Exhibit #4
Home Office: 0 Xxxxxx Xxxx Xxxxx
Xxxxxxxxxxx, Xxxxxxxx 00000-0001
0-000-000-0000
Individual Deferred Fixed And Variable
Retirement Annuity Contract
Flexible purchase payments
Nonparticipating -- dividends not paid.
All payments and values under this contract which are based on investment
results of the Separate Account are variable and not guaranteed as to fixed
dollar amount.
We agree to provide the benefits and other rights described in this contract in
accordance with the terms of the contract.
Signed for the Company at Springfield, Illinois as of the Contract Date.
President Countersigned Corporate Secretary
RIGHT TO EXAMINE CONTRACT FOR 15 DAYS
It is important to us that you are satisfied with this contract. We hope that it
meets the retirement goals for which you planned. If you are not satisfied, you
may return the contract to us or the agent from whom you purchased it, within 15
days after it is delivered to you, and receive a full refund of any purchase
payments paid to the fixed account and/or the market value of the assets, less
taxes if any, purchased by payments paid to the variable account. Upon return of
the contract, it shall be void as if no contract has been issued.
IC-408000
This is a legal contract between the contract Owner and Xxxxxx Xxxx Life
Insurance Company.
Read your policy carefully
We are providing a brief outline of some of the important features of our
contract. This is not part of the insurance contract. Only the actual contract
provisions will control. The contract sets forth, in detail, the rights and
obligations of both you and your insurance company. It is therefore important
that you read your contract carefully.
This individual deferred flexible premium fixed and variable retirement annuity
contract provides for retirement income. It may be renewed on each Renewal Date
for another period of time up to the Maturity Date. The purchase payments,
guaranteed interest rate, surrender charge rate, annual maintenance fee, early
withdrawal penalty rate, transfer fee, annual mortality risk fee, expense risk
fee and distribution expense risk fee for this contract are shown on the
Contract Data page.
Table of contents Page
Face page
Section 1. Contract Data.............................................................................. 2
Section 2. Fixed Accounts............................................................................. 3
Section 3. Definitions of certain terms............................................................... 4
Section 4. General provisions......................................................................... 5
Section 5. Ownership and beneficiary provisions....................................................... 7
Section 6. Payments to the Company.................................................................... 8
Section 7. Death benefit.............................................................................. 8
Section 8. The Fixed Account.......................................................................... 8
Section 9. The Variable Account....................................................................... 11
Section 10. Settlement option provisions.............................................................. 12
Settlement option tables.............................................................................. 16
Additional benefit provisions or restrictions, if any, and a copy of the application follow page 18.
Home Office: 0 Xxxxxx Xxxx Xxxxx
Xxxxxxxxxxx, Xxxxxxxx 00000-0001
0-000-000-0000
Individual Deferred Fixed And Variable
Retirement Annuity Contract
Flexible purchase payments
Nonparticipating -- dividends not paid.
All payments and values under this contract which are based on investment
results of the Separate Account are variable and not guaranteed as to fixed
dollar amount.
SECTION 1 -- CONTRACT DATA
Contract number: XXXXXXXXXX
Annuitant: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
Contract Date: XXXXXXXXXX
Maturity Date: XXXXXXXXXX
Renewal Date: XXXXXXXXXX
Age at issue: XX
Sex: XXXXXX
Owner and beneficiary: as stated in the application unless changed.
Annuity payments: Annuity payments will commence on the Maturity
Date if the annuitant is then living. These income
payments are determined by applying the total cash
value of the contract in accordance with the
contract's provisions. The factors in section 10
are guaranteed through the Maturity Date.
Purchase payment(s): $Z,ZZZ,ZZZ.99 per year, payable in ZZ
installment(s), to be allocated as follows:
Fixed Account: ZZ9.99%
Variable Account:
HM Balanced fund ZZ9.99%
HM Income fund ZZ9.99%
XX Xxxxx-term investment fund ZZ9.99%
HM Growth fund ZZ9.99%
HM Socially responsible fund ZZ9.99%
HM International equity fund ZZ9.99%
HM Small cap growth fund ZZ9.99%
Total ZZ9.99%
The contract's minumum annual payment(s) must equal $225. The minimum annual
purchase payment(s) allocated to the Fixed Account or to each mutual fund in the
Variable Account must equal $225. Purchase payment(s) received prior to the
Maturity Date cannot exceed $500,000. See application for details of additional
money allocations, if any.
Guaranteed interest rate
Fixed Account: 4.5% per year prior to the Maturity Date.
Variable Account: none.
Surrender charge rates Fixed Account and Variable Account:
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During contract year % charged
1 8%
2 8%
3 6%
4 4%
5 2%
thereafter -0-
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SECTION 1 (CONTINUED) -- CONTRACT DATA
Contract number: XXXXXXXXXX
Annuitant: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
Annual maintenance fees
$25 per year: plus
Fixed Account: $5 if money is in this account.
Variable Account: $5 for each division in which there is money.
Early withdrawal penalty rate
Fixed Account: 5% if a dollar amount is withdrawn or
transferred or the contract is surrendered on
any date other than the Renewal Date.
Variable Account: none.
Transfer fee
Fixed Account: none.
Variable Account: $5 will be charged for each transfer made from a
division of the Variable Account.
Annual mortality risk, expense risk and distribution expense risk fee
Fixed Account: none.
Variable Account: 1.35% per year.
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SECTION 2 -- FIXED ACCOUNT'S TABLE OF GUARANTEED MONTHLY INCOME AT MATURITY AND
MINIMUM CASH AND SURRENDER VALUES*
Contract number: XXXXXXXXXX
Annuitant: XXXXXXXXXXXXXXXXXXXXXXXXXXXXX
Contract Minimum Minimum Guaranteed
Anniversary Attained Guaranteed Guaranteed Monthly Income
Date Age Cash Value Surrender Value at Maturity
XX XX $ZZ,ZZZ,ZZZ.99 $ZZ,ZZZ,ZZZ.99 $ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
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Section 3. Definitions of certain terms
"Age at issue" is the Annuitant's age last birthday on the Contract Date.
"Annual maintenance fees" are fees for administrative expenses deducted annually
from the total cash value. These fees are shown on the Contract Data page.
"Annuitant" is the person insured in this contract as shown on the Contract Data
page.
"Annuity income payment" is an income payment made by us to the payee.
"Beneficiary" is the person to whom any benefits will be paid in the event of
the death of the Annuitant prior to the Maturity Date.
"Commuted value" is a lump sum payment made in lieu of periodic future income
payments.
"Company," "we," "us" and "our" refer only to the Xxxxxx Xxxx Life Insurance
Company.
"Contract anniversary" is the same day and month as the Contract Date for each
succeeding year of this contract.
"Current interest rate" is the total rate of interest that we will credit to the
Fixed Account.
"Contract Date" is the effective date of this contract. It is the date from
which purchase payment due dates, contract years, Renewal Dates and contract
anniversaries are determined.
"Division" is a subcategory of the Separate Account in which money is invested
in shares of the mutual fund which corresponds to that division. Each division
may receive payments from an Annuitant's Variable Account. There is a division
for each mutual fund shown on the Contract Data page.
"Early withdrawal penalty" is an amount charged when a withdrawal, transfer or
surrender is made from the Fixed Account at any time other than on the Renewal
Date.
"Excess interest rate" is the current interest rate less the guaranteed interest
rate.
"Fixed Account" represents net payments and interest earned thereon allocated to
our general account and invested along with other insurance funds in this
general account.
"Fixed cash value" refers to the dollar value of the Fixed Account prior to the
Maturity Date. See Section 8 for details.
"Guaranteed interest rate" is the minimum interest to be credited to the Fixed
Account.
"Home Office" means our executive office at 0 Xxxxxx Xxxx Xxxxx, Xxxxxxxxxxx,
Xxxxxxxx.
"Maturity Date" is the date you selected for the payee to begin receiving
annuity income payments. It is shown on the Contract Data page.
"Mutual funds" are open-end diversified management investment companies which
are registered under the Investment Company Act of 1940, as amended. These
companies are shown on the Contract Data page. Each mutual fund has a specific
investment objective as stated in its prospectus. The prospectus should be read
for complete details.
"Net payment" means the purchase payment less any applicable premium tax on the
payment received.
"Owner" (referred to in this contract as "you" and "your") is the Annuitant
unless otherwise stated in the application.
"Payee" is any person entitled to receive income payments under any settlement
option benefit.
"Payee's actual age" means the payee's age last birthday when the first annuity
income payment is due.
"Purchase payment" means a dollar amount paid to us in return for the benefits
described in this contract.
"Renewal Date" is the date from which the Fixed Account may be renewed for
another period of time.
"Renewal period" is the period of time from the Contract Date to the Renewal
Date of the Fixed Account. If the Fixed Account has been renewed, it is the
period to the next Renewal Date.
Page 4
"Separate Account" is the segregated asset account which was established by us
to receive the invest net payments allocated to Annuitants' Variable Accounts.
It has individual divisions which correspond to various mutual funds.
"Settlement option" is the method by which annuity income payments are made to
the payee at the Maturity Date or the Annuitant's death. See settlement option
tables for guaranteed rates.
"Surrender charge" is an amount charged during the first 5 years if a withdrawal
is made or the contract is surrendered for its total cash value. The rate varies
by contract year as shown on the Contract Data page.
"Surrender value" is the total cash value less applicable surrender charges and
early withdrawal penalties, if any.
"Supplemental contract" is a form stating the terms of the settlement under an
option elected.
"Total cash value" is an amount equal to the sum of the fixed cash value and the
variable cash value prior to the Maturity Date.
"Valuation date" is a date upon which the net value of each share of the mutual
fund(s) is determined. It will be on any day which the New York Stock Exchange
is open for trading.
"Valuation period" is the time from the end of one business day on the New York
Stock Exchange to the end of the next business day.
"Variable cash value" refers to the dollar value of the Variable Account prior
to the Maturity Date. See Section 9 for details.
"Variable Account" is your portion of the Separate Account set up to receive the
net payments and other cash distributions allocated to it. Money in this account
is invested along with other Variable Account money in our Separate Account.
Section 4. General provisions
Entire contract -- This is your contract. It is issued in consideration of your
application and receipt of the purchase payments. This contract and the
application make the entire contract. A copy of the application is attached to
this contract. All statements made in the application in the absence of fraud
will be treated as representations and not as warranties. If we challenge a
claim or attempt to void this contract, we agree not to use any statement in
defense of a claim under this contract unless contained in a written statement.
A copy of such statement must be attached to this contract when issued.
Change of contract provisions -- We have the right to change the provisions of
this contract in certain cases. We will make any change necessary for continued
compliance under any federal or state laws that affect this contract. We may
also change the contract with respect to any increase in purchase payments over
that shown on page 2.
This contract shall include any provisions required by the state in which it was
issued. Any provision omitted from this contract at date of issue will be
included as required by the state in which it was delivered.
No person other than our president, vice president, or the secretary can, on our
behalf, change or waive any condition or provision of this contract. Such change
or waiver must be made in writing and signed by one of the officers named above.
Incontestability -- This contract shall be incontestable after 1 year from the
Contract Date.
Maturity Date -- The Maturity Date is the contract anniversary following the
Annuitant's 65th birthday. You may choose a different date if agreed upon by us.
In no case can you choose a date later than the anniversary on or following the
Annuitant's 70th birthday or the 10th anniversary of the contract, whichever is
later.
Change of Maturity Date -- You may change the Maturity Date. To do so, we must
receive your written request at least 90 days prior to the then current Maturity
Date. This change must be approved by us.
Nonparticipating -- This contract is nonparticipating and does not participate
in the profits of the Company.
Minimum values -- All values and benefits for this contract are not less than
the minimum required by the laws of the state in which this contract is
delivered.
Assignment -- You may assign or transfer this contract unless it is issued as a
part of a retirement plan qualified under the Internal Revenue Code which will
not allow any transfer or assignment. We will not be responsible for the
validity of any assignment. It must be filed in writing at our Home Office.
Until received, we will not be considered to have knowledge of it. When it is
filed your rights and those of any beneficiary will be subject to it.
Page 5
Misstatement of age -- If the age of the Annuitant or any other payee has been
misstated, the annuity income payments under this contract will be that amount
which the purchase payments would have provided at the correct age. We will
require proof of the correct age.
If the annuity income payments were too large because of a misstatement, we will
deduct the difference with interest from the benefits falling due until totally
repaid. If such payments were too small, we will add the difference with
interest to the next benefit due. The interest rate will not exceed 6 percent
per year.
Exchange of contract -- You may exchange this contract for another annuity
contract issued by us if we approve it.
Proof of survival -- We may require proper proof that a payee, beneficiary, or
Annuitant is living when payment depends upon such person's survival.
Periodic reports -- During each contract year prior to the Maturity Date, we
will periodically send you reports which show your total cash value, purchase
payments and other contract transactions.
At any time, you may request a statement of the contract's total cash value. Any
other information or reports legally required will be sent to you. All material
will be sent to your last address known by us.
Premium tax -- Any premium tax deducted will be determined by the Annuitant's
place of residence.
Annual maintenance fees -- The annual maintenance fees are deducted from the
total cash value of the contract on its anniversary date. These fees will not
change and are shown on the Contract Data page. Such fees cover the general
maintenance of the contract as well as the additional cost for maintenance of
multiple accounts.
Section 5. Ownership and beneficiary provisions
Ownership -- The Owner is the Annuitant listed on the Contract Data page unless
otherwise designated in the application. The Owner may be changed subject to the
Change of ownership or beneficiary provision. This contract belongs to you.
Unless you provide otherwise, you may exercise all rights and privileges granted
by this contract during the Annuitant's lifetime.
Beneficiary -- The beneficiary is named in the application; however, you may
change it. The change will be subject to the Change of ownership or beneficiary
provision.
For payment purposes, we will assume that the beneficiary's death occurred prior
to the Annuitant's death if the beneficiary:
1. dies before or on the same date as the Annuitant's death; or
2. dies within 15 days after the Annuitant's death.
Change of ownership or beneficiary -- You may change the Owner or beneficiary of
this contract during the lifetime of the Annuitant unless:
1. you provide otherwise; or
2. the contract is issued as part of a retirement plan qualified under
the Internal Revenue Code which will not allow any transfer or
assignment.
Changes must be requested in writing on a form satisfactory to us. The request
must be sent to our Home Office. We may require return of the contract for an
endorsement. A change is valid only when it is received by us in our Home
Office; but, upon receipt it is effective as of the date that you signed the
written request. All changes are subject to any payments made or other action
taken by us before receipt of the written request.
Section 6. Payments to the Company
Purchase payments -- You may make purchase payments at any time up to 30 days
prior to the Maturity Date. These payments will be allocated to the Fixed
Account and/or Variable Account as elected in your application.
You may change the allocation to these accounts no more than twice in any
contract year. You may increase or decrease the payments. We will not allow
payments which do not comply with the minimums and maximum shown on the Contract
Data page. Your request to make these changes must be sent to the Home Office.
An approved change will be made as of the date we receive your request.
Grace period -- A grace period of 31 days shall be allowed for every purchase
payment due after the first.
Paid-up value -- If any purchase payment of this contract is not paid within the
grace period,
Page 6
the contract shall be considered paid-up. The paid-up value is the total cash
value of the contract.
Reinstatement -- If the purchase payment has not been paid within the grace
period and the contract has not been surrendered or cancelled, it may be
reinstated during the lifetime of the Annuitant and before the contract Maturity
Date by the resumption of payments.
Contract cancellation -- We reserve the right to cancel this contract if:
1. you have not made any purchase payments for two years; and
2. the total cash value of the contract is less than that needed to
purchase a $20 monthly income payment at maturity.
We will send you a notice of our intent to cancel. You have 31 days after we
mail the notice to your last known address to make a purchase payment. If we
cancel it, we will pay you the total cash value of the contract. Thereafter, we
will be free of any contract liability.
Section 7. Death benefit
Payment at Annuitant's death -- A lump sum payment shall be paid if the
Annuitant's death occurs prior to the Maturity Date and the contract has not
been surrendered for its total cash value or a settlement option has not been
elected. The beneficiary may elect a settlement option in place of the lump sum
payment.
Proof of the Annuitant's death must be sent to our Home Office. As of the date
we receive such proof, we will pay the beneficiary the greater of:
1. the total cash value of the contract, less any applicable premium tax;
or
2. the sum of all purchase payments paid under this contract less any
partial withdrawals.
Section 8. The Fixed Account
Allocation and credits to Fixed Account -- The Fixed Account will receive the
net payments allocated to it, guaranteed interest, excess interest and dollar
amounts transferred from the Variable Account.
On the date we receive your purchase payment for the Fixed Account, the net
payment will be allocated to this account. As of the date we receive your
request to transfer an amount from the Variable Account, such amount will be
deposited to the Fixed Account.
All purchase payments must be received at the Home Office.
Guaranteed interest rate -- Prior to the Maturity Date, guaranteed interest will
be credited to the Fixed Account. The guaranteed interest rate is shown on the
Contract Data page. This interest will be credited from:
1. the date the purchase payment is received by us; or
2. the date a dollar amount is transferred from the Variable Account.
Excess interest rate -- We may pay interest in excess of the guaranteed amount.
This excess interest will be credited on a daily basis to the Fixed Account. Any
excess interest paid, as determined by us, will be applied on an equitable basis
and credited to this class of contracts. The excess interest will be over and
above the guaranteed interest applied to this class of contracts.
Renewal of Fixed Account -- The Fixed Account will be automatically renewed on
its Renewal Date. The new Renewal Date will be set for a period equal to the
initial renewal period. You may choose a different Renewal Date if allowed by
us.
If you choose, you may withdraw the fixed cash value of the account without
charge or penalty on the Renewal Date.
We will send you a notice 90 days prior to the Renewal Date. This notice will
explain your renewal rights. If you want a different Renewal Date or choose to
withdraw the fixed cash value, your request must be received at least 30 days
prior to the Renewal Date. If we do not receive a request, we will automatically
renew your Fixed Account. Upon each renewal, a new Contract Data page will be
sent to you.
The guaranteed interest rate and the guaranteed settlement option factors are
established on the Contract Date. These rates will never be changed.
Transfers -- You may transfer money from the Fixed Account to various divisions
of the Variable Account. Any 1 transfer must be for an amount not less than
$1,000.
Page 7
A partial transfer may not be made if such transfer would reduce the Fixed
Account's cash value to less than $600. Transfers must be made at least 30 days
prior to the Maturity Date.
The early withdrawal penalty will be charged when transfers are made at any time
other than on the Renewal Date.
Your request to make a transfer must be sent to the Home Office. An approved
transfer will be made as of the date we receive your request.
Fixed Account cash withdrawal and surrender privilege -- You may at any time
during the Annuitant's lifetime and prior to the Maturity Date, elect to
withdraw part or surrender all of the fixed cash value. Any 1 withdrawal must be
for an amount not less than $200. We will deduct the surrender charges and early
withdrawal penalties, if any, from the fixed cash value. The amount due will be
sent to you.
We will figure the fixed cash value of your account as of the date we receive
your written request. The written request must be on a form satisfactory to us.
The request must be sent to the Home Office. The payment is usually paid within
30 days. However, we reserve the right to postpone payment for not more than 6
months from the date your request was received by us. If payment is deferred
after the 30 days, we will continue to credit current interest, if any.
Surrender charge -- The surrender charge during the first 5 years is a portion
of the fixed cash value kept by us if you make a cash withdrawal from or
surrender your Fixed Account. The rate varies by contract year as shown on the
Contract Data page.
There is no surrender charge after the fifth contract year.
Early withdrawal penalty -- The early withdrawal penalty is a portion of the
fixed cash value kept by us if you make a partial withdrawal, make a transfer to
the Variable Account or surrender this contract for its total cash value. There
will be no early withdrawal penalty for cash withdrawals, transfers or
surrenders on the Renewal Date.
The early withdrawal penalty is established on the Contract Date. This fee will
not be changed throughout the lifetime of the contract prior to the Maturity
Date.
Waiver of charges and penalties -- No surrender charge or early withdrawal
penalty will be made on a partial withdrawal from the Fixed Account or a
transfer to the Variable Account if all the following occur:
1. it is made after the contract has been in force 2 years;
2. it is more than 12 months since the last transfer or withdrawal was
made; and
3. the amount is not more than 15 percent of the then current fixed cash
value.
No surrender charge or early withdrawal penalty will be made:
1. on any fixed cash value applied to the payment of either settlement
Options 1, 2, 6 or 7; or
2. on or after the Maturity Date if the contract has been in force for at
least 10 years; or
3. if annuity income payments are selected to be made in equal
installments over a period of at least 5 years; during such period the
elected annuity benefit cannot be surrendered; or
4. if an Annuitant is disabled continuously for 3 months and satisfactory
proof of such disability is sent to the Home Office.
Guaranteed return of payments -- We guarantee the return of the purchase payment
credited to the Fixed Account or the surrender value of the Fixed Account,
whichever is greater, upon surrender of this contract if:
1. the contract has been in force more than 2 years; and
2. no cash withdrawals or transfers to the Variable Account have been
made from the Fixed Account.
Section 9. The Variable Account
Allocations to Variable Account -- The Variable Account will receive the net
payments allocated to it and dollar amounts transferred from the Fixed Account.
We will allocate these amounts, as you instruct, to the division(s) of our
Separate Account. These are processed as of the date we receive your payment or
the transfer request at the Home Office.
Each division invests in shares of the mutual fund which corresponds to that
division. Your net payments purchase Separate Account units at their current
value.
All dividends and other distributions paid by a mutual fund to a division shall
be used to purchase additional shares of the mutual fund which corresponds to
that division. Any expenses or fees due shall be deducted before such payment.
The number of Variable Account units will be increased accordingly. The value of
each division's Separate Account unit varies relative to the
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underlying mutual fund unit value.
If shares of a mutual fund are no longer available for investment by the
Separate Account or if we determine further investments in a mutual fund are
inappropriate in view of the objectives of the contract issued, we may
substitute shares of another mutual fund for fund shares already purchased and
apply your future purchase payments to the purchase of shares of the substitute
mutual fund or other securities. No substitutions will be made until prior
approval has been received from the Securities and Exchange Commission and we
receive prior favorable vote of a majority of the votes entitled to be cast by
persons having a voting interest in the mutual fund shares.
Transfers -- You may transfer money from the Variable Account to the Fixed
Account or between the various divisions of the Variable Account. The minimum
amount which may be transferred from 1 division to another or from an individual
division to the Fixed Account is $1,000 or the entire dollar value of such
divisions, whichever is less. No partial transfers may be made which would
reduce your interest in a division to less than $600. Transfers must be made at
least 30 days prior to the Maturity Date.
Transfers may be made as often as you choose; however, no transfers between
divisions are allowed after annuity income payments commence. A fee will be
charged to cover the administrative cost of any transfer made. This fee is shown
on the Contract Data page and cannot be changed.
Variable Account cash withdrawal and surrender privilege -- You may at any time
during the Annuitant's lifetime and prior to the Maturity Date, elect to
withdraw part or surrender all of the variable cash value of this contract.
We will deduct the surrender charges, if any, from the amount being surrendered
or withdrawn. Any 1 withdrawal from an individual division must be for an amount
not less than $200. We will not allow a withdrawal which would reduce the
individual division's dollar value to less than $600; however, the cash value of
your account in the division may be withdrawn at any time. We will not allow
more than 2 withdrawals from the Variable Account during a contract year.
We will figure the variable cash value as of the date your written request was
received by us. The amount of the payment due will be sent to you within 7 days
after the date such value was figured. The written request must be on a form
satisfactory to us. The request must be sent to the Home Office.
Surrender charge -- The surrender charge is a portion of the variable cash value
kept by us if you make a cash withdrawal from or surrender your Variable
Account. The rate varies by contract year as shown on the Contract Data page.
Maximum surrender charge -- In no case will the surrender charge applied to the
variable cash value be greater than 9 percent of the purchase payments
attributable to the amount surrendered from the Variable Account.
Annual mortality risk, expense risk and distribution expense risk fee -- To
cover the mortality risk, expense risk and distribution expense risk fee not
included in the annual maintenance fees, we will charge your Variable Account a
weekly fee of an amount equivalent to 1.35 percent per year. Further details of
this fee are in the prospectus.
Voting rights -- We will vote shares held in the Separate Account according to
your instructions.
We will send the notices and instructions to the person having voting rights
under this contract. Votes for which we do not receive instructions will be cast
by us in the same proportion as the votes for which instructions have been
received.
Xxxxxx of surrender charge -- No surrender charge will be made on a partial
withdrawal from the Variable Account if all the following occur:
1. it is made after the contract has been in force 2 years;
2. it is more than 12 months since the last withdrawal was made; and
3. the amount is not more than 15 percent of the then current variable
cash value.
No surrender charge will be made:
1. on any variable cash value applied to the payment of either settlement
Options 1, 2, 6 or 7; or
2. if an Annuitant is disabled continuously for 3 months and satisfactory
proof of such disability is sent to the Home Office.
Section 10. Settlement option provisions
Page 9
Application of proceeds -- On the Maturity Date or the date we receive proof of
the Annuitant's death at the Home Office, the proceeds payable under this
contract shall be applied to the payment of the settlement option elected. The
amount of proceeds equals the total cash value plus the purchase price of any
additional annuity benefits.
If the amount of proceeds to be applied under any 1 fixed or variable annuity
settlement option is less than $2,000 or would provide less than a $20 monthly
annuity income payment, the proceeds will be paid in a lump sum to the payee.
Prior to the payment of any settlement option selected, we reserve the right to
verify the age of the payee and to make any adjustments necessary to reflect the
accurate payment for the proper age.
Option to purchase additional annuity benefits at maturity -- You may purchase
an additional annuity benefit at the Maturity Date. To do so you must send a
written request to the Home Office. This request along with a payment for the
benefit must be received by us 30 days prior to the Maturity Date. We may limit
the amount of the additional benefit being purchased. The premium tax, if any,
will be deducted from this single payment.
Election of option -- Your election of a settlement option must be made by
written request. The written request must be sent to the Home Office. At least
30 days prior to the Maturity Date you may elect a settlement option or change a
previous election. If upon the death of an Annuitant prior to the Maturity Date
no election has been made, the beneficiary may elect a settlement option. This
election must be made within 60 days after the Annuitant's death notice has been
received by us. The payee will not have the right to assign or transfer any
settlement option elected.
Absence of election -- If no valid election has been made, the proceeds, if any,
will be paid as follows:
1. proceeds from the Fixed Account will be paid under a fixed settlement
option in the form of a life income with 10 year period certain. See
Option 1 for details; and
2. proceeds from the Variable Account will be paid under a variable
settlement option in the form of a life income with 10 year period
certain. See Option 6 for details.
Supplemental contract -- This contract, together with any document showing proof
of a previous election of an option, must be surrendered at the time proceeds
become payable. We will issue supplemental contracts providing for the
settlement options chosen. They will be issued as of the date of the settlement.
Unless otherwise provided in the supplemental contract, the first annuity income
payment under each fixed option (Options 1,2,3,4 and 5) and each variable option
(Options 6 and 7) shall be made on the first day of the month coincident with or
next succeeding the date that proceeds are applied. Subsequent annuity income
payments will be made as of the first day of each succeeding month unless
another mode of payment is selected and has been approved by us.
If the original payee dies, unless otherwise provided in the supplemental
contract, the beneficiary of such payee will be paid:
1. under Options 1 and 6, the rest of the annuity income payments during
the period certain, if any; or
2. under Options 3 and 4, the rest of the annuity income payments due, if
any; or
3. under Option 5, the proceeds due, if any.
If no beneficiary is living at the time of the payee's death, the commuted
value, if any, of the remaining annuity income payments or proceeds will be paid
in a lump sum to the estate of such payee. If the payee dies and the
supplemental contract does not provide for continued payments, the contract(s)
will terminate.
Under the supplemental contract, the commuted value of any option will be
figured at the interest rate used to determine the annuity payment. In no case
will annuity income payments under Options 1, 2, 6 and 7 be commuted during the
lifetime of the original payees.
Unless you elect otherwise, the payee will have the right to terminate the
supplemental contract. In this case the payee will receive the commuted value in
1 lump sum.
Variable annuity payments -- The dollar amount of the first monthly payment to
be made under a variable annuity option will be determined by applying the
amount of the proceeds to the appropriate factor in the settlement option
tables, or if more favorable to the payee, by such factor as may be shown in a
corresponding table in a variable annuity contract issued by us as of the date
the proceeds are applied.
The number of annuity units is determined by dividing the amount of the first
monthly payment by the current value of a variable retirement account unit in
the appropriate division on the valuation date coincident with the date that
proceeds were applied toward the variable annuity option. The
Page 10
second and each following payment under this option will be based on the
experience of the underlying mutual fund.
Fixed annuity settlement options --
Option 1. Fixed life income with or without period certain -- We will pay an
income based on the adjusted age of the payee for the period certain elected;
thereafter, we will pay income for the remaining lifetime of the payee. The
period certain may be 10, 15, or 20 years. If no period certain is requested, we
will pay an income during the lifetime of the payee. See Table 1 on page 16.
Option 2. Joint life and survivor annuity -- We will pay an income for as long
as either or both payees live. The income will be based on the adjusted ages of
the 2 payees. Upon the death of 1 payee, the amount payable will be two-thirds
of the amount paid while both were living. Income payments will cease following
the death of the surviving payee. See Table 2 on page 17.
Option 3. Income for a fixed period -- We will pay an income for a specified
number of years, 1 through 30 years. But, income payments cannot extend beyond
the 90th birthday of the payee. The payments will be made in equal installments.
See Table 3 on page 18.
Option 4. Income for a fixed amount -- We will pay an income of a specified
amount until the proceeds and interest at the rate of 4 percent per year are all
paid out to the payee. The income payments cannot extend beyond the 90th
birthday of the payee.
Option 5. Interest income payments -- We will hold the proceeds and pay interest
on such proceeds at a rate determined by us. The interest rate will never be
less than 4 percent per year. Interest will be credited at the end of each
payment period as agreed upon. The payee may elect another Option at the end of
any payment period. The payee may withdraw the proceeds in whole or in part upon
written request. The request must be made prior to the end of the agreed period.
This period must end before the 80th birthday of the payee.
Variable annuity settlement options --
Option 6. Variable life income with or without period certain -- We will pay a
variable income based on the adjusted age of the payee for the period certain
elected; thereafter, we will pay the variable income for the remaining lifetime
of the payee. The period certain may be 10, 15 or 20 years. If no period certain
is requested, we will pay a variable income during the lifetime of the payee.
See Table 1 on page 16 for the initial payment. Subsequent payments will be
based on the experience of the underlying mutual fund.
Option 7. Variable income for joint life and survivor annuity -- We will pay a
variable income for as long as either or both payees live. The variable income
will be based on the adjusted ages of the 2 payees. See Table 2 on the page 17
for the initial payment. Subsequent payments will be based on the experience of
the underlying mutual fund.
Upon the death of 1 payee, future payments will be reduced by one-third. The
variable income payments will cease following the death of the surviving payee.
Other annuity options -- Upon your request, other fixed and variable annuity
options may be made available by us.
Basis of settlement option tables -- These tables show the dollar amount of
monthly annuity income payments for the payee's adjusted age as follows:
1. the annuity income payment for each $1,000 of proceeds applied under a
fixed income option; and
2. the first annuity income payment for each $1,000 proceeds applied
under a variable annuity option.
The adjusted age is determined from each payee's actual age last birthday at the
time the first annuity income payment is due in the following manner:
Calendar Year
of Xxxxx's Birth Adjusted Age
Before 1905 Actual age plus 1
1905 through 1919 Actual age
1920 through 1934 Actual age minus 1
1935 through 1949 Actual age minus 2
1950 through 1964 Actual age minus 3
After 1964 Actual age minus 4
The amount of each fixed income payment under Options 1, 2 and 3 will never be
less than that shown in the settlement option tables. The guaranteed interest
rate used for all fixed annuity settlement options is 4 percent per year. Where
mortality assumptions are involved, the guaranteed factors are based on the 1971
Individual Annuity Mortality Table. The fixed income
Page 11
payments under these Options may be increased as determined by us on an
equitable basis to this class of contracts.
An assumed investment rate of 4 percent per year will be used to calculate
commuted values under Options 6 and 7 and the first variable annuity income
payment of either option. Where mortality assumptions are involved, the
guaranteed factors are based on the 1971 Individual Annuity Mortality Table.
Page 12
Settlement option tables
Table 1
Income payments for life with or without a period certain
Equal monthly income payments for each $1,000 of proceeds under Options 1 and 6
Adjusted Period certain Adjusted Period certain
age of --------------------------------------- age of --------------------------------------
payee Life 10 yrs 15 yrs 20 yrs payee Life 10 yrs 15 yrs 20 yrs
-----------------------------------------------------------------------------------------------------------------
55 5.09 5.03 4.95 4.84 68 6.96 6.62 6.21 5.69
56 5.19 5.11 5.02 4.90 69 7.20 6.80 6.32 5.74
57 5.29 5.20 5.10 4.97 70 7.46 6.98 6.43 5.78
58 5.39 5.30 5.19 5.03 71 7.74 7.18 6.54
59 5.50 5.40 5.28 5.10 72 8.05 7.37 6.64
60 5.62 5.51 5.37 5.17 73 8.39 7.58 6.74
61 5.75 5.62 5.46 5.24 74 8.75 7.78 6.83
62 5.88 5.74 5.56 5.31 75 9.15 7.99 6.91
63 6.03 5.86 5.66 5.38 76 9.59 8.20
64 6.19 6.00 5.77 5.44 77 10.06 8.40
65 6.36 6.14 5.87 5.51 78 10.58 8.59
66 6.54 6.29 5.98 5.57 79 11.15 8.78
67 6.74 6.45 6.10 5.63 80 11.77 8.96
-----------------------------------------------------------------------------------------------------------------
The age shown is the adjusted age of the payee when income payments begin. If
the fixed annuity income payments under Option 1 are to be paid other than
monthly, multiply the monthly income payment by 2.990 to obtain the quarterly
payment; multiply by 5.951 to obtain the semiannual payment; and multiply by
11.787 to obtain the annual payment.
Page 13
Table 2
Income payments during joint lifetimes of 2 payees with two-thirds to survivor
Initial amount of monthly income payments for each $1,000 of proceeds under
Options 2 and 7
Adjusted ages Monthly income payments
------------------------------------------------------------------------------------------------------------
Payee age 55 56 57 58 59 60 61 62 63 64 65
------------------------------------------------------------------------------------------------------------
Payee age 60 5.31 5.37 5.42 5.48 5.53 5.59 5.65 5.71 5.78 5.84 5.91
------------------------------------------------------------------------------------------------------------
Monthly income payments
------------------------------------------------------------------------------------------------------------
Payee age 60 61 62 63 64 65 66 67 68 69 70
------------------------------------------------------------------------------------------------------------
Payee age 65 5.91 5.98 6.06 6.13 6.21 6.29 6.38 6.47 6.56 6.65 6.74
------------------------------------------------------------------------------------------------------------
Monthly income payments
------------------------------------------------------------------------------------------------------------
Payee age 65 66 67 68 69 70 71 72 73 74 75
------------------------------------------------------------------------------------------------------------
Payee age 70 6.74 6.85 6.96 7.07 7.19 7.31 7.44 7.57 7.70 7.83 7.96
------------------------------------------------------------------------------------------------------------
The ages shown are the adjusted ages of the payees when income payments begin.
Amounts for combinations of ages not shown will be furnished upon request. If
the fixed annuity income payments under Option 2 are to be paid other than
monthly, multiply the monthly income payment by 2.990 to obtain the quarterly
payment; multiply by 5.951 to obtain the semiannual payment; and multiply by
11.787 to obtain the annual payment.
Page 14
Table 3
Income payments for a fixed period
Equal monthly income payments for each $1,000 of proceeds under Option 3
------------------------------------------------------------------------------------------
Number of Monthly Number of Monthly Number of Monthly
years in income years in income years in income
fixed period payment fixed period payment fixed period payment
------------------------------------------------------------------------------------------
1 84.84 11 9.31 21 5.81
2 43.25 12 8.69 22 5.64
3 29.40 13 8.17 23 5.49
4 22.47 14 7.72 24 5.35
5 18.32 15 7.34 25 5.22
6 15.56 16 7.00 26 5.10
7 13.59 17 6.71 27 5.00
8 12.12 18 6.44 28 4.90
9 10.97 19 6.21 29 4.80
10 10.06 20 6.00 30 4.72
------------------------------------------------------------------------------------------
If income payments under Option 3 are to be paid other than monthly, multiply
the monthly income payment by 2.990 to obtain the quarterly payment; multiply by
5.951 to obtain the semiannual payment; and multiply by 11.787 to obtain the
annual payment.
Page 15
Home Office: 0 Xxxxxx Xxxx Xxxxx
Xxxxxxxxxxx, Xxxxxxxx 00000-0001
0-000-000-0000
Certificate For Group Deferred Fixed And Variable
Retirement Annuity Contract
Flexible purchase payments
Nonparticipating -- dividends not paid.
All payments and values under this certificate which are based on investment
results of the Separate Account are variable and not guaranteed as to fixed
dollar amount.
We agree to provide the benefits and other rights described in this certificate
in accordance with the terms of the certificate.
Signed for the Company at Springfield, Illinois as of the Certificate Date.
President Countersigned Corporate Secretary
Right to examine certificate for 15 days -- It is important to us that you are
satisfied with this certificate. We hope that it meets the retirement goals for
which you planned. If you are not satisfied, you may return the certificate to
us or the agent from whom you purchased it, within 15 days after it is delivered
to you, and receive a full refund of any purchase payments paid to the Fixed
Account and/or the market value of the assets, less taxes if any, purchased by
payments paid to the Variable Account. Upon return of the certificate, it shall
be void as if no certificate has been issued.
IC-410000
This certificate is evidence of an annuity provided by the group contract issued
to the Contract Holder.
Read this certificate carefully
This certificate describes certain provisions and benefits determined by the
group contract. This is not part of the group contract. Only the actual group
contract provisions will control. The group contract sets forth, in detail, the
rights and obligations of you, the Contract Holder and the insurance company.
A copy of the group contract is held on file by the Contract Xxxxxx and Xxxxxx
Xxxx Life Insurance Company. It is important that you read your certificate
carefully. If you have any questions, you may contact us or the Contract Holder
with reference to the group contract.
The group deferred flexible premium fixed and variable retirement annuity
contract provides for retirement income. The Fixed Account of this certificate
issued under it may be renewed on each Renewal Date for another period of time
up to the Maturity Date. The purchase payments, guaranteed interest rate,
surrender charge rate, annual maintenance fees, early withdrawal penalty rate,
transfer fee, annual mortality risk fee, expense risk fee and distribution
expense risk fee for this certificate are shown on the Certificate Data pages.
Table of contents Page
Face page
Section 1. Certificate Data.......................................................................... 2
Section 2. Fixed Account.............................................................................. 2
Section 3. Definitions of certain terms............................................................... 4
Section 4. General provisions......................................................................... 6
Section 5. Ownership and beneficiary provisions....................................................... 8
Section 6. Payments to the Company.................................................................... 8
Section 7. Death benefit.............................................................................. 9
Section 8. The Fixed Account.......................................................................... 9
Section 9. The Variable Account....................................................................... 11
Section 10. Settlement option provisions.............................................................. 13
Settlement option tables.............................................................................. 17
Additional benefit provisions or restrictions, if any, and a copy of the
application follow page 19.
Home Office: 0 Xxxxxx Xxxx Xxxxx
Xxxxxxxxxxx, Xxxxxxxx 00000-0001
0-000-000-0000
Certificate For Group Deferred Fixed And Variable
Retirement Annuity Contract
Flexible purchase payments
Nonparticipating -- dividends not paid.
All payments and values under this certificate which are based on investment
results of the Separate Account are variable and not guaranteed as to fixed
dollar amount.
SECTION 1 -- CERTIFICATE DATA
Certificate number: XXXXXXXXXX
Annuitant: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
Certificate Date: XXXXXXXXXX
Maturity Date: XXXXXXXXXX
Renewal Date: XXXXXXXXXX
Age at issue: XX
Sex: XXXXXX
Owner and beneficiary: As stated in the application unless changed.
Annuity payments: Annuity payments will commence on the Maturity Date if
the annuitant is then living. These income payments
are determined by applying the total cash value of the
certificate in accordance with the certificate
provisions. The factors in sections 10 are guaranteed
through the Maturity Date.
Purchase payment(s): $Z,ZZZ,ZZZ.99 per year, payable in ZZ
installment(s), to be allocated as follows:
Fixed Account: ZZ9.99%
Variable Account:
HM Balanced fund ZZ9.99%
HM Income fund ZZ9.99%
XX Xxxxx-term investment fund ZZ9.99%
HM Growth fund ZZ9.99%
HM Socially responsible fund ZZ9.99%
HM International equity fund ZZ9.99%
HM Small cap growth fund ZZ9.99%
Total ZZ9.99%
The certificate's minimum annual purchase payment(s) must equal $225. The
minimum annual purchase payment(s) allocated to the Fixed Account or to each
mutual fund in the Variable Account must equal $225. Purchase payment(s)
received prior to the Maturity Date cannot exceed $500,000. See application for
details of additional money allocations, if any.
Guaranteed interest rate:
Fixed Account: 4.5% per year prior to the Maturity Date.
Page 2
Variable Account: none.
Surrender charge rates: Fixed Account and Variable Account
During certificate year % charged
1 8%
2 8%
3 6%
4 4%
5 2%
thereafter -0-
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
Page 2
SECTION 1 (CONTINUED) -- CERTIFICATE DATA
Certificate number: XXXXXXXXX
Annuitant: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
Annual maintenance fees
$25 per year: plus
Fixed Account: $5 if money is in this account.
Variable Account: $5 for each division in which there is money.
Early withdrawal penalty rate
Fixed Account: 5% if a dollar amount is withdrawn or transferred or
the certificate is surrendered on any date other that
the Renewal Date.
Variable Account: none.
Transfer fee
Fixed Account: none.
Variable Account: $5 will be charged for each transfer made from a
division of the Variable Account.
Annual mortality risk, expense risk and distribution expense risk fee
Fixed Account: none.
Variable Account: 1.35% per year.
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
Page 3A
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
Page 4A
SECTION 2 -- FIXED ACCOUNT'S TABLE OF GUARANTEED MONTHLY INCOME AT MATURITY AND
MINIMUM CASH AND SURRENDER VALUES*
Certificate number: XXXXXXXXXX
Annuitant: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
Certificate Minimum Minimum Guaranteed
Anniversary Attained Guaranteed Guaranteed Monthly Income
Date Age Cash Value Surrender Value at Maturity
XX XX $XX,XXX,XXX.XX $XX,XXX,XXX.XX $XX,XXX,XXX.XX
XX XX XX,XXX,XXX.XX XX,XXX,XXX.XX XX,XXX,XXX.XX
XX XX XX,XXX,XXX.XX XX,XXX,XXX.XX XX,XXX,XXX.XX
XX XX XX,XXX,XXX.XX XX,XXX,XXX.XX XX,XXX,XXX.XX
XX XX XX,XXX,XXX.XX XX,XXX,XXX.XX XX,XXX,XXX.XX
XX XX XX,XXX,XXX.XX XX,XXX,XXX.XX XX,XXX,XXX.XX
XX XX XX,XXX,XXX.XX XX,XXX,XXX.XX XX,XXX,XXX.XX
XX XX XX,XXX,XXX.XX XX,XXX,XXX.XX XX,XXX,XXX.XX
XX XX XX,XXX,XXX.XX XX,XXX,XXX.XX XX,XXX,XXX.XX
XX XX XX,XXX,XXX.XX XX,XXX,XXX.XX XX,XXX,XXX.XX
XX XX XX,XXX,XXX.XX XX,XXX,XXX.XX XX,XXX,XXX.XX
XX XX XX,XXX,XXX.XX XX,XXX,XXX.XX XX,XXX,XXX.XX
XX XX XX,XXX,XXX.XX XX,XXX,XXX.XX XX,XXX,XXX.XX
XX XX XX,XXX,XXX.XX XX,XXX,XXX.XX XX,XXX,XXX.XX
XX XX XX,XXX,XXX.XX XX,XXX,XXX.XX XX,XXX,XXX.XX
XX XX XX,XXX,XXX.XX XX,XXX,XXX.XX XX,XXX,XXX.XX
XX XX XX,XXX,XXX.XX XX,XXX,XXX.XX XX,XXX,XXX.XX
XX XX XX,XXX,XXX.XX XX,XXX,XXX.XX XX,XXX,XXX.XX
XX XX XX,XXX,XXX.XX XX,XXX,XXX.XX XX,XXX,XXX.XX
XX XX XX,XXX,XXX.XX XX,XXX,XXX.XX XX,XXX,XXX.XX
XX XX XX,XXX,XXX.XX XX,XXX,XXX.XX XX,XXX,XXX.XX
XX XX XX,XXX,XXX.XX XX,XXX,XXX.XX XX,XXX,XXX.XX
XX XX XX,XXX,XXX.XX XX,XXX,XXX.XX XX,XXX,XXX.XX
* XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXX
Page 3
Section 3. Definitions of certain terms
"Age at issue" is the Annuitant's age last birthday on the Certificate Date.
"Annual maintenance fees" are fees for administrative expenses deducted annually
from the total cash value. These fees are shown on the Certificate Data page.
"Annuitant" means an eligible Annuitant as set out in the group contract.
"Annuity income payment" is an income payment made by us to the payee.
"Beneficiary" is the person to whom any benefits will be paid in the event of
the death of the Annuitant prior to the Maturity Date.
"Certificate" is this form describing the benefits and certain provisions
determined by the group contract.
"Certificate anniversary" is the same day and month as the Certificate Date for
each succeeding year of this certificate.
"Certificate Date" is the effective date of this certificate. It is the date
from which purchase payment due dates, certificate years, certificate Renewal
Dates and certificate anniversaries are determined.
"Commuted value" is a lump sum payment made in lieu of periodic future income
payments.
"Company," "we," "us" and "our" refer only to the Xxxxxx Xxxx Life Insurance
Company.
"Contract Holder" means the named group in the master application owning the
group contract.
"Current interest rate" is the total rate of interest that we will credit to the
Fixed Account.
"Division" is a subcategory of the Separate Account in which money is invested
in shares of the mutual fund which corresponds to that division. Each division
may receive payments from an Annuitant's Variable Account. There is a division
for each mutual fund shown on the Certificate Data page.
"Early withdrawal penalty" is an amount charged when a withdrawal, transfer or
surrender is made from the Fixed Account at any time other than on the Renewal
Date.
"Excess interest rate" is the current interest rate less the guaranteed interest
rate.
"Fixed Account" represents the net payments and interest earned thereon
allocated to our general account and invested along with other insurance funds
in this general account.
"Fixed cash value" refers to the dollar value of the Fixed Account prior to the
Maturity Date. See Section 8 for details.
"Group contract" is the master contract explaining all rights and benefits
provided for the Annuitants. A copy of it is held on file by the Contract Holder
and us.
"Guaranteed interest rate" is the minimum interest to be credited to the Fixed
Account.
"Home Office" means our executive office at 0 Xxxxxx Xxxx Xxxxx, Xxxxxxxxxxx,
Xxxxxxxx.
"Maturity Date" is the date you selected for the payee to begin receiving
annuity income payments. It is shown on the Certificate Data page.
"Mutual funds" are open-end diversified management investment companies which
are registered under the Investment Company Act of 1940, as amended. These
companies are shown on the Certificate Data page. Each mutual fund has a
specific investment objective as stated in its prospectus. The prospectus should
be read for complete details.
"Net payment" means the purchase payment less any applicable premium tax on the
payment received.
"Owner" (referred to in this certificate as "you" and "your") is the Annuitant
unless otherwise stated in the application.
"Payee" is any person entitled to receive income payments under any settlement
option benefit.
"Payee's actual age" means the payee's age last birthday when the first annuity
income payment is due.
"Purchase payment" means a dollar amount paid to us in return for the benefits
described in this certificate.
"Renewal Date" is the date from which the Fixed Account may be renewed for
another period of time.
"Renewal period" is the period of time from the Certificate Date to the Renewal
Date of the Fixed Account. If the Fixed Account has been renewed, it is the
period to the next Renewal Date.
"Separate Account" is the segregated asset account which was established by us
to receive and invest net payments allocated to Annuitants' Variable Accounts.
It has individual divisions which correspond to various mutual funds.
"Settlement option" is the method by which annuity income payments are made to
the payee at the Maturity Date or the Annuitant's death. See settlement option
tables for guaranteed rates.
"Surrender charge" is an amount charged during the first 5 years if a withdrawal
is made or the certificate is surrendered for its total cash value. The rate
varies by certificate year as shown on the Certificate Data page.
"Surrender value" is the total cash value less applicable surrender charges and
early withdrawal penalties, if any.
"Supplemental contract" is a form stating the terms of the settlement under an
option elected.
"Total cash value" is an amount equal to the sum of the fixed cash value and the
variable cash value prior to the Maturity Date.
"Valuation date" is a date upon which the net value of each share of the mutual
fund(s) is determined. It will be on any day which the New York Stock Exchange
is open for trading.
"Valuation period" is the time from the end of one business day on the New York
Stock Exchange to the end of the next business day.
"Variable cash value" refers to the dollar value of the Variable Account prior
to the Maturity Date. See Section 9 for details.
"Variable Account" is your portion of the Separate Account set up to receive the
net payments and other cash distributions allocated to it. Money in this account
is invested along with other Variable Account money in our Separate Account.
Section 4. General provisions
Entire contract -- The contract is between us, the Contract Holder and each
Annuitant. It consists of:
1. the group contract;
2. the master application; and
3. the application for the certificate.
The certificate is issued in consideration of your application and receipt of
the purchase payments.
Your application is attached to and made a part of this certificate.
All statements made in your application in the absence of fraud will be treated
as representations and not as warranties. If we challenge a claim or attempt
to void this certificate, we agree not to use any statement in defense of a
claim unless contained in a written statement. A copy of such statement must
be attached to this certificate when issued.
Change of contract provisions -- We have the right to change the provisions of
the group contract or the certificates issued under it in certain cases. We
will make any change necessary for continued compliance under any federal or
state laws that affect the group contract or the certificates issued under it.
We may also change the certificate with respect to any increase in purchase
payments over that shown on page 2.
This certificate shall include any provisions required by the state in which it
was issued. Any provision omitted from this certificate at date of issue will
be included as required by the state in which it was delivered.
No person other than our president, vice president, or the secretary can, on our
behalf, change or waive any condition or provision of this certificate. Such
change or waiver must be made in writing and signed by one of these officers
named.
Incontestability -- This certificate shall be incontestable after 1 year from
the Certificate Date.
Maturity Date -- The Maturity Date is the certificate anniversary following the
Annuitant's 65th birthday. You may choose a different date if agreed upon by
us. In no case can you choose a date later than the anniversary on or
following the Annuitant's 70th birthday or the 10th anniversary of this
certificate, whichever is later.
Change of Maturity Date -- You may change the Maturity Date. To do so, we must
receive your written request at least 90 days prior to the then current
Maturity Date. This change must be approved by us.
Assignment -- You may assign or transfer this certificate unless it is issued as
a part of a retirement plan qualified under the Internal Revenue Code which
will not allow any transfer or assignment. We will not be responsible for the
validity of any assignment. It must be filed in writing at our Home Office.
Until received, we will not be considered to have knowledge of it. When it is
filed your rights and those of any beneficiary will be subject to it.
Misstatement of age -- If the age of the Annuitant or any other payee has been
misstated, the annuity income payments under this certificate will be that
amount which the purchase payments would have provided at the correct age. We
will require proof of the correct age.
If the annuity income payments were too large because of a misstatement, we will
deduct the difference with interest from the benefits falling due until
totally repaid. If such payments were too small, we will add the difference
with interest to the next benefit due. The interest rate will not exceed 6
percent per year.
Proof of survival -- We may require proper proof that a payee, beneficiary, or
an Annuitant is living when payment depends upon such person's survival.
Periodic reports -- During each certificate year prior to the Maturity Date, we
will periodically send you reports which show your total
cash value, purchase payments and other certificate transactions.
At any time, you may request a statement of the certificate's total cash value.
Any other information or reports legally required will be sent to you. All
material will be sent to your last address known by us.
Annual maintenance fees -- The annual maintenance fees are deducted from the
total cash value of the certificate on its anniversary date. These fees will
not change and are shown on the Certificate Data page. Such fees cover the
general maintenance of the certificate as well as the additional cost for
maintenance of multiple accounts.
Nonparticipating -- This certificate is nonparticipating and does not
participate in the profits of the Company.
Minimum values -- All values and benefits for this certificate are not less than
the minimum required by the laws of the state in which it is delivered.
Premium tax -- Any premium tax deducted will be determined by the Annuitant's
place of residence.
Termination of contract -- The group contract under which this certificate is
issued may be terminated by the Contract Holder. To do so, the written request
must be received at the Home Office at least 90 days prior to the termination
date specified. We will not accept any purchase payments after the termination
date. Upon termination of the group contract, you will be eligible to purchase
an individual annuity contract.
Conversion to individual contract -- The Annuitant may purchase from us an
individual annuity contract if:
1. the group contract is terminated;
2. the Annuitant is no longer an eligible Annuitant; or
3. the Annuitant elects to stop making purchase payments to us.
The request to purchase the new annuity contract must be sent to the Home
Office. This request must be received at least 30 days prior to the requested
effective date of the new contract.
Section 5. Ownership and beneficiary provisions
Ownership -- The Owner is the Annuitant listed on the Certificate Data page
unless otherwise designated in the application. The Owner may be changed subject
to the Change of ownership or beneficiary provision. This certificate belongs to
you. Unless you provide otherwise, you may exercise all rights and privileges
granted by this certificate during the Annuitant's lifetime.
Beneficiary -- The beneficiary is named in the application; however, you may
change it. The change will be subject to the Change of ownership or beneficiary
provision.
For payment purposes, we will assume that the beneficiary's death occurred prior
to the Annuitant's death if the beneficiary:
1. dies before or on the same date as the Annuitant's death; or
2. dies within 15 days after the Annuitant's death.
Change of ownership or beneficiary -- You may change the Owner or beneficiary of
this certificate during the lifetime of the Annuitant unless:
1. you provide otherwise; or
2. the certificate is issued as part of a retirement plan qualified under the
Internal Revenue Code which will not allow any transfer or assignment.
Page 7
Changes must be requested in writing on a form satisfactory to us. The request
must be sent to our Home Office. We may require return of the certificate for an
endorsement. A change is valid only when it is received by us in our Home
Office; but, upon receipt it is effective as of the date that you signed the
written request. All changes are subject to any payments made or other action
taken by us before receipt of the written request.
Section 6. Payments to the Company
Purchase payments -- You may make purchase payments at any time up to 30 days
prior to the Maturity Date. These payments will be allocated to the Fixed
Account and/or Variable Account as elected in your application. All payments
must be sent to the Home Office.
You may change the allocation to these accounts no more than twice in any
certificate year. You may increase or decrease the payments. We will not allow
payments which do not comply with the minimums and maximum shown on the
Certificate Date page. Your request to make these changes must be sent to the
Home Office. An approved change will be made as of the date we receive your
request.
Grace period -- A grace period of 31 days shall be allowed for every purchase
payment due after the first.
Paid-up value -- If any purchase payment of this certificate is not paid within
the grace period, the certificate shall be considered paid-up. The paid-up value
is the total cash value of the certificate.
Reinstatement -- If the purchase payment has not been paid within the grace
period, this certificate may be reinstated during the lifetime of the Annuitant
and before its Maturity Date by the resumption of payments if:
1. this certificate has not been surrendered for its value; and
2. the group contract has not been terminated.
Certificate cancellation -- We reserve the right to cancel this certificate if:
1. you have not made any purchase payments for 2 years; and
2. the total cash value of this certificate is less than that needed to
purchase a $20 monthly income payment at maturity.
We will send you a notice of our intent to cancel. You will have 31 days after
we mail the notice to your last known address to make a purchase payment. If we
cancel it, we will pay you the total cash value of the certificate. Thereafter,
we will be free of any contract liability for this cancelled certificate.
Section 7. Death benefit
PAYMENT AT ANNUITANT'S DEATH: A lump sum payment shall be paid if the
Annuitant's death occurs prior to the maturity date and this certificate has not
been surrendered for its total cash value or a settlement option has not been
elected. The beneficiary may elect a settlement option in place of the lump sum
payment.
Proof of the Annuitant's death must be sent to our Home Office. As of the date
we receive such proof, we will pay the beneficiary the greater of:
1. the total cash value of this certificate, less any applicable premium tax;
or
2. the sum of all purchase payments paid under this certificate less any
partial withdrawals.
Section 8. The Fixed Account
Allocation and credits to Fixed Account -- The Fixed Account will receive the
net payments allocated to it, guaranteed interest, excess interest and dollar
amounts transferred from the Variable Account.
On the date we receive your purchase payment for the Fixed Account, the net
payment will be allocated to this account. As of the date we receive your
request to transfer an amount from the Variable Account, such amount will be
deposited to the Fixed Account.
All purchase payments must be received at the Home Office.
Guaranteed interest rate -- Prior to the Maturity Date, guaranteed interest will
be credited to the Fixed Account. The guaranteed interest rate is shown on the
Certificate Data page. This interest will be credited from:
1. the date the purchase payment is received by us; or
2. the date a dollar amount is transferred from the Variable Account.
Excess interest rate -- We may pay interest in excess of the guaranteed amount.
This excess interest will be credited on a daily basis to the Fixed Account. Any
excess interest paid, as determined by us, will be applied on an equitable basis
and credited to this class of certificates.
The excess interest will be over and above the guaranteed interest applied to
this class of certificates.
Renewal of Fixed Account -- The Fixed Account will be automatically renewed on
its Renewal Date. The new Renewal Date will be set for a period equal to the
initial renewal period. You may choose a different Renewal Date if allowed by
us.
If you choose, you may withdraw the fixed cash value of the Fixed Account
without charge or penalty on the Renewal Date.
We will send you a notice 90 days prior to the Renewal Date. This notice will
explain your renewal rights. If you want a different Renewal Date or choose to
withdraw the fixed cash value, your request must be received at least 30 days
prior to the Renewal Date. If we do not receive a request, we will automatically
renew your Fixed Account. Upon each renewal, a new Certificate Data page will be
sent to you.
The guaranteed interest rate and the guaranteed settlement option factors are
established on the Certificate Date. These rates will never be changed.
Transfers -- You may transfer money from the Fixed Account to various divisions
of the Variable Account. Any 1 transfer must be for an amount not less than
$1,000.
A partial transfer may not be made if such transfer would reduce the Fixed
Account's cash value to less than $600. Transfers must be made at least 30 days
prior to the Maturity Date.
The early withdrawal penalty will be charged when transfers are made at any time
other than on the Renewal Date.
Your request to make a transfer must be sent to the Home Office. An approved
transfer will be made as of the date we receive your request.
Fixed Account cash withdrawal and surrender privilege -- You may at any time
during the Annuitant's lifetime and prior to the Maturity Date, elect to
withdraw part or surrender
page 7
all of the fixed cash value. Any one withdrawal must be for an amount not less
than $200. We will deduct the surrender charges and early withdrawal penalties,
if any, from the fixed cash value. The amount due will be sent to you.
We will figure the fixed cash value of your account as of the date we receive
your written request. The written request must be on a form satisfactory to us.
The request must be sent to the Home Office. The payment is usually paid within
30 days. However, we reserve the right to postpone payment for not more than 6
months from the date your request was received by us. If payment is deferred
after the 30 days, we will continue to credit current interest, if any.
Surrender charge -- The surrender charge during the first 5 years is a portion
of the fixed cash value kept by us if you make a cash withdrawal from or
surrender the Fixed Account. The rate varies by certificate year as shown on the
Certificate Data page.
There is no surrender charge after the fifth certificate year.
Early withdrawal penalty -- The early withdrawal penalty is a portion of the
fixed cash value kept by us if you make a partial withdrawal, make a transfer to
the Variable Account or surrender this certificate for its total cash value.
There will be no early withdrawal penalty for cash withdrawals, transfers or
surrenders on any Renewal Date.
The early withdrawal penalty is established on the Certificate Date. This fee
will not be changed throughout the lifetime of the certificate prior to the
Maturity Date.
Waiver of charges and penalties -- No surrender charge or early withdrawal
penalty will be made on a partial withdrawal from the Fixed Account or a
transfer to the Variable Account if all the following occur:
1. it is made after the certificate has been in force 2 years;
2. it is more than 12 months since the last transfer or withdrawal was
made; and
3. the amount is not more than 15 percent of the then current fixed cash
value.
No surrender charge or early withdrawal penalty will be made:
1. on this certificate's fixed cash value applied to the payment of
either settlement Options 1, 2, 6 or 7; or
2. on or after the Maturity Date if this certificate has been in force
for at least 10 years; or
3. if annuity income payments are selected to be made in equal
installments over a period of at least 5 years; during such period the
elected annuity benefit cannot be surrendered; or
4. if an Annuitant is disabled continuously for 3 months and satisfactory
proof of such disability is sent to the Home Office.
Guaranteed return of payments -- We guarantee the return of the purchase
payments credited to the Fixed Account or the surrender value of the Fixed
Account, whichever is greater, upon surrender of this certificate if:
1. this certificate has been in force more than 2 years; and
2. no cash withdrawals or transfers to the Variable Account have been
made from the Fixed Account.
Section 9. The Variable Account
Allocations to Variable Account -- The Variable Account will receive the net
payments allocated to it and dollar amounts transferred from the Fixed Account.
We will allocate these amounts, as you instruct, to the division(s) of our
Separate Account. These are processed as of the date we receive your payment or
the transfer request at the Home Office.
Each division invests in shares of the mutual fund which corresponds to that
division. Your net payments purchases Separate Account units at their current
value.
All dividends and other distributions paid by a mutual fund to a division shall
be used to purchase additional shares of the mutual fund which corresponds to
that division. Any expenses or fees due shall be deducted before such payment.
The number of Variable Account units will be increased accordingly. The value of
each division's Separate Account unit varies relative to the underlying mutual
fund unit value.
If shares of a mutual fund are no longer available for investment by the
Separate Account or if we determine further investments in a mutual fund are
inappropriate in view of the objectives of the contract issued, we may
substitute shares of another mutual fund for fund shares already purchased and
apply your future purchase payments to the purchase of shares of the substitute
mutual fund or other securities. No substitutions will be made until prior
approval has been
Page 8
received from the Securities and Exchange Commission and we receive prior
favorable vote of a majority of the votes entitled to be cast by persons having
a voting interest in the mutual fund shares.
Transfers -- You may transfer money from the Variable Account to the Fixed
Account or between the various divisions of the Variable Account. The minimum
amount which may be transferred from 1 division to another or from an individual
division to the Fixed Account is $1,000 or the entire dollar value of such
division, whichever is less. No partial transfers may be made which would reduce
your interest in a division to less than $600. Transfers must be made at least
30 days prior to the Maturity Date.
Transfers may be made as often as you choose; however, no transfers between
divisions are allowed after annuity income payments commence.
A fee will be charged to cover the administrative cost of any transfer made.
This fee is shown on the Certificate Data page and cannot be changed.
Variable Account cash withdrawal and surrender privilege -- You may at any time
during the Annuitant's lifetime and prior to the Maturity Date, elect to
withdraw part or surrender all of the variable cash value of this certificate.
We will deduct the surrender charges, if any, from the amount being surrendered
or withdrawn. Any 1 withdrawal from an individual division must be for an amount
not less than $200. We will not allow a withdrawal which would reduce the
individual division's dollar value to less than $600; however, the cash value of
your account in the division may be withdrawn at any time. We will not allow
more than 2 withdrawals from the Variable Account during a certificate year.
We will figure the variable cash value as of the date your written request was
received by us. The amount of the payment due will be sent to you within 7 days
after the date such value was figured. The written request must be on a form
satisfactory to us. The request must be sent to the Home Office.
Surrender charge -- The surrender charge is a portion of the variable cash value
kept by us if you make a cash withdrawal from or surrender your Variable
Account. The rate varies by certificate year as shown on the Certificate Data
page.
Maximum surrender charge -- In no case will the surrender charge applied to the
variable cash value be greater than 9 percent of the purchase payments
attributable to the amount surrendered from the Variable Account.
Annual mortality risk, expense risk and distribution expense risk fee -- To
cover the mortality risk, expense risk and distribution expense risk fee not
included in the annual maintenance fees, we will charge your Variable Account a
weekly fee of an amount equivalent to 1.35 percent per year. Further details of
this fee are in the prospectus.
Voting rights -- We will vote shares held in the Separate Account according to
your instructions.
We will send the notices and instructions to the person having voting rights
under this certificate. Votes for which we do not receive instructions will be
cast by us in the same proportion as the votes for which instructions have been
received.
Xxxxxx of surrender charge -- No surrender charge will be made on a partial
withdrawal from the Variable Account if all the following occur:
1. it is made after this certificate has been in force 2 years;
2. it is more than 12 months since the last withdrawal was made; and
3. the amount is not more than 15 percent of the then current variable
cash value.
No surrender charge will be made:
1. on any variable cash value applied to the payment of either settlement
Options 1, 2, 6 or 7; or
2. if an Annuitant is disabled continuously for 3 months and satisfactory
proof of such disability is sent to the Home Office.
Section 10. Settlement option provisions
Application of proceeds -- On the Maturity Date or the date we receive proof of
the Annuitant's death at the Home Office, the proceeds payable under this
certificate shall be applied to the payment of the settlement option elected.
The amount of proceeds equals the total cash value plus the purchase price of
any additional annuity benefits.
If the amount of proceeds to be applied under any 1 fixed or variable annuity
settlement option is
Page 9
less than $2,000 or would provide less than a $20 monthly annuity income
payment, the proceeds will be paid in a lump sum to the payee.
Prior to the payment of any settlement option selected, we reserve the right to
verify the age of the payee and to make any adjustments necessary to reflect the
accurate payment for the proper age.
Option to purchase additional annuity benefits at maturity -- You may purchase
an additional annuity benefit at the Maturity Date. To do so you must send a
written request to the Home Office. This request along with a payment for the
benefit must be received by us 30 days prior to the Maturity Date. We may limit
the amount of the additional benefit being purchased. The premium tax, if any,
will be deducted from this single payment.
Election of option -- Your election of a settlement option must be made by
written request. The written request must be sent to the Home Office. At least
30 days prior to the Maturity Date, you may elect a settlement option or change
a previous election. If upon the death of an Annuitant prior to the Maturity
Date no election has been made, the beneficiary may elect a settlement option.
This election must be made within 60 days after the Annuitant's death notice has
been received by us. The payee will not have the right to assign or transfer any
settlement option elected.
Absence of election -- If no valid election has been made, the proceeds, if any,
will be paid as follows:
1. proceeds from the Fixed Account will be paid under a fixed settlement
option in the form of a life income with 10 year period certain. See
Option 1 for details; and
2. proceeds from the Variable Account will be paid under a variable
settlement option in the form of a life income with 10 year period
certain. See Option 6 for details.
Supplemental contract -- This certificate, together with any document showing
proof of a previous election of an option, must be surrendered at the time
proceeds become payable. We will issue supplemental contracts providing for the
settlement options chosen. They will be issued as of the date of the settlement.
Unless otherwise provided in the supplemental contract, the first annuity income
payment under each fixed option (Options 1, 2, 3, 4 and 5) and each variable
option (Options 6 and 7) shall be made on the first day of the month coincident
with or next succeeding the date that proceeds are applied. Subsequent annuity
income payments will be made as of the first day of each succeeding month unless
another mode of payment is selected and has been approved by us.
If the original payee dies, unless otherwise provided in the supplemental
contract, the beneficiary of such payee will be paid:
1. under Options 1 and 6, the rest of the annuity income payments during
the period certain, if any; or
2. under Options 3 and 4, the rest of the annuity income payments due, if
any; or
3. under Option 5, the proceeds due, if any.
If no beneficiary is living at the time of the payee's death, the commuted
value, if any, of the remaining annuity income payments or proceeds will be paid
in a lump sum to the estate of such payee. If the payee dies and the
supplemental contract does not provide for continued payments, the contract(s)
will terminate.
Under the supplemental contract, the commuted value of any option will be
figured at the interest rate used to determine the annuity payment. In no case
will annuity income payments under Options 1, 2, 6 and 7 be commuted during the
lifetime of the original payee.
Unless you elect otherwise, the payee will have the right to terminate the
supplemental contract. In this case the payee will receive the commuted value in
1 lump sum.
Variable annuity payments -- The dollar amount of the first monthly payment to
be made under a variable annuity option will be determined by applying the
amount of the proceeds to the appropriate factor in the settlement option
tables, or if more favorable to the payee, by such factor as may be shown in a
corresponding table in a variable annuity contract issued by us as of the date
the proceeds are applied.
The number of annuity units is determined by dividing the amount of the first
monthly payment by the current value of a variable retirement account unit in
the appropriate division on the valuation date coincident with the date that
proceeds were applied toward the variable annuity option. The second and each
following payment under this option will be based on the experience of the
underlying mutual fund.
Fixed annuity settlement options --
Page 10
Option 1. Fixed life income with or without period certain -- We will pay an
income based on the adjusted age of the payee for the period certain elected;
thereafter, we will pay income for the remaining lifetime of the payee. The
period certain may be 10, 15 or 20 years. If no period certain is requested, we
will pay an income during the lifetime of the payee. See Table 1 on page 15.
Option 2. Joint life and survivor annuity -- We will pay an income for as long
as either or both payees live. The income will be based on the adjusted ages of
the 2 payees. Upon the death of 1 payee, the amount payable will be two-thirds
of the amount paid while both were living. Income payments will cease following
the death of the surviving payee. See Table 2 on page 15.
Option 3. Income for a fixed period -- We will pay an income for a specified
number of years, 1 through 30 years. But, income payments cannot extend beyond
the 90th birthday of the payee. The payments will be made in equal installments.
See Table 3 on page 16.
Option 4. Income for a fixed amount -- We will pay an income of a specified
amount until the proceeds and interest at the rate of 4 percent per year are all
paid out to the payee. The income payments cannot extend beyond the 90th
birthday of the payee.
Option 5. Interest income payments -- We will hold the proceeds and pay interest
on such proceeds at a rate determined by us. The interest rate will never be
less than 4 percent per year. Interest will be credited at the end of each
payment period as agreed upon. The payee may elect another Option at the end of
any payment period. The payee may withdraw the proceeds in whole or in part upon
written request. The request must be made prior to the end of the agreed period.
This period must end before the 80th birthday of the payee.
Variable annuity settlement options --
Option 6. Variable life income with or without period certain --We will pay a
variable income based on the adjusted age of the payee for the period certain
elected; thereafter, we will pay the variable income for the remaining lifetime
of the payee. The period certain may be 10, 15 or 20 years. If no period certain
is requested, we will pay a variable income during the lifetime of the payee.
See Table 1 on page 15 for the initial payment. Subsequent payments will be
based on the experience of the underlying mutual fund.
Option 7. Variable income for joint life and survivor annuity -- We will pay a
variable income for as long as either or both payees live. The variable income
will be based on the adjusted ages of the 2 payees. See Table 2 on page 15 for
the initial payment. Subsequent payments will be based on the experience of the
underlying mutual fund.
Upon the death of 1 payee, future payments will be reduced by one-third. The
variable income payments will cease following the death of the surviving payee.
Other annuity options -- Upon your request, other fixed and variable annuity
options may be made available by us.
Basis of settlement option tables -- These tables show the dollar amount of
monthly annuity income payments for the payee's adjusted age as follows:
1. the annuity income payment for each $1,000 of proceeds applied under a
fixed income option; and
2. the first annuity income payment for each $1,000 proceeds applied
under a variable annuity option.
The adjusted age is determined from each payee's actual age last birthday at the
time the first annuity income payment is due in the following manner:
Calendar Year
of Xxxxx's Birth Adjusted Age
Before 1905 Actual age plus 1
1905 through 1919 Actual age
1920 through 1934 Actual age minus 1
1935 through 1949 Actual age minus 2
1950 through 1964 Actual age minus 3
After 1964 Actual age minus 4
The amount of each fixed income payment under Options 1, 2, and 3 will never be
less than that shown in the settlement option tables. The guaranteed interest
rate used for all fixed annuity settlement options is 4 percent per year. Where
mortality assumptions are involved, the guaranteed factors are based on the 1971
Individual Annuity Mortality Table. The fixed income payments under these
Options may be increased as determined by us on an equitable basis to this class
of certificates.
An assumed investment rate of 4 percent per year will be used to calculate
commuted values
Page 11
under Options 6 and 7 and the first variable annuity income payment of either
Option. Where mortality assumptions are involved, the guaranteed factors are
based on the 1971 Individual Annuity Mortality Table.
Page 12
Settlement option tables
Table 1
Income payments for life with or without a period certain
Equal monthly income payments for each $1,000 of proceeds under Options 1 and 6
---------------------------------------------------------------------------------------------------------
Adjusted Period certain Adjusted Period certain
age of -------------------------------------- age of ---------------------------------------
payee Life 10 yrs 15 yrs 20 yrs payee Life 10 yrs 15 yrs 20 yrs
---------------------------------------------------------------------------------------------------------
55 5.09 5.03 4.95 4.84 68 6.96 6.62 6.21 5.69
56 5.19 5.11 5.02 4.90 69 7.20 6.80 6.32 5.74
57 5.29 5.20 5.10 4.97 70 7.46 6.98 6.43 5.78
58 5.39 5.30 5.19 5.03 71 7.74 7.18 6.54
59 5.50 5.40 5.28 5.10 72 8.05 7.37 6.64
60 5.62 5.51 5.37 5.17 73 8.39 7.58 6.74
61 5.75 5.62 5.46 5.24 74 8.75 7.78 6.83
62 5.88 5.74 5.56 5.31 75 9.15 7.99 6.91
63 6.03 5.86 5.66 5.38 76 9.59 8.20
64 6.19 6.00 5.77 5.44 77 10.06 8.40
65 6.36 6.14 5.87 5.51 78 10.58 8.59
66 6.54 6.29 5.98 5.57 79 11.15 8.78
67 6.74 6.45 6.10 5.63 80 11.77 8.96
---------------------------------------------------------------------------------------------------------
The age shown is the adjusted age of the payee when income payments begin. If
the fixed annuity income payments under Option 1 are to be paid other than
monthly, multiply the monthly income payment by 2.990 to obtain the quarterly
payment; multiply by 5.951 to obtain the semiannual payment; and multiply by
11.787 to obtain the annual payment.
Page 13
Table 2
Income payments during joint lifetimes of 2 payees with two-thirds to survivor
Initial amount of monthly income payments for each $1,000 of proceeds under
Options 2 and 7
----------------------------------------------------------------------------------------------------------
Adjusted ages Monthly income payments
----------------------------------------------------------------------------------------------------------
Payee age 55 56 57 58 59 60 61 62 63 64 65
----------------------------------------------------------------------------------------------------------
Payee age 60 5.31 5.37 5.42 5.48 5.53 5.59 5.65 5.71 5.78 5.84 5.91
----------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------
Monthly income payments
----------------------------------------------------------------------------------------------------------
Payee age 60 61 62 63 64 65 66 67 68 69 70
----------------------------------------------------------------------------------------------------------
Payee age 65 5.91 5.98 6.06 6.13 6.21 6.29 6.38 6.47 6.56 6.65 6.74
----------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------
Monthly income payments
----------------------------------------------------------------------------------------------------------
Payee age 65 66 67 68 69 70 71 72 73 74 75
----------------------------------------------------------------------------------------------------------
Payee age 70 6.74 6.85 6.96 7.07 7.19 7.31 7.44 7.57 7.70 7.83 7.96
----------------------------------------------------------------------------------------------------------
The ages shown are the adjusted ages of the payees when income payments begin.
Amounts for combinations of ages not shown will be furnished upon request. If
the fixed annuity income payments under Option 2 are to be paid other than
monthly, multiply the monthly income payment by 2.990 to obtain the quarterly
payment; multiply by 5.951 to obtain the semiannual payment; and multiply by
11.787 to obtain the annual payment.
Page 14
Table 3
Income payments for a fixed period
Equal monthly income payments for each $1,000 of proceeds under Option 3
------------------------------------------------------------------------------------------------------
Number of Monthly Number of Monthly Number of Monthly
years in income years in income years in income
fixed period payment fixed period payment fixed period payment
------------------------------------------------------------------------------------------------------
1 84.84 11 9.31 21 5.81
2 43.25 12 8.69 22 5.64
3 29.40 13 8.17 23 5.49
4 22.47 14 7.72 24 5.35
5 18.32 15 7.34 25 5.22
6 15.56 16 7.00 26 5.10
7 13.59 17 6.71 27 5.00
8 12.12 18 6.44 28 4.90
9 10.97 19 6.21 29 4.80
10 10.06 20 6.00 30 4.72
------------------------------------------------------------------------------------------------------
If income payments under Option 3 are to be paid other than monthly, multiply
the monthly income payment by 2.990 to obtain the quarterly payment; multiply by
5.951 to obtain the semiannual payment; and multiply by 11.787 to obtain the
annual payment.
Page 15
Home Office: 0 Xxxxxx Xxxx Xxxxx
Xxxxxxxxxxx, Xxxxxxxx 00000-0001
0-000-000-0000
Individual Single Premium Deferred Fixed and Variable Retirement Annuity
Contract
Nonparticipating -- dividends not paid
Any payments and values under this contract which are based on investment
results of the Separate Account are variable and not guaranteed.
Right to cancel -- You may cancel this contract by delivering or mailing a
written notice or sending a telegram to Xxxxxx Xxxx Life Insurance Company, 0
Xxxxxx Xxxx Xxxxx, Xxxxxxxxxxx, XX 00000-0001 or to the agent from whom you
purchased it, within 30 days after it is delivered to you. Notice given by mail
and return of contract by mail are effective on being postmarked, properly
addressed, and postage prepaid. We will refund all purchase payments made to the
Fixed Account and the market value of any purchase payments applied to the
Separate Account, less taxes, if any, within 10 days after we receive notice of
cancellation and the returned contract. Upon return of the contract, it shall be
void as if none had been issued.
We agree to provide the benefits described in this contract.
Signed for the Company at Springfield, Illinois as of the Contract Date.
President Countersigned Corporate Secretary
IC-417000
This is a legal contract between the contract Owner and Xxxxxx Xxxx Life
Insurance Company.
This page provides a brief outline of some of the important features of your
contract. It is not part of the insurance contract. Only the actual contract
provisions will control. The contract sets forth, in detail, the rights and
obligations of both you and Xxxxxx Xxxx Life Insurance Company. It is therefore
important that you read your contract carefully.
This individual single premium deferred fixed and variable retirement annuity
contract provides for accumulation of cash value for income payments.
Table of contents Page
Section 1. Contract Data...................................................................................2
Section 2. Fixed Account Tables of Guaranteed Values.......................................................3
Section 3. Definitions of certain terms....................................................................4
Section 4. General provisions..............................................................................6
Section 5. Ownership and beneficiary provisions............................................................7
Section 6. Payment to the Company..........................................................................8
Section 7. Death benefit...................................................................................8
Section 8. The Fixed Account...............................................................................8
Section 9. The Variable Account...........................................................................10
Section 10. Annuity income options........................................................................12
Section 11. Annuity income option tables..................................................................17
Additional benefit provisions or restrictions, if any, and a copy of the
application follow page 19.
All written communications should be directed to Xxxxxx Xxxx Life Insurance
Company, P. O. Box 4657, Springfield, IL 62708-4657.
Home Office: 0 Xxxxxx Xxxx Xxxxx
Xxxxxxxxxxx, Xxxxxxxx 00000-0001
0-000-000-0000
Individual Single Premium Deferred Fixed and Variable Retirement Annuity
Contract
Nonparticipating -- dividends not paid
Any payments and values under this contract which are based on investment
results of the Separate Account are variable and not guaranteed.
SECTION 1 -- CONTRACT DATA
Contract number: XXXXXXXXXX
Annuitant: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
Contract Date: XXXXXXXXXX
Maturity Date: XXXXXXXXXX
Renewal Date: XXXXXXXXXX
Age at issue: XX
Sex: XXXXXX
Owner and beneficiary: As stated in the application unless changed.
Purchase payment: Single premium of $ZZZ,ZZZ.99 payable on or
before the Contract Date. To be allocated as
follows:
Fixed Account: ZZ9.99%
Variable Account divisions:
HM Growth Fund: ZZ9.99%
HM Balanced Fund: ZZ9.99%
HM Income Fund: ZZ9.99%
XX Xxxxx-Term Fund: ZZ9.99%
HM Socially responsible fund ZZ9.99%
HM International equity fund ZZ9.99%
HM Small cap growth fund ZZ9.99%
Total ZZ9.99%
Minimum purchase payment: $5,000
Maximum purchase payment: $500,000
Guaranteed annual effective interest rate:
Fixed Account: 3%
Surrender charge rates: Fixed and Variable Accounts:
During contract year % charged
1 5%
2 4%
3 3%
4 2%
5 1%
thereafter 0%
Fixed Account early withdrawal
Page 2
penalty: 5% if a dollar amount is withdrawn or transferred
or the contract is surrendered on any date other
than the Renewal Date. The Fixed Account early
withdrawal penalty will cease on the annuitant's
65th birthday.
Page 2
SECTION 1 (CONTINUED) -- CONTRACT DATA
Contract number: XXXXXXXXXX
Annuitant: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
Annual maintenance charge: $25 deducted if the total cash value is less than
$10,000.
Income payments: Income payments will commence on the Maturity
Date if the annuitant is living. Income payments
are determined according to the contract
provisions. The annuity income rates in section
11 are guaranteed.
Variable Account annual
mortality risk, expense risk
and distribution expense risk
fee: 1.35%
Page 2A
SECTION 2 -- FIXED ACCOUNT TABLE OF GUARANTEED CASH VALUES AND GUARANTEED
MONTHLY INCOME AT MATURITY
Contract number: XXXXXXXXXX
Annuitant: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
Contract Attained Guaranteed Guranteed
Anniversary Age Cash Value Monthly Income
XX XX $ZZ,ZZZ,ZZZ.99 $ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
Page 3
SECTION 2 (CONTINUED) -- FIXED ACCOUNT TABLE OF GUARANTEED SURRENDER VALUES
Contract number: XXXXXXXXXX
Annuitant: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
Guaranteed
Contract Attained Surrender
Anniversary Age Value
XX XX $ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
Page 3A
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXX
Page 4
Section 3. Definitions of certain terms
"Age at issue" is the Annuitant's attained age on the Contract Date.
"Annuitant" is the person insured in this contract as shown on the Contract Data
pages.
"Annuity income option" is the method by which income payments are made at the
Maturity Date or upon the Annuitant's death. See annuity income option tables
for guaranteed rates.
"Beneficiary" is the person to whom any benefits will be paid in the event of
the death of the Annuitant prior to the Maturity Date.
"Commuted value" is a lump sum payment made in lieu of periodic future income
payments.
"Company," "we," "us" and "our" refer only to the Xxxxxx Xxxx Life Insurance
Company.
"Contract anniversary" is the same day and month as the Contract Date for each
succeeding year of this contract.
"Contract Date" is the effective date of this contract as shown on the Contract
Data pages. It is the date from which contract years, Renewal Dates and contract
anniversaries are determined.
"Current interest rate" is the effective annual interest rate that we will
credit to the Fixed Account. It may be greater than or equal to the guaranteed
interest rate.
"Division" is a subcategory of the Separate Account in which money is invested
in shares of a corresponding mutual fund. You may direct payments to any or all
divisions of the Separate Account. Divisions for each mutual fund are shown on
the Contract Data pages.
"Early withdrawal penalty" is an amount charged when a withdrawal, transfer or
surrender is made from the Fixed Account at any time other than on the Renewal
Date.
"Excess interest rate" is the current interest rate less the guaranteed interest
rate.
"Fixed Account" is an interest-bearing account. The Fixed Account is invested in
the Company's general account.
"Fixed cash value" refers to the dollar value of the Fixed Account prior to the
time annuity income payments begin.
"Guaranteed interest rate" is the minimum effective annual interest rate to be
credited to the Fixed Account.
"Home Office" means our executive office at 0 Xxxxxx Xxxx Xxxxx, Xxxxxxxxxxx,
Xxxxxxxx, 00000-0000.
"Income payments" are payments made by us to the payee.
"Maturity Date" is the date you elect for income payments to begin. It is shown
on the Contract Data pages.
"Mutual funds" are open-end diversified management investment companies
registered under the Investment Company Act of 1940, as amended. The mutual
funds designated by you as the underlying investment vehicle(s) for the variable
portion of your contract are shown on the Contract Data pages. Each mutual fund
has a specific investment objective as stated in its prospectus. The prospectus
should be read for complete details.
"Net payment" is the purchase payment less any applicable premium tax on the
payment received.
"Owner" (referred to in this contract as "you" and "your") is the Annuitant
unless another Owner is named.
"Payee" is any person entitled to receive income payments under any annuity
income option.
"Purchase payment" means a dollar amount paid to us in return for the benefits
described in this contract. The purchase payment must be received at the Home
Office.
"Renewal Date" is the date on which the fixed portion of your contract may be
renewed for another period of time.
"Renewal period" is the period of time from the Contract Date to the Renewal
Date for the fixed portion of your contract. If the fixed portion has been
renewed, the renewal period is the period to
Page 4
the next Renewal Date.
"Separate Account" is the segregated asset account which receives and invests
net payments allocated to it. The Separate Account has individual divisions
which correspond to various mutual funds.
"Surrender charge" is an amount charged, when applicable, if a withdrawal is
made or the contract is surrendered for its total cash value. The rate varies by
contract year as shown on the Contract Data pages.
"Surrender value" is the total cash value of your contract less applicable
surrender charges and early withdrawal penalties, if any.
"Supplemental contract" is an agreement setting forth the terms of the annuity
income option you elected.
"Total cash value" is an amount equal to the sum of the fixed cash value and the
variable cash value.
"Valuation date" is any day on which the New York Stock Exchange is open for
trading and on which the net value of each share of an underlying mutual fund is
determined. See prospectus for details.
"Valuation period" is the time from the end of 1 business day on the New York
Stock Exchange to the end of the next business day.
"Variable Account" is your portion of the Separate Account set up to receive net
payments and other cash distributions allocated to it.
"Variable accumulation unit" is a measure used to determine the value of a
particular division of the Separate Account on or before the Maturity Date. The
value of a variable accumulation unit in a division depends on the investment
experience of the corresponding mutual fund.
"Variable cash value" refers to the dollar value of the Variable Account prior
to the time annuity income payments begin.
"Variable retirement unit" is a measure used to determine the amount payable
from a particular division of the Separate Account for a variable income
payment. The value of a variable retirement unit in a division depends on the
investment experience of the corresponding mutual fund.
Section 4. General provisions
Entire contract -- This contract is issued in consideration of your application
and receipt of the purchase payment. This document, the attached copy of the
application, and any attached endorsements and amendments constitute the entire
contract. All statements made in the application in the absence of fraud will be
treated as representations and not as warranties. If we challenge a claim or
attempt to void this contract, we agree to use only statements made in this
contract.
Change of contract provisions -- We have the right to change the provisions of
this contract as necessary for continued compliance under any federal or state
laws that affect this contract.
This contract shall be deemed to include any provisions required by the state in
which it was delivered.
No person other than our president, vice president, or the corporate secretary
can change or waive any condition or provision of this contract. Such change or
waiver must be made in writing and signed by one of the officers named above.
Incontestability -- This contract shall be incontestable 1 year after the
Contract Date.
Maturity Date -- The Maturity Date is the contract anniversary following the
Annuitant's 65th birthday. You may choose a different date if agreed upon by us.
Distributions must begin no later than specified in the Internal Revenue Code.
Nonparticipating -- This contract does not share in the profits of the Company.
Minimum values -- All values and benefits for this contract are not less than
the minimum required by the laws of the state in which it is delivered.
Assignment -- You may assign or transfer this contract unless it is prohibited
by the Internal Revenue Code. We will not be responsible for the validity of any
assignment. It must be filed in writing at our Home Office. Until received, we
will not be deemed to have knowledge of it.
Misstatement of age -- If the age of the Annuitant or any other payee has been
misstated,
Page 5
the income payments under this contract will be that amount which the purchase
payment would have provided at the correct age. We will require proof of the
correct age.
If the income payments were too large because of a misstatement of age, we will
deduct the difference with interest from the benefits falling due until totally
repaid. If such payments were too small, we will add the difference with
interest to the next benefit due. The interest rate will not exceed 6 percent
per year.
Exchange of contract -- You may exchange this contract for another annuity
contract issued by us if we approve it.
Proof of survival -- We may require proper proof that a payee, beneficiary, or
Annuitant is living when payment depends upon such person's survival.
Periodic reports -- During each contract year prior to the Maturity Date, we
will periodically send you reports which show your total cash value, purchase
payment and other contract transactions.
At any time, you may request a statement of the contract's total cash value. Any
other information or reports legally required will be sent to you. All material
will be sent to your last address known by us.
Premium tax -- Any premium tax deducted will be determined by the Owner's place
of residence.
Annual maintenance charge -- The annual maintenance charge is deducted from the
total cash value of the contract on its anniversary date. This charge will not
change and is shown on the Contract Data pages. This charge covers the general
maintenance of the contract as well as the additional cost for maintenance of
multiple accounts. When deducted from the Fixed Account, the maintenance charge
will be deducted only from interest credited above the guaranteed interest rate.
Section 5. Ownership and beneficiary provisions
Ownership -- The Owner is the Annuitant listed on the Contract Data pages unless
another Owner is named. Unless you provide otherwise, the Owner may exercise all
rights and privileges granted by this contract during the Annuitant's lifetime.
Beneficiary -- The beneficiary is named in the application; however, you may
change it.
For payment purposes, we will assume that the beneficiary's death occurred prior
to the Annuitant's death if the beneficiary:
1. dies before or on the same date as the Annuitant's death; or
2. dies within 15 days after the Annuitant's death.
Change of ownership or beneficiary -- You may change the Owner or beneficiary of
this contract during the lifetime of the Annuitant unless:
1. you provide otherwise; or
2. the contract is issued as part of a retirement plan qualified under the
Internal Revenue Code which will not allow any transfer or assignment of
ownership.
Changes must be requested in writing in a form satisfactory to us. The request
must be sent to our Home Office. We may require return of the contract for an
endorsement. A change is valid only when it is received by us in our Home
Office; but, upon receipt it is effective as of the date that you signed the
written request. All changes are subject to any payments made or other action
taken by us before receipt of the written request.
Section 6. Payment to the Company
Purchase payment -- Your single premium purchase payment is shown on page 2. It
is payable on or before the Contract Date. After the first payment, no other
payments are due.
The payment will be allocated to the Fixed Account and/or Variable Account as
elected in your application.
Contract cancellation -- We reserve the right to cancel this contract if the
total cash value is less than $2,000 or would provide less than a $20 monthly
income payment at maturity.
We will send you a notice of our intent to cancel. When this contract is
cancelled, we will pay you
Page 6
the total cash value. Thereafter, we will be free of any contract liability.
Section 7. Death benefit
Payment at Annuitant's death -- A lump sum payment shall be paid if the
Annuitant's death occurs prior to the Maturity Date and the contract has not
been surrendered for its total cash value or an annuity income option has not
been elected. The beneficiary may elect an annuity income option in place of the
lump sum payment.
Proof of the Annuitant's death must be sent to our Home Office. As of the date
we receive such proof, we will pay the beneficiary the greater of:
1. the total cash value of the contract, less any applicable premium tax; or
2. the purchase payment paid under this contract less any partial withdrawals.
Section 8. The Fixed Account
Allocation and credits to Fixed Account -- The Fixed Account will receive the
net payment allocated to it, guaranteed interest, excess interest and dollar
amounts transferred from the Variable Account.
On the date we receive your purchase payment for the Fixed Account, the net
payment will be allocated to this account. As of the date we receive your
request to transfer an amount from the Variable Account, such amount will be
deposited to the Fixed Account.
Guaranteed interest rate -- Prior to the Maturity Date, guaranteed interest will
be credited on a daily basis to the Fixed Account. The guaranteed interest rate
is shown on the Contract Data pages. This interest will be credited from:
1. the date the purchase payment is received by us; or
2. the date a dollar amount is transferred from the Variable Account.
The guaranteed interest rate and the guaranteed annuity income option rates are
established on the Contract Date. These rates will never be changed.
Excess interest rate -- We may pay interest in excess of the guaranteed amount.
This excess interest will be credited on a daily basis to the Fixed Account.
Renewal of Fixed Account -- The fixed portion of your contract will be
automatically renewed on the contract Renewal Date. The new Renewal Date will be
set for a period equal to the initial renewal period. You may choose a different
renewal period if allowed by us.
If you choose, you may withdraw your fixed cash value from the Fixed Account
without charge or penalty on the Renewal Date.
We will send you a notice 90 days prior to the Renewal Date. This notice will
explain your renewal rights. If you want a different Renewal Date or choose to
withdraw the fixed cash value, your written request must be received at the Home
Office prior to the Renewal Date. If we do not receive a written request, we
will automatically renew the fixed portion of your contract. Upon each renewal,
new Contract Data pages will be sent to you.
Transfers -- You may transfer money from the Fixed Account to various divisions
of the Variable Account. Any 1 transfer must be for an amount not less than
$200.
A partial transfer may not be made if such transfer would reduce the Fixed
Account's cash value to less than $200.
The early withdrawal penalty will be charged when transfers are made at any time
other than on the Renewal Date.
Your written request to make a transfer must be sent to the Home Office. An
approved transfer will be made as of the date we receive your request.
Fixed Account cash withdrawal and surrender privilege -- You may at any time
during the Annuitant's lifetime and prior to the Maturity Date, elect to
withdraw part or surrender all of the fixed cash value. Any 1 withdrawal must be
for an amount not less than $200. We will deduct the surrender charges and early
withdrawal penalties, if any, from the fixed cash value. The amount due will be
sent to you.
We will figure the fixed cash value of your account as of the date we receive
your written request. The written request must be in a form satisfactory to us.
The request must be sent to the Home Office. The payment is usually paid within
30 days. However, we reserve the right to postpone payment for not more than 6
months from the date your request was received by us. If payment is deferred
after the 30 days, we will continue to credit current interest, if any.
Page 7
Surrender charge -- A surrender charge is deducted from your fixed cash value if
you make a cash withdrawal from or surrender the fixed cash value. The rate
varies by contract year as shown on the Contract Data pages.
Early withdrawal penalty -- An early withdrawal penalty is deducted from your
fixed cash value if you make a partial withdrawal from, make a transfer to the
Variable Account or surrender your fixed cash value. There will be no early
withdrawal penalty for cash withdrawals, transfers or surrenders made on the
Renewal Date. The early withdrawal penalty is shown on the Contract Data pages.
Waiver of charges and penalties -- No surrender charge or early withdrawal
penalty will apply:
1. on a partial withdrawal from the Fixed Account or a transfer to the
Variable Account if all the following occur:
a. it is made after the contract has been in force 2 years;
b. it is more than 12 months since the last transfer or withdrawal was
made; and
c. the amount is not more than 15 percent of the then current fixed cash
value.
2. on fixed cash value applied to annuity income Options 1, 2, 6 or 7.
3. on or after the Maturity Date if the contract has been in force for at
least 10 years.
4. if a distribution is required by the Internal Revenue Code.
5. if the Annuitant is totally disabled, as defined by the Internal Revenue
Code, for a period of at least 3 months immediately prior to the surrender
or withdrawal request. Satisfactory proof of such disability must be sent
to the Home Office.
Guaranteed return of payment -- We guarantee the return of the net payment
credited to the Fixed Account upon surrender of this contract if:
1. the contract has been in force more than 2 years; and
2. no cash withdrawals or transfers to the Variable Account have been made
from the Fixed Account.
Section 9. The Variable Account
Allocations to Variable Account -- The Variable Account will receive the net
payment allocated to it and dollar amounts transferred from the Fixed Account.
We will allocate these amounts, as you instruct, to the division(s) of the
Separate Account. These are processed as of the date we receive your payment or
the transfer request at the Home Office.
Within each division, the value of a variable accumulation unit is determined by
valuing daily the underlying securities within that division with a reduction
for operating expenses and then dividing the result by the outstanding number of
all variable accumulation units of that division of the Separate Account. The
value of each division's variable accumulation unit varies relative to the
experience of the corresponding mutual fund investments.
All dividends and other distributions paid by a mutual fund to a division shall
be used to purchase additional shares of the mutual fund which corresponds to
that division.
The increase or decrease in the number of variable accumulation units for a
particular transaction is determined by dividing the dollar amount of the
transaction by the unit value of the appropriate division.
The number of units the Annuitant has in a particular division on any date is
equal to the sum of variable accumulation units that have been added through net
payments, dividend distributions, and transfers from other divisions minus the
sum of variable accumulation units that have been withdrawn or transferred from
such division.
If shares of a mutual fund are no longer available for investment by the
Separate Account or if we determine further investments in a mutual fund are
inappropriate in view of the objectives of the contract issued, we may
substitute shares of another mutual fund for fund shares already purchased and
apply future purchase payments to the purchase of shares of the substitute
mutual fund or other securities. No substitutions will be made until prior
approval has been received from the Securities and Exchange Commission and we
receive prior favorable vote of a
Page 8
majority of the votes entitled to be cast by persons having a voting interest in
the mutual fund shares.
Transfers -- You may transfer money from the Variable Account to the Fixed
Account or between the various divisions of the Variable Account. The minimum
amount which may be transferred from 1 division to another or from an individual
division to the Fixed Account is $200 or the entire dollar value of such
division, whichever is less. No partial transfers may be made which would reduce
your interest in a division to less than $200.
Transfers may be made as often as you choose; however, no transfers between
divisions are allowed after income payments commence.
Variable Account cash withdrawal and surrender privilege -- You may at any time
during the Annuitant's lifetime and prior to the Maturity Date, elect to
withdraw part or surrender all of the variable cash value of this contract.
We will deduct the surrender charges, if any, from the amount being surrendered
or withdrawn. Any 1 withdrawal from an individual division must be for an amount
not less than $200. We will not allow a withdrawal which would reduce the
individual division's dollar value to less than $200.
We will figure the variable cash value as of the date your written request was
received by us. The amount of the payment due will be sent to you within 7 days
after the date such value was figured. The written request must be in a form
satisfactory to us. The request must be sent to the Home Office.
Surrender charge -- The surrender charge is deducted from your variable cash
value if you make a cash withdrawal from or surrender your Variable Account. The
charge varies by contract year as shown on the Contract Data pages.
Maximum surrender charge -- In no case will the surrender charge applied to the
variable cash value be greater than 8.5 percent of the purchase payment and
transfers attributable to the amount surrendered from the Variable Account.
Annual mortality risk, expense risk and distribution expense risk fee -- To
cover the mortality risk, expense risk and distribution expense risk fee not
included in the annual maintenance charge, we will charge your Variable Account
a weekly fee of an amount equivalent to 1.35 percent per year. Further details
of this fee are in the prospectus.
Voting rights -- We will vote shares held in the Separate Account according to
your instructions. We will send the notices and instructions to the person
having voting rights under this contract. Votes for which we do not receive
instructions will be cast by us in the same proportion as the votes for which
instructions have been received.
Xxxxxx of surrender charge -- No surrender charge will be made:
1. on a partial withdrawal from the Variable Account if all the following
occur:
a. it is made after the contract has been in force 2 years;
b. it is more than 12 months since the last withdrawal was made; and
c. the amount is not more than 15 percent of the then current variable
cash value.
2. on variable cash value applied to annuity income Options 1, 2, 6 or 7.
3. if a distribution is required by the Internal Revenue Code.
4. if the Annuitant is totally disabled, as defined by the Internal Revenue
Code, for a period of at least 3 months immediately prior to the surrender
or withdrawal request. Satisfactory proof of such disability must be sent
to the Home Office.
Section 10. Annuity income options
Application of proceeds -- On the Maturity Date or the date we receive proof of
the Annuitant's death at the Home Office, the proceeds payable under this
contract shall be applied to the payment of the annuity income option elected.
The amount of proceeds equals the total cash value plus the purchase price of
any additional annuity benefits.
If the amount of proceeds to be applied under any 1 fixed or variable annuity
income option is less than $2,000 or would provide less than a $20 monthly
annuity income payment, the proceeds will be paid in a lump sum to the payee.
Prior to the payment of any annuity income option selected, we reserve the right
to verify the age of the payee and to make any adjustments necessary to reflect
the accurate payment for the
Page 9
proper age.
Option to purchase additional annuity benefits at maturity -- You may purchase
an additional annuity benefit at the Maturity Date. To do so, you must send a
written request to the Home Office. This request along with a payment for the
benefit must be received by us 30 days prior to the Maturity Date. We may limit
the amount of the additional benefit being purchased. The premium tax, if any,
will be deducted from this single payment.
Election of option -- At least 30 days prior to the Maturity Date you may elect
by written request an annuity income option or change a previous election. The
written request must be sent to the Home Office. If the Annuitant dies prior to
the Maturity Date and no election has been made, the beneficiary may elect an
annuity income option. This election must be made within 60 days after we
receive proof of the Annuitant's death.
Absence of election -- If no valid election has been made, the proceeds, if any,
will be paid as follows:
1. Proceeds from the Fixed Account will be paid under a fixed annuity income
option in the form of a life income with 10-year period certain.
2. Proceeds from the Variable Account will be paid under a variable annuity
income option in the form of a life income with 10-year period certain.
Supplemental contract -- We will issue supplemental contracts setting forth the
terms of the annuity income options chosen.
Unless otherwise provided in the supplemental contract, the first income payment
under each fixed option (Options 1, 2, 3, 4 and 5) and each variable option
(Options 6 and 7) shall be made no later than the first day of the month next
succeeding the date that proceeds are applied. Subsequent income payments will
be made as of the first day of each succeeding month unless another mode of
payment is selected and has been approved by us.
If the original payee dies, unless the supplemental contract provides otherwise,
the beneficiary of such payee will be paid:
1. under Options 1 and 6, the rest of the income payments during the period
certain, if any; or
2. under Options 3 and 4, the rest of the income payments due, if any; or
3. under Option 5, the proceeds due, if any.
If no beneficiary is living at the time of the payee's death, the commuted
value, if any, of the remaining income payments or proceeds will be paid in a
lump sum to the estate of such payee. If the payee dies and the supplemental
contract does not provide for continued payments, the contract(s) will
terminate.
Under the supplemental contract, the commuted value of any option will be
figured at the interest rate used to determine the income payment. In no case
will income payments under Options 1, 2, 6 and 7 be commuted during the lifetime
of the original payees.
Unless you elect otherwise, the payee will have the right to terminate the
supplemental contract. In this case the payee will receive the commuted value in
1 lump sum.
Variable income payments -- The amount of proceeds being applied to the variable
income payments are allocated to the divisions of the Separate Account as
instructed. The dollar amount of the first monthly payment to be made under a
variable annuity income option will be determined by applying the amount of such
proceeds to the appropriate rate in the annuity income option tables, or if more
favorable to the payee, by such rate as may be shown in a corresponding table in
a variable annuity contract issued by us as of the date the proceeds are
applied.
The variable income payment of each division is determined by multiplying the
number of variable retirement units by the value of such unit for the
corresponding division. The total dollar amount of second and subsequent
variable income payments is determined by summing the payments of each division
of the Separate Account, where applicable.
Within each division, the number of variable retirement units is determined by
dividing (a) by (b) where:
(a) is the amount of the first monthly payment, and
(b) is the current value of a variable retirement unit in the appropriate
division on the valuation date coincident with the date that proceeds
were applied toward the variable annuity income option(s).
Page 10
The number of such units will not change when figuring the second and subsequent
income payments except under Option 7 where such units will be reduced by one-
third upon the death of the first payee.
The second and subsequent payments of each division under the variable annuity
options(s) will be based on the investment experience of the corresponding
mutual fund(s). The value of each variable retirement unit for each division of
the Separate Account was initially set at $10.00 as of the date income payments
were first figured. Subsequent variable retirement unit values of any division
are determined by multiplying the previous variable retirement unit value by the
current net investment factor for such division.
The net investment factor for each division of the Separate Account is computed
by dividing (a) by (b) and multiplying by (c) where:
(a) is the division's current net asset value per share on the last
valuation date plus any dividends or other distributions in the
current valuation period;
(b) is the net asset value of such shares on the last valuation date of
the preceding valuation period, and
(c) is .995666 which reflects the annual rate of 1.35 percent asset charge
and the assumed interest rate of 4 percent per year.
The value of the net assets in the Separate Account shall be taken at their fair
market value, or where there is no readily available market, their fair value,
as determined in accordance with generally accepted accounting practice and
applicable laws and regulations. The value of each share for each division is
determined by dividing the net assets of each division by the number of shares
outstanding for each respective division.
Fixed annuity income options--
Option 1. Fixed life income with or without a period certain -- We will pay an
income based on the adjusted age of the payee for the period certain elected;
thereafter, we will pay income for the remaining lifetime of the payee. The
period certain may be 10, 15, or 20 years. If no period certain is requested, we
will pay an income during the lifetime of the payee. See Table 1 in Section 11.
Option 2. Joint life and survivor annuity -- We will pay an income for as long
as either or both payees live. The income will be based on the adjusted ages of
the 2 payees. Upon the death of 1 payee, the amount payable will be two-thirds
of the amount paid while both were living. Income payments will cease following
the death of the surviving payee. See Table 2 in Section 11.
Option 3. Income for a fixed period -- We will pay an income of a specified
number of years, 1 through 30 years. But, income payments cannot extend beyond
the life expectancy of the payee as defined by the Internal Revenue Code. The
payments will be made in equal installments. See Table 3 in Section 11.
Option 4. Income for a fixed amount -- We will pay an income of a specified
amount until the proceeds and interest at the rate of 4 percent per year are all
paid out to the payee. The income payments cannot extend beyond the normal life
expectancy of the payee, as defined by the Internal Revenue Code.
Option 5. Interest income payments -- We will hold the proceeds and pay interest
on such proceeds at a rate determined by us. The interest rate will never be
less than 4 percent per annum. Interest will be credited at the end of each
payment period as agreed upon.
The payee may elect another Option at the end of any payment period. Prior to
the end of the payment period and subject to the restrictions imposed by the
Internal Revenue Code, the payee may withdraw the proceeds in whole or in part
upon written request. Distributions of both principal and interest must begin no
later than the date specified by the Internal Revenue Code.
Variable annuity income options --
Option 6. Variable life income with or without period certain -- We will pay a
variable income based on adjusted age of the payee for the period certain
elected; thereafter, we will pay the variable income for the remaining lifetime
of the payee. The period certain may be 10, 15, or 20 years. If no period
certain is requested, we will pay a variable income during the lifetime of the
payee. See Table 1 in Section 11 for the initial payment. Subsequent payments
will be based on the investment experience of the underlying mutual fund.
Option 7. Variable income for joint life and survivor annuity -- We will pay a
variable income for as long as either or both payees live. The variable income
will be based on the adjusted age of the 2 payees. See Table 2 in Section 11 for
the initial payment. Subsequent payments will be based on the investment
experience of the underlying mutual fund. Upon the death of 1 payee, future
payments will be reduced by one-third. The variable income payments will cease
following the death of the surviving payee.
Page 11
Other annuity options -- Upon your request, other fixed and variable annuity
options may be made available by us.
Basis of annuity income option tables -- These tables show the dollar amount of
monthly annuity income payments for the payee's adjusted age as follows:
1. the annuity income payment for each $1,000 of proceeds applied under a
fixed income option; and
2. the first annuity income payment for each $1,000 proceeds applied under a
variable annuity option.
The adjusted age is determined from each payee's attained age at the time the
first annuity income payment is due in the following manner:
Calendar Year Xxxxx's
of Xxxxx's Birth Adjusted Age
Before 1950 Attained age minus 2
1950 through 1964 Attained age minus 3
After 1964 Attained age minus 4
The amount of each fixed income payment under Options 1, 2 and 3 will never be
less than the rates shown in the annuity income option tables. The guaranteed
interest rate used for all fixed annuity income options is 4 percent per year.
Where mortality assumptions are involved, the guaranteed rates are based on the
1971 Individual Annuity Mortality Table. The fixed income payments under these
options may be increased as determined by us on an equitable basis to this class
of contracts.
An assumed interest rate of 4 percent per year will be used to calculate
commuted values under Options 6 and 7 and the first variable income payment of
either option. Where mortality assumptions are involved, the guaranteed rates
are based on the 1971 Individual Annuity Mortality Table.
Page 12
Section 11. Annuity income option tables
Table 1 -- Options 1 and 6
Income payments for life with or without period certain
Equal monthly income payments for each $1,000 of proceeds
-------------------------------------------------------------------------------------------------------------------
Age Period certain Age Period certain
of ---------------------------- of -----------------------------
payee Life 10 yrs 15 yrs 20 yrs payee Life 10 yrs 15 yrs 20 yrs
-------------------------------------------------------------------------------------------------------------------
55 5.09 5.03 4.95 4.84 68 6.96 6.62 6.21 5.69
56 5.19 5.11 5.02 4.90 69 7.20 6.80 6.32 5.74
57 5.29 5.20 5.10 4.97 70 7.46 6.98 6.43 5.78
58 5.39 5.30 5.19 5.03 71 7.74 7.18 6.54
59 5.50 5.40 5.28 5.10 72 8.05 7.37 6.64
60 5.62 5.51 5.37 5.17 73 8.39 7.58 6.74
61 5.75 5.62 5.46 5.24 74 8.75 7.78 6.83
62 5.88 5.74 5.56 5.31 75 9.15 7.99 6.91
63 6.03 5.86 5.66 5.38 76 9.59 8.20
64 6.19 6.00 5.77 5.44 77 10.06 8.40
65 6.36 6.14 5.87 5.51 78 10.58 8.59
66 6.54 6.29 5.98 5.57 79 11.15 8.78
67 6.74 6.45 6.10 5.63 80 11.77 8.96
-------------------------------------------------------------------------------------------------------------------
The age shown is the adjusted age of the payee when income payments begin. If
the income payments under Option 1 are to be paid other than monthly, multiply
the monthly income payments by 2.990 to obtain the quarterly payment; multiply
by 5.951 to obtain the semiannual payment; and multiply by 11.787 to obtain the
annual payment.
Page 13
Table 2 -- Options 2 and 7
Joint life income with two-thirds to survivor
Initial monthly income payments for each $1,000 of proceeds
-------------------------------------------------------------------------------------------------------------
Ages of
payees 55 56 57 58 59 60 61 62 63 64 65
-------------------------------------------------------------------------------------------------------------
60 5.31 5.37 5.42 5.48 5.53 5.59 5.65 5.71 5.78 5.84 5.91
65 5.57 5.64 5.70 5.77 5.84 5.91 5.98 6.06 6.13 6.21 6.29
70 5.87 5.94 6.02 6.10 6.18 6.27 6.35 6.45 6.54 6.64 6.74
-------------------------------------------------------------------------------------------------------------
The ages shown are the adjusted ages of the payees when income payments begin.
Amounts for combinations of ages not shown will be furnished upon request. If
the fixed income payments under Option 2 are to be paid other than monthly,
multiply the monthly income payment by 2.990 to obtain the quarterly payment;
multiply by 5.951 to obtain the semiannual payment; and multiply by 11.787 to
obtain the annual payment.
Page 14
Table 3 -- Option 3
Income payments for a fixed period
Equal monthly income payments for each $1,000 of proceeds
----------------------------------------------------------------------------------------------------
Number of Monthly Number of Monthly Number of Monthly
years in income years in income years in income
fixed period payment fixed period payment fixed period payment
----------------------------------------------------------------------------------------------------
1 84.84 11 9.31 21 5.81
2 43.25 12 8.69 22 5.64
3 29.40 13 8.17 23 5.49
4 22.47 14 7.72 24 5.35
5 18.32 15 7.34 25 5.22
6 15.56 16 7.00 26 5.10
7 13.59 17 6.71 27 5.00
8 12.12 18 6.44 28 4.90
9 10.97 19 6.21 29 4.80
10 10.06 20 6.00 30 4.72
----------------------------------------------------------------------------------------------------
If income payments under Option 3 are to be paid other than monthly, multiply
the monthly income payment by 2.990 to obtain the quarterly payment; multiply by
5.951 to obtain the semiannual payment; and multiply by 11.787 to obtain the
annual payment.
Page 15
Home Office: 0 Xxxxxx Xxxx Xxxxx
Xxxxxxxxxxx, Xxxxxxxx 00000-0001
0-000-000-0000
Individual Single Premium Deferred Fixed and Variable
Retirement Annuity Contract
Nonparticipating -- dividends not paid
Any payments and values under this contract which are based on investment
results of the Separate Account are variable and not guaranteed.
Right to cancel -- You may cancel this contract by delivering or mailing a
written notice or sending a telegram to Xxxxxx Xxxx Life Insurance Company, 0
Xxxxxx Xxxx Xxxxx, Xxxxxxxxxxx, XX 00000-0001 or to the agent from whom you
purchased it, within 30 days after it is delivered to you. Notice given by mail
and return of contract by mail are effective on being postmarked, properly
addressed, and postage prepaid. We will refund all purchase payments made to the
Fixed Account and the market value of any purchase payments applied to the
Separate Account, less taxes, if any, within 10 days after we receive notice of
cancellation and the returned contract. Upon return of the contract, it shall be
void as if none had been issued.
We agree to provide the benefits described in this contract.
Signed for the Company at Springfield, Illinois as of the Contract Date.
President Countersigned Corporate Secretary
IC-418000
This is a legal contract between the contract Owner and Xxxxxx Xxxx Life
Insurance Company.
This page provides a brief outline of some of the important features of your
contract. It is not part of the insurance contract. Only the actual contract
provisions will control. The contract sets forth, in detail, the rights and
obligations of both you and Xxxxxx Xxxx Life Insurance Company. It is therefore
important that you read your contract carefully.
This individual single premium deferred fixed and variable retirement annuity
contract provides for accumulation of cash value for income payments.
Table of contents Page
Section 1. Contract Data.................................................... 2
Section 2. Fixed Account Tables of Guaranteed Values........................ 3
Section 3. Definitions of certain terms..................................... 4
Section 4. General provisions............................................... 5
Section 5. Ownership and beneficiary provisions............................. 7
Section 6. Payment to the Company........................................... 7
Section 7. Death benefit.................................................... 8
Section 8. The Fixed Account................................................ 8
Section 9. The Variable Account............................................. 9
Section 10. Annuity income options..........................................11
Section 11. Annuity income option tables....................................16
Additional benefit provisions or restrictions, if any, and a copy of the
application follow the annuity income option tables.
All written communications should be directed to Xxxxxx Xxxx Life Insurance
Company, P. O. Box 4657, Springfield, IL 62708-4657.
Home Office: 0 Xxxxxx Xxxx Xxxxx
Xxxxxxxxxxx, Xxxxxxxx 00000-0001
0-000-000-0000
Individual Single Premium Deferred Fixed and Variable
Retirement Annuity Contract
Nonparticipating -- dividends not paid
Any payments and values under this contract which are based on investment
results of the Separate Account are variable and not guaranteed.
SECTION 1 -- CONTRACT DATA
Contract number: XXXXXXXXXX
Annuitant: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
Contract Date: XXXXXXXXXX
Maturity Date: XXXXXXXXXX
Age at issue: XX
Sex: XXXXXX
Owner and beneficiary: As stated in the application unless changed.
Purchase payment: Single premium of $ZZZ,ZZ9.99 payable on or
before the Contract Date. To be allocated as
follows:
Fixed Account: ZZZ.99%
Variable Account divisions:
HM Growth Fund: ZZZ.99%
HM Balanced Fund: ZZZ.99%
HM Income Fund: ZZZ.99%
XX Xxxxx-Term Fund: ZZZ.99%
HM Socially Responsible fund: ZZZ.99%
HM International equity fund: ZZZ.99%
Hm Small cap growth fund: ZZZ.99%
Total ZZZ.99%
Minimum purchase payment: $ 5,000
Maximum purchase payment: $500,000
Guaranteed annual effective interest rate:
Fixed Account: 3%
Surrender charge rates: During Fixed Account Variable Account
contract year % charged % charged
1 8% 5%
2 7% 4%
3 6% 3%
4 5% 2%
5 4% 1%
6 3% 0%
7 2%
8 1%
9 0%
Page 2
SECTION 1 (CONTINUED) -- CONTRACT DATA
Contract number: XXXXXXXXXX
Annuitant: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
Annual maintenance charge: $25 deducted if the total cash value is less than
$10,000.
Income payments: Income payments will commence on the Maturity
Date if the annuitant is living. Income payments
are determined according to the contract
provisions. The annuity income rates in section
II are guaranteed.
Variable Account annual mortality
risk, expense risk and distribution
expense risk fee: 1.35%
Page 2A
SECTION 2 -- FIXED ACCOUNT TABLE OF GUARANTEED CASH VALUES AND GUARANTEED
MONTHLY INCOME AT MATURITY
Contract number: XXXXXXXX
Annuitant: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
Contract Attained Guaranteed Guaranteed
Anniversary Age Cash Value Monthly Income
XX XX $ZZ,ZZZ,ZZZ.99 $ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99 ZZ,ZZZ,ZZZ.99
XXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXX
Page 3
SECTION 2 (CONTINUED) -- FIXED ACCOUNT TABLE OF GUARANTEED SURRENDER VALUES
Contract number: XXXXXXXXXX
Annuitant: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
Guaranteed
Contract Attained Surrender
Anniversary Age Value
XX XX $ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XX XX ZZ,ZZZ,ZZZ.99
XXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
Page 3A
Section 3. Definitions of certain terms
"Age at issue" is the Annuitant's attained age on the Contract Date.
"Annuitant" is the person insured in this contract as shown on the Contract Data
pages.
"Annuity income option" is the method by which income payments are made at the
Maturity Date or upon the Annuitant's death. See annuity income option tables
for guaranteed rates.
"Beneficiary" is the person to whom any benefits will be paid in the event of
the death of the Annuitant prior to the Maturity Date.
"Commuted value" is a lump sum payment made in lieu of periodic future income
payments.
"Company," "we," "us" and "our" refer only to the Xxxxxx Xxxx Life Insurance
Company.
"Contract anniversary" is the same day and month as the Contract Date for each
succeeding year of this contract.
"Contract Date" is the effective date of this contract as shown on the Contract
Data pages. It is the date from which contract years and contract anniversaries
are determined.
"Current interest rate" is the effective annual interest rate that we will
credit to the Fixed Account. It may be greater than or equal to the guaranteed
interest rate.
"Division" is a subcategory of the Separate Account in which money is invested
in shares of a corresponding mutual fund. You may direct payments to any or all
divisions of the Separate Account. Divisions for each mutual fund are shown on
the Contract Data pages.
"Excess interest rate" is the current interest rate less the guaranteed interest
rate.
"Fixed Account" is an interest-bearing account. The Fixed Account is invested in
the Company's general account.
"Fixed cash value" refers to the dollar value of the Fixed Account prior to the
time annuity income payments begin.
"Guaranteed interest rate" is the minimum effective annual interest rate to be
credited to the Fixed Account.
"Home Office" means our executive office at 0 Xxxxxx Xxxx Xxxxx, Xxxxxxxxxxx,
Xxxxxxxx, 00000-0000.
"Income payments" are payments made by us to the payee.
"Maturity Date" is the date you elect for income payments to begin. It is shown
on the Contract Data pages.
"Mutual funds" are open-end diversified management investment companies
registered under the Investment Company Act of 1940, as amended. The mutual
funds designated by you as the underlying investment vehicle(s) for the variable
portion of your contract are shown on the Contract Data pages. Each mutual fund
has a specific investment objective as stated in its prospectus. The prospectus
should be read for complete details.
"Net payment" is the purchase payment less any applicable premium tax on the
payment received.
"Owner" (referred to in this contract as "you" and "your") is the Annuitant
unless another Owner is named.
"Payee" is any person entitled to receive income payments under any annuity
income option.
"Purchase payment" means a dollar amount paid to us in return for the benefits
described in this contract. The purchase payment must be received at the Home
Office.
"Separate Account" is the segregated asset account which receives and invests
net payments allocated to it. The Separate Account has individual divisions
which correspond to various mutual funds.
"Surrender charge" is an amount charged, when applicable, if a withdrawal is
made or the contract is surrendered for its total cash value. The rate varies by
contract year as shown on the Contract Data pages.
Page 4
"Surrender value" is the total cash value of your contract less applicable
surrender charges.
"Supplemental contract" is an agreement setting forth the terms of the annuity
income option you elected.
"Total cash value" is an amount equal to the sum of the fixed cash value and the
variable cash value.
"Valuation date" is any day on which the New York Stock Exchange is open for
trading and on which the net value of each share of an underlying mutual fund is
determined. See prospectus for details.
"Valuation period" is the time from the end of one business day on the New York
Stock Exchange to the end of the next business day.
"Variable Account" is your portion of the Separate Account set up to receive net
payments and other cash distributions allocated to it.
"Variable accumulation unit" is a measure used to determine the value of a
particular division of the Separate Account on or before the Maturity Date. The
value of a variable accumulation unit in a division depends on the investment
experience of the corresponding mutual fund.
"Variable cash value" refers to the dollar value of the Variable Account prior
to the time annuity income payments begin.
"Variable retirement unit" is a measure used to determine the amount payable
from a particular division of the Separate Account for a variable income
payment. The value of a variable retirement unit in a division depends on the
investment experience of the corresponding mutual fund.
Section 4. General provisions
Entire contract -- This contract is issued in consideration of your application
and receipt of the purchase payment. This document, the attached copy of the
application, and any attached endorsements and amendments constitute the entire
contract. All statements made in the application in the absence of fraud will be
treated as representations and not as warranties. If we challenge a claim or
attempt to void this contract, we agree to use only statements made in this
contract.
Change of contract provisions -- We have the right to change the provisions of
this contract as necessary for continued compliance under any federal or state
laws that affect this contract.
This contract shall be deemed to include any provisions required by the state in
which it was delivered.
No person other than our president, vice president, or the corporate secretary
can change or waive any condition or provision of this contract. Such change or
waiver must be made in writing and signed by 1 of the officers named above.
Incontestability -- This contract shall be incontestable 1 year after the
Contract Date.
Maturity Date -- The Maturity Date is the contract anniversary following the
Annuitant's 65th birthday or the tenth contract anniversary, whichever is later.
You may choose a different date if agreed upon by us. Distributions must begin
no later than specified in the Internal Revenue Code.
Nonparticipating -- This contract does not share in the profits of the Company.
Minimum values -- All values and benefits for this contract are not less than
the minimum required by the laws of the state in which it is delivered.
Assignment -- You may assign or transfer this contract unless it is prohibited
by the Internal Revenue Code. We will not be responsible for the validity of any
assignment. It must be filed in writing at our Home Office. Until received, we
will not be deemed to have knowledge of it.
Misstatement of age -- If the age of the Annuitant or any other payee has been
misstated, the income payments under this contract will be that amount which the
purchase payment would have provided at the correct age. We will require proof
of the correct age.
If the income payments were too large because of a misstatement of age, we will
deduct the difference with interest from the benefits falling due until totally
repaid. If such payments were too small, we will add the difference with
interest to the next benefit due. The interest rate will not exceed 6 percent
per year.
Exchange of contract -- You may exchange this contract for another annuity
contract issued by us if we approve it.
Proof of survival -- We may require proper proof that a payee, beneficiary, or
Annuitant is
Page 5
living when payment depends upon such person's survival.
Periodic reports -- During each contract year prior to the Maturity Date, we
will periodically send you reports which show your total cash value, purchase
payment and other contract transactions.
At any time, you may request a statement of the contract's total cash value. Any
other information or reports legally required will be sent to you. All material
will be sent to your last address known by us.
Premium tax -- Any premium tax deducted will be determined by the Owner's place
of residence.
Annual maintenance charge -- The annual maintenance charge is deducted from the
total cash value of the contract on its anniversary date. This charge will not
change and is shown on the Contract Data pages. This charge covers the general
maintenance of the contract as well as the additional cost for maintenance of
multiple accounts. When deducted from the Fixed Account, the maintenance charge
will be deducted only from interest credited above the guaranteed interest rate.
Section 5. Ownership and beneficiary provisions
Ownership -- The Owner is the Annuitant listed on the Contract Data pages unless
another Owner is named. Unless you provide otherwise, the Owner may exercise all
rights and privileges granted by this contract during the Annuitant's lifetime.
Beneficiary -- The beneficiary is named in the application; however, you may
change it.
For payment purposes, we will assume that the beneficiary's death occurred prior
to the Annuitant's death if the beneficiary:
1. dies before or on the same date as the Annuitant's death; or
2. dies within 15 days after the Annuitant's death.
Change of ownership or beneficiary -- You may change the Owner or beneficiary of
this contract during the lifetime of the Annuitant unless:
1. you provide otherwise; or
2. the contract is issued as part of a retirement plan qualified under
the Internal Revenue Code which will not allow any transfer or
assignment of ownership.
Changes must be requested in writing in a form satisfactory to us. The request
must be sent to our Home Office. We may require return of the contract for an
endorsement. A change is valid only when it is received by us in our Home
Office; but, upon receipt it is effective as of the date that you signed the
written request. All changes are subject to any payments made or other action
taken by us before receipt of the written request.
Section 6. Payment to the Company
Purchase payment -- Your single premium purchase payment is shown on page 2. It
is payable on or before the Contract Date. After the first payment, no other
payments are due.
The payment will be allocated to the Fixed Account and/or Variable Account as
elected in your application.
Contract cancellation -- We reserve the right to cancel this contract if the
total cash value is less than $2,000 or would provide less than a $20 monthly
income payment at maturity.
We will send you a notice of our intent to cancel. When this contract is
cancelled, we will pay you the total cash value. Thereafter, we will be free of
any contract liability.
Section 7. Death benefit
Payment at Annuitant's death -- A lump sum payment shall be paid if the
Annuitant's death occurs prior to the Maturity Date and the contract has not
been surrendered for its total cash value or an annuity income option has not
been elected. The beneficiary may elect an annuity income option in place of the
lump sum payment.
Proof of the Annuitant's death must be sent to our Home Office. As of the date
we receive such
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proof, we will pay the beneficiary the greater of:
1. the total cash value of the contract, less any applicable premium tax;
or
2. the purchase payment paid under this contract less any partial
withdrawals.
Section 8. The Fixed Account
Allocation and credits to Fixed Account -- The Fixed Account will receive the
net payment allocated to it, guaranteed interest, excess interest and dollar
amounts transferred from the Variable Account.
On the date we receive your purchase payment for the Fixed Account, the net
payment will be allocated to this account. As of the date we receive your
request to transfer an amount from the Variable Account, such amount will be
deposited to the Fixed Account.
Guaranteed interest rate -- Prior to the Maturity Date, guaranteed interest will
be credited on a daily basis to the Fixed Account. The guaranteed interest rate
is shown on the Contract Data pages. This interest will be credited from:
1. the date the purchase payment is received by us; or
2. the date a dollar amount is transferred from the Variable Account.
The guaranteed interest rate and the guaranteed annuity income option rates are
established on the Contract Date. These rates will never be changed.
Excess interest rate -- We may pay interest in excess of the guaranteed amount.
This excess interest will be credited on a daily basis to the Fixed Account.
Transfers -- You may transfer money from the Fixed Account to various divisions
of the Variable Account. Any 1 transfer must be for an amount not less than
$200. A partial transfer may not be made if such transfer would reduce the Fixed
Account's cash value to less than $200.
Your written request to make a transfer must be sent to the Home Office. An
approved transfer will be made as of the date we receive your request.
Fixed Account cash withdrawal and surrender privilege -- You may at any time
during the Annuitant's lifetime and prior to the Maturity Date, elect to
withdraw part or surrender all of the fixed cash value. Any 1 withdrawal must be
for an amount not less than $200. We will deduct the surrender charges, if any,
from the fixed cash value. The amount due will be sent to you.
We will figure the fixed cash value of your account as of the date we receive
your written request. The written request must be in a form satisfactory to us.
The request must be sent to the Home Office. The payment is usually paid within
30 days. However, we reserve the right to postpone payment for not more than 6
months from the date your request was received by us. If payment is deferred
after the 30 days, we will continue to credit current interest, if any.
Surrender charge -- A surrender charge is deducted from your fixed cash value if
you make a cash withdrawal from or surrender the fixed cash value. The rate
varies by contract year as shown on the Contract Data pages.
Waiver of charges -- No surrender charge will apply:
1. on a partial withdrawal from the Fixed Account or a transfer to the
Variable Account if all the following occur:
a. it is made after the contract has been in force 2 years;
b. it is more than 12 months since the last transfer or withdrawal
was made; and
c. the amount is not more than 15 percent of the then current fixed
cash value.
2. on fixed cash value applied to annuity income Options 1, 2, 6 or 7.
3. income payments elected to be made in equal installments over a period
which extends to or beyond the eighth contract anniversary.
4. on or after the Maturity Date if the contract has been in force for at
least 8 years.
5. if a distribution is required by the Internal Revenue Code.
6. if the Annuitant is totally disabled, as defined by the Internal
Revenue Code, for a period of at least 3 months immediately prior to
the surrender or withdrawal request. Satisfactory proof of such
disability must be sent to the Home Office.
Guaranteed return of payment -- We guarantee the return of the net payment
credited to the Fixed Account upon surrender of this contract if:
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1. the contract has been in force more than 2 years; and
2. no cash withdrawals or transfers to the Variable Account have been
made from the Fixed Account.
Section 9. The Variable Account
Allocations to Variable Account -- The Variable Account will receive the net
payment allocated to it and dollar amounts transferred from the Fixed Account.
We will allocate these amounts, as you instruct, to the division(s) of the
Separate Account. These are processed as of the date we receive your payment or
the transfer request at the Home Office.
Within each division, the value of a variable accumulation unit is determined by
valuing daily the underlying securities within that division with a reduction
for operating expenses and then dividing the result by the outstanding number of
all variable accumulation units of that division of the Separate Account. The
value of each division's variable accumulation unit varies relative to the
experience of the corresponding mutual fund investments.
All dividends and other distributions paid by a mutual fund to a division shall
be used to purchase additional shares of the mutual fund which corresponds to
that division.
The increase or decrease in the number of variable accumulation units for a
particular transaction is determined by dividing the dollar amount of the
transaction by the unit value of the appropriate division.
The number of units the Annuitant has in a particular division on any date is
equal to the sum of variable accumulation units that have been added through net
payments, dividend distributions, and transfers from other divisions minus the
sum of variable accumulation units that have been withdrawn or transferred from
such division.
If shares of a mutual fund are no longer available for investment by the
Separate Account or if we determine further investments in a mutual fund are
inappropriate in view of the objectives of the contract issued, we may
substitute shares of another mutual fund for fund shares already purchased and
apply future purchase payments to the purchase of shares of the substitute
mutual fund or other securities. No substitutions will be made until prior
approval has been received from the Securities and Exchange Commission and we
receive prior favorable vote of a majority of the votes entitled to be cast by
persons having a voting interest in the mutual fund shares.
Transfers -- You may transfer money from the Variable Account to the Fixed
Account or between the various divisions of the Variable Account. The minimum
amount which may be transferred from 1 division to another or from an individual
division to the Fixed Account is $200 or the entire dollar value of such
division, whichever is less. No partial transfers may be made which would reduce
your interest in a division to less than $200.
Transfers may be made as often as you choose; however, no transfers between
divisions are allowed after income payments commence.
Variable Account cash withdrawal and surrender privilege -- You may at any time
during the Annuitant's lifetime and prior to the Maturity Date, elect to
withdraw part or surrender all of the variable cash value of this contract.
We will deduct the surrender charges, if any, from the amount being surrendered
or withdrawn. Any 1 withdrawal from an individual division must be for an amount
not less than $200. We will not allow a withdrawal which would reduce the
individual division's dollar value to less than $200.
We will figure the variable cash value as of the date your written request was
received by us. The amount of the payment due will be sent to you within 7 days
after the date such value was figured. The written request must be in a form
satisfactory to us. The request must be sent to the Home Office.
Surrender charge -- The surrender charge is deducted from your variable cash
value if you make a cash withdrawal from or surrender your Variable Account. The
charge varies by contract year as shown on the Contract Data pages.
Maximum surrender charge -- In no case will the surrender charge applied to the
variable cash value be greater than 8.5 percent of the purchase payment and
transfers attributable to the amount surrendered from the Variable Account.
Annual mortality risk, expense risk and distribution expense risk fee -- To
cover the mortality risk, expense risk and distribution expense risk fee not
included in the annual maintenance charge, we will charge your Variable Account
a weekly fee of an amount equivalent to 1.35 percent per year. Further details
of this fee are in the prospectus.
Voting rights -- We will vote shares held in the Separate Account according to
your instructions. We will send the notices and instructions to the person
having voting rights under
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this contract. Votes for which we do not receive instructions will be cast by us
in the same proportion as the votes for which instructions have been received.
Xxxxxx of surrender charge -- No surrender charge will be made:
1. on a partial withdrawal from the Variable Account if all the following
occur:
a. it is made after the contract has been in force 2 years;
b. it is more than 12 months since the last withdrawal was made; and
c. the amount is not more than 15 percent of the then current
variable cash value.
2. on variable cash value applied to annuity income Options 1, 2, 6 or 7.
3. if a distribution is required by the Internal Revenue Code.
4. if the Annuitant is totally disabled, as defined by the Internal
Revenue Code, for a period of at least 3 months immediately prior to
the surrender or withdrawal request. Satisfactory proof of such
disability must be sent to the Home Office.
Section 10. Annuity income options
Application of proceeds -- On the Maturity Date or the date we receive proof of
the Annuitant's death at the Home Office, the proceeds payable under this
contract shall be applied to the payment of the annuity income option elected.
The amount of proceeds equals the total cash value plus the purchase price of
any additional annuity benefits.
If the amount of proceeds to be applied under any 1 fixed or variable annuity
income option is less than $2,000 or would provide less than a $20 monthly
annuity income payment, the proceeds will be paid in a lump sum to the payee.
Prior to the payment of any annuity income option selected, we reserve the right
to verify the age of the payee and to make any adjustments necessary to reflect
the accurate payment for the proper age.
Option to purchase additional annuity benefits at maturity -- You may purchase
an additional annuity benefit at the Maturity Date. To do so, you must send a
written request to the Home Office. This request along with a payment for the
benefit must be received by us 30 days prior to the Maturity Date. We may limit
the amount of the additional benefit being purchased. The premium tax, if any,
will be deducted from this single payment.
Election of option -- At least 30 days prior to the Maturity Date you may elect
by written request an annuity income option or change a previous election. The
written request must be sent to the Home Office. If the Annuitant dies prior to
the Maturity Date and no election has been made, the beneficiary may elect an
annuity income option. This election must be made within 60 days after we
receive proof of the Annuitant's death.
Absence of election -- If no valid election has been made, the proceeds, if any,
will be paid as follows:
1. proceeds from the Fixed Account will be paid under a fixed annuity
income option in the form of a life income with 10-year period
certain.
2. proceeds from the Variable Account will be paid under a variable
annuity income option in the form of a life income with 10-year period
certain.
Supplemental contract -- We will issue supplemental contracts setting forth the
terms of the annuity income options chosen.
Unless otherwise provided in the supplemental contract, the first income payment
under each fixed option (Options 1, 2, 3, 4 and 5) and each variable option
(Options 6 and 7) shall be made no later than the first day of the month next
succeeding the date that proceeds are applied. Subsequent income payments will
be made as of the first day of each succeeding month unless another mode of
payment is selected and has been approved by us.
If the original payee dies, unless the supplemental contract provides otherwise,
the beneficiary of such payee will be paid:
1. under Options 1 and 6, the rest of the income payments during the
period certain, if any; or
2. under Options 3 and 4, the rest of the income payments due, if any; or
3. under Option 5, the proceeds due, if any.
Page 9
If no beneficiary is living at the time of the payee's death, the commuted
value, if any, of the remaining income payments or proceeds will be paid in a
lump sum to the estate of such payee. If the payee dies and the supplemental
contract does not provide for continued payments, the contract(s) will
terminate.
Under the supplemental contract, the commuted value of any option will be
figured at the interest rate used to determine the income payment. In no case
will income payments under Options 1, 2, 6 and 7 be commuted during the lifetime
of the original payees.
Unless you elect otherwise, the payee will have the right to terminate the
supplemental contract. In this case the payee will receive the commuted value in
1 lump sum.
Variable income payments -- The amount of proceeds being applied to the variable
income payments are allocated to the divisions of the Separate Account as
instructed. The dollar amount of the first monthly payment to be made under a
variable annuity income option will be determined by applying the amount of such
proceeds to the appropriate rate in the annuity income option tables, or if more
favorable to the payee, by such rate as may be shown in a corresponding table in
a variable annuity contract issued by us as of the date the proceeds are
applied.
The variable income payment of each division is determined by multiplying the
number of variable retirement units by the value of such unit for the
corresponding division. The total dollar amount of second and subsequent
variable income payments is determined by summing the payments of each division
of the Separate Account, where applicable.
Within each division, the number of variable retirement units is determined by
dividing (a) by (b) where:
(a) is the amount of the first monthly payment, and
(b) is the current value of a variable retirement unit in the appropriate
division on the valuation date coincident with the date that proceeds
were applied toward the variable annuity income option(s).
The number of such units will not change when figuring the second and subsequent
income payments except under Option 7 where such units will be reduced by one-
third upon the death of the first payee.
The second and subsequent payments of each division under the variable annuity
option(s) will be based on the investment experience of the corresponding mutual
fund(s). The value of each variable retirement unit for each division of the
Separate Account was initially set at $10.00 as of the date income payments were
first figured. Subsequent variable retirement unit values of any division are
determined by multiplying the previous variable retirement unit value by the
current net investment factor for such division.
The net investment factor for each division of the Separate Account is computed
by dividing (a) by (b) and multiplying by (c) where:
(a) is the division's current net asset value per share on the last
valuation date plus any dividends or other distributions in the
current valuation period;
(b) is the net asset value of such shares on the last valuation date of
the preceding valuation period, and
(c) is .995666 which reflects the annual rate of 1.35 percent asset charge
and the assumed interest rate of 4 percent per year.
The value of the net assets in the Separate Account shall be taken at their fair
market value, or where there is no readily available market, their fair value,
as determined in accordance with generally accepted accounting practice and
applicable laws and regulations. The value of each share for each division is
determined by dividing the net assets of each division by the number of shares
outstanding for each respective division.
Fixed annuity income options --
Option 1. Fixed life income with or without a period certain -- We will pay an
income based on the adjusted age of the payee for the period certain elected;
thereafter, we will pay income for the remaining lifetime of the payee. The
period certain may be 10, 15, or 20 years. If no period certain is requested, we
will pay an income during the lifetime of the payee. See Table 1 in Section 11.
Option 2. Joint life and survivor annuity -- We will pay an income for as long
as either or both payees live. The income will be based on the adjusted ages of
the 2 payees. Upon the death of 1 payee, the amount payable will be two-thirds
of the amount paid while both were living. Income payments will cease following
the death of the surviving payee. See Table 2 in Section 11.
Option 3. Income for a fixed period -- We will pay an income of a specified
number of
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years, 1 through 30 years. But, income payments cannot extend beyond the life
expectancy of the payee as defined by the Internal Revenue Code. The payments
will be made in equal installments. See Table 3 in Section 11.
Option 4. Income for a fixed amount -- We will pay an income of a specified
amount until the proceeds and interest at the rate of 4 percent per year are all
paid out to the payee. The income payments cannot extend beyond the normal life
expectancy of the payee, as defined by the Internal Revenue Code.
Option 5. Interest income payments -- We will hold the proceeds and pay interest
on such proceeds at a rate determined by us. The interest rate will never be
less than 4 percent per annum. Interest will be credited at the end of each
payment period as agreed upon.
The payee may elect another Option at the end of any payment period. Prior to
the end of the payment period and subject to the restrictions imposed by the
Internal Revenue Code, the payee may withdraw the proceeds in whole or in part
upon written request. Distributions of both principal and interest must begin no
later than the date specified by the Internal Revenue Code.
Variable annuity income options --
Option 6. Variable life income with or without period certain -- We will pay a
variable income based on adjusted age of the payee for the period certain
elected; thereafter, we will pay the variable income for the remaining lifetime
of the payee. The period certain may be 10, 15, or 20 years. If no period
certain is requested, we will pay a variable income during the lifetime of the
payee. See Table 1 in Section 11 for the initial payment. Subsequent payments
will be based on the investment experience of the underlying mutual fund.
Option 7. Variable income for joint life and survivor annuity -- We will pay a
variable income for as long as either or both payees live. The variable income
will be based on the adjusted age of the 2 payees. See Table 2 in Section 11 for
the initial payment. Subsequent payments will be based on the investment
experience of the underlying mutual fund. Upon the death of 1 payee, future
payments will be reduced by one-third. The variable income payments will cease
following the death of the surviving payee.
Other annuity options -- Upon your request, other fixed and variable annuity
options may be made available by us.
Basis of annuity income option tables -- These tables show the dollar amount of
monthly annuity income payments for the payee's adjusted age as follows:
1. the annuity income payment for each $1,000 of proceeds applied under a
fixed income option; and
2. the first annuity income payment for each $1,000 proceeds applied
under a variable annuity option.
The adjusted age is determined from each payee's attained age at the time the
first annuity income payment is due in the following manner:
Calendar Year Xxxxx's
of Xxxxx's Birth Adjusted Age
Before 1950 Attained age minus 2
1950 through 1964 Attained age minus 3
After 1964 Attained age minus 4
The amount of each fixed income payment under Options 1, 2 and 3 will never be
less than the rates shown in the annuity income option tables. The guaranteed
interest rate used for all fixed annuity income options is 4 percent per year.
Where mortality assumptions are involved, the guaranteed rates are based on the
1971 Individual Annuity Mortality Table. The fixed income payments under these
options may be increased as determined by us on an equitable basis to this class
of contracts.
An assumed interest rate of 4 percent per year will be used to calculate
commuted values under Options 6 and 7 and the first variable income payment of
either option. Where mortality assumptions are involved, the guaranteed rates
are based on the 1971 Individual Annuity Mortality Table.
Page 11
Section 11. Annuity income option tables
Table 1 -- Options 1 and 6
Income payments for life with or without a period certain
Equal monthly payments for each $1,000 of proceeds
-------------------------------------------------------------------------------------------------------------------
Age Period certain Age Period certain
of ---------------------------- of -----------------------------
payee Life 10 yrs 15 yrs 20 yrs payee Life 10 yrs 15 yrs 20 yrs
-------------------------------------------------------------------------------------------------------------------
55 5.09 5.03 4.95 4.84 68 6.96 6.62 6.21 5.69
56 5.19 5.11 5.02 4.90 69 7.20 6.80 6.32 5.74
57 5.29 5.20 5.10 4.97 70 7.46 6.98 6.43 5.78
58 5.39 5.30 5.19 5.03 71 7.74 7.18 6.54
59 5.50 5.40 5.28 5.10 72 8.05 7.37 6.64
60 5.62 5.51 5.37 5.17 73 8.39 7.58 6.74
61 5.75 5.62 5.46 5.24 74 8.75 7.78 6.83
62 5.88 5.74 5.56 5.31 75 9.15 7.99 6.91
63 6.03 5.86 5.66 5.38 76 9.59 8.20
64 6.19 6.00 5.77 5.44 77 10.06 8.40
65 6.36 6.14 5.87 5.51 78 10.58 8.59
66 6.54 6.29 5.98 5.57 79 11.15 8.78
67 6.74 6.45 6.10 5.63 80 11.77 8.96
-------------------------------------------------------------------------------------------------------------------
The age shown is the adjusted age of the payee when income payments begin. If
the income payments under Option 1 are to be paid other than monthly, multiply
the monthly income payments by 2.990 to obtain the quarterly payment; multiply
by 5.951 to obtain the semiannual payment; and multiply by 11.787 to obtain the
annual payment.
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Table 2 -- Options 2 and 7
Joint life income with two-thirds to survivor
Initial monthly income payments for each $1,000 of proceeds
-------------------------------------------------------------------------------------------------------------
Ages of
payees 55 56 57 58 59 60 61 62 63 64 65
-------------------------------------------------------------------------------------------------------------
60 5.31 5.37 5.42 5.48 5.53 5.59 5.65 5.71 5.78 5.84 5.91
65 5.57 5.64 5.70 5.77 5.84 5.91 5.98 6.06 6.13 6.21 6.29
70 5.87 5.94 6.02 6.10 6.18 6.27 6.35 6.45 6.54 6.64 6.74
-------------------------------------------------------------------------------------------------------------
The ages shown are the adjusted ages of the payees when income payments begin.
Amounts for combinations of ages not shown will be furnished upon request. If
the fixed income payments under Option 2 are to be paid other than monthly,
multiply the monthly income payment by 2.990 to obtain the quarterly payment;
multiply by 5.951 to obtain the semiannual payment; and multiply by 11.787 to
obtain the annual payment.
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Table 3 -- Option 3
Income payments for a fixed period
Equal monthly income payments for each $1,000 of proceeds
---------------------------------------------------------------------------------------
Number of Monthly Number of Monthly Number of Monthly
years in income years in income years in income
fixed period payment fixed period payment fixed period payment
---------------------------------------------------------------------------------------
1 84.84 11 9.31 21 5.81
2 43.25 12 8.69 22 5.64
3 29.40 13 8.17 23 5.49
4 22.47 14 7.72 24 5.35
5 18.32 15 7.34 25 5.22
6 15.56 16 7.00 26 5.10
7 13.59 17 6.71 27 5.00
8 12.12 18 6.44 28 4.90
9 10.97 19 6.21 29 4.80
10 10.06 20 6.00 30 4.72
---------------------------------------------------------------------------------------
If income payments under Option 3 are to be paid other than monthly, multiply
the monthly income payment by 2.990 to obtain the quarterly payment; multiply by
5.951 to obtain the semiannual payment; and multiply by 11.787 to obtain the
annual payment.
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