EXHIBIT 99.B(4)
HARTFORD LIFE INSURANCE COMPANY
X.X. XXX 0000
XXXXXXXX, XXXXXXXXXXX 00000-0000
(A stock life insurance company, hereinafter called the Company)
The Company agrees with the Contract Owner to provide the benefits as described
in this contract.
Signed for the Company
/s/ X. Xxxxxxx /s/ X. X. Xxxxxx
----------------------------------- -----------------------------------
X. Xxxxxxx, SECRETARY X. X. Xxxxxx, PRESIDENT
INDIVIDUAL SINGLE PREMIUM DEFERRED ANNUITY CONTRACT
READ THIS CONTRACT CAREFULLY
This is a legal contract between the Contract Owner and the Company.
MARKET VALUE ADJUSTMENT FORMULA
This contract contains a Market-Value Adjustment formula. The formula may result
in both upward and downward adjustments in the Gross Surrender Value.
The Market-Value Adjustment formula will not be applied when the Contract Owner
requests. In Writing:
a) a full or partial surrender at the end of any Guarantee Period if the
Company receives the request during the 30 day period preceding the end of
such Guarantee Period; or
b) the interest that would have been credited at the end of the Contract Year
on the date such interest would have been credited if the Company receives
the written request within 30 days at the end of the Contract Year.
NON-PARTICIPATING
RIGHT TO EXAMINE CONTRACT
The Company wants the Contract Owner to be satisfied with this contract. The
Company urges the Contract Owner to examine it closely. If for any reason the
Contract Owner is not satisfied with this contract, the Contract Owner may
surrender the contract by returning the contract within ten days after it was
purchased. A written request to surrender the contract must accompany the
contract. In such event, the contract will be cancelled and any premium paid
will be refunded in full.
[LOGO]
THE HARTFORD
Form HL-12148 INDIVIDUAL SINGLE PREMIUM
Printed in U.S.A. DEFERRED ANNUITY CONTRACT
TABLE OF CONTENTS
PAGE
--------------------------------------------------------------------------------
Contract Specifications 3
Definitions 4
Purchase Payment 5
Contract Control Provisions 5
General Provisions 6
Crediting of Interest and Guarantee Periods 6
Termination Provisions 7
Settlement Provisions 8
Annuity Tables 10
Form HL-12148
Printed in U.S.A.
2
CONTRACT SPECIFICATIONS
CONTRACT NUMBER SAMPLE CONTRACT DATE OCTOBER 1, 1987
NAME OF ANNUITANT XXXXXXX XXXXX DATE OF ISSUE OCTOBER 1, 1987
AGE OF ANNUITANT 35 ANNUITANT COMMENCEMENT DATE OCTOBER 1, 2037
SEX OF ANNUITANT MALE PURCHASE PAYMENT $5,000
CONTINGENT ANNUITANT INITIAL GUARANTEE PERIOD 5 YEARS
BENEFICIARY XXXXX XXXXX INITIAL GUARANTEE RATE 8%
CONTRACT OWNER XXXXXXX XXXXX
FORM NUMBERS DESCRIPTION OF BENEFITS
HL-
12148, 12142, INDIVIDUAL SINGLE PREMIUM DEFERRED ANNUITY CONTRACT
12150, 12151,
12152, 12146,
12129, 12168,
12986, 11613
SURRENDER CHARGE
THIS CHARGE IS A PERCENTAGE OF THE GROSS SURRENDER VALUE FOR ANY AMOUNT
SURRENDERED DURING THE FIRST 7 CONTRACT YEARS. THIS CHARGE EQUALS:
CHARGE CONTRACT YEARS
------------------------------------------
7% 1
6% 2
5% 3
4% 4
3% 5
2% 6
1% 7
0% THEREAFTER
FOR A SURRENDER MADE AT THE END OF THE INITIAL GUARANTEE PERIOD, NO SURRENDER
CHARGE WILL BE APPLIED PROVIDED SUCH SURRENDER OCCURS ON OR AFTER THE END OF THE
3RD CONTRACT YEAR. FOR A SURRENDER MADE AT THE END OF ANY OTHER GUARANTEE
PERIOD, NO SURRENDER CHARGE WILL BE APPLIED PROVIDED SUCH SURRENDER OCCURS ON OR
AFTER THE END OF THE 5TH CONTRACT YEAR. A REQUEST FOR SURRENDER AT THE END OF
THE GUARANTEE PERIOD MUST BE RECEIVED IN WRITING 30 DAYS PRIOR TO THE END OF THE
GUARANTEE PERIOD.
ANNUAL MAINTENANCE FEE
THE ANNUAL CONTRACT MAINTENANCE FEE IS $0
Form HL-12142
Printed in U.S.A.
3
DEFINITIONS
The definitions in this section apply to the following words and phrases
whenever and wherever they appear in this contract.
ACCOUNT VALUE - The sum of the Purchase Payment and all interest earned to that
date; less the sum of the Gross Surrender Value of any surrenders made to that
date; and less the sum of the Annual Contract Maintenance Fees deducted to that
date.
ANNUAL CONTRACT MAINTENANCE FEE - An amount which is deducted from the Account
Value at the end of the Contract Year or on the date of full surrender, if
earlier. The amount is shown on Page 3.
ANNUITANT - The person on whose life this contract is issued.
ANNUITY COMMENCEMENT DATE - The date shown on Page 3.
BENEFICIARY - The person entitled to receive benefits as per the terms of the
contract in case of the death of the Annuitant or the Contract Owner or
joint
Contract Owner as applicable.
COMPANY - The
Hartford Life Insurance Company
CONTINGENT ANNUITANT - The person so designated by the Contract Owner who, upon
the Annuitant's death, prior to the Annuity Commencement Date becomes the
Annuitant.
CONTRACT DATE - The date shown on Page 3. Contract Years are measured from the
Contract Date.
CONTRACT OWNER - The owner(s) of the contract.
CURRENT RATE - The applicable interest rate contained in a schedule of rates
established by the Company from time to time for various durations.
DUE PROOF OF DEATH - A certified copy of the death certificate, an order of a
court of competent jurisdiction, a statement from a physician who attended the
deceased, or any other proof acceptable to the Company.
GROSS SURRENDER VALUE - That portion of the Account Value specified by the
Contract Owner for a full or partial surrender.
GUARANTEE PERIOD - The period for which either an Initial or Subsequent
Guarantee Rate is credited.
INITIAL GUARANTEE RATE - The rate of interest credited to the Purchase Payment
as described in the Crediting of Interest and Guarantee Periods section. The
rate of interest is specified on Page 3.
IN WRITING - A written form satisfactory to the Company and filed at their
office in Hartford, Connecticut. All correspondence with the Company should be
sent to their office at X.X. Xxx 0000, Xxxxxxxx, Xxxxxxxxxxx 00000-0000.
NET SURRENDER VALUE - The amount payable to the Contract Owner on full surrender
or partial surrender under this contract after the application of any contract
charges and/or Market Value Adjustment. It is described in the General
Surrenders section of the Termination Provisions.
PREMIUM TAX - The amount of tax, if any, charged by a state or municipality on
purchase payments, from Gross Surrender Value upon Surrender, or from the amount
applied to effect an annuity.
SUBSEQUENT GUARANTEE RATE - The rate of interest established by the Company for
the applicable subsequent Guarantee Period, but in no event less than 3%.
SURRENDER DATE - The date the Company receives the written request for a
surrender.
Form HL-12150
Printed in U.S.A.
4
PURCHASE PAYMENT
PURCHASE PAYMENT - The Purchase Payment is shown on Page 3. Purchase Payments
are payable at the designated office(s) of the Company. The Company reserves the
right to limit the amount of the Purchase Payment which will be accepted.
ALLOCATION OF PURCHASE PAYMENT
The Purchase Payment (less applicable Premium Taxes, if any) will be allocated
to a separate account established by the Company for the Contract Owners of
those contracts. The Contract Owner's Account Value will be determined in
accordance with the terms of this contract.
CONTRACT CONTROL PROVISIONS
ANNUITANT, CONTINGENT ANNUITANT AND CONTRACT OWNER
The Annuitant may not be changed.
The designations of Contract Owner and Contingent Annuitant will remain in
effect until changed by the Contract Owner. Changes in the designation of the
Contract Owner may be made during the lifetime of the Annuitant by written
notice to the Company. Changes in the designation of the Contingent Annuitant
may be made at any time prior to the Annuity Commencement Date by written notice
to the Company.
The Contract Owner has the sole power to exercise all rights, options and
privileges granted by this contract or permitted by The Company and to agree
with the Company to any change in or amendment to the contract. The rights of
the Contract Owner shall be subject to the rights of any assignee of record with
the Company and of any irrevocably designated Beneficiary. In the case of
joint
Contract Owners, each Contract Owner alone may exercise all rights, options and
privileges, except with respect to Termination Provisions.
BENEFICIARY
The Designated Beneficiary will remain in effect until changed by the Contract
Owner. Changes in the Designated Beneficiary may be made during the lifetime of
the Annuitant by written notice to the Company. If the Designated Beneficiary
has been designated irrevocably, however, such designation cannot be changed or
revoked without such Beneficiary's written consent. Upon receipt of such notice
and written consent, if required, at the offices of the Company, the new
designation will take effect as of the date of the notice is signed, whether or
not the Annuitant or Participant is alive at the time of receipt of such notice.
The change will be subject to any payments made or other action taken by the
Company before the receipt of the notice.
In the event of the death of the Annuitant when there is no surviving Contingent
Annuitant the Beneficiary will be as follows. If the Annuitant is a
joint
Contract Owner and the death of the Annuitant occurs prior to the Annuity
Commencement Date, the Beneficiary shall be the surviving Contract Owner,
notwithstanding that the Designated Beneficiary may be different. Otherwise, the
Beneficiary will be the Designated Beneficiary then in effect. If there is no
Designated Beneficiary in effect or if the Designated Beneficiary is no longer
living, the Contract Owner will be the Beneficiary. If the Annuitant is the sole
Contract Owner and there is no Designated Beneficiary in effect, the Annuitant's
estate will be the Beneficiary.
In the event of the death of the Contract owner prior to the Annuity
Commencement Date, the Beneficiary will be as follows. Upon the death of the
joint Contract Owner, the Beneficiary will be the surviving
joint Contract
Owner, not withstanding that the Designated Beneficiary may be different. If the
Contract Owner was the sole Contract Owner, the Beneficiary shall be the
Designated Beneficiary then in effect. If no Beneficiary designation is in
effect or if the Designated Beneficiary has predeceased the Contract Owner, the
Contract Owner's estate will be the Beneficiary. At the first death of a
joint
Contract Owner prior to the Annuity Commencement Date, the Beneficiary shall be
the surviving Contract Owner not withstanding that the Designated Beneficiary
may be different.
Form HL-12150
Printed in U.S.A.
5
GENERAL PROVISIONS
THE CONTRACT
This contract constitutes the entire contract.
MINIMUM VALUE STATEMENT
Any values available under the Termination or Surrender Provisions of this
contract equal or exceed those required by the state in which the contract is
delivered.
MODIFICATION
The only way the contract may be modified is by a written agreement with the
Contract Owner signed by our President, or one of our Vice Presidents,
Secretaries, or Assistant Secretaries. No modification will affect the amount or
term of any annuity begun prior to the modification unless it is required to
conform the contract to any Federal or State statute. No modification of the
contract will affect the method by which the Contract Owner's Account Value will
be determined.
MISSTATEMENT OF AGE AND SEX
If the age and/or sex of the Annuitant is incorrectly stated, death benefits or
annuity payments will be adjusted to the payment which would have been provided
at the correct age and sex adjusted for any overpayments or underpayments which
had been made. The adjusted annuity payment or death benefit will include
interest of 3 1/2% in the event of an underpayment or will deduct interest of 3
1/2% in the event of an overpayment.
CHANGE OF ANNUITY COMMENCEMENT DATE
The Contract Owner may change the Annuity Commencement Date provided the Company
is notified in Writing 30 days before the proposed Annuity Commencement Date;
and the proposed date selected is the later of:
a) the Annuitant's attained age 85, or
b) the end of the Initial Guarantee Period provided such Initial Guarantee
Period is 10 years or less.
NON-PARTICIPATING
This contract is non-participating. It does not earn dividends.
ANNUAL REPORT
The Contract Owner will receive a report once each Contract Year showing the
Account Value of this contract and any other information required by the
Superintendent of Insurance.
CREDITING OF INTEREST AND GUARANTEE PERIODS
The Purchase Payment (less the Gross Surrender Value of all surrenders made and
less applicable Premium Taxes, if any) will earn interest at the Initial
Guarantee Rate, compounded annually, during the initial Guarantee Period.
Within 45 days prior to the end of any Guarantee Period, the Company will notify
the Contract Owner of the expiry of the current Guarantee Period, and that a
subsequent Guarantee Period of the same duration will commence, unless the
Contract Owner has:
a) requested, In Writing, a surrender within 30 days prior to the end of the
current Guarantee Period; or
b) elected, In Writing, a Guarantee Period of a different duration from among
those offered by the Company at the time within 30 days prior to the end of
the current Guarantee Period; or
c) selected a subsequent Guarantee Period that extends beyond the Annuity
Commencement Date then in effect. In this case, the Company will
automatically establish a subsequent Guarantee Period that will end nearest
to the Annuity Commencement Date then in effect, unless the Contract Owner
elects, In Writing, for a subsequent Guarantee Period of shorter duration.
Form HL-12151
Printed in U.S.A.
6
CREDITING OF INTEREST AND GUARANTEE PERIODS (CONTINUED)
The Account Value at the beginning of any subsequent Guarantee Period will be
equal to the Account Value at the end of the Guarantee Period just ending. The
Account Value will earn interest at the Subsequent Guarantee Rate, compounded
annually in the subsequent Guarantee Period. This rate will be at least equal to
the Initial Guarantee Rates being credited to Purchase Payments for new
contracts at the time the Subsequent Guarantee Rate is determined.
The Initial Guarantee Rate and the Subsequent Guarantee Rate will never be less
than 4%. Surrenders made during a Guarantee Period will be subject to a Market
Value Adjustment.
TERMINATION PROVISIONS
GENERAL SURRENDERS
Full surrenders may be made under this contract at any time. Partial surrenders
may only be made if:
a) the Gross Surrender Value is at least $1,000; and
b) the remaining Account Value after the Gross Surrender Value has been
deducted is at least $5,000.
In the case of all surrenders, the Account Value will be reduced by the Gross
Surrender Value on the Surrender Date and the Net Surrender Value will be
payable to the Contract Owner. Except as provided for in the Special Surrender
Section, the Net Surrender Value is calculated by the Company on a daily basis
as follows:
(A - B) x C, where:
A = the Gross Surrender Value reduced by any applicable Annual
Contract Maintenance Fee;
B = the surrender charge, shown on Page 3, plus any unpaid
Premium Taxes;
C = the Market Value Adjustment described below.
MARKET VALUE ADJUSTMENT
The formula which will be used to determine the Market Value Adjustment is
calculated by the Company on a daily basis as follows:
1 + I
[-------] [TO THE POWER OF N/12]
1 + J
I = Guarantee Rate in effect for the Current Guarantee Period
(expressed as a decimal, e.g. -1% = .01).
J = The Current Rate (expressed as a decimal, e.g. -1% = .01) in
effect for durations equal to the number of years remaining
in the current Guarantee Period (years are rounded to the
next highest number of years). If not available, the Company
will utilize a rate equal to the most recent Moody's
Corporate Bond Yield Average - Monthly Average Corporates
(for the applicable duration) as published by Xxxxx'x
investors Service, Inc. In the event the Moody's Corporate
Bond Yield Average - monthly Average Corporates is no longer
available, a suitable replacement index, subject to the
approval of the Superintendent, would be utilized.
N = The number of complete months from the Surrender Date to the
end of the current Guarantee Period.
Form HL-12151
Printed in U.S.A.
7
TERMINATION PROVISIONS (CONTINUED)
SPECIAL SURRENDERS
A full or partial surrender made at the end of a Guarantee Period may be subject
to a surrender charge as set forth on page 3. A Market Value Adjustment will not
be applied. A request for a surrender at the end of a Guarantee Period must be
received In Writing during the 30 day period preceding the end of such Guarantee
Period.
In addition, if the Contract Owner notifies the Company, In Writing, the Company
will send the Contract Owner any interst credited during the prior Contract
Year. No surrender charge or Market Value Adjustment will be imposed on such
interest payments.
TERMINATION AFTER THE ANNUITY COMMENCEMENT DATE
This contract may not be surrendered after the commencement of annuity payments.
PAYMENT UPON SURRENDER - DEFERRAL OF PAYMENT
The Company may defer payment of a partial or full surrender request for up to
six months from the date of the request. If payment is deferred for more than 10
days from the date the request is received, the Company will pay interest of 4
1/2% or the interest rate currently being paid on proceeds left under the
interest settlement option, whichever is higher, on the amount deferred.
DEATH BENEFIT
If the Annuitant dies prior to the Annuity Commencement Date and there is no
designated Contingent Annuitant surviving, or if the Contract Owner dies before
the Annuity Commencement Date, the death benefit will be payable to the
Beneficiary as determined under the Control Provisions. The death benefit equals
the Account Value as of the date the Company receives written notification of
Due Proof of Death.
The death benefit will be due and payable within a reasonable period of time
(not to exceed 6 months) after the Company receives Due Proof of Death. The
death benefit may be taken in one sum or under any of the annuity options
available under the contract provided however, that, in the event of the
Contract Owner's death, any annuity option selected must provide that any amount
payable as a death benefit will be distributed within 5 years of the date of
death; or, if the annuity option selected provides for the death benefit to be
payable over a period not extending beyond the life expectancy of the
Beneficiary or over the life of the Beneficiary, such distribution must commence
within one year of the date of death. Notwithstanding the previous sentence, if
the Beneficiary is the spouse of the Contract Owner and the Annuitant is living,
such spouse may elect, in lieu of receiving the death benefit, to be treated as
the Contract Owner.
SETTLEMENT PROVISIONS
ANNUITY BENEFIT
On the Annuity Commencement Date, unless directed otherwise, the Company will
apply the Contract Owner's Account Value multiplied by the Market Value
Adjustment, if any, to purchase the monthly income payments according to the
Annuity Option elected. If the Annuity Commencement Date coincides with the end
of any Guarantee Period, no Market Value Adjustment will be applied in the
determination of the monthly income payments. No surrender charge will be
applied upon annuitization.
Form HL-12152
Printed in U.S.A.
8
SETTLEMENT PROVISIONS (CONTINUED)
ELECTION OF ANNUITY OPTIONS
The Contract Owner may elect any of the annuity options described below or any
other Annuity Option being offered by the Company at the time of annuitization.
In the absence of such election, the second option providing a life annuity with
120 monthly payments certain will apply.
Election of any of these options must be made In Writing to the Company at least
30 days prior to the date such election is to become effective.
DATE OF PAYMENT
The first payment under any option shall be made on the tenth day of the month
following the Annuity Commencement Date. Subsequent payments shall be made on
the tenth day of each month in accordance with the manner of payment selected.
The Contract Owner, or in the event the Contract Owner has not done so, the
Beneficiary after the death of the Annuitant, may elect, in lieu of payment in
one sum, that any amount or part thereof due by the Company under this contract
to the Beneficiary will be applied under any of the options described below.
Such election must be made within one year after the death of the Annuitant by
written notice to the offices of the Company.
DEATH OF ANNUITANT
In the event of the death of the Annuitant while receiving annuity payments, the
present values of the current dollar amount on the date of death of any
remaining guaranteed number of payments, or any then remaining balance of
proceeds under the Fifth Option will be paid in one sum to the Beneficiary
unless other provisions shall have been made and approved by the Company.
However, if the Contract Owner was also the Annuitant, any method of
distribution must provide that any amount payable as a death benefit will be
distributed at least as rapidly as under the method of distribution in effect at
the Contract Owner's death. Calculations of such present value of the guaranteed
payments remaining will be based on the interest rate that is used by the
Company to determine the amount of each certain payment.
ANNUITY OPTIONS
FIRST OPTION - Life Annuity - An annuity payable monthly during the lifetime of
the Annuitant, ceasing with the last payment due prior to the death of the
Annuitant.
SECOND OPTION - Life Annuity - with 120, 180, or 240 Monthly Payments Certain -
An annuity providing monthly income to the Annuitant for a fixed period of 120
months, 180 months, or 240 months (as selected), and for as long thereafter as
the Annuitant shall live.
THIRD OPTION - Cash Refund Life Annuity - An annuity payable monthly during the
lifetime of the Annuitant, ceasing with the last payment due prior to the death
of the Annuitant provided that, at the death of the Annuitant, the beneficiary
will receive an additional payment equal to the excess, if any, of (a) over (b)
where: (a) is the Account Value applied on the Annuity Commencement Date under
this option: and (b) is the dollar amount of annuity payments already paid.
FOURTH OPTION - Joint and Last Survivor Life Annuity - An annuity payable
monthly during the joint lifetime of the Annuitant and a secondary payee, and
thereafter during the remaining lifetime of the survivor, ceasing with the last
payment prior to the death of the survivor.
FIFTH OPTION - Payments for a designated Period - An amount payable monthly for
the number of years selected which may be from 5 to 30 years.
Form HL-12152
Printed in U.S.A.
9
ANNUITY TABLES
The attached tables show the dollar amount of monthly payments for each $1,000
applied under the five options. Under the First, Second, or Third Options, the
amount of each payment will depend upon the age and sex of the Annuitant at the
time the first payment is due. Under the Fourth Option, the amount of each
payment will depend upon the sex of both payees and their ages at the time first
payment is due.
MINIMUM PAYMENT
The option elected must result in a payment of at least $20.00. If at any time
payments are less than $20.00, the Company has the right to change the frequency
to an interval resulting in a payment of at least $20.00. If any amount due is
less than $20.00 per year, the Company may make other arrangements that are
equitable to the Annuitant.
DESCRIPTION OF TABLES
The tables for the First, Second, Third and Fourth Options are based on the
1983a. Individual Annuity Mortality Table with ages set back one year and a net
investment rate of 4% per annum. The Table for the Fifth Option is based on a
net investment rate of 4% per annum.
Form HL-12146
Printed in U.S.A.
10
AMOUNT OF FIRST MONTHLY PAYMENT
FOR EACH $1,000 APPLIED
FIRST, SECOND AND THIRD OPTIONS - SINGLE LIFE ANNUITIES WITH:
MALE PAYEE
MONTHLY PAYMENTS GUARANTEED
AGE NONE 120 180 240 CASH REFUND
---------------------------------------------------------------------------
35 $4.03 $4.02 $4.01 $3.99 $3.99
40 4.22 4.21 4.19 4.16 4.16
45 4.47 4.44 4.41 4.36 4.36
50 4.79 4.74 4.68 4.60 4.63
51 4.86 4.81 4.74 4.65 4.68
52 4.94 4.88 4.80 4.71 4.74
53 5.02 4.95 4 87 4.76 4.81
54 5.10 5.03 4.94 4.82 4.88
55 5.19 5.11 5.01 4.88 4.95
56 5.29 5.20 5.09 4.94 5.03
57 5.39 5.29 5.17 5.00 5.11
58 5.49 5.38 5.25 5.06 5.20
59 5.61 5.48 5.33 5.12 5.28
60 5.73 5.59 5.42 5.18 5.38
61 5.86 5.70 5.51 5.24 5.48
62 6.00 5.82 5.60 5.31 5.59
63 6.16 5.95 5.69 5.37 5.71
64 6.32 6.08 5.79 5.43 5.84
65 6.49 6.21 5.89 5.48 5.98
66 6.68 6.35 5.98 5.54 6.13
67 6.88 6.50 6.08 5.59 6.23
68 7.09 6.65 6.18 5.64 6.40
69 7.31 6.81 6.28 5.69 6.58
70 7.56 6.97 6.37 5.73 6.77
75 9.05 7.83 6.80 5.89 7.89
80 11.16 8.66 7.10 5.97 9.86
FEMALE PAYEE
MONTHLY PAYMENTS GUARANTEE
AGE NONE 120 180 240 CASH REFUND
---- --------------------------------------------------------------------
35 $3.86 $3.86 $3.85 $3.84 $3.84
40 4.01 4.00 3.99 3.98 3.98
45 4.19 4.18 4.17 4.15 4.15
50 4.44 4.42 4.39 4.36 4.37
51 4.50 4.47 4.45 4.40 4.41
52 4.56 4.53 4.50 4.45 4.47
53 4.62 4.59 4.56 4.50 4.51
54 4.69 4.66 4.62 4.56 4.58
55 4.76 4.72 4.68 4.61 4.64
56 4.84 4.80 4.74 4.67 4.70
57 4.92 4.87 4.81 4.73 4.77
58 5.00 4.95 4 88 4.79 4.84
59 5.09 5.03 4.96 4.85 4.91
60 5.19 5.12 5.04 4.91 5.02
61 5.29 5.22 5.12 4.98 5.07
62 5.40 5.32 5.21 5.05 5.17
63 5.52 5.42 5.30 5.11 5.26
64 5.65 5.53 5.39 5.18 5.36
65 5.78 5.65 5.49 5.25 5.48
66 5.92 5.77 5.58 5.32 5.59
67 6.08 5.90 5.69 5.39 5.72
68 6.24 6.04 5.79 5.45 5.86
69 6.42 6.19 5.90 5.51 6.01
70 6.61 6.34 6.01 5.58 6.18
75 7.83 7.21 6.54 5.82 7.21
80 9.65 8.19 6.97 5.94 8.68
FOURTH OPTION - JOINT AND LAST SURVIVOR ANNUITY
AGE OF AGE OF FEMALE PAYEE
MALE PAYEE 35 40 45 50 55
-----------------------------------------------------------------------------
35 $3.62 $3.68 $3.73 $3.77 $3.81
40 3.65 3.73 3.80 3.86 3.92
45 3.68 3.77 3.86 3.95 4.04
50 3.70 3.80 3.92 4.04 4.16
55 3.72 3.83 3.96 4.11 4.27
60 3.73 3.85 4.00 4.17 4.36
65 3.74 3.87 4.03 4.21 4.44
70 3.75 3.88 4.05 4.25 4.50
75 3.76 3.89 4.06 4.27 4.54
80 3.76 3.90 4.07 4.29 4.57
AGE OF AGE OF FEMALE PAYEE
MALE PAYEE 60 65 70 75 80
------------ ----------------------------------------------------------
35 $3.84 $3.87 $3.89 $3.90 $3.91
40 3.97 4.01 4.04 4.07 4.09
45 4.12 4.18 4.23 4.27 4.30
50 4.27 4.37 4.45 4.52 4.57
55 4.43 4.58 4.71 4.81 4.89
60 4.57 4.79 4.99 5.17 5.30
65 4.70 4.99 5.29 5.57 5.80
70 4.81 5.17 5.57 5.99 6.38
75 4.88 5.31 5.82 6.40 7.00
80 4.94 5.41 6.01 6.75 7.58
FIFTH OPTION - PAYMENTS FOR A DESIGNATED PERIOD
AMOUNT OF AMOUNT OF AMOUNT OF
NO. OF MONTHLY NO. OF MONTHLY NO. OF MONTHLY
YEARS PAYMENTS YEARS PAYMENTS YEARS PAYMENTS
---------------------------------------------------------------------------------------------------------
5 $18.32 10 $10.06 15 $7.34
6 15.56 11 9.31 16 7.00
7 13.59 12 8.69 17 6.71
8 12.12 13 8.17 18 6.44
9 10.97 14 7.72 19 6.21
AMOUNT OF AMOUNT OF AMOUNT OF
NO. OF MONTHLY NO. OF MONTHLY NO. OF MONTHLY
YEARS PAYMENTS YEARS PAYMENTS YEARS PAYMENTS
---- -------------------------------------------------------------------------------------------------
20 $6.00 25 $5.22 30 $4.72
21 5.81 26 5.10
22 5.64 27 5.00
23 5.49 28 4.90
24 5.35 29 4.80
The monthly payment for any ages not shown will be quoted upon request.
[LOGO]
THE HARTFORD
Form HL-12129
Printed in U.S.A
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THE HARTFORD
GUARANTEE PERIOD TRANSFER RIDER
This rider is issued as part of the contract to which it is attached. The Date
of Issue and Contract Date applicable to this rider are the same as those of the
contract.
The General Provisions of the contract to which this rider is attached are
amended by adding the following:
TRANSFERS BETWEEN GUARANTEE PERIODS
Once each Contract Year, the Contract Owner may elect, In Writing, to transfer
out of the current Guarantee Period and into a Guarantee Period of different
duration. At that time, a new Guarantee Period will be established for the
duration chosen by the Contract Owner, and the Account Value at the beginning of
the new Guarantee Period will equal the Account Value for the current Guarantee
Period multiplied by the Market Value Adjustment for the current Guarantee
Period. The Company reserves the right to charge for any such transfer by
reducing the Account Value at the beginning of the new Guarantee Period by an
amount not to exceed $50.00.
Surrender charges will continue to be based on the appropriate Contract Year as
determined from the original Contract Date.
Signed for the
HARTFORD LIFE INSURANCE COMPANY
/s/ Xxxx X. Ginnatti /s/ X.X. Xxxxxx
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Xxxx X. Ginnatti, SECRETARY X.X. Xxxxxx, PRESIDENT
Form HL-12168
Printed in U.S.A
Annuity [LOGO] REGULAR MAIL TO:
Application THE HARTFORD
HARTFORD LIFE INSURANCE COMPANY
Please Print ATTN: BROKER/DEALER OPERATIONS - CRC
X.X. XXX 0000
XXXXXXXX, XX 00000-0000
EXPRESS MAIL TO: 000 XXXXXXXXX XXXXXX
XXXXXXXX, XX 00000
CONTRACT OWNER (Also the Annuitant unless the Annuitant block below is completed)
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Name Street, City, State, Zip Code Sex Birthdate (Mo. Day Yr.) Tax ID/Soc. Sec. No.
Xxxxxxx Xxxxx 1 Main st, /X/ Male 11-12-51 123-45-6789
Xxxxxxxx XX 00000 / / Female
JOINT CONTRACT OWNER
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Name Street, City, State, Zip Code Birthdate (Mo. Day Yr.) Tax ID/Soc. Sec. No.
ANNUITANT (If other than
Contract Owner)
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Name Street, City, State, Zip Code Sex Birthdate (Mo. Day Yr.) Tax ID/Soc. Sec. No.
/ / Male
/ / Female
CONTINGENT ANNUITANT
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Name Street, City, State, Zip Code Sex Birthdate (Mo. Day Yr.) Tax ID/Soc. Sec. No.
/ / Male
/ / Female
DESIGNATED BENEFICIARY
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Primary Relationship Contingent Relationship
Xxxxx Xxxxx Wife
CONTRACT PROVISIONS
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A. The Purchase Payment in the amount of $5,000 is submitted herewith.
B. The Initial / / 3 Years /X/ 5 Years / / 6 Years / / 7 Years / / 8 Years / / 9 Years
Guarantee Period is:
/ / 10 Years / / Other (Subject to availability)
SPECIAL REMARKS
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FOR TAX QUALIFIED PLAN. Check appropriate box / / XXX Rollover / / 403(b) Rollover
Tax year in which contribution is being made
Unless a box has been checked, it will be assumed that this is going to be a
non-qualified Plan.
REPLACEMENT
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Will the annuity applied for replace one or more existing annuity or life / / Yes /X/ No
insurance contracts?
If yes. explain
Have you purchased another Hartford annuity during the previous 12 months? / / Yes /X/ No
I hereby represent my answers to the above questions to be true and
correct to the best of my knowledge and belief.
/X/ RECEIPT OF A PROSPECTUS IS HEREBY ACKNOWLEDGED. If not checked, the appropriate prospectus will be mailed
to you.
Amounts payable under the contract for which you are applying are
subject to a market value adjustment prior to maturity.
SIGNED AT Hartford, CT ON September 27,1987
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REGISTERED
REPRESENTATIVE Xxxx Xxxxx
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(Print) (Signature of Contract Owner)
Xxxx Xxxxx
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(Signature) (Signature of
Joint Contract Owner)
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(Signature of Annuitant if other than Contract
Owner)
MUST BE COMPLETED BY REGISTERED REPRESENTATIVE
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Do you have reason to believe the Contract applied for will replace existing annuities or insurance / / Yes /X/ No
owned by the annuitant?
Registered Representative Signature Xxxx Xxxxx
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Print or type Representative name Xxxx Xxxxx
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Registered
Representative Code 1122 334455 Broker/Dealer Xxxxx Xxxxxx
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Sales/Branch Office Hartford
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Field Office Code 121 Staff Code 40 Telephone 529-9000
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Form HL-12155
Printed in U.S.A
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THE HARTFORD
HARTFORD LIFE INSURANCE COMPANY
X.X. XXX 0000
XXXXXXXX XXXXXXXXXXX 00000-0000
(A stock life insurance company)
INDIVIDUAL SINGLE PREMIUM DEFERRED ANNUITY CONTRACT
Form HL-12148 INDIVIDUAL SINGLE PREMIUM
Printed in U.S.A. DEFERRED ANNUITY CONTRACT