EXHIBIT 4
[LETTERHEAD OF XXXX XXXXXXX APPEARS HERE] Variable Life Insurance Xxxx Xxxxxxx Place
Company Boston, Mass 02117
0-000-000-0000
OWNER XXXX XXXXXXX
ANNUITANT XXXX XXXXXXX ANNUITY NUMBER
VA 000 000
INDIVIDUAL FLEXIBLE PREMIUM DEFERRED ANNUITY WITH FIXED AND VARIABLE OPTIONS
The Xxxx Xxxxxxx Variable Life Insurance Company ("the Company") agrees to
provide the benefits, rights and privileges as stated in this contract.
Benefits available under the contract are not less than those required by any
statute of the state in which the contract is delivered.
If the contract is in force on the Date of Maturity, we will pay an Annuity to
the Annuitant, unless otherwise directed by the Owner. The variable and fixed
portions of each Annuity payment will be determined in accordance with the
"Conversion" provision of this contract. The variable portion may increase or
decrease depending upon the investment experience of the Subaccounts in which
the Net Premiums are invested. Unless otherwise elected, Annuity payments will
be payable at monthly intervals for a period of 10 years and as long thereafter
as the Annuitant lives. The variable portion of Annuity payments will not
decrease if the annual effective rate of investment return earned on assets of
the Subaccounts is at least 3.5% (unless otherwise elected) after deductions
made directly to such Subaccounts of 1.4% per annum.
By written notice, the Owner may elect the Date of Maturity at any time,
provided the Date elected is: (i) not later than the Annuitant's 95th birthday
without our prior approval; (ii) at least 31 days after the written notice; and
(iii) at least six months after the date the first premium is applied to the
contract without our prior approval. If no other election is made, the Date of
Maturity will be the Annuitant's 95th birthday.
A Death Benefit will be payable if the Annuitant's death occurs before the Date
of Maturity and before the Surrender Date, as stated in the "Death Benefit" and
other contract provisions.
We are issuing this contract in consideration of the application and the payment
of premiums.
The Contract Specifications on page 3 and the conditions and provisions on this
and the following pages are part of the contract.
10 DAY RIGHT TO CANCEL - THIS CONTRACT MAY BE RETURNED BY DELIVERING OR MAILING
IT WITHIN 10 DAYS AFTER ITS RECEIPT TO THE COMPANY AT BOSTON, MASSACHUSETTS, OR
TO THE AGENT OR AGENCY OFFICE THROUGH WHICH IT WAS DELIVERED, WITH A WRITTEN
REQUEST FOR CANCELLATION. IMMEDIATELY ON SUCH DELIVERY OR MAILING AND SUCH
WRITTEN REQUEST, THE CONTRACT SHALL BE DEEMED VOID FROM THE BEGINNING AND A
REFUND WILL BE MADE WITHIN 10 DAYS. THE AMOUNT REFUNDED WILL BE THE SUM OF (I)
THE ACCUMULATED VALUE AT THE END OF THE VALUATION PERIOD DURING WHICH WE RECEIVE
THE CONTRACT AND (II) THE SUM OF ALL CHARGES MADE WITH RESPECT TO THE CONTRACT.
Signed for the Company at Boston, Massachusetts.
President Secretary
Flexible Premium Combination Fixed/Variable Deferred Annuity - monthly Annuity
payable to Annuitant beginning on the Date of Maturity for a guaranteed period
of 10 years and thereafter for life, unless otherwise elected.
Nonparticipating
Initial premium is shown on page 3.
THIS POLICY IS A LEGAL CONTRACT BETWEEN THE APPLICANT AND THE INSURER. READ
YOUR POLICY CAREFULLY.
THE BENEFITS, PAYMENTS AND ACCUMULATED VALUE UNDER THIS CONTRACT, WHEN BASED ON
THE INVESTMENT EXPERIENCE OF A SEPARATE ACCOUNT, ARE VARIABLE AND NOT GUARANTEED
AS TO DOLLAR AMOUNT. THE VALUES OF THE SUBACCOUNTS MAY INCREASE OR DECREASE.
SEE SECTION 8 FOR DETAILS.
CONTRACT PROVISIONS
Section
1. Specifications
2. Definitions
3. Owner, Beneficiary
4. The Contract
5. Payment of Premiums
6. Investment and Account Transfer Options
7. Accumulations in Variable and Fixed Accounts
8. Accumulation Shares and Annuity Unit Valuation
9. Death Benefit
10. Contract Fee and Premium Taxes
11. Partial Withdrawals
12. Withdrawal Charge
13. Surrender Provision
14. Conversion
15. Settlement Options
16. Proof Required for Payment
17. Misstatements
18. Incontestability
19. Assignment
20. Claims of Creditors
21. Right to Make Changes
22. Annual Statement
23. Miscellaneous
--------------------------------------------------------------------------------
1. CONTRACT SPECIFICATIONS
--------------------------------------------------------------------------------
OWNER Xxxx Xxxxxxx
ANNUITANT Xxxx Xxxxxxx
ANNUITY NUMBER VA00 000 000
ISSUE AGE 35
DATE OF ISSUE September 1, 1997
DATE OF MATURITY September 1, 2057
INITIAL PREMIUM $11,000.00
SUBSEQUENT PREMIUMS MAY BE PAID IN ACCORDANCE WITH SECTION 5.
CURRENT ANNUAL CONTRACT FEE: $30 APPLICABLE TO CONTRACTS WITH ACCUMULATED VALUE
UNDER $10,000 ONLY. SEE SECTION 10.
3
--------------------------------------------------------------------------------
2. DEFINITIONS
--------------------------------------------------------------------------------
"ACCOUNT", unmodified, means a Subaccount or a Fixed Account.
"ACCUMULATED VALUE", unmodified, means the value of this contract on any date
prior to the commencement of life annuity payments. This value equals the sum of
this contract's (i) accumulated values for all Subaccounts and (ii) accumulated
value in the Fixed Account. The accumulated value for each Subaccount as of any
date will equal the number of Accumulation Shares for that Subaccount then
credited to this contract multiplied by the Accumulation Share Value for that
Subaccount on that date.
"ACCUMULATION SHARE" means a unit of measurement used in determining the value
of this contract prior to the commencement of life annuity payments. The
Accumulation Share Value for each Subaccount will reflect the investment
experience of that Subaccount. It will vary in dollar amount.
"ANNUITY UNIT" means a unit of measurement used in determining the amount of the
variable portion of each Annuity payment. The value of an Annuity Unit for each
Subaccount will depend on the assumed investment rate and the investment
experience of that Subaccount. It will vary in dollar amount.
"FIFTH INTERVAL CONTRACT ANNIVERSARY" means each contract anniversary that is a
multiple of five measured from the Date of Issue.
"FIXED ACCOUNT" means an Account established by us which accumulates at rates,
not less than 3%, which we will determine and declare from time to time.
"FUND" means a series type mutual fund registered under the 1940 Act as an open-
end diversified management investment company.
"IN FORCE" means that the Annuitant is living and the Accumulated Value of the
contract has not become payable.
"MEASURING PERSON" means the person on whose life Annuity payments will be
based.
"NET PREMIUM" means the premium paid less any applicable taxes based on the
amount of premium payment.
"PAYMENT" means, unless otherwise stated, payment at our Home Office in Boston,
Massachusetts.
"PORTFOLIO" means each division of a Fund which has a specific investment
objective.
"SEPARATE ACCOUNT", unmodified, means a separate investment account, established
by us under Massachusetts law, in which you are eligible to invest under this
contract.
"SUBACCOUNT" means each division of a Separate Account. The assets of each
Subaccount are invested solely in shares of the corresponding Portfolio of a
Fund.
"SURRENDER DATE" means the date of receipt of written notice of surrender under
Section 13.
"VALUATION DATE" means any date on which the New York Stock Exchange is open for
trading and on which the Fund values its shares.
"VALUATION PERIOD" means that period of time from the beginning of the day
following a Valuation Date to the end of the next following Valuation Date.
"WE", "US", "OUR" refer only to the Company.
"WRITTEN NOTICE" means, unless otherwise stated, a written notice received at
our Home Office in Boston, Massachusetts.
"YOU" AND "YOUR" refer only to the Owner of this contract.
"1940 ACT" means the Investment Company Act of 1940, as amended.
4
--------------------------------------------------------------------------------
3. OWNER, BENEFICIARY
--------------------------------------------------------------------------------
THE OWNER AND THE BENEFICIARY WILL BE AS SHOWN IN THE APPLICATION UNLESS YOU
CHANGE THEM OR THEY ARE CHANGED BY THE TERMS OF THIS PROVISION.
IF THE ANNUITANT DIES AND THERE IS NO SURVIVING BENEFICIARY, YOU WILL BE THE
BENEFICIARY, BUT IF YOU WERE THE ANNUITANT, YOUR ESTATE WILL BE THE BENEFICIARY.
YOU SHALL HAVE THE SOLE AND ABSOLUTE POWER TO EXERCISE ALL RIGHTS AND PRIVILEGES
WITHOUT THE CONSENT OF ANY OTHER PERSON EXCEPT AS OTHERWISE PROVIDED BY THIS
CONTRACT OR UNLESS YOU PROVIDE OTHERWISE BY WRITTEN NOTICE.
WHILE THE ANNUITANT IS ALIVE, YOU MAY CHANGE THE OWNER BY WRITTEN NOTICE. YOU
MAY CHANGE THE BENEFICIARY BY WRITTEN NOTICE NO LATER THAN RECEIPT OF THE
REQUIRED DUE PROOF OF THE ANNUITANT'S DEATH. A CHANGE WILL TAKE EFFECT WHEN THE
NOTICE IS RECEIVED AND FILED AT OUR HOME OFFICE. THE CHANGE WILL TAKE EFFECT
WHETHER OR NOT YOU OR THE ANNUITANT IS THEN ALIVE. A CHANGE SHALL BE SUBJECT TO
THE RIGHTS OF ANY ASSIGNEE OF RECORD WITH US AND SUBJECT TO ANY PAYMENT MADE OR
OTHER ACTION TAKEN BY US BEFORE WE RECEIVED AND FILED THE NOTICE.
JOINT OWNERS
If joint Owners are named in the application, each joint Owner will be
considered the primary Beneficiary of the other joint Owners. Should another
person or entity be designated as Beneficiary in the application, such
Beneficiary will be deemed a contingent Beneficiary for all Owners with rights
subordinate to the rights of each joint Owner. Signatures of all joint Owners
are required for any exercise of ownership rights requiring written
notification.
--------------------------------------------------------------------------------
4. THE CONTRACT
--------------------------------------------------------------------------------
The entire contract between the Applicant and us consists of this contract and
the application, a copy of which is attached.
Contract years, contract months and contract anniversaries are measured from the
Date of Issue.
Only the President, a Vice President, the Secretary, or an Assistant Secretary
of the Company has authority to waive or agree to change in any respect any of
the conditions or provisions of the contract.
--------------------------------------------------------------------------------
5. PAYMENT OF PREMIUMS
--------------------------------------------------------------------------------
All premium payments shall be made to us at our Home Office. Premium payments
are subject to the following conditions:
(a) Each premium payment must be at least $50.
(b) The maximum premium that may be deposited to the contract in any
contract year is $1,000,000.
(c) The maximum premium that may be deposited in any Subaccount in any
contract year is $1,000,000 less any amount previously transferred
to such Subaccount in such year.
(d) The maximum premium that may be deposited in the Fixed Account in
any contract year, exclusive of the initial premium payment, is
$100,000 less any amount previously transferred to the Fixed
Account in such year.
(e) No premium payments may be deposited to the Fixed Account after
the end of the tenth contract year.
(f) No premium payments may be made to the contract after the
Annuitant's 85th birthday.
Upon request we will consider waiving any of the above conditions.
5
--------------------------------------------------------------------------------
6. INVESTMENT AND ACCOUNT TRANSFER OPTIONS
--------------------------------------------------------------------------------
INVESTMENT OPTION
The Net Premium will be allocated to the Accounts according to the Investment
Option then in effect. The Initial Investment Option is that elected by you in
the application. You may elect by written notice to change the Investment
Option. The change will be effective as to the allocation of any Net Premium
made on or after the date of receipt at our Home Office of such written notice
satisfactory to us. The minimum percentage that may be allocated to any Account
and the maximum number of Accounts in which amounts may be held will be subject
to our administrative rules in effect at the time of the election. All
percentages you elect must be whole numbers.
ACCOUNT TRANSFER OPTION
You may elect to reallocate amounts among Accounts (i) by written notice
satisfactory to us or (ii) by telephone instructions if you have elected the
Telephone Transfer Option. Such election may be made in the application or at
any time thereafter by written notice satisfactory to us. We reserve the right
to terminate, suspend or modify the Telephone Transfer Option at any time
without notice. We may record any telephone conversation relating to Account
transfers.
Transfers among Accounts will be effective on the date of receipt of the
required written notice or telephone instruction. The number of Accumulation
Shares or Annuity Units and the amount of accumulated value of the Fixed Account
transferred to or from each Account will reflect the respective values in each
Account. Transfers to or from the Fixed Account are prohibited after
commencement of Annuity payments.
If the Accumulated Value is invested in more than four Accounts on the Date of
Maturity or other date elected for commencement of Annuity payments and before
conversion in accordance with Section 14, we will allocate the Accumulated Value
to the four Accounts then having the largest portions of the Accumulated Value.
The Accumulated Value in Accounts other than such four Accounts will be
allocated to the four Accounts in proportion to the amounts in the four
Accounts. Such allocation will be made not withstanding any transfer
restrictions specified in this Section 6. The rules that will be applied as of
any date will be those in effect on that date.
ACCOUNT TRANSFER RESTRICTIONS
General Restrictions
--------------------
Subject to the limitations below, you may elect to transfer amounts among the
Accounts at any time while the contract is in force. You may elect no more than
12 transfers during any contract year without incurring a transfer charge. We
reserve the right to impose a charge for each transfer that exceeds 12 in any
contract year in an amount not to exceed $25 per transfer. A transfer will be
effective at the end of the Valuation Period in which we receive notice
satisfactory to us. No transfer will be permitted on or within 30 days of the
Maturity Date. The maximum number of Accounts in which Accumulated Value may be
held will be subject to our rules in effect at the time of transfer.
Restrictions on Transfers to Subaccounts
----------------------------------------
Without our prior approval, the maximum amount which may be transferred to a
Subaccount in any contract year is $1,000,000 less net premiums previously
deposited to such Subaccount in such contract year.
Restrictions on Transfers out of and to the Fixed Account
---------------------------------------------------------
During the first contract year, only one transfer is permitted out of the Fixed
Account, and may be made at any time. In each subsequent contract year, only
one transfer is permitted out of the Fixed Account, and may be made provided
such transfer is at least 180 days subsequent to any prior transfer. If the
accumulated value of the Fixed Account is $2,500 or less, then a transfer made
out of the Fixed Account may not exceed $500 without our prior approval. If the
accumulated value of the Fixed Account exceeds $2,500, then no more than 20% of
that value may be transferred out of the Fixed Account without our prior
approval. Without our prior approval, the maximum amount that may be
transferred to the Fixed Account in any contract year is $100,000 less net
premiums previously deposited to the Fixed Account in such year. A transfer to
the Fixed Account may not be made within 6 months of a transfer out of the Fixed
Account. No transfers may be made to the Fixed Account after the end of the
tenth contract year without our prior approval. No transfers may be made to or
from the Fixed Account after the commencement of Annuity payments.
6
--------------------------------------------------------------------------------
7. ACCUMULATIONS IN VARIABLE AND FIXED ACCOUNTS
--------------------------------------------------------------------------------
PURCHASE OF ACCUMULATION SHARES
The portion of the Net Premium not allocated to the Fixed Account will be
allocated to each elected Subaccount for investment with other funds in each
such Subaccount and applied to the purchase of Accumulation Shares to the credit
of this contract. The number of Accumulation Shares in each Subaccount
purchased by each premium payment will be determined by dividing the applicable
portion of the Net Premium by the applicable Accumulation Share Value of the
Subaccount on the first Valuation Date which is the same as or next follows the
receipt of the premium payment at our Home Office.
ACCUMULATED VALUE IN THE FIXED ACCOUNT
We will accumulate (i) the portion of any Net Premium allocated to the Fixed
Account and (ii) any amount transferred from a Subaccount, from the date the
premium is received or the transfer is made. The accumulated value of the
contract's share of the Fixed Account on any date prior to the date annuity
payments commence is the sum of such Net Premiums and transfers accumulated with
interest to that date less the sum of (a), (b) and (c) accumulated with interest
to that date, where:
(a) is any withdrawal made from the Fixed Account;
(b) is any transfer made from the Fixed Account; and
(c) is any charge deducted from the Fixed Account.
Interest will be credited daily and will then earn interest from that date. The
interest rates used will be the applicable rates that we declare. All such
declared rates will be expressed on an annual effective basis and will never be
less than the guaranteed minimum rate of 3% on an annual effective basis. The
interest credited on any given day will be at a rate which, if compounded daily
for one year, would equal the applicable declared rate.
--------------------------------------------------------------------------------
8. ACCUMULATION SHARES AND ANNUITY UNIT VALUATION
--------------------------------------------------------------------------------
ACCUMULATION SHARE VALUE
The Accumulation Share Value is calculated separately for each Subaccount. The
value of one Accumulation Share was set at $10.00 on the date assets were first
allocated to each Subaccount. The value of one Accumulation Share on any
Valuation Date thereafter will be determined for each Subaccount by multiplying
the immediately preceding Accumulation Share Value by the applicable Net
Investment Factor for the Valuation Period ending on that Valuation Date. On
any date other than a Valuation Date, the Accumulation Share Value will be the
same as that on the next following Valuation Date.
ANNUITY UNIT VALUE
The Annuity Unit Value is calculated separately for each Subaccount. The value
of one Annuity Unit was set at $1.00 on the date assets were first allocated to
each Subaccount. The value of one Annuity Unit on any Valuation Date thereafter
will be determined for each Subaccount by multiplying (1) the Immediately
preceding Annuity Unit Value by (2) the applicable Net Investment Factor for the
Valuation Period ending on the Valuation Date reduced by 0.00009425 (assuming
annual effective interest at the rate of 3 1/2%) times the applicable Net
Investment Factor for each calendar day in the Valuation Period. On any date
other than a Valuation Date, the Annuity Unit Value will be the same as that on
the next following Valuation Date.
NET INVESTMENT FACTOR
The Net Investment Factor for each Subaccount for any Valuation Period is equal
to one plus the applicable net investment rate for such period. A Net
Investment Factor may be more or less than one. The net investment rate for
each Subaccount for any Valuation Period will be determined by: (1) taking the
sum of the accrued investment income and capital gains and losses, realized or
unrealized, of the Subaccount for the Valuation Period; (2) subtracting the sum
of (i) an amount for any applicable income taxes and (ii) an amount for
mortality and expense risks and administrative expenses computed by multiplying
0.00003836 times the value of the Subaccount at the beginning of the Valuation
Period times the number of calendar days in the Valuation Period; and (3)
dividing the result by the value of the Subaccount at the beginning of the
Valuation Period.
7
VALUATION OF ASSETS
The values of the assets in the Subaccounts shall be determined at a fair value
in accordance with applicable law. Liabilities attributable to the Subaccount
will be deducted to determine the value of the Subaccount.
ADJUSTMENT OF UNITS AND VALUES
We reserve the right to change the number and value of the Accumulation Shares
or Annuity Units or both without your consent or the consent of any other
person, provided strict equity is preserved and the change does not affect the
benefits, provisions or investment return of this contract.
--------------------------------------------------------------------------------
9. DEATH BENEFIT
--------------------------------------------------------------------------------
If the Annuitant dies before the Date of Maturity, we will pay the Death Benefit
to the Beneficiary. The Death Benefit will equal the greatest of: (i) the
Accumulated Value as of the date of receipt of due proof of the Annuitant's
death; (ii) the amount of the premiums paid less the amount of all withdrawals
made, if any; or (iii) the Accumulated Value as of any Fifth Interval Contract
Anniversary preceding the date of receipt of due proof of the Annuitant's death
and preceding the contract anniversary nearest the Annuitant's 81st birthday
plus any premiums paid since such Fifth Interval Contract Anniversary less any
withdrawals made since such Fifth Interval Contract Anniversary.
Notwithstanding the above, the following will apply upon the death of the Owner
or of any joint Owner, if this contract has not already been converted into an
annuity in accordance with Section 14:
(i) If the Beneficiary is the spouse of the Owner, the Beneficiary may
continue the contract in force as Owner.
(ii) If the Beneficiary is not the spouse of the Owner, or if the
Beneficiary is the spouse of the Owner but does not choose to continue
the contract, we will pay the Death Benefit (or the Surrender Value if
the Owner is not the Annuitant) in full to the Beneficiary within 5
years of the Owner's death or apply the Accumulated Value in full
towards the purchase of a life annuity on the Beneficiary with
payments beginning within 1 year of the Owner's death.
--------------------------------------------------------------------------------
10. CONTRACT FEE AND PREMIUM TAXES
--------------------------------------------------------------------------------
We will deduct a contract fee not to exceed $50 (see Section 1 for current
contract fee information), subject to applicable state regulations, on each
contract anniversary prior to the Date of Maturity and on the date of surrender
of the contract, but only if the Accumulated Value on any such date is then less
than $10,000. No contract fee will be deducted if the Accumulated Value is
$10,000 or more.
The contract fee will be deducted from the accumulated value for each Account in
the same proportion as such value bears to the Accumulated Value. However, no
deduction will be made from the accumulated value in the Fixed Account which
results in an accumulation at less than the 3% guaranteed rate.
A deduction for a premium tax, if any, or a similar tax, if any, will be made
either from premiums or from the Accumulated Value if and when such a tax is
incurred by us. However, if premium taxes or similar taxes are incurred by us
at the time premiums are paid and we defer the deduction for such taxes, then a
deduction will be made upon any withdrawal under Section 11 and either on the
Surrender Date, the Date of Maturity, or the date of payment of the Death
Benefit. Such deduction will be equal to the tax percentage multiplied by (i)
in the case of withdrawals, the withdrawal amount requested, (ii) in the case of
surrender or annuitization, the Accumulated Value as of the Surrender Date or
the Date of Maturity as the case may be, or (iii) in the case of death, the
Death Benefit as of the date of receipt of due proof of the Annuitant's death.
The "tax percentage" is equal to the percentage of premium which the premium tax
or similar tax in question constitutes.
8
--------------------------------------------------------------------------------
11. PARTIAL WITHDRAWALS
--------------------------------------------------------------------------------
Subject to the limits described in this section, you may request to withdraw an
amount less than the Surrender Value. Such request must be made in writing and
must be received before the Annuitant's death and before the commencement of
Annuity payments. A withdrawal may or may not be subject to a withdrawal charge
as described in Section 12. The total of the amount you request and any
applicable withdrawal charge will be deducted from the Accumulated Value. The
amount as deducted is referred to as the "partial withdrawal." Unless otherwise
specified by you, any partial withdrawal will be deducted from the accumulated
value of each Account in the same proportion as such value bears to the
Accumulated Value. Without our prior approval, we will not permit a partial
withdrawal of less than $100 nor will we permit a partial withdrawal if the
Accumulated Value after such requested withdrawal would be less than $1,000.
We may defer the payment of any withdrawal in the same manner as described in
the Surrender Provision.
--------------------------------------------------------------------------------
12. WITHDRAWAL CHARGE
--------------------------------------------------------------------------------
A withdrawal charge will be computed upon surrender of the policy and upon each
partial withdrawal. In any one contract year, you may withdraw free of any
withdrawal charge an aggregate amount up to 10% of the Accumulated Value of the
contract as of the first day of that contract year. This aggregate amount is
the "free withdrawal amount."
To determine the withdrawal charge, we will first deduct the following amounts
from the premium payments made to date in the order that such payments were
received:
(a) The sum of all contract fees deducted to date;
(b) The sum of all prior partial withdrawals;
We will then withdraw the amount of the surrender or partial withdrawal first
from the remaining premium payments in the order that they were received, and
then from earnings, if necessary. The withdrawal charge table below will be
applied to all premium payments withdrawn in any one contract year that exceed
the free withdrawal amount. A withdrawal charge will not be imposed on
earnings. Earnings is defined as any portion of the Accumulated Value which
exceeds the total of all net premiums received.
Withdrawal Charge Table
-----------------------
Time from premium payment
to date of surrender or partial withdrawal Charge
------------------------------------------ ------
7 years or more No Charge
At least 6 years, but less than 7 years 1%
At least 5 years, but less than 6 years 2%
At least 4 years, but less than 5 years 3%
At least 3 years, but less than 4 years 4%
At least 2 years, but less than 3 years 5%
At least 1 year, but less than 2 years 6%
Less than 1 year 7%
--------------------------------------------------------------------------------
13. SURRENDER PROVISION
--------------------------------------------------------------------------------
We will determine and pay the Accumulated Value of this contract, less any
withdrawal charge described in Section 12, as a Surrender Value on receipt at
our Home Office before the Annuitant's death and before the commencement of
Annuity payments of written notice requesting payment of the Surrender Value.
We reserve the right to defer the payment of the Surrender Value from the Fixed
Account for a period of six months. We will pay the Surrender Value from the
Subaccounts within 7 days (plus any period of extension under the applicable
laws, rules and regulations governing the redemption of variable Annuities)
after the date of receipt of the written notice unless a different method of
settlement is mutually agreed upon, in writing, between you and us.
9
--------------------------------------------------------------------------------
14. CONVERSION
--------------------------------------------------------------------------------
CONVERSION OF ACCUMULATION SHARES TO ANNUITY UNITS
On the Date of Maturity or other date elected under Section 15 for commencement
of Annuity payments, the Accumulation Shares credited to the contract will be
converted into Annuity Units. Annuity payments will then commence subject to
the limitations specified in Section 15 and all other applicable provisions. The
number of Annuity Units credited to each Subaccount will be determined by: (1)
multiplying the number of Accumulation Shares credited to that Subaccount on the
date of conversion by the Accumulation Share Value for the Subaccount as of 10
days prior to the date the first Annuity payment is due; (2) subtracting
applicable premium tax, if any; (3) dividing the resulting value by 1,000; (4)
multiplying the value from (3) by the applicable factor from the Table of First
Variable Annuity Payment Factors in Section 15 for the option elected, or if no
option is elected the applicable factor for Option A (Variable) with a
guaranteed period of ten years, to determine that Subaccount's portion of the
variable portion of the first monthly Annuity payment, and (5) dividing the
value from (4) by the Annuity Unit Value for the Subaccount as of 10 days prior
to the date the first Annuity payment is due.
VARIABLE ANNUITY PAYMENTS
The amount of the variable portion of the monthly Annuity payment due on the
first payment date is equal to the sum of the portions for each Subaccount
determined as described in the preceding paragraph. The amount of the variable
portion of any monthly Annuity payment subsequent to the first will be
determined by adding together for each Subaccount the product of the number of
Annuity Units credited to the Subaccount and the Annuity Unit Value for the
Subaccount 10 days prior to the date the payment is due. We guarantee that the
Annuity Unit Values used in determining Annuity payments will not be affected by
variations in our mortality experience or our actual expenses from those
assumed.
CONVERSION OF ACCUMULATED VALUE IN FIXED ACCOUNT
On the Date of Maturity or other date elected under Section 15 for commencement
of Annuity payments, we will convert the accumulated value in the Fixed Account
into a fixed monthly Annuity. Annuity payments will then commence subject to
the limitations specified in Section 15 and all other applicable provisions. We
will determine the fixed monthly Annuity by (1) subtracting any applicable
premium tax from the accumulated value in the Fixed Account on the date the
first Annuity payment is due, (2) dividing the resulting value by 1,000, and (3)
multiplying the value from (2) by the greatest of the following; (i) the
applicable Fixed Monthly Annuity Option Rate then in effect for the option
elected, or if no option is elected, the applicable rate for Option A (Fixed)
with a guaranteed period of ten years; (ii) the applicable rate from the Table
of Fixed Annuity Payment Factors in Section 15; or (iii) the current rate for a
single consideration immediate annuity.
10
--------------------------------------------------------------------------------
15. SETTLEMENT PROVISIONS
--------------------------------------------------------------------------------
ANNUITY ON DATE OF MATURITY
We shall make the Annuity payments automatically as a Life Annuity with Payments
for a Guaranteed Period of 10 Years in accordance with the provisions of Option
A unless another option is elected. We shall determine the amounts of the
Annuity payments in accordance with the provisions of this section and of the
"Conversion" provision in Section 14. Amounts in the Subaccounts will be used
to provide variable benefits. Amounts in the Fixed Account will be used to
provide fixed benefits.
If the amount of the first monthly Annuity payment would be less than $20, we
will make a single payment equal to the Accumulated Value on the Date of
Maturity. This single payment shall be in place of all other benefits
provided by this contract. If the amount of the first monthly Annuity payment
would be at least $20 but less than $50, we may make payments at quarterly,
semi-annual or annual intervals.
OPTIONAL METHODS OF SETTLEMENT
In place of (i) the Annuity on the Date of Maturity specified in the first
sentence of this Section 15 or (ii) a single payment in case of death prior to
the date Annuity payments commence or (iii) a single payment in case of
surrender which occurs at least 6 months after the date the first premium is
applied to the contract, proceeds payable under this contract may be left with
us in accordance with one of the optional methods of settlement then available
for contracts of this type and the terms of a supplementary agreement to be
issued when the option becomes effective, but only if (i) such proceeds are in
an amount of $5,000 or more and (ii) the amount of the first monthly Annuity
payment would be $50 or more. The following settlement options will always be
available.
OPTION A
A (Variable) - Life Annuity on a Variable Basis with Payments for a Guaranteed
Period of 5, 10, or 20 Years. If the Measuring Person's death occurs within the
guaranteed period, payments will be made for the remainder of the guaranteed
period in accordance with the terms of the supplementary agreement.
A (Fixed) - Life Annuity with Payments for a Guaranteed Period of 5, 10, or 20
Years. If the Measuring Person's death occurs within the guaranteed period,
payments will be made for the remainder of the guaranteed period in accordance
with the terms of the supplementary agreement.
OPTION B
B (Variable) - Life Annuity on a Variable Basis Without Further Payment on Death
of the Measuring Person.
B (Fixed) - Life Annuity Without Further Payment on Death of the Measuring
Person.
You may elect an option by written notice before the death of the Annuitant and
before the commencement of Annuity payments. If you have made no election
before the death of the Annuitant, the Beneficiary may make an election by
written notice before the proceeds become payable.
11
ANNUITY PAYMENT AND OPTION LIMITATIONS
While the Annuitant is living (i) the Measuring Person will be the Annuitant;
(ii) the Payee will be the Annuitant unless otherwise directed by you; and (iii)
the Contingent Payee will be the Beneficiary unless otherwise provided by
written notice.
If the Annuitant dies and Death Benefit proceeds are left with us in accordance
with a settlement option election (i) the Measuring Person will be the
Beneficiary; (ii) the Payee will be the Beneficiary unless otherwise designated
in the election; and (iii) the Contingent Payee will be the person or persons so
designated in the election and in accordance with the terms of the supplementary
agreement.
Optional methods of settlement are not available without our consent if the
proceeds are payable to an executor, administrator, trustee, corporation,
partnership or association.
If the Owner of this contract dies on or after annuity payments have begun, any
remaining benefit under such annuity on the date of the Owner's death must be
paid out at least as rapidly as under the method of making annuity payments then
in effect.
FIRST VARIABLE ANNUITY PAYMENT FACTORS
The Table of First Variable Annuity Payment Factors in this Section 15 shows the
amount of the variable portion of the first monthly Annuity payment under Option
A (Variable) and Option B (Variable) for each $1,000 applied. The factors in
this table are based on the 1983a Individual Annuity Mortality Table with
mortality and age adjustments and annual effective interest at the rate of 3
1/2%. The amount of the variable portion of the first payment will depend on
the sex and adjusted age of the Measuring Person. The adjusted age is
determined from the actual age on the Measuring Person's birthday nearest the
date the first Annuity payment is due, by subtracting one year for each complete
10 year period elapsed since the Date of Issue.
FIXED ANNUITY PAYMENTS
The Table of Fixed Annuity Payment Factors in this Section 15 shows the
guaranteed amount of the fixed portion of the monthly Annuity payments for each
$1,000 applied. The factors in the table are based on the 1983 Female Annuity
Mortality Table with mortality and age adjustments and annual effective interest
at the rate of 2 1/2%. The guaranteed amount of the fixed portion of the
Annuity payments will depend on the adjusted age of the Measuring Person. The
adjusted age is determined from the actual age on the Measuring Person's
birthday nearest the date the first Annuity payment is due, by subtracting one
year for each complete 10 year period elapsed since the Date of Issue.
12
TABLE OF FIRST VARIABLE ANNUITY PAYMENT FACTORS
Monthly life annuity with payments on a variable basis for each $1,000 applied.
--------------------------------------------------------------------------------
Adjusted Option A (Variable) Option B
Age of (Variable)
Measuring Life Annuity with Payments Life Annuity
Person on for a Guaranteed Period Without
----------------------- Further Payment
Birthday on Death
Nearest Date 5 Years 10 Years 20 Years of Measuring
of First Payment ------- -------- -------- ------------
-----------------
Person
------
Male Female Male Female Male Female Male Female
--------- ----------- ---------- ----------- ---------- --------- --------- ---------
55 4.50 4.13 4.46 4.11 4.32 4.05 4.51 4.13
56 4.58 4.19 4.54 4.18 4.38 4.10 4.59 4.20
57 4.67 4.26 4.62 4.24 4.44 4.16 4.68 4.27
58 4.76 4.33 4.71 4.31 4.50 4.22 4.78 4.34
59 4.86 4.41 4.80 4.39 4.57 4.28 4.88 4.42
60 4.96 4.49 4.90 4.46 4.63 4.35 4.98 4.50
61 5.08 4.58 5.00 4.55 4.70 4.41 5.10 4.59
62 5.20 4.67 5.11 4.64 4.77 4.48 5.22 4.69
63 5.32 4.77 5.23 4.73 4.84 4.55 5.36 4.79
64 5.46 4.88 5.35 4.83 4.91 4.62 5.50 4.89
65 5.61 4.99 5.47 4.94 4.97 4.69 5.65 5.01
66 5.76 5.11 5.61 5.05 5.04 4.77 5.81 5.13
67 5.93 5.24 5.74 5.17 5.11 4.84 5.99 5.27
68 6.10 5.38 5.89 5.29 5.17 4.92 6.17 5.41
69 6.29 5.53 6.04 5.43 5.24 5.00 6.37 5.56
70 6.49 5.69 6.20 5.57 5.30 5.07 6.59 5.73
71 6.69 5.86 6.36 5.72 5.35 5.15 6.81 5.91
72 6.91 6.05 6.52 5.88 5.41 5.22 7.05 6.10
73 7.14 6.25 6.69 6.04 5.46 5.29 7.31 6.32
74 7.39 6.46 6.87 6.22 5.50 5.35 7.58 6.55
75 7.65 6.70 7.05 6.40 5.54 5.41 7.88 6.79
76 7.92 6.94 7.23 6.59 5.58 5.47 8.19 7.06
77 8.21 7.20 7.41 6.78 5.61 5.52 8.53 7.35
78 8.52 7.48 7.59 6.98 5.64 5.56 8.90 7.66
79 8.84 7.78 7.78 7.19 5.67 5.61 9.29 8.00
80 9.17 8.10 7.96 7.40 5.69 5.64 9.71 8.36
81 9.52 8.44 8.14 7.61 5.71 5.67 10.16 8.76
82 9.88 8.81 8.31 7.82 5.73 5.70 10.64 9.20
83 0.26 9.19 8.48 8.03 5.74 5.72 11.16 9.67
84 0.65 9.59 8.64 8.23 5.74 5.73 11.71 10.18
85 and over 1.05 10.02 8.79 8.42 5.75 5.74 12.30 10.74
13
TABLE OF FIXED ANNUITY PAYMENT FACTORS
Monthly life annuity with payments on a fixed basis for each $1,000 applied.
_______________________________________________________________________________
Adjusted Option A (Fixed) Option B (Fixed)
Age of Measuring
Person on Birthday Life Annuity with Payments Life Annuity Without
Nearest Date for a Guaranteed Period Further Payment on Death
of First Payment ----------------------- of Measuring Person
---------------- -------------------
5 Years 10 Years 20 Years
------------- -------------- -------------
55 3.55 3.54 3.48 3.55
56 3.62 3.60 3.54 3.62
57 3.69 3.67 3.60 3.69
58 3.76 3.74 3.66 3.77
59 3.82 3.82 3.73 3.85
60 3.92 3.90 3.79 3.93
61 4.01 3.99 3.86 4.02
62 4.11 4.08 3.94 4.12
63 4.21 4.17 4.01 4.22
64 4.32 4.28 4.08 4.33
65 4.43 4.38 4.16 4.45
66 4.55 4.50 4.24 4.57
67 4.68 4.62 4.32 4.70
68 4.82 4.75 4.40 4.85
69 4.97 4.88 4.48 5.00
70 5.14 5.03 4.56 5.17
71 5.31 5.18 4.64 5.35
72 5.50 5.34 4.71 5.54
73 5.70 5.51 4.78 5.75
74 5.91 5.69 4.85 5.98
75 6.14 5.87 4.92 6.23
76 6.39 6.07 4.97 6.49
77 6.65 6.27 5.03 6.78
78 6.93 6.47 5.08 7.09
79 7.23 6.58 5.12 7.42
80 7.55 6.90 5.16 7.79
81 7.90 7.11 5.19 8.18
82 8.26 7.33 5.22 8.62
83 8.65 7.54 5.23 9.08
84 9.05 7.74 5.25 9.59
85 and over 9.48 7.94 5.26 10.15
14
--------------------------------------------------------------------------------
16. PROOF REQUIRED FOR COMMENCEMENT AND FOR CONTINUATION OF ANNUITY PAYMENTS
--------------------------------------------------------------------------------
Before making the first Annuity payment, we shall have the right to require
proof of the correct age of the Measuring Person. We shall also have the right
to require proof that the Measuring Person is living on the date each Annuity
payment is due.
--------------------------------------------------------------------------------
17. MISSTATEMENTS
--------------------------------------------------------------------------------
If the age or sex of the Measuring Person has been misstated, we will adjust the
amount of each Annuity payment and every other benefit to that which the premium
paid would have purchased at the correct age and sex. We will charge any
overpayments and credit any underpayments against future payments we make under
the contract.
--------------------------------------------------------------------------------
18. INCONTESTABILITY
--------------------------------------------------------------------------------
This contract shall be incontestable after it has been in force for 1 year from
its Date of Issue.
--------------------------------------------------------------------------------
19. ASSIGNMENT
--------------------------------------------------------------------------------
You may assign your interest in this contract, except as otherwise provided,
without the consent of any revocable Beneficiary. Your interest, any interest
of the Annuitant and of any revocable Beneficiary shall be subject to the terms
of the assignment.
We will not be on notice of any assignment unless it is in writing; nor will we
be on notice until a duplicate of the original assignment has been filed at our
Home Office. We assume no responsibility for the validity or sufficiency of any
assignment.
If the application indicates that this contract is issued in a TSA or HR-10
plan, this contact is subject to assignment restrictions for Federal Income Tax
purposes. In such event, this contract shall not be sold, assigned, discounted,
or pledged as collateral for a loan or as security for the performance of an
obligation or for any other purpose, to any person other than us.
--------------------------------------------------------------------------------
20. CLAIMS OF CREDITORS
--------------------------------------------------------------------------------
The proceeds and all other payments under the contract will be exempt from the
claims of creditors to the extent permitted by law. The proceeds and payments
may not be assigned or withdrawn before becoming payable without our agreement.
15
--------------------------------------------------------------------------------
21. RIGHT TO MAKE CHANGES
--------------------------------------------------------------------------------
We reserve the right to make certain changes if, in our judgment, they would
best serve the interest of the owners of contracts such as this or would be
appropriate in carrying out the purposes of such contracts. Any changes will be
made only to the extent and in the manner permitted by applicable laws. Also,
when required by law, we will obtain your approval of the changes and approval
from any appropriate regulatory authority.
If any changes result in a material change in the underlying investment of
Subaccounts to which the reserves for this contract are allocated, we will
notify you of such change. You may then make a new election under the
Investment Option and the Account Transfer Option provisions.
--------------------------------------------------------------------------------
22. ANNUAL STATEMENT
--------------------------------------------------------------------------------
We will furnish you with reports annually, or more frequently, as required by
applicable law. They will include: (i) a statement of the investments held in
each Portfolio; and (ii) a statement of the condition and value of this contract
which will show the number of Accumulation Shares, if any, credited to each
Subaccount, the value of each Accumulation Share, and the Accumulated Value of
this contract.
--------------------------------------------------------------------------------
23. MISCELLANEOUS
--------------------------------------------------------------------------------
If the Accumulated Value of the contract becomes zero, we reserve the right to
terminate this contact.
Under applicable law, all income, gains and losses, realized or unrealized, of
the Separate Accounts shall be credited to or charged against the amounts placed
in the Separate Accounts without regard to our other income, gains and losses.
The assets of the Separate Accounts are owned solely by us. We are not a
trustee with respect to any part or the whole of those assets. The portion of
the assets in the Separate Accounts equal to the reserves and other liabilities
under this contract with respect to the Separate Accounts shall not be
chargeable with liabilities arising out of any other business we may conduct.
In place of operating each Separate Account as a unit investment trust, we
reserve the right to make investments directly, operating the Separate Account
as a "management-type investment company" under the 1940 Act, or in any other
form permitted by law, the investment adviser of which would be us or an
affiliate. The Separate Account assets would be invested as provided with
respect to the investment objectives of the Separate Account.
16
Communications about this contract should be sent to the Company at Xxxx Xxxxxxx
Place, Boston, Massachusetts 02117.
Flexible Premium Combination Fixed/Variable Deferred Annuity -- monthly Annuity
payable to Annuitant beginning on Date of Maturity for a guaranteed period of 10
years and thereafter for life, unless otherwise elected.
Nonparticipating
Initial premium is shown on page 3
THE BENEFITS, PAYMENTS AND ACCUMULATED VALUE UNDER THIS CONTRACT, WHEN BASED ON
THE INVESTMENT EXPERIENCE OF A SEPARATE ACCOUNT, ARE VARIABLE AND NOT GUARANTEED
AS TO DOLLAR AMOUNT. THE VALUES OF THE SUBACCOUNTS MAY INCREASE OR DECREASE.
SEE SECTION 8 FOR DETAILS.
