XXXXXX XXXX LIFE INSURANCE COMPANY [LOGO]
HOME OFFICE: 0 Xxxxxx Xxxx Xxxxx
Xxxxxxxxxxx, Xxxxxxxx 00000-0001
0-000-000-0000
MAILING ADDRESS: PO Box 4657
Springfield, IL 62708-4657
DEPOSIT ADMINISTRATION CONTRACT
(GROUP FLEXIBLE 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(s) ARE VARIABLE AND NOT GUARANTEED.
We agree to provide the benefits described in this contract.
Signed for the Company at Springfield, Illinois, as of the Contract Date.
/s/ Xxx Xxxxx /s/ Xxx Xxxxxxx /s/ Xxx X. Xxxxxxxx
--------------- --------------- -------------------
Presidents Countersigned Corporate Secretary
XXXXXX XXXX LIFE INSURANCE COMPANY [LOGO]
This deposit administration contract is a contract between the plan
administrator and Xxxxxx Xxxx Life Insurance Company. This contract provides for
the accumulation of value for retirement income.
TABLE OF CONTENTS
Starting on
Section Page
Contract specifications 3
1 Definitions of certain terms 4
2 Contract expense(s) 7
3 Investment accounts 8
4 Contribution provisions 10
5 Contract control and general provisions 12
6 Valuation provisions 15
7 Fixed Account liquidity provisions 16
8 Contract discontinuance 17
9 Effect of contract discontinuance 17
10 Death benefit 18
11 Annuity income options 19
12 Annuity income option tables 24
Endorsement(s)
Copy of application
Administrative notice(s)
XXXXXX XXXX LIFE INSURANCE COMPANY [LOGO]
CONTRACT SPECIFICATIONS
Contract Owner: [Chicago Public School District]
Contract effective date: [03/01/2002]
Contract jurisdiction: [Illinois]
Contract number: [0123456789]
Guaranteed interest rate:
Fixed Account: 3% per year prior to the start of income payments.
Variable Account: none
Guaranteed annuity income option rate: 3%
Contract term: [10] years.
Separate Account(s): [ ]
Endorsements: [ ]
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XXXXXX XXXX LIFE INSURANCE COMPANY [LOGO]
SECTION 1. DEFINITIONS OF CERTAIN TERMS
"Accumulation unit" is an accounting unit of measure used to calculate the
Separate Account values.
"Administrative notice" is a notice issued to and made a part of the contract.
"Annuitant" is the individual whose life shall serve as the measuring life for
purposes of annuity payments under this contract.
"Annuity commencement date" is the date as of which annuity payments to a
Participant are to begin as described under "Annuity income options" in this
contract. However, these will be in accordance with Code Section 401 (a)(9).
"Code" is the Internal Revenue Code of 1986, as amended, or any successor
thereto, along with the rulings and regulations issued thereunder.
"Company" is Xxxxxx Xxxx Life Insurance Company (may be referred to in this
contract as "we" or "us").
"Contract anniversary date" is the first day of a contract year after the first
contact year.
"Contract effective date" is the effective date of this contract. It is the date
from which contract years are determined.
"Contract Owner" is the named employer or benefit trust in the Master Group
Application (may be referred to in this contract as "you" and "your").
"Contract year" is a period of 12 months commencing with the contract effective
date or with any contract anniversary.
"Date of coverage" is the date on which the application made on behalf of a
Participant is received by the Company in good order.
"Fixed Account" refers to all assets of the Company other than those in the
Separate Account(s), or in any other separate investment account established by
the Company.
"Fund" is the underlying investment(s) to which net contributions may be
allocated under a Separate Account.
"Good order" is an authorized Participant or Contract Owner instruction to the
Company given with such clarity and completeness that the Company is not
required to exercise any discretion, utilizing such forms as the Company may
require.
"Home Office" is our executive office at 0 Xxxxxx Xxxx Xxxxx, Xxxxxxxxxxx, XX
00000-0000.
"Minimum death benefit" is the minimum amount payable upon the death of a
Participant prior to age 70 and before any annuity income option has commenced.
"Participant" is a person who participates in the plan and elects to participate
in this contract.
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XXXXXX XXXX LIFE INSURANCE COMPANY [LOGO]
"Participant's account" is a bookkeeping account to which the Fixed Account
values and Separate Account values held by the Contract Owner on behalf of a
Participant are allocated, together with credited earnings and losses and less
any prior surrenders (including transfers).
"Participant's contract year" is a period of 12 months commencing with the
Participant's date of coverage under this contract and each successive twelve 12
month period thereafter.
"Plan" is the deferred compensation plan, 403(b) plan or qualified retirement
plan that is funded by this contract.
"Premium tax" is the tax or amount of tax, if any, charged by a state or
municipality on premiums or contract value.
"Proof of death" is a certified copy of the death certificate or an order of a
court of competent jurisdiction.
"Related contract" is any plan funding vehicle identified by the Contract Owner
in writing and accepted by the Company for the purpose of calculating or
determining certain charges, services and/or benefits in connection with this
contract as set forth in an administrative notice.
"Related Participant directed account option" is any Participant directed
investment account under the plan as identified by the Contract Owner and
accepted by the Company for the purpose of Participant directed transfers of
amounts from the contract for investment outside of the contract.
"Separate Account" is the segregated asset account which receives and invests
net contributions allocated to it. The Separate Account(s) supporting this
contract are shown on the Contract Specifications page.
"Subaccount" is an account established within a Separate Account with respect
to a fund.
"Supplemental contract" is a contract issued to a Participant or beneficiary, in
order to effect an annuity income option under this contract.
"Supplemental contract owner" is the Participant or beneficiary to whom a
supplemental contract is issued.
"Termination value" for each Participant's account for any day prior to the
annuity commencement date is the value of the Participant's account on that
valuation day, less:
(a) any applicable premium taxes not previously deducted; and
(b) any applicable contingent deferred sales charges as shown on the
Contract Specifications page.
The portion of a Participant's termination value invested in a Separate Account
may decrease or increase from day to day and is determined by the daily unit
values of the Sub account(s) on the day of termination.
"Valuation day" is every day the New York Stock Exchange is open for trading on
which a value is
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XXXXXX XXXX LIFE INSURANCE COMPANY [LOGO]
calculated. The value of a Separate Account is determined as of the close of the
New York Stock Exchange on such days.
"Valuation period" is the period between close of business on successive
valuation days.
"Variable retirement unit" is an accounting unit of measure used to calculate
the Separate Account values for supplemental contract owners.
SECTION 2. CONTRACT EXPENSE(S)
ANNUAL MAINTENANCE CHARGE -- The annual maintenance charge, if applicable, is
deducted from the total accumulation value of the Participant's account or a
proportionate amount will be collected upon Participant's account termination.
The annual maintenance charge is deducted from the Subaccount containing the
greatest dollar amount or from the Fixed Account when none of the Subaccounts
have any value. This charge is shown in the endorsement listed on the Contract
Specifications page and covers the general maintenance of the Participant's
account.
CONTINGENT DEFERRED SALES CHARGES -- Surrenders and transfers from this contract
shall be subject to a contingent deferred sales charge. The contingent deferred
sales charge is a percentage of the Participant's account value transferred or
surrendered. The number of Participant's certificate years completed prior to
the surrender or transfer will determine the amount of the contingent deferred
sales charge. For the purpose of calculating the contingent deferred sales
charge only, the number of Participant's certificate years under this contract
shall be deemed to have commenced with the Participant's date of coverage under
a related contract, provided such related contract is so accepted by the Company
for such purpose.
(a) The contingent deferred sales charge to be applied under this contract
shall be equal to:
[5] percent of the surrendered or transferred amount from the
Participant's account during the Participant's first [5] certificate
years. After the Participant's [fifth] certificate year, surrenders or
transfers will no longer be subject to any deduction for contingent
deferred sales charges.
(b) The contingent deferred sales charge described in (a) above shall not
apply to an eligible surrender. For purposes of this contract, an eligible
surrender is a surrender, including a surrender applied to effect an
annuity income option under Section 11, "Annuity income options," where
such surrender is (1) made on account of a qualifying event and (2)
payable directly to the Participant, or, if applicable, to the
Participant's beneficiary. For the purposes of this contract, qualifying
events shall be those agreed to by the Contract Owner and the Company and
shall be delineated by endorsement to this contract.
(c) The contingent deferred sales charges shall not apply to a transfer of
contract values from this contract to a related Participant directed
account option or between the Fixed Account and/or the subaccounts of the
Separate Account(s) in this contract.
(d) Notwithstanding any other provisions of this contract, the contingent
deferred sales charge
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XXXXXX XXXX LIFE INSURANCE COMPANY [LOGO]
shall not apply if a Participant elects an annuity income option of at
least five years in duration.
DEDUCTION FOR MORTALITY AND EXPENSE RISK -- For assuming the mortality and
expense risk and administrative undertakings under this contract the Company
makes a deduction from the average daily net assets of the Separate Account(s)
as follows:
The annualized rate of the deduction for such risks and undertakings has
initially been set at the rate indicated in the table below. These deductions
may be decreased at the sole discretion of the Company, and may be increased by
the Company upon 90 days advance written notice to the Contract Owner, and
subject to a maximum deduction of 1.50 percent per year from the average daily
net assets of each investment option (subaccount) under the Separate Account(s)
included in this contract. Deductions applicable to each investment option
(subaccount) under the Separate Account(s) included in this contract may
increase or decrease based on the amount of assets under this contract.
The following table demonstrates the initial annualized rates of deduction for
assuming the mortality, expense and administrative undertakings to be applied
under this contract.
ANNUALIZED RATES OF DEDUCTION--
Group A Investment options Group B Investment options Group C Investment options
[1.25%] [1.25%] [1.25%]
SECTION 3. INVESTMENT ACCOUNTS
THE FIXED ACCOUNT
ALLOCATION AND TRANSFER TO FIXED ACCOUNT -- The Fixed Account will receive the
net contributions allocated to it and dollar amounts transferred from the
Separate Account(s).
As of the date we receive net contributions at the Home Office for the Fixed
Account, we will allocate the net contribution to this account. As of the date
we receive a Participant's valid request to transfer an amount from a Separate
Account, or as of a requested future date, we will deposit the transfer amount
to the Fixed Account.
GUARANTEED INTEREST RATE -- Guaranteed interest will be credited on a daily
basis to the Fixed Account. Interest will be credited from the date we receive
each net contribution or a dollar amount transferred from a Separate Account.
The guaranteed interest rate for the Fixed Account value prior to the start of
income payments is shown on the contact specifications page, but will in no
instance be less than 3 percent per year.
CURRENT INTEREST RATES -- We may pay interest in excess of the guaranteed
amount. The current interest rates for new net contributions and transferred
amounts are declared in advance and will be credited on a daily basis to the
Fixed Account. Similarly, the current interest rates for existing Fixed Account
values are declared in advance and will be credited on a daily basis to the
Fixed Account. Any excess interest paid, as we determine, will be applied on an
equitable basis. Current interest rates are not guaranteed and may be changed at
any time.
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XXXXXX XXXX LIFE INSURANCE COMPANY [LOGO]
COMPETING FUND(s) -- For purposes of applying the transfer restrictions
described under Section 4. "Contribution provisions," competing funds are those
specified as such in the most recent administrative notice which is attached to
and made part of this contract.
The Company reserves the right, in its sole discretion, to determine whether or
not any fund included in this contract on the effective date or subsequently
added to this contract after the effective date is or has become a competing
fund.
THE SEPARATE ACCOUNT(s)
ALLOCATIONS TO SEPARATE ACCOUNT(s) -- A Separate Account will receive the net
contributions allocated to it and dollar amounts transferred from the Fixed
Account. We will allocate these amounts, as the Participant instructs, to the
sub account(s) of the Separate Account(s).
We reserve the right to set a minimum allocation to a sub account and a maximum
number of subaccounts to which allocations can be made. These amounts are
processed as of the date we receive the net contribution or the transfer request
at the Home Office.
The various Separate Account subaccounts under this contract and the
corresponding investment funds for each subaccount are set forth in the most
recent administrative notice which is attached to and made part of this
contract. A list of the investment options selected by the Contract Owner and
available under this contract will be provided to the Contract Owner from time
to time in an administrative notice. The various investment options/subaccounts
available under this contract are set forth in accordance with the most recent
administrative notice issued by the Company. An administrative notice will be
furnished when investment options/subaccounts have been added, frozen,
eliminated or replaced under the contract. Such notice may also reflect
information relative to such investment options, including, but not limited to,
the applicable deduction for mortality and expense risk and administrative
undertakings, its classification as a competing fund (if applicable), and any
applicable transfer restrictions.
Within each subaccount, the value of an accumulation unit is determined by
valuing daily the underlying securities within that subaccount with a reduction
for operating expenses. That result is divided by the outstanding number of all
accumulation units of that subaccount. The value of each subaccount's
accumulation unit depends on the investment experience of the underlying fund.
The increase or decrease in the number of accumulation units for a particular
transaction is determined by dividing the dollar amount of the transaction by
the unit value of the appropriate subaccount.
The number of units the Contract Owner has in a subaccount on any date is equal
to the sum of accumulation units that have been added through net contributions
and transfers minus the sum of accumulation units that have been withdrawn or
transferred.
If shares of an underlying fund are no longer available for investment by the
Separate Account or if we determine further investments in an underlying fund
are inappropriate in view of the
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XXXXXX XXXX LIFE INSURANCE COMPANY [LOGO]
objectives of the contract issued, we may substitute shares of another
underlying fund for fund shares already purchased and apply future net
contributions to the purchase of shares of the substitute underlying fund.
The Company also reserves the right, in its sole discretion and subject to
compliance with applicable law, to add, replace or delete the Separate
Account(s) and/or fund(s) (with or without differing investment objectives) to
or from this contract, and to terminate ongoing contributions to the Separate
Accounts) and/or fund(s) under this contract, provided the Company gives the
Contract Owner 30 days advance written notice of its intent to do so, and
further provided that the Company takes the same action(s) with respect to all
contracts of the same class and risk characteristics. If the Company adds
additional Separate Account(s) and/or fund(s) to this contract, the Separate
Account(s) and/or fund(s) so added will be subject to the charges, fees and
transfer restrictions then in effect for such Separate Account(s) and/or fund(s)
at the time they are added to this contract.
SECTION 4. CONTRIBUTION PROVISIONS
CONTRIBUTIONS -- During each contract year, the Contract Owner will remit to the
Company all contributions to be made on behalf of the Participant. Net
contributions will be applied by the Company to the Fixed Account and/or the
Separate Account(s) for accumulation units in the Separate Account(s) on behalf
of a Participant in accordance with the valuation provisions and the
instructions of the Contract Owner or, with the consent of the Contract Owner,
the instructions of the Participant. The minimum contribution which may be made
at any time on behalf of any Participant is $30, except where the Plan requires
a lesser amount which in any event may not be less than $10.
ALLOCATION OF CONTRIBUTIONS -- The Contract Owner, or the Participant, if
applicable, shall specify that portion of a net contribution on behalf of a
Participant to be allocated to the Fixed Account and/or to each subaccount of a
Separate Account in multiples of 10 percent or a lower multiple as specified by
the Company from time to time. Such allocation may be changed by written notice
submitted to the Company with each net contribution.
TRANSFER OR RE-ALLOCATION OF CONTRACT VALUES WITHIN THE CONTRACT/RELATED
CONTRACTS -- With respect to a Participant's account, the Contract Owner, or the
Participant, if applicable, may transfer monies between accounts under this
contract, subject to the provisions of this Section 4. If elected by the
Contract Owner and agreed to by the Company, such transfers may also be made
between accounts under this contract and a related Participant directed account
option.
Separate Account values may be re-allocated between sub accounts within the
Separate Account(s) or, if applicable, between subaccounts within separate
account(s) under a related contract and transferred to the Fixed Account at any
time.
Fixed Account values may be transferred to one or more subaccounts within the
Separate
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XXXXXX XXXX LIFE INSURANCE COMPANY [LOGO]
Account(s) or, if applicable, to one or more subaccounts within a separate
account under a related contract. The Company may limit the sum of any such
transfers for a Participant's account in any contract year to the greater of
[25] percent of the Fixed Account value of such Participant's account as of the
end of the preceding contract year or the amount transferred under this
provision with respect to such Participant's account in the preceding contract
year.
In addition, a transfer of contract values within the contract or, if
applicable, between this contract and a related contract, is subject to the
following restrictions:
Transfers of assets held in the Fixed Account, or which were held in the Fixed
Account at any time during the preceding 30 day period, to a competing fund are
prohibited. Similarly, transfers of assets held in a competing fund, or which
were held in a competing fund or the Fixed Account during the preceding 30 days,
to the Fixed Account are prohibited. Competing fund{s) shall also include any
investment options under a related contract, as determined by the Company in its
sole discretion.
TERMINATION OF CONTRIBUTIONS ON BEHALF OF A PARTICIPANT -- After termination of
contributions on behalf of a Participant, the Contract Owner may continue the
Participant's account in force under the contract or notify the Company as to
the manner in which the termination value of the Participant's account is to be
disbursed under the plan document's did minimums rule.
ROLLOVERS -- Rollovers are allowed unless specifically excluded by the plan
document.
SECTION 5. CONTRACT CONTROL AND GENERAL PROVISIONS
THE CONTRACT -- This contract, the most recent administrative notice issued in
conjunction with this contract and the application for the contract which is
attached hereto when issued to the Contract Owner, constitute the entire
contract. All statements in the application shall, in the absence of fraud, be
deemed representations and not warranties. No statement shall void this contract
or be used in defense of a claim under it unless contained in the written
application for this contract. Contract years, months and anniversaries shall be
computed from the contract effective date.
The Contract Owner has the power to exercise all the rights, privileges and
options granted by this contract or permitted by the Company and to agree with
the Company to any change in or amendment to the contract. The assets and income
of this contract may not be used for or diverted to purposes other than the
exclusive benefit of Participants and their beneficiaries, except as permitted
under the Code, The preceding sentence does not limit the Company's exercise of
the rights granted to the Company by this contract, including the right to
deduct and retain amounts specified in the contract.
All statements made in the Participant's application or enrollment forms under
the plan, in the absence of fraud, will be treated as representations and not as
warranties. If we challenge a claim, we agree to use only written statements
made in this contract and the certificate, if any.
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XXXXXX XXXX LIFE INSURANCE COMPANY [LOGO]
BENEFICIARY -- The beneficiary is the person to whom any death benefit from the
contract on behalf of a Participant is payable in the event of the Participant's
death. The beneficiary is designated by (and may be changed by) the Participant,
subject to any rules established by the Contract Owner or the Company, subject
to applicable state or federal law. The surviving spouse will be the designated
beneficiary when required by law. If no designated beneficiary remains living at
a Participant's death, the Participant's estate is the beneficiary.
ASSIGNMENT ON BEHALF OF PARTICIPANT -- Amounts held under the contract on behalf
of a Participant are nontransferable and cannot be sold, assigned, or pledged as
security, for a loan or for any other purpose to any person other than the
Company, except as permitted under the Code and the terms of this contract.
ASSIGNMENT ON BEHALF OF CONTRACT OWNER -- The Contract Owner's interest in this
contract may be assigned only if agreed to by the Company. The Contract Owner
agrees to provide the Company with such information as the Company may
reasonably request concerning any proposed assignment. The Company assumes no
responsibility for the validity of any assignment.
MODIFICATION OF THE CONTRACT -- This contract may be modified at any time by
written agreement between the Contract Owner and the Company. In addition, this
contract may be modified at any time by the Company to comply with applicable
law. No modification may operate in a manner inconsistent with the contract
control and general provisions of this contract. No modification will affect the
amount or term of any annuities begun prior to the effective date of the
modification, unless it is required to conform this contract to, or give the
Contract Owner the benefit of any federal or state statutes or any rule or
regulation of the United States Treasury Department.
On and after the fifth contract anniversary date, the Company may modify any or
all of the terms of this contract upon 90 days advance written notice of such
change to the Contract Owner. In the absence of written dissent by the Contract
Owner within 30 days of such notice, consent to such change is assumed.
Notwithstanding any such changes, the annuity tables, guaranteed interest rates
and contingent deferred sales charges which apply on the date of coverage of a
Participant's account will continue to apply to all contributions made to such
Participant's account.
The Company may also modify this contract in any manner it deems necessary or
appropriate to satisfy the requirements of any law or regulation applicable to
it.
Any modification of this contract requires the signature of the President, a
Vice President, a Secretary, or an Assistant Secretary of the Company.
SUSPENSION OF THE CONTRACT -- The Contract Owner may suspend this contract upon
90 days advance written notice to the Company at its Home Office in Springfield,
Illinois (or at any other address the Company may specify). The contract will be
suspended automatically on a contract anniversary date if the Contract Owner
fails to assent to any modifications, as described under modification of the
contract above, which would have been effective on or before that
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XXXXXX XXXX LIFE INSURANCE COMPANY [LOGO]
contract anniversary date. On suspension, contributions will be accepted by the
Company on behalf of Participants covered under the contract prior to the date
of suspension, but no contributions will be accepted on behalf of new
Participants. Suspension of the contract will not affect payments to be made by
the Company under an annuity income option that commenced prior to the date of
suspension or with respect to required minimum distribution rules.
NON-PARTICIPATING -- This contract does not share in the surplus earnings of the
Company.
REPORTS TO THE CONTRACT OWNER -- The Company will, shortly following the end of
each calendar year, transmit to each Contract Owner a written statement of
account showing the total value of Fixed Account and Separate Account interests
held under this contract. Other administrative responsibilities may be assumed
by the Company by way of a separate administrative service agreement and do not
infer any additional rights or privileges under this contract.
VOTING RIGHTS -- The Company shall cause the Contract Owner to be advised, in a
timely manner, of any fund(s) shareholders' meetings at which the fund shares
held for the Contract Owner may be voted. The Company shall also cause to be
sent to the Contract Owner proxy materials and a form of instruction by means of
which the Contract Owner can instruct the Company with respect to the voting of
the fund shares held under the contract. In connection with the voting of fund
shares held by it, the Company shall arrange for the handling and tallying of
proxies received from the Contract Owner. The Company, as such, shall have no
right, except as herein provided, to vote any fund shares held by it hereunder
which may be registered in its name or the names of its nominees.
The Company will vote the fund shares held by it under this contract in
accordance with the instructions received from the Contract Owner. If the
Contract Owner desires to attend any meeting at which the fund shares held for
the Contract Owner's benefit may be voted, the Contract Owner may request that
the Company furnish a proxy or otherwise arrange for the exercise of voting
rights with respect to the fund shares held for such Contract Owner's account.
In the event the Contract Owner gives no instructions or leaves the manner of
voting discretionary, the Company will vote such shares of each fund in the same
proportion as shares of that fund held in the same Separate Account for which
instructions have been received.
When this contract is used to fund a 403(b) plan the certificate Owner shall
exercise all voting rights heretofore specified.
INFORMATION FROM THE CONTRACT OWNER -- The Contract Owner will furnish any
information which the Company may reasonably require to administer this
contract. If the Contract Owner cannot furnish any required item of information,
the Company may request the person concerned to furnish the information. The
Company will not be liable for the fulfillment of any obligations under this
contract which are dependent upon that information unless and until it receives
such information in a form satisfactory to it.
INDIVIDUAL CERTIFICATES -- The Company may issue a certificate to each
Participant for whom contributions are being made to this contract and for whom
an annuity has not yet been
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XXXXXX XXXX LIFE INSURANCE COMPANY [LOGO]
effected. A certificate will evidence the contributions being made to this
contract and describe the Participant's rights and duties under this contract.
EXPERIENCE CREDITS -- The Company may, at its sole discretion, apply experience
credits under this contract based on investment, administrative, mortality or
other factors. Experience credits may be applied, either prospectively or
retrospectively, as a reduction in the deduction for mortality and expense risk
and administrative undertakings, a reduction in the term or amount of any
applicable contingent deferred sales charges, an increase in the rate of
interest credited under the contract, a payment to be allocated as directed by
the Contract Owner, or any combination of the foregoing. The Company may apply
and allocate experience credits in such manner as the Company deems appropriate.
Experience credits are not guaranteed and may be discontinued at the Company's
discretion.
PLAN DOCUMENT -- This contract shall be governed by the plan document which
shall comply with the Code relative to the plan's intended tax qualification
status.
PLAN CHANGES -- The Contract Owner will furnish the Company a copy of the
deferred compensation plan, or qualified retirement plan which is funded by this
contract, prior to or concurrent with issuance of the contract. While this
contract remains in force, the Contract Owner will also furnish a copy of each
amendment to such plan. The terms of the plan are those in effect on the
contract effective date. Plan amendments received by the Company will also apply
to this contract unless the Company notifies the Contract Owner otherwise within
90 days following its receipt of the plan amendment. The Company will not
unreasonably withhold consent subject to the applicable state or federal rules,
regulations or law.
GOVERNING LAW -- This contract will be governed by and construed in accordance
with the laws of the contract jurisdiction set forth on page 3 of this contract.
This contract shall be deemed to include any provisions required by the state
where it was issued. This contract will conform to any requirements of federal
law concerning deferred compensation or retirement plans.
NOWAIVER -- The Company may, in its sole discretion, elect not to exercise a
right or reservation specified in this contract. Such election shall not
constitute a waiver of the right to exercise such right or reservation at any
subsequent time, nor shall it constitute a waiver of any other provisions of the
contract.
WITHDRAWALS -- Withdrawals are subject to the terms of this contract and the
plan document. If there is conflict between the contract and plan document, the
plan document will control.
SECTION 6. VALUATION PROVISIONS
NET CONTRIBUTIONS -- The net contribution to the contract on behalf of a
Participant is equal to the total contributions made on behalf of that
Participant less any applicable premium taxes. The net contribution for the
Fixed Account or Separate Account(s) (determined in accordance with the account
allocation percentages elected) is applied to provide Fixed Account values or
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XXXXXX XXXX LIFE INSURANCE COMPANY [LOGO]
Separate Account accumulation units. The number of accumulation units credited
to a Separate Account is determined by dividing the net contribution for that
account by the dollar value of one accumulation unit next computed after the
receipt of the contribution by the Company.
Distributed earnings with respect to the underlying fund(s) will be credited to
the Contract Owner by increasing the value of units of interest held under this
contract, not by increasing the number of accumulation units held under this
contract. The number of accumulation units so determined will not be affected by
any subsequent change in the value of accumulation units. The accumulation unit
value in a Separate Account may decrease or increase from day to day as
specified below.
NET INVESTMENT RATE AND NET INVESTMENT FACTOR -- The Fixed Account net
investment rate applicable to this contract for any day is guaranteed to be at
least the rate shown under the contract specifications section of this contract.
The net investment rate for each subaccount in each of the Separate Account(s)
for any day is equal to the gross investment rate for such subaccount expressed
in decimal form to at least six decimal places, less applicable deductions by
the Company for mortality and expense, income option, and administrative
undertakings are shown on the Contract Specifications page of the contract. The
gross investment rate for a subaccount is
(a) its investment income for the valuation day plus its capital gains
and minus its capital losses, whether realized or unrealized, and
less a deduction for any applicable taxes arising from the income
and the realized and unrealized capital gains attributable to that
subaccount, divided by
(b) the value of that subaccount on the previous valuation day.
The net investment factor for each subaccount is the sum of 1.000000 plus the
net investment rate for that account.
SEGREGATION OF SEPARATE ACCOUNT ASSETS -- That portion of the assets of a
Separate Account equal to the reserves and other contract liabilities of the
Separate Account shall not be chargeable with liabilities arising out of any
other business the Company may conduct. The assets of a Separate Account are
segregated from all other assets of the Company and are subject only to the
claims of contracts participating in such Separate Account.
ACCUMULATION UNIT VALUE -- The value of an accumulation unit for each sub
account of a Separate Account was set at an initial fixed value on the date the
subaccount was established. The value of the respective accumulation units for
any subsequent day is determined by multiplying the accumulation unit value for
the preceding valuation day by the net investment factor for that subaccount
for the current valuation day.
SECTION 7. FIXED ACCOUNT LIQUIDITY PROVISIONS
Prior to the date of discontinuance as defined in the contract discontinuance
provisions in
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XXXXXX XXXX LIFE INSURANCE COMPANY [LOGO]
Section 8, a request for a surrender or transfer of Fixed Account values in the
contract may be made at any time; provided, however, any and all such requests
shall be subject to the transfer restrictions set forth in Section 4 and the
liquidity provisions set forth in paragraphs (a) and (b) of this Section 7, the
plan and the relevant state and/or federal law except with respect to required
minimum distribution rules.
(a) Notwithstanding any benefits which may be payable to Participants or
beneficiaries under the terms of the plan, including, but not limited to,
benefits under the plan on account of retirement, death, separation from
service, or financial hardship, the Contract Owner specifically agrees
that the Company has the absolute right to deny any request for any
surrender or transfer of Fixed Account values in the contract, when the
sum of all requests for surrenders and transfers of such Fixed Account
values in any contract year exceeds the greater of:
(1) [25] percent of the Fixed Account values held in the contract at
the end of the immediately preceding contract year, or
(2) the amount surrendered or transferred under this provision in
the preceding contract year.
The Company reserves the right to defer any request for a surrender or
transfer in excess of (1) or (2). Any surrender or transfer request
deferred to a later contract year shall be counted towards, and shall be
subject to, the limit applicable to the contract year to which such
surrender or transfer is deferred.
(b) Unless the Contract Owner gives the Company written direction
otherwise, deferred surrenders and transfers shall be made in the order
originally received.
SECTION 8. CONTRACT DISCONTINUANCE
This contract shall be discontinued:
(a) if the Contract Owner gives written notice to the Company that the
contract is being discontinued, in which event the date of discontinuance
shall be the later of:
(1) the first business day following the date on which such notice
is received by the Company at its Home Office in Springfield,
Illinois, or
(2) the business day specified in such notice; or
(b) if no contributions are made to the contract with respect to a
contract year and the Company gives written notice to the Contract Owner
that the date of discontinuance will occur as of the date specified in
such notice, such date not to be earlier than 31 days after the date such
notice is mailed by the Company; or
(c) notwithstanding any provision of this contract to the contrary, after
five completed contract years, the Company shall have the right, in
accordance with its existing administrative practices and procedures, to
discontinue the contract and pay all contract values without
15
XXXXXX XXXX LIFE INSURANCE COMPANY [LOGO]
application of contingent deferred sales charges under the contract, to
the Contract Owner in full, provided that the Company gives the Contract
Owner 90 days advance written notice, and further provided that the
Company takes the same action with respect to all contracts of the same
class and risk characteristics.
SECTION 9. EFFECT OF CONTRACT DISCONTINUANCE
On and after the date of discontinuance as defined in the contract
discontinuance provisions of Section 8, no contributions will be payable to, or
accepted by, the Company. Notwithstanding any other provision of this contract
to the contrary, after the date of discontinuance, contract values shall be paid
in accordance with paragraph (c) of Section 8 or this Section 9.
FIXED ACCOUNT VALUES -- The total amount of all Fixed Account values under the
contract shall be reduced as of the date of discontinuance, by any:
(a) premium taxes not previously deducted, and
(b) contingent deferred sales charges as set forth in the contract
specifications, except where discontinuance is effected under Section
8(c).
The resulting amount shall be referred to as the "balance at discontinuance."
Notwithstanding any benefits which may be payable to participants or
beneficiaries under the terms of the plan, including, but not limited to,
benefits under the plan on account of retirement, death, separation from
service, or financial hardship, the Contract Owner specifically agrees that the
Company has the absolute right to pay the balance at discontinuance in five
equal installments, plus any interest due, annually over a period of five years.
The Company shall pay the first such installment not later than 30 days after
the date of discontinuance. The remaining four installments, plus interest,
shall be payable on each successive anniversary of the date of discontinuance.
The balance at discontinuance shall be credited with interest at a rate of not
less than 3 percent per year commencing on the date of discontinuance.
CONTRACT FUNDS HELD UNDER THE SEPARATE ACCOUNT(S) -- As of the date of
discontinuance, all contract funds held under the Separate Account(s) shall be
reduced by any:
(a) premium taxes not previously deducted, and
(b) contingent deferred sales charges as set forth in the contract
specifications, except where discontinuance is effected under Section
8(c).
The resulting amount shall be paid within seven days following the date of
discontinuance except as the Company may be permitted to defer payment under
applicable law.
SECTION 10. DEATH BENEFIT
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XXXXXX XXXX LIFE INSURANCE COMPANY [LOGO]
PAYMENT AT PARTICIPANT'S DEATH -- The death benefit shall be paid upon the
Participant's death if the certificate, if any, has not been surrendered and the
effective date of a selected annuity income option has not occurred. The
beneficiary may receive the death benefit by electing an annuity income option
or a lump sum payment in accordance with the plan.
Proof of the Participant's death must be sent to our Home Office. As of the date
we receive such proof, we will pay the beneficiary the death benefit, which is
the greater of:
1. the total value of the Participant's account less any applicable
premium tax; or
2. the sum of all contributions under the Participant's account, less any
applicable premium tax, any outstanding loan balance and withdrawals.
REQUIRED DISTRIBUTIONS AT DEATH -- Distributions will be paid as required by the
Code and the plan document.
SECTION 11. ANNUITY INCOME OPTIONS
APPLICATION OF PARTICIPANT'S ACCOUNT VALUE -- On the effective date of an
annuity income option, the requested portion of the Participant's account value
payable under the Participant's account shall be applied to the payment of the
annuity income option elected.
If the Participant's account value to be applied under any one fixed or variable
annuity income option is less than $2,000 or would provide less than a $20
monthly annuity income payment, we will pay the Participant's account value 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 correct age.
ELECTION OF OPTION -- At least 30 days prior to the requested effective date of
an annuity income option, the Participant may elect by written request an
annuity income option or change a previous election. We must receive the written
request at the Home Office. Income payments must begin no later than specified
in the Code, If the Participant dies before the effective date of the annuity
income option, the beneficiary may elect an annuity income option. This election
must be made within 60 days after we receive proof of the Participant's death.
SUPPLEMENTAL CONTRACT -- We may issue a supplemental contract for each annuity
income option chosen.
MISSTATEMENT OF AGE -- If the age of a Participant or any other payee has been
misstated, the annuity income payments under the supplemental contract will be
that amount which the Participant's account value 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, 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
17
XXXXXX XXXX LIFE INSURANCE COMPANY [LOGO]
6 percent per year.
PROOF OF SURVIVAL -- We may require proper proof that a payee, beneficiary, or a
Participant is living when payment depends upon such person's survival. Proof
includes a dated and witnessed signature.
PAYMENT START DATE -- For Options 1,2,3,4,6 and 7, the first payment will be
made on or before the 15th business day of the month following receipt of the
Participant's request and the effective date of the annuity income option.
Subsequent income payments for these options will be made as of the first
business day of each succeeding month, unless another mode of payment is
selected by the supplemental Contract Owner and has been approved by us. For
Option 5, the income payments will be made as of the first business day after
the end of the payment period.
If the original payee dies after income payments begin, 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 present value plus unpaid interest, if any.
If no beneficiary is living at the time of the payee's death, the present value,
if any, of the remaining income payments will be paid in a lump sum to the
estate of such payee. If the payee dies and the option elected does not provide
for continued payments, the supplemental contract will terminate.
Under the supplemental contract, the present value of any option will be figured
at the interest rate used to determine the income payment. In no case will a
lump sum distribution be allowed under Options 1,2,6 and 7 during the lifetime
of the original payee(s).
Unless the supplemental Contract Owner elects otherwise, the payee will have the
right under Options 3, 4, and 5 to terminate the supplemental contract. In this
case the payee will receive the present value in one lump sum payment.
VARIABLE INCOME PAYMENTS -- The Participant's account value applied to the
variable income payments is allocated to the subaccount(s) as instructed by the
supplemental contract owner (Participant). Not all subaccount(s) may be
available for income payments. The dollar amount of the first monthly payment
from each subaccount to be made under a variable annuity option will be
determined by applying the amount of the Participant's account value allocated
to that subaccount to the appropriate rate in the annuity income option tables.
The variable income payment from each subaccount is determined by multiplying
the number of variable retirement units by the value of such unit for the
corresponding subaccount.
Within each subaccount, the number of variable retirement units is determined
by dividing the:
- amount of the first monthly payment by
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XXXXXX XXXX LIFE INSURANCE COMPANY [LOGO]
- the value of the variable retirement unit in the appropriate
subaccount on the valuation day coincident with the date that the
Participant's account value was applied toward the variable annuity
option(s).
The number of such units will not change when figuring the second and subsequent
income payments. Under Option 7, such units will be reduced upon the death of
the first payee to the survivor percentage previously elected by the
supplemental Contract Owner (Participant).
The second and subsequent payment(s) will be based on the investment experience
of the underlying fund(s) and will be affected by the mortality risk and expense
risk fee shown in the supplemental contract. The value of each variable
retirement unit for each subaccount was initially set at $10 as of the date
income payments were first calculated. Subsequent variable retirement unit
values of any subaccount are determined by multiplying the previous variable
retirement unit value by the current net investment factor.
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.
FIXED ANNUITY INCOME OPTIONS
OPTION 1. FIXED LIFE INCOME WITH OR WITHOUT PERIOD CERTAIN -- We will pay an
income based on the attained 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.
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 ages of the two
payees. Upon the death of one payee, future payments will be reduced to the
survivor percentage elected. Income payments will cease following the death of
the surviving payee. See Tables 2, 3 and 4.
OPTION 3. INCOME FOR A FIXED PERIOD -- We will pay an income for a specified
number of years, one through 30 years. But, income payments cannot extend beyond
the life expectancy of the payee, as defined by the Code. The payments will be
made in equal installments. The payee may withdraw a part of the present value
of future benefits upon written request. Following a withdrawal, the remaining
payments will be recalculated. See Table 5.
OPTION 4. INCOME FOR A FIXED AMOUNT -- We will pay an income of a specified
amount until the Participant's account value and interest are all paid out to
the payee. The income payments cannot extend beyond the life expectancy of the
payee, as defined by the Code. The payee may withdraw a part of the present
value of future benefits upon written request. Following a withdrawal, the
remaining number of payments will be adjusted.
OPTION 5. INTEREST INCOME PAYMENTS -- We will hold the Participant's account
value and pay interest at a rate we determine. The interest rate will never be
less than the income option rate specified on the contract specifications page.
Interest will be credited at the end of each payment period. The payee may elect
another option at the end of any payment period. Subject
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XXXXXX XXXX LIFE INSURANCE COMPANY [LOGO]
to the restrictions imposed by the Code, the payee may withdraw the value of the
supplemental contract held under this option, in whole or in part, upon written
request. Distributions of both principal and interest must begin no later than
the date specified by the Code.
VARIABLE ANNUITY INCOME OPTIONS
OPTION 6. VARIABLE LIFE INCOME WITH OR WITHOUT PERIOD CERTAIN -- We will pay a
variable income based on the attained 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 for the initial payment. Subsequent payments will be based on the
investment experience of the underlying 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 ages of the two payees. See Table 2, 3 or 4 for the initial
payment. Subsequent payments will be based on the investment experience of the
underlying fund. Upon the death of one payee, future payments will be reduced to
the survivor percentage elected. The variable income payments will cease
following the death of the surviving payee.
OTHER ANNUITY OPTIONS -- Upon the Participant's request, we may make other fixed
and variable annuity options available.
BASIS OF ANNUITY INCOME OPTION TABLES -- The following tables show the dollar
amount of monthly annuity income payments for the payee's attained age when the
supplemental contract is issued.
The amount of each fixed income payment under Options 1, 2 and 3 will never be
less than that shown in the annuity income option tables at the time the
supplemental contract is issued. The guaranteed annuity income option rate used
for all fixed annuity income options is shown on the contract specifications
page. The guaranteed factors for lifetime options are unisex and based on the
Annuity 2000 Mortality Table using 100 percent female mortality. The income
payments under these options may be increased as we determine.
The age used in the annuity income option tables is the attained age of the
payee when income payments begin. Amounts for ages not shown or for quarterly,
semi-annual or annual payments will be furnished upon request.
The interest rate used in the annuity income option tables is that shown on the
Contract Specifications page.
MINIMUM DISTRIBUTIONS -- Any distribution to a Participant under these annuity
income options shall be made in accordance with the provisions of the plan
established by the Contract Owner, but in no event will such distribution be
made at a time or in a method that fails to satisfy the requirements of the
Code.
20
XXXXXX XXXX LIFE INSURANCE COMPANY [LOGO]
SECTION 12. ANNUITY INCOME OPTION TABLES
TABLE 1-OPTIONS 1 AND 6
Income Payments for life with or without a period certain
Initial monthly income payments for each $1.000 of Participant's account value
Attained Period certain Attained Period certain
age of ------------------------------- age of -------------------------------
payee Life 10yrs 15 yrs 20 yrs payee Life 10 yrs 15 yrs 20 yrs
-------- ---- ----- ------ ------- -------- ---- ------ ------ ------
55 4.19 4.16 4.12 4.06 68 5.73 5.55 5.30
56 4.27 4.24 4.19 4.12 69 5.91 5.70 5.41
57 4.35 4.32 4.27 4.19 70 6.11 5.86 5.53
58 4.44 4.40 4.34 4.25 71 6.32 6.02 5.64
59 4.54 4.49 4.42 4.32 72 6.55 6.20
60 4.64 4.58 4.51 4.39 73 6.80 6.38
61 4.75 4.68 4.59 4.46 74 7.07 6.57
62 4.86 4.79 4.68 4.53 75 7.37 6.76
63 4.98 4.90 4.78 4.60 76 7.68 6.96
64 5.11 5.01 4.88 4.67 77 8.03 7.16
65 5.25 5.14 4.98 4.75 78 8.40 7.36
66 5.40 5.26 5.08 79 8.80 7.56
67 5.55 5.40 5.19 80 9.23
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XXXXXX XXXX LIFE INSURANCE COMPANY [LOGO]
TABLE 2 -- OPTIONS 2 AND 7
Joint life income with 50 percent to survivor
Initial monthly income payments for each $1,000 of Participant's account value
Attained
ages of
payees 55 56 57 58 59 60 61 62 63 64 65
-------- ---- ---- ---- ---- ---- ---- ---- ---- ---- ---- ----
55 4.19
56 4.23 4.27
57 4.27 4.31 4.35
58 4.31 4.36 4.40 4.44
59 4.36 4.40 4.44 4.49 4.54
60 4.40 4.45 4.49 4.54 4.59 4.64
61 4.45 4.50 4.54 4.59 4.64 4.69 4.75
62 4.50 4.55 4.59 4.64 4.69 4.75 4.80 4.86
63 4.55 4.60 4.65 4.70 4.75 4.80 4.86 4.92 4.98
64 4.61 4.65 4.70 4.75 4.81 4.86 4.92 4.98 5.04 5.11
65 4.66 4.71 4.76 4.81 4.87 4.92 4.98 5.05 5.11 5.18 5.25
66 4.72 4.77 4.82 4.87 4.93 4.99 5.05 5.11 5.18 5.25 5.32
67 4.78 4.83 4.88 4.94 5.00 5.06 5.12 5.18 5.25 5.32 5.40
68 4.84 4.89 4.95 5.00 5.06 5.12 5.19 5.26 5.33 5.40 5.48
69 4.90 4.96 5.01 5.07 5.13 5.20 5.26 5.33 5.41 5.48 5.56
70 4.97 5.03 5.08 5.14 5.21 5.27 5.34 5.41 5.49 5.56 5.65
22
XXXXXX XXXX LIFE INSURANCE COMPANY [LOGO]
TABLE 3 -- OPTIONS 2 AND 7
Joint life income with 66 2/3 percent to survivor
Initial monthly income payments for each $1,000 of Participant's Account value
Attained
ages of
payees 55 56 57 58 59 60 61 62 63 64 65
-------- ---- ---- ---- ---- ---- ---- ---- ---- ---- ---- ----
55 4.02
56 4.06 4.10
57 4.09 4.13 4.17
58 4.13 4.17 4.21 4.25
59 4.17 4.21 4.25 4.29 4.33
60 4.20 4.25 4.29 4.33 4.38 4.42
61 4.24 4.29 4.33 4.37 4.42 4.47 4.52
62 4.28 4.33 4.37 4.42 4.47 4.52 4.57 4.62
63 4.32 4.37 4.41 4.46 4.51 4.56 4.62 4.67 4.72
64 4.36 4.41 4.46 4.51 4.56 4.61 4.67 4.72 4.78 4.84
65 4.40 4.45 4.50 4.55 4.61 4.66 4.72 4.78 4.84 4.90 4.96
66 4.44 4.49 4.55 4.60 4.66 4.71 4.77 4.83 4.90 4.96 5.02
67 4.49 4.54 4.59 4.65 4.71 4.77 4.83 4.89 4.95 5.02 5.09
68 4.53 4.58 4.64 4.70 4.76 4.82 4.88 4.95 5.02 5.08 5.16
69 4.57 4.63 4.69 4.75 4.81 4.87 4.94 5.01 5.08 5.15 5.22
70 4.62 4.68 4.74 4.80 4.86 4.93 5.00 5.07 5.14 5.22 5.29
23
XXXXXX XXXX LIFE INSURANCE COMPANY [LOGO]
TABLE 4 -- OPTIONS 2 AND 7
Joint life income with 100 percent to survivor
Initial monthly income payments for each $1,000 of Participant's account value
Attained
ages of
payees 55 56 57 58 59 60 61 62 63 64 65
-------- ---- ---- ---- ---- ---- ---- ---- ---- ---- ---- ----
55 3.73
56 3.75 3.78
57 3.78 3.81 3.84
58 3.81 3.84 3.87 3.91
59 3.83 3.87 3.90 3.94 3.97
60 3.86 3.89 3.93 3.97 4.01 4.04
61 3.88 3.92 3.96 4.00 4.04 4.08 4.12
62 3.90 3.94 3.99 4.03 4.07 4.12 4.16 4.20
63 3.92 3.97 4.01 4.06 4.10 4.15 4.19 4.24 4.28
64 3.94 3.99 4.04 4.09 4.13 4.18 4.23 4.28 4.33 4.37
65 3.96 4.01 4.06 4.11 4.16 4.22 4.27 4.32 4.37 4.42 4.47
66 3.98 4.03 4.08 4.14 4.19 4.25 4.30 4.36 4.41 4.47 4.52
67 4.00 4.05 4.11 4.16 4.22 4.28 4.33 4.39 4.45 4.51 4.57
68 4.01 4.07 4.13 4.18 4.24 4.30 4.37 4.43 4.49 4.55 4.62
69 4.03 4.09 4.15 4.21 4.27 4.33 4.40 4.46 4.53 4.59 4.66
70 4.04 4.10 4.16 4.23 4.29 4.36 4.42 4.49 4.56 4.63 4.71
24
XXXXXX XXXX LIFE INSURANCE COMPANY [LOGO]
TABLE 5 -- OPTION 3
Income payments for a fixed period
Equal monthly income payments for each $1,000 of Participant's account value
Number of years in Monthly income Number of years in Monthly income Number of years in Monthly income
fixed period payment fixed period payment fixed period payment
------------------ -------------- ------------------ -------------- ------------------ --------------
1 84.47 11 8.86 21 5.32
2 42.86 12 8.24 22 5.15
3 28.99 13 7.71 23 4.99
4 22.06 14 7.26 24 4.84
5 17.91 15 6.87 25 4.71
6 15.14 16 6.53 26 4.59
7 13.16 17 6.23 27 4.47
8 11.68 18 5.96 28 4.37
9 10.53 19 5.73 29 4.27
10 9.61 20 5.51 30 4.18
25
XXXXXX XXXX LIFE INSURANCE COMPANY [LOGO]
HOME OFFICE: 0 Xxxxxx Xxxx Xxxxx
P.O. Box 4657
Springfield, Illinois 62708-4657
ENDORSEMENT: QUALIFYING EVENT (CHICAGO)
This endorsement is part of the Xxxxxx Xxxx Life insurance contract to which it
is attached. The endorsement amends this contract effective as of the Contract
Date.
For purposes of this contract, the term "Qualifying Event" shall mean:
1. the death of the Participant; or
2. financial hardship, as defined in the Plan; or
3. disability as defined in the Plan or the Code; or
4. an amount surrendered for transfer to the funding vehicle of another
approved investment provider for the Plan.
Separation from service is not a "Qualifying Event" under the contract.
Notwithstanding the above, the Participant may withdraw an amount not to exceed
10 percent of the Participant account value per year without application of the
contingent deferred sales charge.
/s/ Xxx Xxxxx /s/ Xxx Xxxxxxxx
------------------ -------------------
President Corporate Secretary
XXXXXX XXXX LIFE INSURANCE COMPANY [LOGO]
ADMINISTRATIVE NOTICE FOR DEPOSIT ADMINISTRATION CONTRACT:
To be included as an attachment to your Deposit Administration Contract
effective______________________________________
Re: Investment options available to
Deposit Administration Contract #_______________________________________________
I. The following investment options are available under the aforementioned
Deposit Administration Contract
COMPANY FIXED ACCOUNT OPTIONS
Xxxxxx Xxxx Fixed Account
COMPETING FUNDS UNDER SECTION 3:
[________________________]
SEPARATE ACCOUNT
The Separate Account(s) of the Company supporting the contract are entitled:
The various Separate Account subaccounts under this contract and the
corresponding investment funds for each subaccount are as follows:
INVESTMENT OPTION SUBACCOUNTS IN GROUP "A":
[_______________________]
[_______________________]
[_______________________]
INVESTMENT OPTION SUBACCOUNTS IN GROUP "B":
[_______________________]
[_______________________]
[_______________________]
XXXXXX XXXX LIFE INSURANCE COMPANY [LOGO]
INVESTMENT OPTION SUBACCOUNTS IN GROUP "C":
[_______________________]
[_______________________]
[_______________________]
II. This administrative notice forms a part of, and should be kept with your
Deposit Administration Contract #_______________________________________.
2
XXXXXX XXXX LIFE INSURANCE COMPANY [LOGO]
(This Page intentionally Left blank)
XXXXXX XXXX LIFE INSURANCE COMPANY [LOGO]
HOME OFFICE: 0 Xxxxxx Xxxx Xxxxx
Xxxxxxxxxxx, Xxxxxxxx 00000-0001
0-000-000-0000
MAILING ADDRESS: PO Box 4657
Springfield, IL 62708-4657
DEPOSIT ADMINISTRATION CONTRACT
(GROUP FLEXIBLE 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(S) ARE VARIABLE AND NOT GUARANTEED.
ILLINOIS LIFE AND HEALTH INSURANCE
GUARANTY ASSOCIATION LAW
Residents of Illinois who purchase health insurance, life insurance, and
annuities should know that the insurance companies licensed in Illinois to write
these types of insurance are members of the Illinois Life and Health Insurance
Guaranty Association. The purpose of this Guaranty Association is to assure that
policyholders will be protected, within limits, in the unlikely event that a
member insurer becomes financially unable to meet its policy obligations. If
this should happen, the Guaranty Association will assess its other member
insurance companies for the money to pay the covered claims of policyholders
that live in Illinois (and their payees, beneficiaries, and assignees) and, in
some cases, to keep coverage in force. The valuable extra protection provided by
these insurers through the Guaranty Association is not unlimited, however, as
noted below.
ILLINOIS LIFE AND
HEALTH INSURANCE GUARANTY ASSOCIATION
DISCLAIMER
THE ILLINOIS LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION PROVIDES COVERAGE OF
CLAIMS UNDER SOME TYPES OF POLICIES IF THE INSURER BECOMES IMPAIRED OR
INSOLVENT. COVERAGE MAY NOT BE AVAILABLE FOR YOUR POLICY. EVEN IF COVERAGE IS
PROVIDED, THERE ARE SUBSTANTIAL LIMITATIONS AND EXCLUSIONS. COVERAGE IS
GENERALLY CONDITIONED ON CONTINUED RESIDENCE IN ILLINOIS. OTHER CONDITIONS MAY
ALSO PRECLUDE COVERAGE.
YOU SHOULD NOT RELY ON AVAILABILITY OF COVERAGE UNDER THE LIFE AND HEALTH
INSURANCE GUARANTY ASSOCIATION LAW WHEN SELECTING AN INSURER. YOUR INSURER AND
AGENT ARE PROHIBITED BY LAW FROM USING THE EXISTENCE OF THE ASSOCIATION OR ITS
COVERAGE TO SELL YOU AN INSURANCE POLICY.
THE ILLINOIS LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION OR THE ILLINOIS
DEPARTMENT OF INSURANCE WILL RESPOND TO ANY QUESTIONS YOU MAY HAVE WHICH ARE NOT
ANSWERED BY THIS DOCUMENT. POLICYHOLDERS WITH ADDITIONAL QUESTIONS MAY CONTACT:
ILLINOIS LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION
000X XXXX XXXX XXXX XXXXXX
XXXXXXX, XXXXXXXX 00000
(000) 000-0000
ILLINOIS DEPARTMENT OF INSURANCE
000 XXXX XXXXXXXXXX XXXXXX
0XX XXXXX
XXXXXXXXXXX, XXXXXXXX 00000
(000)000-0000
SUMMARY OF GENERAL PURPOSES AND
CURRENT LIMITATIONS OF COVERAGE
The Illinois law that provides for this safety-net coverage is called the
Illinois Life and Health Insurance Guaranty Association Law ("Law") [215 ILCS
5/531.01, et seq.]. The following contains a brief summary of the Law's
coverages, exclusions, and limits. This summary does not cover all provisions,
nor does it in any way change anyone's rights or obligations under the Law or
the rights or obligations of the Guaranty Association. If you have obtained this
document from an agent in connection with the purchase of a policy, you should
be aware that its delivery to you does not guarantee that your policy is covered
by the Guaranty Association.
(Please turn to back of page)
IL-M504IL (11/00)
COVERAGE
The Illinois Life and Health Insurance Guaranty Association provides coverage to
policyholders that reside in Illinois for insurance issued by members of the
Guaranty Association, including:
- life insurance, health insurance, and annuity contracts;
- life, health or annuity certificates under direct group policies or
contracts;
- unallocated annuity contracts; and
- contracts to furnish health care services and subscription
certificates for medical or health care services issued by certain
licensed entities. The beneficiaries, payees, or assignees of such
persons are also protected, even if they live in another state.
EXCLUSIONS FROM COVERAGE
The Guaranty Association does not provide coverage for:
- any policy or portion of a policy for which the individual has
assumed the risk;
- any policy of reinsurance (unless an assumption certificate was
issued);
- interest rate guarantees which exceed certain statutory limitations;
- certain unallocated annuity contracts issued to an employee benefit
plan protected under the Pension Benefit Guaranty Corporation and
any portion of a contract which is not issued to or in connection
with a specific employee, union or association of natural persons
benefit plan or a government lottery;
- any portion of a variable life insurance or variable annuity
contract not guaranteed by an insurer; or
- any stop loss insurance.
In addition, persons are not protected by the Guaranty Association if:
- the Illinois Director of Insurance determines that, in the case of
an insurer which is not domiciled in Illinois, the insurer's home
state provides substantially similar protection to Illinois
residents which will be provided in a timely manner; or
- their policy was issued by an organization which is not a member
insurer of the Association.
LIMITS ON AMOUNT OF COVERAGE
The Law also limits the amount the Illinois Life and Health Insurance Guaranty
Association is obligated to pay. The Guaranty Association's liability is limited
to the lesser of either:
- the contractual obligations for which the insurer is liable or for
which the insurer would have been liable if it were not an impaired
or insolvent insurer; or
- with respect to any one life, regardless of the number of policies,
contracts, or certificates:
- in the case of life insurance, $300,000 in death benefits but
not more than $100,000 in net cash surrender or withdrawal
values;
- in the case of health insurance, $300,000 in health insurance
benefits, including net cash surrender or withdrawal values;
and
- with respect to annuities, $100,000 in the present value of
annuity benefits, including net cash surrender or withdrawal
values, and $100,000 in the present value of annuity benefits
for individuals participating in certain government retirement
plans covered by an unallocated annuity contract. The limit
for coverage of unallocated annuity contracts other than those
issued to certain governmental retirement plans is $5,000,000
in benefits per contract holder, regardless of the number of
contracts.
However, in no event is the Guaranty Association liable for more than $300,000
with respect to any one individual.
IL-M5041L(11/00)
