Exhibit 4
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FLEXIBLE PREMIUM
DEFERRED VARIABLE ANNUITY
Flexible Premium Deferred Variable Annuity in which the accumulation value may
be allocated between the variable sub-accounts of the separate account and the
interest rate guarantee periods of the guaranteed interest account. Amounts
allocated to the variable sub-accounts may increase or decrease based on the
investment experience of the variable sub-accounts selected. Annuity payments
begin on the maturity date. A death benefit is payable if the Owner's death
occurs before annuity payments begin. Non-participating (No dividends).
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This policy is a legal contract between the Owner and the Company.
Please read your policy carefully.
Jefferson Pilot Financial Insurance Company will make annuity payments beginning
on the maturity date, subject to this policy being in force and subject to the
provisions of this policy.
The maturity date and the payment option may be changed by the Owner at anytime
before the annuity payments begin.
This policy provides a death benefit if the Owner's death occurs before the
annuity payments begin, while this policy is in force, and subject to the
provisions of this policy.
Riders providing supplemental benefits or policy changes, and a copy of the
application, if any, follow page 14.
Signed for the Company at its Home Office in Concord, New Hampshire, on the
policy date.
/s/ David A. Stonecipher /s/ Robert A. Reed
David A. Stonecipher Robert A. Reed
Chief Executive Officer Secretary
Right to Cancel Policy
You may cancel this policy within 10 days after you receive it. Simply return it
to our Variable Annuity Service Center at [P.O. Box 515, Concord, New Hampshire
03302-0515,] [Phone: 1-800-258-3648, ext. 5394,] or to your registered
representative. Canceling this policy will void it from the beginning, and we
will refund to you the accumulation value. If this policy was issued as an IRA
and it is canceled, we will refund to you any premiums paid.
Jefferson Pilot Financial Insurance Company
[One Granite Place]
[Concord, New Hampshire 03301]
A Stock Company
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94-516
<PAGE>
Table of Contents Page No.
Account Allocation ............................................... 7
Accumulation Period .............................................. 5
Accumulation Unit ................................................ 7
Accumulation Unit Value .......................................... 7
Accumulation Value ............................................... 7
Administrative Expense Charge .................................... 3
Age .............................................................. 5
Amount of Annuity Payment ........................................ 11
Annual Administrative Fee ........................................ 3
Annual Statement ................................................. 9
Annuitant ........................................................ 3,5
Annuity Period ................................................... 5
Annuity Proceeds ................................................. 11
Annuity Unit ..................................................... 5
Annuity Unit Value ............................................... 11
Annuitization .................................................... 11
Assignment ....................................................... 6
Beneficiary ...................................................... 5
Benefit and Payment Provisions ................................... 10
Cash Surrender Value ............................................. 8
Charges and Deductions ........................................... 3
Company .......................................................... 5
Conformity with Law .............................................. 6
Death Benefit After Annuity Payments Begin ....................... 10
Death Benefit Before Annuity Payments Begin ...................... 10
Death of Payee ................................................... 12
Definitions ...................................................... 5
Due Proof ........................................................ 5
Fixed and Variable Payment Options ............................... 11
Fixed Payment Options ............................................ 11
Free Partial Withdrawals ......................................... 9
General Information .............................................. 3
General Provisions ............................................... 6
Guaranteed Excess Interest for
Fixed Payment Options ............................................ 12
Guaranteed Interest Account ...................................... 3,8
Guaranteed Minimum Interest Rate (For the Interest
Rate Guarantee Periods) ........................................ 3,8
Home Office ...................................................... 5
Incontestability ................................................. 6
Initial Premium Allocations ...................................... 3
Interest Rate Guarantee Period ................................... 8
Interest Rates ................................................... 6
Irrevocable Beneficiary .......................................... 5
JPF Variable Annuity Separate Account ............................ 3
Joint Owner ...................................................... 3,5
Market Value Adjustment ("MVA") .................................. 8
Maturity Date .................................................... 3,5,10
Maximum Free Partial Withdrawal Percentage ....................... 3,9
Minimum Values ................................................... 9
Misstatement of Age or Sex ....................................... 6
Mortality and Expense Risk Charge ................................ 3
Net Investment Factor ............................................ 7
Non-Participating ................................................ 5
Notice, Election, Request ........................................ 5
Owner ............................................................ 3,5
Payee ............................................................ 5
Payment of Annuity ............................................... 10
Payment of Premiums .............................................. 6
Payment Option Tables ............................................ 12,13
Payment Options .................................................. 11,12
Policy ........................................................... 6
Policy Anniversary ............................................... 5
Policy Changes ................................................... 6
Policy Date ...................................................... 3,5
Policy Earnings .................................................. 9
Policy Values Provisions ......................................... 7
Policy Year ...................................................... 5
Premium Enhancement .............................................. 3
Premium Provision ................................................ 6
Premiums ......................................................... 3
Proof of Survival ................................................ 11
Protection Against Creditors ..................................... 12
Schedule Page .................................................... 3
Separate Account ................................................. 5
Settlement ....................................................... 6
Supplementary Contract ........................................... 12
Taxes ............................................................ 8
Transfer Fee ..................................................... 3
Transfers ........................................................ 8
Valuation Day .................................................... 6
Valuation Period ................................................. 6
Variable Annuity Service Center .................................. 6
Variable Payment Options ......................................... 11
Variable Sub-Accounts ............................................ 3,7
We, Our, Us ...................................................... 6
When Annuity Payments Begin ...................................... 12
Withdrawal Charge Schedule ....................................... 3,9
Withdrawals ...................................................... 9
You, Your ........................................................ 6
Page 2
<PAGE>
SCHEDULE PAGE FOR POLICY NUMBER: [123456789]
GENERAL INFORMATION
Owner: [John Doe]
Owner's Issue Age and Sex: [35 Male]
Joint Owner: [Jane Doe]
Joint Owner's Age and Sex: [35 Female]
Annuitant: [John Doe]
Annuitant's Issue Age and Sex: [35 Male]
Policy Date: [January 1, 2000]
Maturity Date: [January 1, 2030]
PREMIUMS
Initial Premium Payment: [$10,000.00]
(Additional premiums are
payable at the Owner's discretion)
Minimum Additional
Premium Payment: [$50.00]
Premium Enhancement: [None]
[The premium enhancement shown above will be added to the initial and subsequent
premium payments. The amount of the premium enhancement, if any, is determined
as a percentage of each premium paid to the policy.]
94-516 Page 3a
<PAGE>
SCHEDULE PAGE (continued)
INITIAL PREMIUM ALLOCATIONS
JPF Variable Annuity Separate Account
Initial Allocation
Variable Sub-Accounts Percentage
---------------------------------------------------------- --------------------
[JPVF World Growth Stock Portfolio - Templeton] [0.00%]
[JPVF International Equity Portfolio - Lombard Odier] [20.00%]
[JFVF Emerging Growth Portfolio - MFS] [0.00%]
[JPVF Capital Growth Portfolio - Janus ] [0.00%]
[JPVF Small Company Portfolio - Lord, Abbett & Co.] [0.00%]
[JPVF Growth Portfolio - Strong] [0.00%]
[JPVF S&P 500* Index Portfolio - Barclays] [0.00%]
[Fidelity VIP Growth ] [20.00%]
[Fidelity VIP II Contrafund ] [0.00%]
[Oppenheimer Capital Appreciation Fund/VA] [0.00%]
[MFS Research Series] [0.00%]
[MFS Utilities Series] [0.00%]
[Fidelity VIP Equity Income] [20.00%]
[JPVF Value Portfolio - Credit Suisse] [0.00%]
[JPVF Balanced Portfolio - Janus] [0.00%]
[JFVF High Yield Bond Portfolio - MFS] [0.00%]
[JPVF Money Market Portfolio - MFS] [0.00%]
[Oppenheimer Bond Fund/VA] [20.00%]
[Oppenheimer Strategic Bond Fund/VA] [0.00%]
[* "Standard & Poor's(R)", "S&P(R)", "S&P 500(R)", "Standard & Poor's 500", and
"500" are trademarks of The McGraw-Hill Companies, Inc. and have been licensed
for use by Jefferson Pilot Variable Corporation. This annuity is not sponsored,
endorsed, sold or promoted by Standard & Poor's and Standard & Poor's makes no
representation regarding the advisability of purchasing this annuity.]
Guaranteed Interest Account
<TABLE>
<CAPTION>
Initial Initial Allocation
Interest Rate Guarantee Periods Interest Rate Percentage
---------------------------------------------- --------------- ----------------------
<S> <C> <C>
[1-Year] [5.25%] [0.00%]
[3-Year**] [5.75%] [0.00%]
[5-Year**] [6.00%] [20.00%]
</TABLE>
[**A Market Value Adjustment ("MVA") may apply to amounts transferred, withdrawn
or annuitized.]
Guaranteed Minimum Interest Rate (For the Interest Rate
Guarantee Periods): [3.00%]
[Transfers from any 1-Year interest rate guarantee period into a current 1-Year
interest rate guarantee period are not permitted.]
Page 3b
<PAGE>
SCHEDULE PAGE (continued)
WITHDRAWAL CHARGE SCHEDULE
Complete Years Elapsed Withdrawal
Since Premium Paid Charge Percentages*
------------------ -------------------
[Less than 1] [8%]
[1] [8%]
[2] [7%]
[3] [6%]
[4] [5%]
[5] [4%]
[6] [3%]
[7] [0%]
*A separate withdrawal charge schedule applies to each premium. The withdrawal
charge percentage for each premium varies according to the complete years
elapsed since the premium payment was received by us. There will be no
withdrawal charges on withdrawals of policy earnings.
<TABLE>
<S> <C>
Maximum Free Partial Withdrawal Percentage: [10.00%]
CHARGES AND DEDUCTIONS
[Annual Administrative Fee: ] [$35.00] [(Waived if the accumulation value
is $50,000.00 or more on the last day
of the policy year.)]
[Transfer Fee:] [$10.00] [(Per transfer, after 12 transfers
in any given policy year.)]
Variable Sub-Account Charges Annualized Charge - Deducted Daily
[Mortality and Expense Risk Charge:] [1.10%]
[Administrative Expense Charge:] [0.15%]
[Enhanced Death Benefit - Option 1 :] [0.10%] [(Please refer to attached rider for
an explanation of this benefit and
charge.)]
[Enhanced Death Benefit - Option 2:] [0.15%] [(Please refer to attached rider for
an explanation of this benefit and
charge.)]
[Waiver of Withdrawal Charges for Extended Care]
[Confinement and Terminal Illness:] [0.05%] [(Please refer to attached rider for
an explanation of this benefit and
charge.)]
---------
[Total Annualized Charges:] [1.55%]
</TABLE>
[Annual Administrative Fee
An annual administrative fee is deducted from the accumulation value at the end
of each policy year and upon full withdrawal of the cash surrender value. The
annual administrative fee is shown above.]
[Transfer Fee
A transfer fee may be deducted from the accumulation value for each transfer
after the 12th transfer in a policy year. The transfer fee is shown above.]
[Mortality and Expense Risk Charge
The mortality and expense risk charge is deducted daily from each variable
sub-account. This charge is calculated as a percentage of the account value for
each variable sub-account value. The annualized mortality and expense risk
charge is shown above.]
[Administrative Expense Charge
The administrative expense charge is deducted daily from each variable
sub-account. This charge is calculated as a percentage of the account value for
each variable sub-account value. The annualized administrative expense charge is
shown above.]
94-516 Page 3c Insert A5163c
<PAGE>
This page was intentionally left blank.
Page 4
<PAGE>
Definitions
Accumulation Period
(May be referred to as the Pay-in Period)
The period which begins on the policy date and ends on the maturity date.
Age
Age last birthday.
Annuitant
The natural person on whose age and sex the annuity payments are based. Unless
stated otherwise in writing, the Owner is the Annuitant. The Annuitant is shown
on the schedule page.
Annuity Period
(May be referred to as the Pay-out Period)
The period which begins on the maturity date and ends with the last annuity
payment under a variable payment option.
Annuity Unit
A unit of measure used to determine the amount of each variable annuity payment.
Beneficiary
The person or persons named in writing who receives a death benefit. You may
name anyone as the beneficiary. A beneficiary must survive the Owner and any
Joint Owner by more than 24 hours to receive a death benefit. You may change the
beneficiary by providing us with a signed request. Changing the beneficiary is
subject to the rights of any irrevocable beneficiary.
The death benefit will be paid to your estate if you have not named a
beneficiary or if no beneficiary survives you by more than 24 hours when you
die.
Company
Jefferson Pilot Financial Insurance Company.
Due Proof
Information that we need to process a death benefit claim. This information
includes a death certificate and a death benefit claim form acceptable to us.
Home Office
[One Granite Place, Concord, New Hampshire 03301.]
Irrevocable Beneficiary
A beneficiary whose interest cannot be changed without his or her consent.
Joint Owner
The person named in writing as the Joint Owner. Our consent is needed to name a
Joint Owner that is not the Owner's spouse. You may change the Joint Owner by
sending us a notice signed by the Owner and any Joint Owner. You must have our
consent to change the Joint Owner. The Joint Owner, if any, is shown on the
schedule page.
Maturity Date
The date the annuity payments begin. The maturity date is shown on the schedule
page.
Non-Participating
This policy does not share in the Company's divisible surplus. This policy does
not pay dividends.
Notice, Election, Request
Unless otherwise permitted by the Company, a writing that is in a form
acceptable to us. A notice, election or request is not binding on any payment or
action we make prior to receiving such notice, election or request at our
variable annuity service center.
Owner
The person or entity who may exercise every right in this policy. The Owner must
be named in writing. You may request a change in ownership by sending us a
signed notice. You must have our consent to change the Owner. You must also have
our consent to name an Owner that is not a natural person. These rights are
subject to the written consent of any irrevocable beneficiary. The Owner is
shown on the schedule page.
Payee
The person or entity you name to receive the annuity payments. Our consent is
needed if the Payee is an executor, a personal representative, an administrator,
a trustee, a corporation, a partnership or an association. If the payment option
is Payment Option 2 - Life Income, the Payee must be the Annuitant.
Policy Anniversary
Any policy date anniversary.
Policy Date
The date from which we measure the policy anniversaries. The policy date is
shown on the schedule page.
Policy Year
Each consecutive 12-month period. The 1st policy year begins on the policy date.
Therefore, each policy year begins on a policy anniversary.
Separate Account
The JPF Variable Annuity Separate Account.
94-516 Page 5 Insert A5165
<PAGE>
Definitions (continued)
Valuation Day
Any day on which both the New York Stock Exchange is open for trading and the
Company is open.
Valuation Period
The period of time beginning at the close of business for the New York Stock
Exchange on any valuation day and ending at the close of business on the next
valuation day. A valuation period may be more than one day.
Variable Annuity Service Center
Our variable annuity service center is located at [P.O. Box 515, Concord, New
Hampshire 03302-0515,] [Phone: 1-800-258-3648, ext. 5394.] Send all policy
correspondence to this address.
We, Our, Us
Jefferson Pilot Financial Insurance Company.
You, Your
The Owner, and any Joint Owner.
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General Provisions
Policy
This policy is issued in consideration of the initial premium. If a check is
used to pay the initial premium, and the check is not honored, this policy will
be void. This policy, and any attached endorsements, riders and copy of the
application, if any, form the entire policy.
Policy Changes
Only our Chief Executive Officer, President, Executive Vice President or
Secretary can change the policy terms. Any such changes must be in writing.
Assignment
You may assign this policy only before the maturity date. We are not bound by an
assignment unless we receive notice of it at our variable annuity service
center. All policy rights and benefits are subject to any assignment. We are not
responsible for determining the validity or sufficiency of any assignment.
Incontestability
This policy is incontestable from the policy date.
Interest Rates
All interest rates are expressed as annual effective interest rates.
Settlement
Policy payment or settlement is made at our variable annuity service center. We
may require you to surrender the policy at settlement.
Misstatement of Age or Sex
If the Annuitant's age or sex is misstated, the benefits will be those that the
annuity proceeds would have purchased at the true age and sex. If we made any
underpayments because of misstatement, we will pay the Payee underpayments with
interest at 6.00% per year. If we made any overpayments because of misstatement,
we will charge overpayments with interest at 6.00% per year against the current
or the succeeding annuity payments.
Conformity with Law
This policy conforms with the minimum state requirements where it is delivered.
The state law where this policy is delivered supersedes any conflicting laws of
any other state where the Owner may live on or after the policy date. If any
provision of this policy is contrary to any law to which it is subject, such
provision is amended to conform to that law.
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Premium Provision
Payment of Premiums
The initial premium must be paid on or before the policy date. The initial
premium amount is shown on the schedule page. Premiums paid after the initial
premium may vary in amount and frequency. Subsequent premiums must be at least
the minimum additional premium amount that is shown on the schedule page, unless
agreed by us in writing at our variable annuity service center. We reserve the
right to limit additional premiums to a maximum of $25,000.00 each policy year.
All premium payments must be made payable to the Company at our variable annuity
service center, or made payable to the Company and delivered to your registered
representative.
Page 6
<PAGE>
Policy Values Provisions
Accumulation Value
The initial accumulation value equals:
1. The initial premium; plus
2. Any applicable premium enhancement; less
3. Any taxes.
The accumulation value on or before the maturity date equals:
1. The sum of the variable sub-account values; plus
2. The value of the guaranteed interest account.
Account Allocation
The Owner must specify the allocation percentages that will be used to allocate
the initial accumulation value between the variable sub-accounts of the separate
account and the interest rate guarantee periods of the guaranteed interest
account. The initial allocation percentages are shown on the schedule page.
These allocation percentages will be used to allocate subsequent premiums unless
the Owner changes them. The Owner must request any such change in a form
acceptable to us. Account allocation percentages and dollar amounts may be
subject to minimums.
Variable Sub-Accounts
A variable sub-account is a division of the JPF Variable Annuity Separate
Account. Each variable sub-account is not chargeable with liabilities arising
out of any other variable sub-account, any other separate account or any of our
business. The variable sub-accounts available on the policy date are shown on
the schedule page. At our discretion we may add, delete or substitute variable
sub-accounts.
For each variable sub-account, the account value equals the number of
accumulation units attributable to the policy in that variable sub-account
multiplied by the value of the accumulation unit for that variable sub-account.
Accumulation Unit
Premiums allocated to a variable sub-account or amounts transferred to a
variable sub-account are converted into accumulation units. The number of
accumulation units is determined by dividing the dollar amount allocated to a
variable sub-account by the value of an accumulation unit for that variable
sub-account for the valuation day on which the premium or transferred amount is
invested in the variable sub-account. Therefore, premiums allocated or amounts
transferred to a variable sub-account increase the number of accumulation units
of that variable sub-account.
The events which will reduce the number of accumulation units of a variable
sub-account are as follows:
1. Withdrawals or transfers from a variable sub-account;
2. Full withdrawal of the policy;
3. Payment of a death benefit;
4. Application of a variable sub-account value to a payment option; and
5. Applicable charges and deductions.
Accumulation units are reduced as of the end of the valuation period in which
the event occurs.
Accumulation Unit Value
The value of an accumulation unit at the end of every valuation day is the value
of the accumulation unit at the end of the previous valuation day multiplied by
the net investment factor.
Net Investment Factor
The net investment factor is used to measure the investment performance of a
variable sub-account. The net investment factor for any variable sub-account for
any valuation period is determined by 1 divided by 2, minus 3, where:
1. Is the result of:
a. The value of the assets held in the separate account for that
variable sub-account at the end of the current valuation period;
plus
b. The dividend or capital gain distributions credited to those assets
at the end of the valuation period for which the net investment
factor is being determined; minus
c. Any amount charged against the separate account for taxes, or any
amount we set aside during the valuation period as a provision for
taxes attributable to the operation or maintenance of the separate
account; and
2. Is the value of the assets held in the separate account for that variable
sub-account at the end of the preceding valuation period; and
3. Is a factor for the valuation period representing the mortality and
expense risk charge, administrative expense charge, and any applicable
optional benefit rider charge deducted from the variable sub-account. The
annualized rate for these charges are shown on the schedule page.
Page 7
<PAGE>
Policy Values Provisions (continued)
Guaranteed Interest Account
The guaranteed interest account is guaranteed by the General Account of the
Company. Within the guaranteed interest account, amounts may be allocated to the
interest rate guarantee periods. The value of the guaranteed interest account
equals the sum of all interest rate guarantee period account values.
Interest Rate Guarantee Period
An interest rate guarantee period is a division of the guaranteed interest
account. Amounts allocated to an interest rate guarantee period are credited
with a fixed interest rate for a specific period. The interest rate guarantee
periods of the guaranteed interest account are shown on the schedule page. At
our discretion we may add or delete interest rate guarantee periods.
At the end of an interest rate guarantee period, a new interest rate will be
declared by the Company at its discretion for the same interest rate guarantee
period as the previous interest rate guarantee period. The guaranteed minimum
interest rate for all interest rate guarantee periods is shown on the schedule
page.
Amounts withdrawn, transferred, or annuitized from interest rate guarantee
periods may be subject to a Market Value Adjustment ("MVA"). Withdrawals,
transfers, or annuitization made during the 30 day period prior to the end of an
interest rate guarantee period are not subject to a MVA. If a MVA applies to an
interest rate guarantee period, it will be shown on the schedule page.
Market Value Adjustment ("MVA")
A MVA may apply to one or more of the interest rate guarantee periods of the
guaranteed interest account. If a MVA applies to an interest rate guarantee
period, it is shown on the schedule page. A MVA, if any, applies to amounts
transferred, withdrawn or annuitized from the related interest rate guarantee
period. The MVA will not be applied during the 30-day period prior to the end of
an interest rate guarantee period. The MVA can be positive or negative, but will
never reduce the return on the guaranteed interest account below the guaranteed
minimum interest rate. The MVA is calculated as follows:
N/12
[[(1+I)/(1+J+.004)] - 1] x A
I = The interest rate being credited on the premium in the interest rate
guarantee period from which the withdrawal or transfer is being taken.
J = The currently available interest rate for the period of time most
closely approximating the duration remaining in the current interest rate
guarantee period. For purposes of calculating this factor, linear
interpolation will be used to determine the interest rate for durations
for which there is currently no available interest rate guarantee period.
If the period is less than 1 year, then the Company will use the currently
available interest rate for the 1-year interest rate guarantee period.
Fractional years will be rounded to the nearest month and the interest
rate will be calculated using linear interpolation.
N = The number of full months remaining in the interest rate guarantee
period.
A = The amount withdrawn, transferred or annuitized.
Guaranteed Minimum Interest Rate (For the Interest Rate Guarantee Periods)
Interest rates credited to the interest rate guarantee periods of the guaranteed
interest account are guaranteed never to be less than the guaranteed minimum
interest rate. The guaranteed minimum interest rate (for the interest rate
guarantee periods) is shown on the schedule page.
Taxes
Some states charge a premium tax. We will deduct premium taxes if we must pay
them. This may occur, for example, at the time when you pay a premium, surrender
the policy, make a full or partial withdrawal, when the policy reaches the
maturity date, or when a death benefit is paid.
No charges are currently imposed for Federal, state, or local taxes other than
state premium taxes. However, we reserve the right to deduct charges in the
future for such taxes that are attributable to this policy.
Transfers
During the accumulation period, you may transfer the accumulation value among
variable sub-accounts of the separate account and the interest rate guarantee
periods of the guaranteed interest account. However, there may be restrictions
on transfers from the interest rate guaranteed periods, see your schedule page
for any limitations.
During the annuity period, if you have chosen a variable annuity payment option,
you may transfer the separate account value among the various variable
sub-accounts, or to a fixed payment option. However, values are not permitted to
be transferred from a fixed payment option.
There are no limits on the number of transfers allowed. However, a transfer fee
may be deducted from the accumulation value after you make 12 transfers in a
policy year. The transfer fee may be applied to each transfer made. All
transfers are subject to minimum amounts. Transfers from the guaranteed interest
account may be subject to a MVA.
Cash Surrender Value
The cash surrender value before annuity payments begin equals:
1. The accumulation value; less
2. Any applicable MVA; less
3. Any annual administrative fee; less
4. Any withdrawal charges; less
5. Any taxes payable by us and not previously deducted.
Page 8
<PAGE>
Policy Values Provisions (continued)
Withdrawals
Before annuity payments begin, you may make a full or partial withdrawal of the
cash surrender value of this policy. The accumulation value is reduced by:
1. The withdrawal amount; and
2. Any applicable MVA; and
3. Any applicable withdrawal charges; and
4. Any taxes payable by us and not previously deducted.
You may specify the variable sub-accounts and the interest rate guarantee
periods from which the withdrawal should be taken. If we do not receive
withdrawal instructions from you, we will allocate the withdrawal among the
variable sub-accounts and the interest rate guarantee periods in the same
proportions as you have instructed us to allocate your premiums.
To complete a withdrawal, we must receive a written notice from you. If there is
a Joint Owner, both the Owner and Joint Owner must agree to and request the
withdrawal.
We may defer paying a full or partial withdrawal from an interest rate guarantee
period for up to 6 months. If we delay payment, we will notify you in writing.
If payment is deferred, we will credit the deferred amount with interest as
required by law.
If any withdrawal would reduce the accumulation value below $2,000.00, we may
treat the request as a request for a full withdrawal. Upon full withdrawal, this
policy is terminated.
Withdrawal Charge Schedule
A separate withdrawal charge schedule applies to each premium. Withdrawal
charges are a percentage of each premium withdrawn. The withdrawal charge
schedule is shown on the schedule page.
Withdrawal charges are calculated assuming that policy earnings are withdrawn
first. After all policy earnings have been withdrawn, premiums are deemed to be
withdrawn in the order in which they were received by us beginning with the
initial premium. A withdrawal charge will not be imposed on withdrawals of
policy earnings.
Policy Earnings
The excess, if any, of the accumulation value over the aggregate premiums as of
the date of a withdrawal.
Aggregate premiums equal the sum of premiums paid less the sum of premiums
withdrawn.
Free Partial Withdrawals
In addition to a free withdrawal of policy earnings during each policy year, you
may also withdraw up to the maximum free partial withdrawal amount without a
withdrawal charge.
The maximum free partial withdrawal amount available at any given time equals
the excess, if any, of 1 less 2 where:
1. Is the maximum free partial withdrawal percentage multiplied by the
aggregate premiums as of the date of withdrawal; and
2. Is the sum of any premiums withdrawn during the same policy year.
Aggregate premiums equal the sum of premiums paid less the sum of premiums
withdrawn.
If a free partial withdrawal amount is still available at the time of a full
withdrawal, any withdrawal charges applicable to the remaining free partial
withdrawal amount will be waived.
Maximum Free Partial Withdrawal Percentage
The maximum free partial withdrawal percentage is the percentage used to
determine the maximum free partial withdrawal amount. The maximum free partial
withdrawal percentage is shown on the schedule page.
Minimum Values
The cash surrender value, paid-up annuity, and death benefit will not be less
than the minimum that is required by state law where this policy is delivered.
Annual Statement
We will send the Owner an annual statement. The annual statement will show the
accumulation value and cash surrender value at the end of the reporting period.
The annual statement will show any other facts required by state or federal laws
or regulations.
94-516 Page 9
<PAGE>
Benefit and Payment Provisions
This policy is intended to qualify as an annuity contract under Section 72 of
the Internal Revenue Code ("IRC") as amended. The Benefit and Payment Provisions
should be interpreted consistently with IRC Section 72(s) minimum distribution
rules. If this policy is sold as a qualified retirement plan (including an
Individual Retirement Annuity or IRC Section 403(b) Tax-Sheltered Annuity),
distribution provisions of the qualified retirement plan endorsement attached to
this policy may amend and replace certain provisions of this policy.
Maturity Date
The maturity date is shown on the schedule page. The Owner may change the
maturity date anytime before annuity payments begin. The new maturity date must:
1. Be no earlier than the 2nd policy anniversary; and
2. Occur on or before the later of:
a. The 10th policy anniversary; and
b. The policy anniversary on or immediately following the Annuitant's
90th birthday.
Death Benefit Before Annuity Payments Begin
If this policy is owned by a trust, a corporation, a partnership, an association
or like entity for the Annuitant's benefit, the Annuitant is considered the
Owner for purposes of this death benefit provision.
Upon the death of the Owner when there is no Joint Owner, and when we receive
due proof of the Owner's death before the maturity date while this policy is in
force, a death benefit will be payable to the beneficiary.
Upon the death of either the Owner or Joint Owner, when there is a Joint Owner,
the surviving Owner, if any, becomes the beneficiary. A surviving Owner must
survive the deceased Owner by more than 24 hours. Any beneficiary at the time of
death is replaced by the surviving Owner.
At the time when we receive due proof of the Owner's or Joint Owner's death
before the maturity date while this policy is in force, a death benefit will be
payable to the beneficiary that equals the greater of:
1. The accumulation value without a MVA; or
2. The sum of all premiums paid less the sum of all partial withdrawals; or
3. If elected, the optional enhanced death benefit.
The enhanced death benefit options cannot be elected after the policy
date. If an enhanced death benefit option is elected, it will be shown on
the schedule page and will be described in an attached rider.
For purposes of calculating the death benefit, we will use policy values as of
the date we receive due proof of the Owner's or Joint Owner's death and the
beneficiary's payment option election.
If the applicable law requires the death benefit to be calculated in a manner
that results in a larger death benefit, we will pay the larger benefit amount.
The entire death benefit must be paid within 5 years of the Owner's death
unless:
1. The beneficiary is the Owner's spouse -- then the beneficiary may choose
to become the Owner and keep this policy in force. If we do not receive a
signed request for the death benefit within 90 days after the Owner's
death, we will deem that the spouse chose to become the Owner and keep
this policy in force; or
2. The beneficiary is not the Owner's spouse -- then the beneficiary may:
a. Have the death benefit paid under a payment option not longer than
the beneficiary's life expectancy. Such payments must start within
one year of the Owner's death; or
b. Elect to leave the death benefit with the Company for 5 years. The
death benefit will be applied under Payment Option 3 - Interest of
the payment options.
If the Owner is not the Annuitant, and the Annuitant dies while this policy is
in force, the Owner must choose a new Annuitant. If the Owner does not choose a
new Annuitant, the Owner becomes the Annuitant.
Death Benefit After Annuity Payments Begin
If the Owner, the Annuitant, or the Payee dies after the maturity date, annuity
payments will continue as provided under the payment option in effect. No
payment option can continue after the Owner's death unless it satisfies IRC
Section 72(s) minimum distribution rules.
Payment of Annuity
If this policy is in force on the maturity date, we will pay the Payee an
annuity under the payment option you choose. If the Owner does not name a Payee,
the Annuitant will become the Payee. The first annuity payment is made on the
maturity date.
Page 10
<PAGE>
Benefit and Payment Provisions (continued)
Fixed and Variable Payment Options
Before the maturity date, you may choose a fixed payment option, a variable
payment option or a combination of a fixed and a variable payment option, or
change a previous payment option. If no payment option is selected, Fixed
Payment Option 2 - Life Income with guaranteed period of 10 years payable
monthly becomes effective. Proof of the Annuitant's age and sex is required
before any Payment Option 2 - Life Income annuity payments begin.
Annuitization
After annuity payments begin, this policy is annuitized. Once annuitized, you
cannot make a full or partial withdrawal.
Amount of Annuity Payment
The initial annuity payment amount is no less than:
1. Each $1,000 of annuity proceeds applied; times
2. The applicable payment option table factor under the payment option
elected.
If Payment Option 2 - Life Income is chosen, the applicable factor is determined
by the Annuitant's age and sex at the time annuity payments begin.
If the annuity payment is less than $50.00, we reserve the right to change the
annuity payment frequency so that the annuity payments are at least equal to
$50.00.
If on the maturity date the annuity proceeds are less than $2,000.00, or would
provide income of less than $20.00 per month, we will pay you the annuity
proceeds in one lump sum.
Annuity Proceeds
The annuity proceeds available on the maturity date equal:
1. The accumulation value before annuity payments begin; less
2. Any applicable MVA; less
3. Any taxes payable by us and not previously deducted.
Proof of Survival
We can require proof that the Annuitant is alive on any date an annuity payment
is payable.
--------------------------------------------------------------------------------
Payment Options
Fixed Payment Options
You may choose a fixed payment option. Payments under a fixed payment option do
not vary in dollar amount. Annuity payments made will equal or exceed those
required by the state where this policy is delivered.
Variable Payment Options
You may choose a variable payment option. Payments under a variable payment
option will fluctuate based on the investment performance of the variable
sub-accounts that you have chosen.
Only options a and b of Payment Option 2 are available as variable payment
options.
Annuity proceeds may be allocated to one or more of the variable sub-accounts.
The first annuity payment is determined based upon the variable payment option
chosen and the amount of annuity proceeds.
The dollar amount of subsequent annuity payments will be determined using
annuity units. The number of annuity units will be determined at the time
annuity payments begin and will remain fixed unless transferred as described
below. The number of annuity units for a variable sub-account is 1 divided by 2,
where:
1. Is the portion of the first annuity payment attributable to that variable
sub-account; and
2. Is the annuity unit value for that variable sub-account on the maturity
date.
After the first annuity payment, each subsequent annuity payment is a dollar
amount equal to the sum of the annuity payment amount for each variable
sub-account. The annuity payment amount for a variable sub-account is the number
of annuity units for that variable sub-account times the annuity unit value for
that variable sub-account on the date the payment is due.
Annuity Unit Value
The annuity unit value of each variable sub-account for any valuation period is
equal to 1 multiplied by 2, divided by 3, where:
1. Is the net investment factor for the valuation period for which the
annuity unit value is being calculated; and
2. Is the annuity unit value for the preceding valuation period; and
3. Is a daily assumed interest rate factor adjusted for the number of days in
the valuation period.
94-516 Page 11
<PAGE>
Payment Options (continued)
Annuity Unit Value (continued)
The assumed interest rate factor is equal to one plus the assumed interest rate.
The assumed interest rate is used to calculate the initial variable annuity
payment. The payment option tables in this policy reflects an assumed interest
rate of 3.00%. If the actual net investment performance of the variable
sub-account is less than the assumed interest rate, then the dollar amount of
the variable annuity payments will decrease. If the actual net investment
performance of the variable sub-account is higher than the assumed interest
rate, then the dollar amount of the actual variable annuity payments will
increase. If the net investment performance exactly equals the assumed interest
rate, then the dollar amount of the actual variable annuity payments will remain
the same.
Annuity units may be transferred upon request. The number of annuity units for
the new variable sub-account is 1 times 2, divided by 3, where:
1. Is the number of annuity units for the current variable sub-account; and
2. Is the value of the annuity unit for the current variable sub-account; and
3. Is the value of the annuity unit for the new variable sub-account.
Payment Options
Only options a and b of Payment Option 2 are available as variable payment
options.
1. Income for Fixed Period Annuity payments are paid as mutually agreed for
at least 5 years.
2. Life Income Annuity Payments are paid as elected under a, b, or c:
a. Life Only - The annuity payments are paid as long as the Annuitant lives.
b. Guaranteed Period - The annuity payments are paid during the guaranteed
period. After that, annuity payments are paid as long as the Annuitant
lives.
c. Installment Refund - The annuity payments are paid until the sum of the
payments equals the amount of annuity proceeds on the maturity date. After
that, the annuity payments are paid as long as the Annuitant lives.
The annuity payment amount is determined by the Annuitant's age and sex at the
time when the annuity payments begin.
3. Interest For an agreed period of at least 5 years, annuity proceeds will
be held by us and will earn interest at a rate we declare annually. During
the period:
a. Interest is paid periodically to the Payee; or
b. Interest accumulates.
Any time during the period, annuity proceeds plus any accumulated interest may
be applied under another payment option. At the end of the period, annuity
proceeds plus any accumulated interest may be taken in a lump sum payment, or
applied under another payment option.
4. Income of Fixed Amount Annuity payments are paid in an agreed amount until
annuity proceeds and interest are exhausted. The payment period must be
for at least 5 years.
We reserve the right to offer additional payment options. Amounts allocated to
any fixed payment option may not be transferred.
When Annuity Payments Begin
Interest under Payment Option 3 will be paid at the end of each payment period.
Annuity payments under all other payment options are made at the beginning of
each payment period. Payment periods begin on the date the annuity payments
begin.
Guaranteed and Excess Interest for Fixed Payment Options
Annuity payments under Payment Options 1, 2, 3, and 4 are calculated at a
guaranteed interest rate of 3.00%. If we declare more than that interest rate,
the excess will be paid as determined by us under Payment Options 1, 3, and 4
and during the Payment Option 2 guaranteed and installment refund periods.
Protection Against Creditors
As permitted by law, funds held and payment option payments shall not be subject
to levy, attachment or other judicial process.
Payment Option Tables
The following tables show monthly annuity payments based on $1,000.00 of annuity
proceeds. Upon request, the payments under any payment option can be paid
quarterly, semi-annually or annually. The annuity payments for any age, sex or
payment frequency not shown are furnished upon request.
Death of Payee
If any annuity payments remain unpaid under a payment option upon the Payee's
death, any remaining annuity payments will be made under the supplementary
contract terms.
Supplementary Contract
Annuity proceeds applied to a fixed payment option must be applied to a
supplementary contract expressing the payment terms. If all of the annuity
proceeds are applied to a fixed payment option, this policy is terminated.
Page 12
<PAGE>
Payment Option Tables
Initial Monthly Income per $1,000 of
Annuity Proceeds
Guaranteed Basis of Calculation for Payment Options
Option 1, 3 and 4: 3.0% interest compounded annually.
Option 2: 3.0% interest compounded annually and the
Annuity 2000 Mortality Table.
<TABLE>
<CAPTION>
Option I - Income for Fixed Period
----------------------------------------------------------------------------------------------------------------------------------
No. of Monthly No. of Monthly No. of Monthly No. of Monthly No. of Monthly No. of Monthly
Years Income Years Income Years Income Years Income Years Income Years Income
----------------------------------------------------------------------------------------------------------------------------------
<S> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C>
5 $17.91 10 $9.61 15 $6.87 19 $5.73 23 $4.99 27 $4.47
6 15.14 11 8.86 16 6.53 20 5.51 24 4.84 28 4.37
7 13.16 12 8.24 17 6.23 21 5.32 25 4.71 29 4.27
8 11.68 13 7.71 18 5.96 22 5.15 26 4.59 30 4.18
9 10.53 14 7.26
----------------------------------------------------------------------------------------------------------------------------------
<CAPTION>
Option 2 - Life Income
-------------------------------------------------------------------------------------------------------------------------------
Male Annuitant Female Annuitant
-------------------------------------------------------------------------------------------------------------------------------
Attained Guaranteed Period Install- Attained Guaranteed Period Install-
Age of Life ment Age of Life ment
Annuitant Only 5 Yrs. 10 Yrs. 15 Yrs. 20 Refund Annuitant Only 5 Yrs. 10 Yrs. 15 Yrs. 20 Yrs. Refund
-------------------------------------------------------------------------------------------------------------------------------
<S> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C>
40 $3.56 $3.56 $3.55 $3.54 $3.52 $3.49 40 $3.39 $3.39 $3.39 $3.38 $3.37 $3.36
41 3.60 3.60 3.59 3.58 3.55 3.53 41 3.43 3.43 3.43 3.42 3.41 3.39
42 3.65 3.65 3.64 3.62 3.59 3.57 42 3.47 3.47 3.46 3.45 3.44 3.42
43 3.70 3.70 3.69 3.67 3.64 3.61 43 3.51 3.51 3.50 3.49 3.48 3.46
44 3.75 3.75 3.74 3.71 3.68 3.66 44 3.55 3.55 3.54 3.53 3.52 3.50
45 3.80 3.80 3.79 3.76 3.73 3.70 45 3.60 3.59 3.59 3.58 3.56 3.54
46 3.86 3.86 3.84 3.81 3.77 3.75 46 3.64 3.64 3.63 3.62 3.60 3.58
47 3.92 3.91 3.90 3.87 3.82 3.80 47 3.69 3.69 3.68 3.67 3.64 3.62
48 3.98 3.97 3.95 3.92 3.87 3.85 48 3.74 3.74 3.73 3.72 3.69 3.67
49 4.05 4.04 4.02 3.98 3.92 3.90 49 3.80 3.80 3.79 3.77 3.74 3.72
50 4.11 4.11 4.08 4.04 3.98 3.96 50 3.86 3.85 3.84 3.82 3.78 3.77
51 4.18 4.18 4.15 4.10 4.03 4.02 51 3.92 3.91 3.90 3.87 3.84 3.82
52 4.26 4.25 4.22 4.17 4.09 4.08 52 3.98 3.98 3.96 3.93 3.89 3.87
53 4.34 4.33 4.29 4.23 4.15 4.14 53 4.05 4.04 4.02 3.99 3.94 3.93
54 4.42 4.41 4.37 4.31 4.21 4.21 54 4.12 4.11 4.09 4.06 4.00 3.99
55 4.51 4.50 4.45 4.38 4.27 4.28 55 4.19 4.19 4.16 4.12 4.06 4.05
56 4.60 4.59 4.54 4.46 4.33 4.35 56 4.27 4.26 4.24 4.19 4.12 4.12
57 4.70 4.68 4.63 4.54 4.39 4.43 57 4.36 4.35 4.32 4.27 4.19 4.19
58 4.81 4.79 4.73 4.62 4.46 4.51 58 4.44 4.43 4.40 4.34 4.25 4.26
59 4.92 4.90 4.83 4.70 4.52 4.60 59 4.54 4.53 4.49 4.42 4.32 4.34
60 5.04 5.01 4.93 4.79 4.59 4.69 60 4.64 4.63 4.58 4.51 4.39 4.42
61 5.17 5.14 5.05 4.89 4.66 4.78 61 4.75 4.73 4.68 4.59 4.46 4.50
62 5.30 5.27 5.16 4.98 4.72 4.88 62 4.86 4.84 4.79 4.69 4.53 4.59
63 5.45 5.41 5.29 5.08 4.79 4.98 63 4.98 4.96 4.90 4.78 4.60 4.69
64 5.60 5.56 5.42 5.18 4.85 5.09 64 5.11 5.09 5.01 4.88 4.67 4.79
65 5.77 5.72 5.55 5.28 4.91 5.21 65 5.25 5.22 5.14 4.98 4.75 4.89
66 5.95 5.89 5.69 5.38 4.97 5.33 66 5.40 5.37 5.27 5.08 4.82 5.00
67 6.14 6.07 5.84 5.48 5.03 5.45 67 5.56 5.52 5.40 5.19 4.89 5.12
68 6.34 6.25 5.99 5.58 5.09 5.59 68 5.73 5.68 5.55 5.30 4.96 5.25
69 6.56 6.45 6.15 5.68 5.14 5.72 69 5.91 5.86 5.70 5.41 5.02 5.38
70 6.78 6.66 6.31 5.78 5.19 5.87 70 6.11 6.05 5.86 5.53 5.08 5.51
71 7.03 6.89 6.47 5.88 5.23 6.03 71 6.32 6.25 6.03 5.64 5.14 5.66
72 7.29 7.12 6.64 5.97 5.27 6.19 72 6.56 6.47 6.20 5.75 5.20 5.82
73 7.57 7.37 6.82 6.07 5.31 6.35 73 6.81 6.70 6.38 5.86 5.24 5.99
74 7.86 7.63 6.99 6.15 5.34 6.54 74 7.08 6.95 6.57 5.97 5.29 6.16
75 8.18 7.90 7.17 6.24 5.37 6.72 75 7.37 7.22 6.76 6.08 5.33 6.35
76 8.52 8.19 7.34 6.32 5.40 6.92 76 7.69 7.50 6.96 6.18 5.36 6.55
77 8.89 8.49 7.52 6.39 5.42 7.12 77 8.03 7.81 7.16 6.27 5.39 6.76
78 9.27 8.81 7.69 6.46 5.44 7.35 78 8.40 8.13 7.36 6.35 5.42 6.97
79 9.69 9.14 7.86 6.52 5.46 7.58 79 8.80 8.47 7.56 6.43 5.44 7.21
80 10.13 9.48 8.03 6.57 5.47 7.82 80 9.24 8.83 7.76 6.50 5.45 7.44
81 10.61 9.84 8.19 6.62 5.48 8.07 81 9.71 9.21 7.95 6.56 5.47 7.71
82 11.12 10.20 8.34 6.67 5.49 8.34 82 10.22 9.61 8.13 6.62 5.48 7.97
83 11.66 10.58 8.48 6.70 5.50 8.62 83 10.78 10.02 8.31 6.67 5.49 8.28
84 12.23 10.96 8.62 6.74 5.50 8.88 84 11.37 10.45 8.47 6.71 5.50 8.57
85 12.84 11.35 8.75 6.76 5.50 9.20 85 12.02 10.88 8.62 6.74 5.50 8.88
-----------------------------------------------------------------------------------------------------------------------------
</TABLE>
Option 3 - Interest Installments
----------------------------------
Monthly $ 2.47
Quarterly 7.42
Semi-Annually 14.89
Annually 30.00
----------------------------------
Option 4 - Income of Fixed Amount
--------------------------------------------------------------------------------
Monthly Monthly Monthly
Income Years Months Income Years Months Income Years Months
$5.00 22 10 $7.50 13 5 $12.50 7 4
6.00 17 10 8.00 12 5 15.00 6 0
6.67 15 6 9.00 10 9 16.67 5 4
7.00 14 7 10.00 9 6 17.50 5 1
--------------------------------------------------------------------------------
At the end of the Payment Option 4 periods shown, there may be a small remaining
balance, which will be paid.
94-516 Page 13
<PAGE>
This page was intentionally left blank.
Page 14
<PAGE>
This page was intentionally left blank.
<PAGE>
================================================================================
FLEXIBLE PREMIUM
DEFERRED VARIABLE ANNUITY
Flexible Premium Deferred Variable Annuity in which the accumulation value may
be allocated between the variable sub-accounts of the separate account and the
interest rate guarantee periods of the guaranteed interest account. Amounts
allocated to the variable sub-accounts may increase or decrease based on the
investment experience of the variable sub-accounts selected. Annuity payments
begin on the maturity date. A death benefit is payable if the Owner's death
occurs before annuity payments begin. Non-participating (No dividends).
================================================================================
Jefferson Pilot Financial Insurance Company
[One Granite Place, Concord, New Hampshire 03301]
Important Information
This policy is a valuable asset. Read it carefully and file it with your other
valuable papers.
When writing our Variable Annuity Service Center please give the policy number,
and the Owner's full name and address.
Contact our Variable Annuity Service Center at [P.O. Box 515, Concord, New
Hampshire 03302-0515, ] [Phone: 1-800-258-3638, ext. 5394,] or your registered
representative for the following services:
1. Information about this policy;
2. Preparing claims papers, or other notices, elections or requests;
3. Examining any proposal to surrender this policy--this is for your own
protection; and
4. Additional annuity or insurance services.
94-516
<PAGE>
Waiver of Withdrawal Charges for Extended Care Confinement and Terminal Illness
Rider
THERE ARE NO BENEFITS UNDER THIS RIDER UNTIL AFTER THE FIRST POLICY ANNIVERSARY.
This rider is a part of the policy to which it is attached, and is effective as
of the policy date.
After the first policy anniversary and subject to the terms of this rider, you
may withdraw any amount of the accumulation value without a withdrawal charge.
This may occur if the Owner or Joint Owner is:
1. Confined to an extended care facility or hospital. Extended Care
Confinement is defined below, and it must be for at least 30 consecutive
days. The Owner's or Joint Owner's confinement must begin after the first
policy anniversary; or
2. First diagnosed with a terminal illness, after the policy date. Terminal
illness is defined below.
The amount available for withdrawal will be determined on the date of withdrawal
as:
1. The accumulation value; less
2. Any taxes payable by us and not previously deducted.
We must receive a written request from you to pay the benefit under this
provision. The accumulation value will be reduced by the amount of your
withdrawal. The accumulation value can also be reduced by any premium tax or
Federal, state or local taxes payable by us that have not been previously
deducted. If the entire accumulation value is withdrawn, the policy will
terminate.
There may be adverse tax consequences if you choose to take a withdrawal under
this rider. Please contact your tax advisor before requesting a withdrawal under
this rider.
Extended Care Facility or Hospital
An extended care facility is a facility which:
1. Is located in the United States or its territories;
2. Is licensed in the jurisdiction in which it is located;
3. Provides custodial care under the supervision of a registered nurse
(R.N.); and
4. Can accommodate three or more persons.
An extended care facility does not include any facility owned or operated by the
Owner or Joint Owner. It also does not include a facility owned or operated by
the Owner's or Joint Owner's spouse, children, parents, grandparents,
grandchildren, siblings or in-laws.
A hospital is a facility which:
1. Is located in the United States or its territories;
2. Is licensed as a hospital in the jurisdiction in which it is located;
3. Is supervised by a staff of licensed physicians;
4. Provides nursing services 24 hours a day by, or under, the supervision of
a R.N.;
5. Operates primarily for the care and treatment of sick or injured persons
as inpatients for a charge; and
6. Has a medical, diagnostic and major surgical facility.
Extended Care Confinement
To be eligible for the benefit under this provision the following conditions
must be satisfied:
1. The Owner's or Joint Owner's confinement must be prescribed by a licensed
medical doctor (M.D.) or a licensed doctor of osteopathy (D.O.) practicing
within the scope of his of her license. The M.D. or D.O. must be licensed
in his or her state of residence and must be practicing within the scope
of his or her license. The M.D. or D.O. may not be the Owner or Joint
Owner. The M.D. or D.O. also can not be the Owner's or Joint Owner's
spouse, child, parent, grandparent, grandchild, sibling or in-law; and
2. The Owner's or Joint Owner's confinement must be medically necessary. The
confinement must be:
a. Appropriate and consistent with the diagnosis in accordance with
accepted standards of practice; and
b. Necessary to avoid adversely affecting the Owner's or Joint Owner's
condition.
Such diagnosis must be confirmed in writing to us by the attending licensed
physician.
We reserve the right to require, at our expense, an examination by a
physician of our choice to confirm the diagnosis. We also reserve the right
to request documents from the Owner's or Joint Owner's attending physician
that support the diagnosis. If there are conflicting opinions between the
diagnosis of the attending physician and the physician of our choice, the
diagnosis of the physician of our choice will be final.
3. You must request the benefit no later than 91 days after the date
confinement ceased.
(Continued)
AE-134 Jefferson Pilot Financial
Insurance Company
<PAGE>
4. We must receive written proof of the Owner's or Joint Owner's confinement.
Such documents must be provided no later than 91 days after the date of
such request.
Terminal Illness
A terminal illness is defined as when the attending licensed physician has
diagnosed the Owner's or Joint Owner's life expectancy to be 12 months or less
measured from the date of the attending licensed physician's statement. Such a
diagnosis must be confirmed in writing to us by the attending licensed
physician.
The Owner's or Joint Owner's terminal illness must be diagnosed by a M.D. The
M.D. must be practicing within the scope of his or her license. The M.D. may not
be the Owner or Joint Owner. The M.D. also can not be the Owner's or Joint
Owner's spouse, child, parent, grandparents, grandchild, sibling or in-law.
We reserve the right to require, at our own expense, an examination by a
physician of our choice to confirm the terminal illness diagnosis. We also
reserve the right to require documents from the Owner's or Joint Owner's
attending physician that support the terminal illness diagnosis. If there are
conflicting opinions between the diagnosis of the attending licensed physician
and the physician of our choice, the diagnosis of the physician of our choice
will be final.
Charge
For this rider, a charge will be deducted daily from each variable sub-account.
On an annual basis, this charge equals 0.05% of each variable sub-account value.
This charge will continue for as long as the policy is in force.
Once elected, this rider cannot be changed or canceled.
We reserve the right to terminate this rider if there is a change in the Owner
or Joint Owner.
Signed for Jefferson Pilot Financial Insurance Company.
/s/ Robert A. Reed
Secretary
<PAGE>
Rider for Enhanced Death Benefit - Option 1
This rider is a part of the policy to which it is attached, and is effective
beginning on the policy date.
For purposes of this rider, if there are Joint Owners, age will be based on the
age of the older Owner.
Enhanced Death Benefit
The enhanced death benefit, referenced in the Death Benefits Before Annuity
Payments Begin provision of the policy, is defined as the greater of:
1. The sum of all premiums paid less the sum of any adjusted partial
withdrawals, accumulated with interest at 4.00% per year through the end
of the policy year in which you reach age 75, but never more than 200% of
all premiums paid less any partial withdrawals; or
2. The accumulation value on the most recent 5th policy anniversary while you
are alive and before you reach age 75, plus any premiums paid less the sum
of any adjusted partial withdrawals made since that policy anniversary.
Adjusted Partial Withdrawals
Adjusted partial withdrawals are the product of 1 times 2 where:
1. Is the ratio of the amount of the partial withdrawal (and any applicable
withdrawal charges or deduction for taxes) to the accumulation value on
the date of (but prior to) the partial withdrawal; and
2. Is the death benefit on the date of (but prior to) the partial withdrawal.
Charge
For this rider, a charge will be deducted daily from each variable sub-account.
On an annual basis, this charge equals 0.10% of each variable sub-account value.
This charge will continue for as long as the policy is in force, including after
the Owner or Joint Owner turns age 75.
Once elected, this rider may not be canceled.
We reserve the right to terminate this rider if there is a change in the Owner
or Joint Owner.
Signed for Jefferson Pilot Financial Insurance Company.
/s/ Robert A. Reed
Secretary
AE-135 Jefferson Pilot Financial
Insurance Company
<PAGE>
Rider for Enhanced Death Benefit - Option 2
This rider is a part of the policy to which it is attached, and is effective
beginning on the policy date.
For purposes of this rider, if there are Joint Owners, age will be based on the
age of the older Owner.
Enhanced Death Benefit
The enhanced death benefit, referenced in the Death Benefits Before Annuity
Payments Begin provision of the policy, is defined as follows:
The greatest accumulation value on any policy anniversary while you are
alive and before you reach age 75, plus any premiums paid, less any
adjusted partial withdrawals made since that policy anniversary.
Adjusted Partial Withdrawals
Adjusted partial withdrawals are the product of 1 times 2 where:
1. Is the ratio of the amount of the partial withdrawal (and any applicable
withdrawal charges or deductions for taxes) to the accumulation value on
the date of (but prior to) the partial withdrawal; and
2. Is the death benefit on the date of (but prior to) the partial withdrawal.
Charge
For this rider, a charge will be deducted daily from each variable sub-account.
On an annual basis, this charge equals 0.15% of each variable sub-account value.
This charge will continue for as long as the policy is in force, including after
the Owner or Joint Owner turns age 75.
Once elected, this option may not be canceled.
We reserve the right to terminate this rider if there is a change in the Owner
or Joint Owner.
Signed for Jefferson Pilot Financial Insurance Company.
/s/ Robert A. Reed
Secretary
AE-136 Jefferson Pilot Financial
Insurance Company
