
GENERAL PROVISIONS
RESERVES, VALUES AND BENEFITS
All reserves are greater than or equal to those required by statute. Any values
and death benefits that may be available under the contract or this Rider are
not less than the minimum benefits required by any statute of the state in which
the Contract is delivered.
All other terms and conditions of the Contract remain unchanged.
Signed for the Company.
/s/ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇ /s/ ▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇
----------------------------- ----------------------------
▇▇▇▇▇ ▇. ▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇
Secretary President
FSA-▇▇▇▇-R1
22
First SunAmerica
Life Insurance Company
FIRST SUNAMERICA
A SunAmerica Company
▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇ ▇▇▇▇▇
▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇ ▇▇▇▇▇
212/888-4540
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VARIABLE ANNUITY QUALIFIED PLAN RIDER
This Rider is a part of the Contract to which it is attached. The effective date
of this Rider is the Issue Date stated in the Contract Data Page.
The attached Contract is issued on a tax qualified basis, so the following
provisions apply:
THE FOLLOWING PROVISIONS apply and replace Contract provisions if the
Application indicates the Contract is to be issued under Internal Revenue Code
("IRC") Section 401 or 408.
(1) Except in the case of a Pension, Profit Sharing, ▇▇▇▇▇ Plan or an IRC
Section 408(a) Plan, the Owner is the Annuitant.
(2) In the case of a 408(b), a Terminal Funding annuity or ▇▇▇▇▇ Plan,
transferability is not permitted except to us on surrender or
settlement.
(3) If issued under IRC Section 408(b) or as a Terminal Funding annuity,
this Contract, and the benefits under it, cannot be sold, assigned or
pledged as collateral for a loan or as security for the performance of
an obligation or for any other purpose to any person.
(4) The Annuitant's entire interest in this Contract is nonforfeitable.
(5) The Contract is amended as follows:
(A) Any payments under Annuity Option 1, if applicable, will be made
only to the Annuitant or the Annuitant's Beneficiary. The
guaranteed period will not exceed the life expectancy of the
Annuitant at the time the first payment is due. "Life expectancy"
means expectancy of life as determined according to the
individual annuity mortality tables we use as of the date on
which the first annuity payment is due.
(B) Any payments under Annuity Option 2, if applicable, will be made
only to the Annuitant and to the Annuitant's spouse, who will be
the payees.
(C) Any payments under Option 3, if applicable, will be made only to
the Annuitant or the Annuitant's Beneficiary. The period of
payment will not exceed the life expectancy of the Annuitant at
the time the first payment is due.
(6) THE FOLLOWING PROVISIONS will apply in addition to the above, and will
replace contrary Contract provisions, if the Application indicates the
Contract is to be issued as an ▇▇▇ pursuant to IRC Section 408(b), a
rollover ▇▇▇ pursuant to IRC Section 408(d) or a Simplified Employee
Pension Plan ▇▇▇ pursuant to IRC Section 408(k).
(A) Within seven days of the date of the Application, you may revoke
the Application and receive a full refund of the Purchase
Payments paid. Your notice of revocation must be made be wire or
telephone to us at our Annuity Service Office.
(B) Except in the case of a rollover contribution, the total
annual Purchase Payments may not exceed the dollar limitation
for an ▇▇▇ or a Simplified Employee Pension Plan ▇▇▇. For an
▇▇▇, such dollar limitation will not exceed an amount equal to
100% of the compensation includable is an Annuitant's gross
income for any taxable year or $2,000, whichever is less. For
a Simplified Employee Pension Plan ▇▇▇, the dollar limitation
will not exceed an amount equal to 15% of compensation
includable in an Annuitant's gross income for any taxable year
or $30,000, whichever is less.
FSA-QUAL-R2
23
(C) The Annuity Date will be no later than April 1 of the calendar
year during which the Annuitant attains age 70 1/2.
(D) A declaration of the Annuitant's intention as to the
disposition of the amount to be paid must be furnished to us
at our Annuity Service Office, except if the Annuitant attains
age 59 1/2, dies or becomes disabled, meaning unable to engage
in any substantial gainful activity by reason of any medically
determinable physical or mental impairment which can be
expected to result in death or to be of long-continued and
indefinite duration,
(E) This Contract is established for the exclusive benefit of the
Annuitant and the Annuitant's Beneficiary.
(F) Life expectancy and joint and last survivor expectancy are
computed by use of the return multiples contained in Section
1.72-9 of the Income Tax Regulations.
(G) If the Annuitant dies before the Annuity Date, the Annuitant's
entire interest will be distributed in accordance with one of the
following four provisions:
(i) The Annuitant's entire interest will be paid within five
(5) years after the date of the Annuitant's death.
(ii) If the Annuitant's interest is payable to a
Beneficiary designated by the Annuitant and the
Annuitant has not elected (i) above, then the entire
interest will be distributed in substantially equal
installments over the life or life expectancy of the
Beneficiary beginning no later than one (1) year
after the date of the Annuitant's death. The
Beneficiary may elect at any time to receive greater
payments.
(iii) If the Beneficiary is the Annuitant's surviving
spouse, the spouse may elect within the five year
period beginning with the Annuitant's date of death
to receive equal or substantially equal payments over
the life or life expectancy of the surviving spouse
beginning at any date prior to the date on which the
deceased Annuitant would have attain age 70 1/2. The
surviving spouse may accelerate these payments at any
time.
(iv) If the Beneficiary is the Annuitant's surviving
spouse, the spouse may treat this Contract as his or
her own individual retirement arrangement (▇▇▇).
This election will be deemed to have been made if the
surviving spouse makes a regular ▇▇▇ contribution to
this Contract, makes a rollover to or from this
Contract or fails to elect any of the above three
provisions.
(H) If the Annuitant dies after the Annuity Date, any remaining
distribution will be made at least as rapidly as under the method
used prior to the Annuitant's death.
(I) Any payments made to a child of the Annuitant will be treated as
if paid to the Annuitant's spouse if, when the child reaches the
age of majority, remaining payments become payable to the spouse.
(J) Any refund of Purchase Payments (other than those attributable to
excess contributions) will be applied as future Purchase Payments
or to purchase additional benefits before the end of the calendar
year following the year of refund.
(K) The Company may, at its option, terminate this Contract by
payment in cash of the then present value of the paid-up benefit
if no Purchase Payments have been received for three (3) full
consecutive Contract Years and the paid-up annuity benefit at
maturity would be less than $20.00 per month.
FSA-QUAL-R2
24
(7) THE FOLLOWING PROVISIONS in addition to those previously stated,
will apply and replace contrary Contract provisions, if the
Application indicates the Contract is to be issued under a ▇▇▇▇▇
Plan pursuant to IRC Section 401.
(A) The Annuitant of this Contract will be the Participant
under the Plan and the Owner of this Contract will be the
Employer under the Plan.
(B) Unless another form of annuity payment is elected as
provided in this Contract, an Annuity will be paid under
Annuity Option 2, with the Annuitant's spouse's continuing
benefit established at 100%.
(8) THE FOLLOWING PROVISIONS, in addition to those previously stated,
will apply and replace contrary Contract provisions, if the
Application indicates the Contract is to be issued under IRC
Section 401 or 408(k).
(A) The last paragraph of the VARIABLE ANNUITY section of the
ANNUITY PERIOD provision is deleted and replaced by the
following paragraph:
"The Annuity Tables contained in this Contract are based
on the 1983 Table A, projected at Scale G with interest as
the rate of 5% per annum and assume births in the year
1942. Under the Annuity Options included in the Annuity
Tables, the amount of each installment will depend upon
the adjusted age of the Annuitant, the joint annuitant, if
any, or other payee. The adjusted age is determined from
the actual age nearest birthday at the time the first
scheduled payment is due according to the Table A below".
(B) The EVIDENCE OF AGE, SEX AND SURVIVAL section of the
ANNUITY PERIOD provision is deleted and replaced by the
following section entitled "EVIDENCE OF AGE AND SURVIVAL":
"EVIDENCE OF AGE AND SURVIVAL - We may require
satisfactory evidence of: (1) the age of any person(s) on
whose life the annuity payments are to be based; and (2)
the continued survival of any person(s) on whose life
annuity payments are based."
(C) The MISSTATEMENT OF AGE AND SEX section of the GENERAL
PROVISIONS is deleted and replaced by the following
section entitled "MISSTATEMENT OF AGE":
"MISSTATEMENT OF AGE - If a payee's age has been
misstated, any amount to be paid based on such age will be
adjusted. The adjustment will be made on the basis of the
corrected information without changing the date of the
first payment. The amount of any underpayment will be paid
accrued at the interest rate of 6%. The amount of any
overpayment will be deducted from payments subsequently
accruing at the interest rate of 6%.
25
(D) The Tables of Monthly Installments under Option 1 are
deleted and replaced by the following:
TABLES OF MONTHLY INSTALLMENTS UNDER OPTION 1
Monthly installments for ages not shown will be furnished on request.
OPTION 1 Life Annuity with Installments Guaranteed
Guaranteed Period - 10 Years
Adjusted Monthly Installment Adjusted Monthly Installments
Age for each $1,000 of Age for each $1,000 of
------------ Amount Applied ------------- Amount Applied
Male Female Male Female
---------------------------------- ------------------------------------
40 46 $4.74 58 64 $5.63
41 47 4.77 59 65 5.70
42 48 4.81 60 66 5.79
43 49 4.84 61 67 5.87
44 50 4.88 62 68 5.96
45 51 4.92 63 69 6.06
46 52 4.96 64 70 6.15
47 53 5.00 65 71 6.26
48 54 5.05 66 72 6.36
49 55 5.09 67 73 6.48
50 56 5.14 68 74 6.59
51 57 5.29 69 75 6.71
52 58 5.24 70 6.84
53 59 5.30 71 6.97
54 60 5.36 72 7.10
55 61 5.42 73 7.23
56 62 5.49 74 7.37
57 63 5.56 75 7.51
--------------------------------------------------------------------------------
"Guaranteed Period - 20 Years" table on the following page.
26
OPTION 1 Life Annuity with Installments Guaranteed
Guaranteed Period - 20 Years
Monthly Installment Monthly Installments
Adjusted for each $1,000 of Adjusted for each $1,000 of
Age Amount Applied Age Amount Applied
---------------------------------- -------------------------------------------
40 $4.69 58 $5.39
41 4.72 59 5.44
42 4.75 60 5.49
43 4.78 61 5.54
44 4.81 62 5.59
45 4.84 63 5.65
46 4.87 64 5.70
47 4.91 65 5.75
48 4.95 66 5.81
49 4.98 67 5.86
50 5.02 68 5.91
51 5.06 69 5.96
52 5.11 70 6.01
53 5.15 71 6.06
54 5.19 72 6.10
55 5.24 73 6.15
56 5.29 74 6.19
57 5.34 75 6.22
--------------------------------------------------------------------------------
(E) The Table of Monthly Installments under Option 2 is deleted
and replaced by the following:
TABLE OF MONTHLY INSTALLMENTS UNDER OPTION 2
Monthly installments for ages or combination of ages not shown
will be furnished on request.
OPTION 2 Joint and Survivor Annuity
Adjusted Age Adjusted Age of Annuitant
of Other Payee -----------------------------------------------------------------
51 56 58 61 63 66 71
--------------------------------------------------------------------------------
50 $ 4.72 $ 4.80 $ 4.84 $ 4.88 $ 4.91 $ 4.95 $ 5.01
55 4.81 4.92 4.96 5.03 5.07 5.13 5.23
57 4.84 4.97 5.02 5.09 5.14 5.21 5.32
60 4.89 5.04 5.10 5.19 5.25 5.34 5.47
62 4.93 5.08 5.15 5.25 5.32 5.42 5.58
65 4.97 5.15 5.23 5.35 5.43 5.55 5.75
70 5.04 5.25 5.35 5.50 5.60 5.77 6.05
--------------------------------------------------------------------------------
All other terms and conditions of the Contract remain unchanged.
Signed for the Company.
/s/ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇ /s/ ▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇
-------------------------- -------------------------
▇▇▇▇▇ ▇. ▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇
Secretary President
FSA-QUAL-R2
27
First SunAmerica
Life Insurance Company First SunAmerica
A SunAmerica Company
▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇ ▇▇▇▇▇
▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇ ▇▇▇▇▇
212/888-4540
--------------------------------------------------------------------------
TAX SHELTERED VARIABLE ANNUITY RIDER
This Rider is a part of the Contract to which it is attached. The effective date
of this Rider is January 1, 1989, or later, the Contract Date (or Issue Date)
shown on the Contract Data Page. However, or tax sheltered annuity programs
established prior to January 1, 1989, the provisions of this Rider shall be
effective at any earlier date(s) as provided by law or regulation.
THE FOLLOWING PROVISIONS APPLY IF THE CONTRACT IS TO BE OR WAS ISSUED AS A
TAX-DEFERRED ANNUITY AS SPECIFIED UNDER SECTION 403(B) OF THE INTERNAL REVENUE
CODE. THE RIDER WILL BE AMENDED TO COMPLY WITH ANY CHANGES IN THE INTERNAL
REVENUE CODE PURSUANT TO SECTION 403(B).
(1) All references in this Contract to:
(a) "Internal Revenue Code" or "IRC" means the Internal Revenue Code
of 1986, as amended and all rules and regulations thereunder; and
(b) "ERISA" means the Employee Retirement Income Security Act of
1974, as amended. A reference to an IRC Section includes any
successor or substituted provision and the regulations issued
thereunder.
(2) The Contract Owner is the Annuitant. The Annuitant must be an employee
("Employee") of an employer described in IRC Section 403(b)(1)(A)
("Employer"). If an Annuitant's employment with the Employer is
terminated, the Annuitant may continue to participate hereunder to the
extent of the Contract Value. No further Purchase Payments will be
accepted by us under the Contract on behalf of any Annuitant who is no
longer employed by the Employer. However, if an Annuitant is employed by
another Employer described in IRC Section 403(b)(1)(A) ("Successor
Employer"), the Annuitant may continue to participate hereunder and
future Purchase Payments may continue to be made. Any reference to
Employer in this Rider shall include a Successor Employer.
(3) Except as otherwise provided in the Internal Revenue Code, Purchase
Payments must be made by the Employer. Purchase Payments made for an
Annuitant's taxable year, other than rollover contributions, as defined
in IRC Section 403(b)(8) or 408(d)(3)(A)(iii), or a transfer made hereto
pursuant to IRC Section 1035, may not exceed:
(a) the exclusion allowance for a taxable year determined pursuant
to IRC Section 403(b)(2);
(b) the maximum amount permitted to be contributed for a taxable year
under IRC Section 415; and/or
(c) the applicable amount specified in IRC Section 402(g) for salary
reduction contributions (or elective deferrals) made under a
salary reduction agreement, as defined in IRC Section
402(g)(3)(C), except as otherwise provided in IRC Section 402(g),
provided that the limitation specified in IRC Section
403(b)(1)(e) is not exceeded. All Purchase Payments are subject
to our approval and acceptance.
(4) The Annuitant's entire interest in this Contract is 100 percent vested
and nonforfeitable. The Annuitants interests, rights and options under
this Contract are at all times subject to requirements and limitations
imposed by any plan pursuant to which this Contract was purchased, the
IRC and ERISA.
We are not a party to, nor bound by, any Plan or any other document or
agreement issued in connection with any Plan, other than this Contract.
We are not responsible for seeing that the funds under this Contract are
sufficient to provide the benefits under any Plan. The provisions of
this Contract govern with respect to Our rights and obligations, and
control over contrary provisions of any Plan.
FSA-TSA-R3
28
(5) This Contract, and the benefits under it, cannot be sold, transferred,
assigned, discounted or pledged as collateral for a loan or as security
for the performance of any obligations or for any other purpose to any
person other than us. Payments under this Contract may not be commuted,
assigned, encumbered or anticipated in any manner.
(6) Withdrawal of amounts attributable to contributions made pursuant to a
salary reduction agreement, as defined in IRC Section 403(b)(11), may be
made only: (a) when the Contract Owner (Annuitant) attains age 50 1/2,
separates from service, dies or becomes disabled, meaning unable to
engage in any substantial gainful activity be reason of any medically
determinable physical or mental impairment which can be expected to
result in death or to be of long-continued and indefinite duration, or
in the case of hardship and (b) as determined in accordance with IRC
Section 403(b)(11), including with respect to the existence of hardship
circumstances.
A hardship withdrawal may not include any income attributable to salary
reduction contributions.
The limitations on withdrawal apply only to salary reduction
contributions made after December 31,1988 and to income attributable to
such contributions and to income attributable to amounts held as of
December 31, 1988.
A withdrawal may be taxable and may be subject to penalty tax. If a
withdrawal is taxable, we will process required tax withholding against
the Contract Value. A Contract Owner (Annuitant) should first consult
with a tax advisor before making a withdrawal. A withdrawal which
violates these limitations may also immediately disqualify the Contract
Owner's Annuitant's) TSA under IRC Section 403(b) and may result in
immediate taxation.
(7) The Contract is amended as follows:
(a) Any payments under Annuity Option 1, if applicable, will be
made only to the Annuitant or the Annuitant's Beneficiary.
The guaranteed period cannot exceed the life expectancy of the
Annuitant, or the Beneficiary, at the time the first payment
is due. "Life expectancy" means expectation of life as
determined according to the individual annuity mortality
tables we use as of the date on which the first annuity
payment is due.
(b) Any payments under Annuity Option 2, if applicable, will be made
only to the Annuitant and to the Annuitant's spouse, who will be
the payees.
(c) Any payments under Annuity Option 3, if applicable, will be made
only to the Annuitant or the Annuitant's Beneficiary. The period
of payment cannot exceed the life expectancy of the Annuitant, or
the Beneficiary, at the time the first payment is due.
(d) The Annuity Option elected by an Annuitant or by or for a
Beneficiary shall meet the requirements of the Internal Revenue
Code.
(e) We will make payments in one lump sum, if the Contract Value to
be applied is less than $2,000, but only if this is permitted
under the Internal Revenue Code.
(8) The Annuity Date must be no later than, and can not be deferred beyond,
April 1 following the calendar year during which the Annuitant attains
age 70 1/2, except:
(a) for a governmental plan or church plan (as defined in IRC Section
89(i)(4)) for which the required beginning date shall mean April
1 of the calendar year following the later of (i) the calendar
year in which the Annuitant attains age 70 1/2, or (ii) the
calendar year in which the Annuitant retires; or
(b) as otherwise provided by law or regulation.
FSA-TSA-R3
29
(9) If an Annuitant dies before the Annuity Date, the entire Death Benefit
must be distributed pursuant to the one of the following:
(a) the Annuitant's entire value will be paid within 5 years after
the date of the Annuitant's death, whether as a single sum
payment or otherwise; or
(b) if the Death Benefit is payable to a Beneficiary designated by
the Contract Owner (Annuitant) and the Beneficiary has elected to
receive annuity payments, then the entire value will be
distributed according to the Annuity Option elected. The term of
the Annuity Option may not exceed the Beneficiary's life
expectancy. Annuity payments must begin no later than one year
after the Annuitant's death; or
(c) if the Beneficiary is the Annuitant's spouse, distribution must
begin no later than the date on which the deceased Annuitant
would have attained age 70 1/2.
If the payee dies after the Annuity Date, he death proceeds, if any,
will depend upon the form of Annuity Option in effect at the time of the
payee's death. If the payee dies after the Annuity Date and before the
entire value in the Annuitant's account has been distributed, the
remaining value, if any, as provided for in the Option selected will be
distributed at least as rapidly as under the method of distribution in
effect at the payee's death.
(10) All contract payments and withdrawals attributed to (a) non-salary
reduction contributions made by a non-governmental employer on behalf of
the Annuitant, which are subject to ERISA, and (b) salary reduction
contributions made by a non-governmental employer for the Annuitant,
which are determined to be subject to ERISA, are subject to the
applicable qualified joint and survivor annuity requirements under IRC
Section 401(a)(11) and 417. If such requirements apply, then we may
require the written and signed consent and waiver to the Annuitant's
spouse. Such consent and waiver shall be in a form as required by law.
(11) The Annuitant or Beneficiary will furnish us with any records, data,
proofs and all other information which in our opinion, is necessary for
the administration of this Contract.
(12) The last paragraph of the VARIABLE ANNUITY provision of the ANNUITY
PERIOD section, the EVIDENCE OF AGE, SEX AND SURVIVAL provision of the
ANNUITY PERIOD section, and the MISSTATEMENT OF AGE OR SEX provision of
the GENERAL PROVISIONS section are changed by deleting any reference to
sex as a required factor in issuing this Contract or as a basis in
determining any annuity amounts paid pursuant to this Contract.
30
(13) The Tables of Monthly Installments under Option 1 are deleted and
replaced by the following:
TABLES OF MONTHLY INSTALLMENTS UNDER OPTION
Monthly installments for ages not shown will be furnished on request.
OPTION 1 Life Annuity with Installments Guaranteed
Guaranteed Period - 10 Years
Monthly Installment Monthly Installments
Adjusted for each $1,000 of Adjusted for each $1,000 of
Age Amount Applied Age Amount Applied
---------------------------------- --------------------------------------
40 $4.74 58 $5.63
41 4.77 59 5.70
42 4.81 60 5.79
43 4.84 61 5.87
44 4.88 62 5.96
45 4.92 63 6.06
46 4.96 64 6.15
47 5.00 65 6.26
48 5.05 66 6.36
49 5.09 67 6.48
50 5.14 68 6.59
51 5.29 69 6.71
52 5.24 70 6.84
53 5.30 71 6.97
54 5.36 72 7.10
55 5.42 73 7.23
56 5.49 74 7.37
57 5.56 75 7.51
--------------------------------------------------------------------------------
OPTION 1 Life Annuity with Installments Guaranteed
Guaranteed Period - 20 Years
Monthly Installment Monthly Installments
Adjusted for each $1,000 of Adjusted for each $1,000 of
Age Amount Applied Age Amount Applied
---------------------------------- ---------------------------------------
40 $4.69 58 $5.39
41 4.72 59 5.44
42 4.75 60 5.49
43 4.78 61 5.54
44 4.81 62 5.59
45 4.84 63 5.65
46 4.87 64 5.70
47 4.91 65 5.75
48 4.95 66 5.81
49 4.98 67 5.86
50 5.02 68 5.91
51 5.06 69 5.96
52 5.11 70 6.01
53 5.15 71 6.06
54 5.19 72 6.10
55 5.24 73 6.15
56 5.29 74 6.19
57 5.34 75 6.22
--------------------------------------------------------------------------------
31
(14) The Table of Monthly Installments under Option 2 is deleted and replaced
by the following:
TABLE OF MONTHLY INSTALLMENTS UNDER OPTION
Monthly installments for ages or combination of ages not shown
will be furnished on request.
OPTION 2 Joint Survivor Annuity
Adjusted Age Adjusted Age of Annuitant
of Other Payee ---------------------------------------------------------------
51 56 58 61 63 66 71
--------------------------------------------------------------------------------
50 $4.72 $4.80 $4.84 $4.88 $4.91 $4.95 $5.01
55 4.81 4.92 4.96 5.03 5.07 5.13 5.23
57 4.84 4.97 5.02 5.09 5.14 5.21 5.32
60 4.89 5.04 5.10 5.19 5.25 5.34 5.47
62 4.93 5.08 5.15 5.25 5.32 5.42 5.58
65 4.97 5.15 5.23 5.35 5.43 5.55 5.75
70 5.04 5.25 5.35 5.50 5.60 5.77 6.05
--------------------------------------------------------------------------------
All other terms and conditions of the Contract remain unchanged.
Signed for the Company.
/s/ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇ /s/ ▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇
-------------------------- -------------------------
▇▇▇▇▇ ▇. ▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇
Secretary President
FSA-TSA-R3
