EXHIBIT 1.(A)(5)(A)
Proposed Form of Policy
<PAGE>
EXHIBIT 1.(A)(5)(A)
Proposed Form of Policy
<PAGE>
INSURED FIELD(1)
POLICY NUMBER FIELD(3)
POLICY TYPE ENCORE!
FLEXIBLE PREMIUM VARIABLE LIFE INSURANCE POLICY. NET CASH SURRENDER
VALUE, IF ANY, PAYABLE AT MATURITY. DEATH BENEFIT PROCEEDS PAYABLE AT DEATH OF
INSURED PRIOR TO MATURITY DATE.
FLEXIBLE PREMIUMS PAYABLE DURING LIFETIME OF INSURED UNTIL MATURITY
DATE (AGE 100).
SOME BENEFITS REFLECT INVESTMENT RESULTS. NON-PARTICIPATING.
THIS POLICY'S ACCUMULATION VALUE IN THE SEPARATE ACCOUNT IS BASED ON THE
INVESTMENT EXPERIENCE OF THAT ACCOUNT AND MAY INCREASE OR DECREASE DAILY. IT IS
NOT GUARANTEED AS TO DOLLAR AMOUNT. SEE SECTION 7.
THE AMOUNT OR THE DURATION OF THE DEATH BENEFIT (OR BOTH) MAY BE FIXED OR MAY
VARY UNDER THE CONDITIONS DESCRIBED IN SECTIONS 9 AND 10.
First Ameritas Life Insurance Corp. of New York agrees to pay the death benefit
proceeds of this policy to the Beneficiary on receipt of satisfactory proof of
death of the Insured while this policy is in force.
/s/ Mitchell F. Politzer /s/ Donald R. Stading
------------------------------- ------------------------
President Secretary
"NOTICE OF TEN-DAY RIGHT TO EXAMINE POLICY"
You are urged to read this policy carefully. If, after examination, you
are dissatisfied with it for any reason, you may return it to the selling
agent or to First Ameritas Life Insurance Corp. of New York at 400 Rella
Boulevard, Suite 304, Suffern NY 10901-4253, for a refund within (1) ten
days from the date of delivery of the policy, (2) ten days after mailing
or delivery of a cancellation notice, or (3) forty-five days after Part I
of the application is signed, whichever is later. If you do so return the
policy, any premium paid will be refunded and it shall be considered void
from its effective date and will be as if it were never in force.
Please read and carefully check the copy of the application attached to
this policy. This application is a part of your policy, and this policy
was issued on the basis that the answers to all questions and the
information shown on this application are true and complete. If any
information shown on it is not true and complete, to the best of your
knowledge, or if any past medical history has been omitted, please notify
First Ameritas Life Insurance Corp. of New York, within ten days from the
date of delivery of the policy to you.
FIRST AMERITAS LIFE INSURANCE CORP. OF NEW YORK LOGO
Form 5118
<PAGE>
POLICY SCHEDULE
INSURED: John D Specimen POLICY NUMBER: 2300005118
INITIAL SPECIFIED POLICY DATE: January 1, 2000
AMOUNT OF INSURANCE: $500,000
*PLANNED ANNUAL
ISSUE AGE - SEX: 35 Male PERIODIC PREMIUM: $3,210.00
OWNER: John D Specimen INITIAL PREMIUM: $3,210.00
INITIAL DEATH BENEFIT OPTION: A
GUARANTEED DEATH BENEFIT PREMIUM: ANNUAL
$3,210.00
GUARANTEED DEATH BENEFIT PERIOD:
The Guaranteed Death Benefit Period will expire on January 1, 2025.
GUARANTEED INTEREST ON FIXED ACCOUNT:
The minimum guaranteed interest rate credited on that part of the
accumulation value in the Fixed Account is an annual effective rate of
3.5%.
NET CASH SURRENDER VALUE BONUS PERCENTAGE:
The current percentage bonus is guaranteed for one year after the issue
date of the policy and is equal to .25% of the net cash surrender value.
The first time we may credit a bonus is at the end of the 21st policy year.
RATING CLASS: PREFERRED, NO TOBACCO USE
LOANS:
The maximum loan interest rate is 5.5%. The interest credited on any loaned
part of the values will be 3.50%.
MODES OF PAYMENT FOR PLANNED PERIODIC PREMIUMS:
Annual Semi-Annual Quarterly Monthly
$3,210.00 $1,605.00 $802.50 $267.50
* This reflects the planned premium and mode you selected at issue. For
further information, see policy Section 3. PREMIUM PAYMENTS.
5118 1-PS
<PAGE>
SCHEDULE OF BENEFITS
INSURED: John D Specimen POLICY NUMBER: 2300005118
BENEFIT INITIAL
SPECIFIED AMOUNT MATURITY OR
Flexible Premium Variable Life OF INSURANCE EXPIRATION DATE*
Form 5118**
$500,000 January 1, 2065
* NOTE: It is possible that coverage may not continue to the maturity date
(age 100) if premium payments are not sufficient. Even if coverage
continues to maturity date there may, in fact, be little or no surrender
value to be paid.
** Form number corresponds to form number in the lower left hand corner of
each benefit description.
5118 1.1-SB
<PAGE>
SCHEDULE OF BENEFITS
(Continued)
INSURED: John D Specimen POLICY NUMBER: 2300005118
INITIAL
BENEFIT SPECIFIED AMOUNT ANNUAL MATURITY OR
OF INSURANCE PREMIUM * EXPIRATION YEAR
Disability Benefit Rider
Form DBR 5901 ** $3,210.00 $124.23 2025
* For any rider, this is the annual rider cost of insurance at issue.
(NOTE: These amounts shown are not additional premiums due but are the
amounts deducted from the accumulation value.) See each rider for
further information.
** Form number corresponds to form number in the lower left hand corner
of each benefit description.
5118 1.2-SB
<PAGE>
LIST OF SUBACCOUNTS AND PORTFOLIOS
Each subaccount of the First Ameritas Life Insurance Corp. of New York (First
Ameritas) Separate Account V invests in a specific portfolio of the following
funds:
Calvert Variable Series, Inc. Ameritas Portfolios ("Ameritas")
Fidelity Variable Insurance Products Fund
Fidelity Variable Insurance Products Fund II
(collectively referred to as "Fidelity")
Alger American Fund ("Alger")
MFS Variable Insurance Trust ("MFS")
Morgan Stanley Dean Witter Universal Funds, Inc. ("MSDW")
INITIAL
CORRESPONDING ALLOCATION OF
FUND PORTFOLIO SUBACCOUNT NET PREMIUMS
Ameritas Money Market Money Market Subaccount 0%
Index 500 Index 500 Subaccount 0%
Growth Growth Subaccount 0%
Income & Growth Income & Growth Subaccount 50%
Small Capitalization Small Capitalization Subaccount 0%
MidCap Growth MidCap Growth Subaccount 0%
Emerging Growth Emerging Growth Subaccount 0%
Research Research Subaccount 0%
Growth With Income Growth With Income Subaccount 0%
Fidelity Equity-Income Equity-Income Subaccount 0%
Growth Growth Subaccount 0%
High Income High Income Subaccount 0%
Overseas Overseas Subaccount 0%
Asset Manager Asset Manager Subaccount 50%
Investment Grade Bond Investment Grade Bond Subaccount 0%
Asset Manager: Growth Asset Manager: Growth Subaccount 0%
Contrafund Contrafund Subaccount 0%
Alger Balanced Balanced Subaccount 0%
Leveraged AllCap Leveraged AllCap Subaccount 0%
MFS Utilities Utilities Subaccount 0%
Global Governments Global Governments Subaccount 0%
New Discovery New Discovery Subaccount 0%
MSDW Emerging Markets Equity Emerging Markets Equity Subaccount 0%
Global Equity Global Equity Subaccount 0%
International Magnum International Magnum Subaccount 0%
Asian Equity Asian Equity Subaccount 0%
U.S. Real Estate U.S. Real Estate Subaccount 0%
Net premiums may also be allocated to the First Ameritas Fixed Account.
INITIAL
First Ameritas Fixed Account ALLOCATION OF
NET PREMIUMS
0%
5118 1-LSP
<PAGE>
SCHEDULE OF CHARGES
ASSET BASED DAILY ADMINISTRATIVE CHARGE:
The maximum daily administrative charge is .000683% (.25% annually).
MORTALITY AND EXPENSE RISK DAILY CHARGE:
The maximum daily mortality and expense risk charge is .002459% (.90%
annually) for years 1 through 20 and .001775% (.65% annually) thereafter.
ADMINISTRATIVE EXPENSE CHARGE:
The maximum monthly administrative expense charge is $9 in year 1 and $8 in
years 2 and thereafter.
PERCENT OF PREMIUM CHARGE:
The maximum percent of premium charge is 5% of premiums received.
TRANSFER CHARGE:
The first 15 transfers between Subaccounts and/or the Fixed Account per
policy year are free. Thereafter, there may be a $10 charge for each
transfer.
PARTIAL WITHDRAWAL CHARGE:
The maximum charge for each partial withdrawal is the lesser of $25 or 5%
of the amount withdrawn.
SURRENDER CHARGE:
The following table shows the surrender charge for the initial specified
amount based on the policy year of surrender.
For any increase in specified amount, a surrender charge based on the
increase will be imposed in addition to the surrender charges stated below.
See Section 10.4 of the policy and the SCHEDULE OF SURRENDER CHARGES FOR
INCREASES for further information.
POLICY YEAR
OF SURRENDER AMOUNT
1 $4,010.00
2 $4,010.00
3 $4,010.00
4 $4,010.00
5 $4,010.00
6 $3,609.00
7 $3,208.00
8 $2,807.00
9 $2,406.00
10 $2,005.00
11 $1,604.00
12 $1,203.00
13 $802.00
14 $401.00
15 $0.00
5118 1-SC
<PAGE>
SCHEDULE OF GUARANTEED ANNUAL
COST OF INSURANCE RATES*
INSURED: John D Specimen POLICY NUMBER: 2300005118
ISSUE AGE - SEX: 35 Male POLICY DATE: January 1, 2000
POLICY YEAR RATE PER $1,000 POLICY YEAR RATE PER $1,000
BEGINNING OF AMOUNT BEGINNING OF AMOUNT
JANUARY 1 AT RISK JANUARY 1 AT RISK
2000 $1.33 2033 $28.50
2001 $1.77 2034 $31.38
2002 $1.88 2035 $34.63
2003 $2.00 2036 $38.31
2004 $2.14 2037 $42.56
2005 $2.29 2038 $47.44
2006 $2.47 2039 $52.92
2007 $2.65 2040 $58.80
2008 $2.86 2041 $65.06
2009 $3.07 2042 $71.64
2010 $3.32 2043 $78.47
2011 $3.59 2044 $85.72
2012 $3.88 2045 $93.67
2013 $4.19 2046 $102.52
2014 $4.54 2047 $112.52
2015 $4.91 2048 $123.79
2016 $5.35 2049 $136.11
2017 $5.86 2050 $149.20
2018 $6.43 2051 $162.80
2019 $7.09 2052 $176.79
2020 $7.82 2053 $190.89
2021 $8.63 2054 $205.29
2022 $9.49 2055 $220.19
2023 $10.42 2056 $235.84
2024 $11.47 2057 $252.75
2025 $12.64 2058 $271.63
2026 $13.94 2059 $295.65
2027 $15.42 2060 $329.96
2028 $17.11 2061 $384.55
2029 $19.02 2062 $480.20
2030 $21.13 2063 $657.98
2031 $23.40 2064 $1,000.00
2032 $25.86
* The rates shown are annual rates per $1000 of insurance. To calculate the
monthly rate, the annual rate is divided by 12 and rounded to the nearest
five decimal places. These rates apply to the basic policy and do not
include the cost for riders. The rates shown have been adjusted if this
policy was issued with a tabular and/or flat rating as shown on the
schedule page.
5118 1-COI
<PAGE>
SCHEDULE OF SURRENDER CHARGES FOR INCREASES
The additional surrender charge imposed under this policy for each requested
increase in specified amount will be based on the table shown below. The charges
shown in the table are surrender charges.
The surrender charge is determined at the time of the increase and is a rate per
$1000 of increased specified amount based on the attained age at the time of the
increase and sex of the Insured. See Section 10.5 of this policy for further
information.
ISSUE
AGE MALE FEMALE UNISEX
---------------------------------------------------------
0 5.67 4.31 5.39
1 4.00 3.45 3.90
2 4.00 3.45 3.90
3 4.00 4.45 3.90
4 4.00 4.45 3.90
---------------------------------------------------------
5 4.00 4.45 3.90
6 4.00 4.45 3.90
7 4.00 4.45 3.90
8 4.00 4.45 3.90
9 4.00 4.45 3.90
---------------------------------------------------------
10 4.00 4.45 3.90
11 4.00 4.45 3.90
12 4.00 4.45 3.90
13 4.00 4.45 3.90
14 4.17 3.45 3.97
---------------------------------------------------------
15 4.33 3.45 4.13
16 4.40 3.45 4.20
17 4.47 3.45 4.27
18 4.54 3.53 4.34
19 4.61 3.61 4.41
---------------------------------------------------------
20 4.73 3.68 4.51
21 4.76 3.75 4.54
22 4.81 3.83 4.61
23 4.88 3.90 4.68
24 4.95 3.98 4.76
---------------------------------------------------------
25 5.02 4.05 4.83
26 5.24 4.23 5.04
27 5.48 4.42 5.27
28 5.73 4.61 5.51
29 6.00 4.83 5.77
---------------------------------------------------------
30 6.29 5.05 6.04
31 6.59 5.29 6.33
32 6.92 5.54 6.64
33 7.27 5.80 6.98
34 7.63 6.08 7.32
---------------------------------------------------------
35 8.02 6.38 7.69
36 8.43 6.69 8.08
37 8.88 7.02 8.51
38 9.34 7.37 8.95
39 9.83 7.74 9.41
---------------------------------------------------------
(CONTINUED)
5118 1.2-SSCI
<PAGE>
SCHEDULE OF SURRENDER CHARGES FOR INCREASES
(CONTINUED)
ISSUE
AGE MALE FEMALE UNISEX
---------------------------------------------------------
40 10.35 8.12 9.90
41 10.90 8.53 10.43
42 11.48 8.95 10.97
43 12.09 9.39 11.55
44 12.74 9.86 12.16
---------------------------------------------------------
45 13.43 10.35 12.81
46 14.17 10.88 13.51
47 14.95 11.43 14.25
48 15.77 12.02 15.02
49 16.65 12.64 15.85
---------------------------------------------------------
50 17.22 13.30 16.74
51 18.00 14.00 17.56
52 18.85 14.74 18.33
53 19.77 15.53 19.15
54 20.29 16.37 19.67
---------------------------------------------------------
55 21.23 17.26 20.52
56 21.92 17.72 21.16
57 22.62 18.18 21.83
58 23.33 18.63 22.49
59 24.05 19.09 23.18
---------------------------------------------------------
60 24.79 19.55 23.88
61 26.03 20.75 25.06
62 27.38 22.04 26.34
63 28.83 23.21 27.72
64 30.41 24.37 29.21
---------------------------------------------------------
65 32.09 25.61 30.80
66 33.65 26.75 32.28
67 35.32 27.97 33.86
68 37.12 29.30 35.58
69 39.08 30.76 37.45
---------------------------------------------------------
70 40.00 32.36 39.48
71 40.00 34.16 40.00
72 40.00 36.13 40.00
73 40.00 38.29 40.00
74 40.00 40.00 40.00
---------------------------------------------------------
75 40.00 40.00 40.00
76 40.00 40.00 40.00
77 40.00 40.00 40.00
78 40.00 40.00 40.00
79 40.00 40.00 40.00
80 40.00 40.00 40.00
---------------------------------------------------------
5118 1.2-SSCI
<PAGE>
TABLE OF CONTENTS
POLICY SCHEDULE PAGES
SECTION 1. DEFINITIONS...............................................4
SECTION 2. GENERAL PROVISIONS........................................6
2.1 Meaning of In Force.......................................6
2.2 When This Policy Terminates...............................6
2.3 Guaranteed Death Benefit..................................6
2.4 The Policy and its Parts..................................7
2.5 Representations and Contestability........................7
2.6 Misstatement of Age or Sex................................7
2.7 Suicide...................................................7
2.8 The Owner.................................................8
2.9 The Beneficiary...........................................8
2.10 Changing the Beneficiary..................................8
2.11 Assigning the Policy......................................8
2.12 Non-Participating.........................................8
SECTION 3. PREMIUM PAYMENTS..........................................9
3.1 Initial Premium...........................................9
3.2 Guaranteed Death Benefit Premium..........................9
3.3 Planned Periodic Premiums.................................9
3.4 Unscheduled Premiums..................................... 9
3.5 Premium Limits........................................... 9
3.6 Where to Pay Premiums....................................10
3.7 Net Premium..............................................10
3.8 Percent of Premium Charge................................10
3.9 Allocation of Net Premiums...............................10
SECTION 4. GRACE PERIOD AND REINSTATEMENT...........................10
4.1 Grace Period.............................................10
4.2 Continuation of Insurance................................11
4.3 Reinstating the Policy...................................11
SECTION 5. SEPARATE ACCOUNT.........................................11
5.1 The Account..............................................11
5.2 The Subaccounts..........................................12
5.3 Valuation of Assets......................................12
5.4 Transfer Among Subaccounts...............................12
5.5 The Funds................................................12
5.6 Portfolio Changes........................................12
SECTION 6. THE FIXED ACCOUNT........................................13
6.1 The Fixed Account........................................13
6.2 Transfers Among the Fixed Account
and the Subaccounts......................................13
5118 2
<PAGE>
SECTION 7. ACCUMULATION VALUE......................................13
7.1 How Accumulation Value of the Policy
is Determined...........................................13
7.2 Accumulation Value of the Subaccounts...................14
7.3 Net Asset Value.........................................14
7.4 Subaccount Unit Value...................................15
7.5 Accumulation Value of the Fixed Account.................15
7.6 Net Cash Surrender Value Bonus..........................16
7.7 Interest Credits........................................16
7.8 Administrative Expense Charge...........................16
7.9 Cost of Insurance.......................................16
7.10 Cost of Insurance Rates.................................16
7.11 Monthly Deduction.......................................17
7.12 Annual Report...........................................17
7.13 Illustrative Reports....................................18
7.14 Changes in Non-guaranteed Cost Factors..................18
7.15 Option to Transfer to Fixed Account.....................18
SECTION 8. POLICY SURRENDER
AND PARTIAL WITHDRAWAL..................................18
8.1 Surrender of the Policy.................................18
8.2 Net Cash Surrender Value................................18
8.3 Surrender Charge........................................18
8.4 Partial Withdrawal......................................19
8.5 Postponement of Payments................................19
SECTION 9. DEATH BENEFIT...........................................20
9.1 Death Benefit Proceeds..................................20
9.2 Interest on Proceeds....................................20
9.3 Death Benefit...........................................20
9.4 Postponement of Payment.................................21
SECTION 10. POLICY CHANGES
AND EXCHANGE OF POLICY..................................21
10.1 Change in Death Benefit Options.........................21
10.2 Change in the Specified Amount..........................22
10.3 Decreasing the Specified Amount.........................22
10.4 Increasing the Specified Amount.........................22
10.5 Surrender Charge for Increase...........................23
SECTION 11. LOAN BENEFITS...........................................23
11.1 Making a Policy Loan....................................24
11.2 Interest................................................24
11.3 Reduced Loan Interest Rate..............................24
11.4 Other Borrowing Rules...................................24
11.5 Repaying a Policy Debt..................................24
SECTION 12. PAYMENT OPTIONS.........................................25
12.1 Payment Option Rules....................................25
12.2 Description of Options..................................25
SECTION 13. NOTES ON OUR COMPUTATIONS...............................26
13.1 Basis of Computations...................................26
13.2 Methods of Computing Values.............................26
TABLES OF SETTLEMENT OPTIONS.................................................28
5118 3
<PAGE>
SECTION 1. DEFINITIONS
"ACCUMULATION VALUE" means the total amount of value held in your accounts at
any time. It is equal to the total of the accumulation value held in the
Account, the Fixed Account, and the accumulation value held in the general
account which secures policy loans.
"BENEFICIARY" means the person to whom the death benefit proceeds are payable
upon the death of the Insured. The beneficiary is named by the Owner in the
application. If changed, the beneficiary is as shown in the latest change filed
and recorded with us. If no beneficiary survives the Insured, the Owner or the
Owner's estate will be the beneficiary. The interest of any beneficiary is
subject to that of any assignee.
"DEATH BENEFIT" means the total amount of insurance coverage provided under the
selected death benefit option of this policy.
"DEATH BENEFIT PROCEEDS" means the proceeds payable to the beneficiary upon
receipt by us of the satisfactory proof of the death of the Insured while this
policy is in force. It is equal to: (1) the death benefit; plus (2) any
additional life insurance proceeds provided by any riders; minus (3) any
outstanding policy debt; minus (4) any overdue monthly deductions, including the
deduction for the month of death.
"GUARANTEED DEATH BENEFIT PERIOD" is the period during which the Guaranteed
Death Benefit is in effect and will end on the earliest of the following dates:
a. The expiration date shown on the schedule pages of this policy or any
revised schedule pages.
b. The date that the net policy funding is less than the Guaranteed Death
Benefit requirement. See Section 2.3.
c. The date on which this policy first terminates even if this policy is
reinstated.
"INSURED" means the person upon whose life this policy is issued.
"ISSUE AGE" means the age at the Insured's nearest birthday on the policy date.
"ISSUE DATE" means the date that all financial, contractual, and administrative
requirements have been completed and processed. The issue date will be shown in
a confirmation notice sent to you.
"MATURITY DATE" means the date we pay any net cash surrender value, if the
Insured is still living. This date is shown on the schedule pages.
"MONTHLY ACTIVITY DATE" means the same date in each succeeding month as the
policy date except that whenever the monthly activity date falls on a date other
than a valuation date, the monthly activity date will be deemed the next
valuation date.
"MONTHLY DEDUCTIONS" means the deductions taken from the accumulation value on
the monthly activity date. These deductions are equal to: 1) the current cost of
insurance for the basic policy plus the cost for any riders; and 2) the
administrative expense charge.
5118 4
<PAGE>
"NET CASH SURRENDER VALUE" means the accumulation value on any valuation date,
less any surrender charges and less any outstanding policy debt.
"NET PREMIUM" means the premium paid less the percent of premium charge.
"OUTSTANDING POLICY DEBT" means the sum of all unpaid policy loans and accrued
interest on policy loans.
"OWNER" means the Owner of this policy, as designated in the application or as
subsequently changed. If a policy has been absolutely assigned, the assignee is
the Owner. A collateral assignee is not the Owner. See Section 2.8 for the
rights and privileges of the Owner.
"PERCENT OF PREMIUM CHARGE" is an amount deducted from each premium received to
cover certain expenses. This charge is a percentage of the premium. The
applicable percentage can be found on the schedule pages.
"PLANNED PERIODIC PREMIUM" means a selected scheduled premium of a level amount
at a fixed interval. The initial planned periodic premium you selected is shown
on the schedule pages. See Section 3.3 of this policy.
"POLICY DATE" means the effective date for all coverage provided in the
application. The policy date is used to determine policy anniversary dates,
policy years and monthly activity dates. Policy anniversaries are measured from
the policy date. The policy date and the issue date will be the same unless: 1)
an earlier policy date is specifically requested, or 2) additional premiums or
application amendments are required at the time of delivery, in which case the
policy date will be earlier.
"POLICY YEAR" means the period from one policy anniversary date until the next
policy anniversary date.
"SEC" means the Securities and Exchange Commission.
"SATISFACTORY PROOF OF DEATH" means all of the following must be submitted:
a. A certified copy of the death certificate;
b. A Notice of Death Claim;
c. This policy; and
d. Any other information that we may reasonably require to establish the
validity of the claim.
"SPECIFIED AMOUNT" means the minimum death benefit under the policy while this
policy remains in force. The initial specified amount is shown on the schedule
pages. Adjustments and changes to the specified amount can occur as discussed in
Section 10.
5118 5
<PAGE>
"SURRENDER CHARGE" means the charge subtracted from the accumulation value on
the surrender of this policy. Refer to the SCHEDULE OF CHARGES and the SCHEDULE
OF SURRENDER CHARGES FOR INCREASES on the schedule pages.
"SURRENDER" means this policy may be terminated by you before the maturity date
during the Insured's life for its net cash surrender value. See Section 8 of
this policy.
"VALUATION DATE" is any day on which the New York Stock Exchange is open for
trading.
"YOU" AND "YOUR" refer to the Owner of this policy. The Insured may or may not
be the Owner.
"WE", "US" AND "OUR" refer to First Ameritas Life Insurance Corp. of New York.
Our Home Office means our administrative office at 400 Rella Boulevard, Suite
304, Suffern, NY 10901-4253.
SECTION 2. GENERAL PROVISIONS
2.1 MEANING OF IN FORCE
This policy will remain in force as long as on each monthly activity date the
net cash surrender value is sufficient to cover monthly deductions.
However, this policy will remain in force if the Guaranteed Death Benefit is in
effect on this policy, even if the net cash surrender value is insufficient to
cover monthly deductions. See Section 2.3.
2.2 WHEN THIS POLICY TERMINATES
This policy will terminate on the earliest of:
a. Any monthly activity date when the net cash surrender value is
insufficient to cover monthly deductions and the grace period ends without
sufficient premium being paid. However, this policy will not terminate if
the Guaranteed Death Benefit is in effect, even if the net cash surrender
value is insufficient to cover monthly deductions.
b. The Insured dies;
c. You request the coverage be terminated and you return this policy; or
d. This policy matures.
2.3 GUARANTEED DEATH BENEFIT
The Guaranteed Death Benefit is a benefit which applies to the policy at issue.
This benefit will ensure that the policy will remain in force as long as the net
policy
5118 6
<PAGE>
funding meets or exceeds the Guaranteed Death Benefit requirement and the policy
is within the Guaranteed Death Benefit Period. The net policy funding is the sum
of all premiums paid, less any partial withdrawals and less any outstanding
policy debt. The Guaranteed Death Benefit requirement is the cumulative
Guaranteed Death Benefit Premium to the monthly activity date. The Guaranteed
Death Benefit Premium is shown on the schedule page. Any changes in the
Guaranteed Death Benefit Premium due to increases in specified amount or
additions of riders will be reflected in the requirement from the effective date
of the change.
If the net policy funding is less than the Guaranteed Death Benefit requirement,
the benefit is no longer in effect. You will be notified by mail and will have
61 days from the date we mail the notice to meet the Guaranteed Death Benefit
requirement. The Guaranteed Death Benefit can not be reinstated once the policy
has lapsed.
2.4 THE POLICY AND ITS PARTS
This policy is a legal contract between you and us. It is issued in return for
the application and payment in advance of the initial premium as described in
Section 3.1. This policy, the application, any supplemental applications,
riders, endorsements, and amendments are the entire contract. No change in this
policy will be valid unless it is in writing, attached to this policy, and
approved by either the president or secretary of the company. No agent may
change this policy or waive any of its provisions.
2.5 REPRESENTATIONS AND CONTESTABILITY
We rely on statements made in the application. These statements are considered
representations and not warranties. We can contest this policy for any material
misrepresentation of fact. The misrepresentation must have been made in the
application attached to this policy when issued or in a supplemental application
made a part of this policy when a change in coverage or reinstatement went into
effect.
We cannot contest this policy after it has been in force during the Insured's
life for two years from the policy date. Nor can we contest any increased
benefits later than two years after the effective date of the increased benefits
during the Insured's life. Any increase or reinstatement will be contestable,
within the two year period, only with regard to statements made in the
supplemental application. This provision does not apply to riders with their own
contestability provision.
2.6 MISSTATEMENT OF AGE OR SEX
If the age or sex of the Insured or any person insured by rider has been
misstated on the application, the death benefit and any additional benefits
provided will be those which would be purchased by the most recent deduction for
the cost of insurance and the cost of any additional benefits at the insured
person's correct age or sex.
2.7 SUICIDE
If the Insured commits suicide, within two years from the policy date, we will
limit the proceeds. The limited amount will equal all premiums paid for this
policy, less outstanding policy debt, partial withdrawals, and the cost for
riders.
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If the Insured commits suicide within two years from the effective date of any
increase in the specified amount, we will limit the proceeds payable with
respect to the increase. The proceeds thus limited will equal the total cost of
insurance applicable to the increase. This provision does not apply to riders
with their own suicide provision.
2.8 THE OWNER
While the Insured is living you have all the benefits, rights and privileges
under this policy. These include naming a successor-owner, changing the
beneficiary, assigning this policy, enjoying all policy benefits, and exercising
all policy options.
If you are not the Insured, you should name a successor-owner who will become
the Owner if you die before the Insured. If you die before the Insured and there
is no successor-owner, ownership will pass to your estate.
2.9 THE BENEFICIARY
You can name primary and contingent beneficiaries. Your original beneficiary
choice is shown in the attached application.
Unless a payment plan is chosen, the proceeds payable at the Insured's death
will be paid in a lump sum to the primary beneficiary. If the primary
beneficiary dies before the Insured, the proceeds will be paid to the contingent
beneficiary. If no beneficiary survives the Insured, the proceeds will be paid
to your estate.
2.10 CHANGING THE BENEFICIARY
You may change the beneficiary during the Insured's lifetime. We do not limit
the number of changes that may be made. To make the change, we must receive a
completed Change of Beneficiary form and any other forms required by the Home
Office. The change will take effect as of the date we record it at the Home
Office, even if the Insured dies before we do so. Each change will be subject to
any payment we made or any other action we took before the change is recorded.
2.11 ASSIGNING THE POLICY
You may assign this policy. For an assignment to bind us, we must receive a
signed copy in the Home Office. We are not responsible for the validity of any
assignment.
An assignment is subject to any policy debt. Policy debt is discussed in Section
11.
2.12 NON-PARTICIPATING
This policy is non-participating. In other words, no dividends will be paid
under this policy.
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SECTION 3. PREMIUM PAYMENTS
3.1 INITIAL PREMIUM
An initial premium of at least 1/12th of the Guaranteed Death Benefit Premium
must be paid on or before delivery of this policy. The initial premium shown on
the schedule pages is the amount received with the application or 1/12th of the
Guaranteed Death Benefit Premium if no money is received with the application.
3.2 GUARANTEED DEATH BENEFIT PREMIUM
You have the option to pay a planned premium based on the annual Guaranteed
Death Benefit Premium. This premium is shown on the schedule pages.
During the Guaranteed Death Benefit Period, also shown on the schedule pages, if
net policy funding meets or exceeds the Guaranteed Death Benefit requirement,
the policy will remain in force, even if the net cash surrender value is
insufficient to cover monthly deductions. Net policy funding is premiums paid
less any partial withdrawals and less any outstanding policy debt.
3.3 PLANNED PERIODIC PREMIUM
This is a flexible premium policy. You may choose to pay planned periodic
premiums, and as indicated in Section 3.2, you may elect to base your planned
periodic premiums on the Guaranteed Death Benefit Premium. However, planned
periodic premiums are not required. The amount and frequency of the planned
periodic premiums you selected when this policy was issued is shown on the
schedule pages. You may change the frequency of the payments or the amount by
sending a written request to the Home Office. Premiums may not be paid after the
maturity date. We reserve the right to limit the amount and frequency of the
planned periodic premiums you choose to pay as described in Section 3.5.
3.4 UNSCHEDULED PREMIUMS
Any premium we receive under this policy in an amount different from the planned
periodic premiums will be considered an unscheduled premium. Unscheduled
premiums can be made at any time while this policy is in force.
3.5 PREMIUM LIMITS
We reserve the right to limit the amount and frequency of premium payments as
described below:
1. The premium payment must be at least $10.00.
2. Any premium that would immediately result in the death benefit becoming
equal to a percentage of the accumulation value.
3. Any premium that would prevent the coverage under this policy from
continuing to qualify as life insurance under the Internal Revenue Code of
1954.
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3.6 WHERE TO PAY PREMIUMS
Each premium after the first one is payable at our Home Office. Upon request, a
receipt signed by our Secretary or an Assistant Secretary will be given for any
premium payment.
3.7 NET PREMIUM
Before the premiums paid are allocated to the Subaccounts and/or Fixed Account,
a percent of premium charge is deducted. The amount of premium then allocated is
called the net premium.
3.8 PERCENT OF PREMIUM CHARGE
The percent of premium charge is deducted from each premium payment received.
The maximum percent of premium charge is shown on the schedule pages. We have
the option of charging a current percent of premium charge, which can be less
than the maximum.
3.9 ALLOCATION OF NET PREMIUMs
As of the issue date, net premiums then received will be allocated to a money
market Subaccount. On the 13th day after the issue date, the accumulation value
will be reallocated to the Subaccounts and/or the Fixed Account as you have
selected on the application. Any additional premium received will be allocated
in accordance with your instructions. You may change the allocation of later net
premiums without charge. The allocation will apply to future net premiums after
we receive the change. The Subaccounts and the Fixed Account are discussed in
Sections 5 and 6.
SECTION 4. GRACE PERIOD
AND REINSTATEMENT
4.1 GRACE PERIOD
This policy will begin a 61 day grace period when:
a. the net cash surrender value on any monthly activity date is not sufficient
to cover monthly deductions; and
b. the Guaranteed Death Benefit is no longer in effect.
The 61 day grace period will begin on the day we mail a notice of the premium
necessary to keep your policy in force. The amount necessary will be the lessor
of:
a) the amount by which the new policy funding is less than the Guaranteed
Death Benefit Premium requirement, if the Guaranteed Death Benefit is
in effect; and
b) the amount by which the net cash surrender value is not sufficient to
cover the monthly deductions.
We will mail this notice to you at your last known address and to any assignee
of record. If sufficient premium is not paid by the end of the grace period,
this policy will terminate without value.
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If the Insured dies during the grace period, the overdue monthly deductions will
be deducted from the death proceeds.
4.2 CONTINUATION OF INSURANCE
Insurance coverage under this policy and any benefits provided by any rider(s)
will be continued through the grace period.
4.3 REINSTATING THE POLICY
If the Insured is living and application is made within three years from the
beginning of any grace period, this policy can be considered for reinstatement
if it terminated because a grace period ended without sufficient premium being
paid.
To apply for reinstatement, you must send evidence satisfactory to us that the
Insured is insurable. The effective date of the reinstatement will be the first
monthly activity date on or next following the date the application for
reinstatement is approved.
To reinstate the policy, you will have to pay a premium equal to the greater of:
a. a premium sufficient to bring the net cash surrender value to an amount
above zero; or
b. three times the current month's monthly deductions.
We will accept a premium larger than the applicable amount described above.
This policy cannot be reinstated if it has been surrendered for its net cash
surrender value, nor can it be reinstated after the maturity date. Any policy
debt will be reinstated.
SECTION 5. SEPARATE ACCOUNT
5.1 THE ACCOUNT
The word Account, where we use it in this policy without qualification, means
the First Ameritas Life Insurance Corp. of New York Separate Account V. This is
a unit investment trust registered with the SEC under the Investment Company Act
of 1940. It is also subject to the laws of New York. We own the assets of the
Account and keep them separate from the assets of our general account.
The Account is used only to fund the variable benefits provided under this
policy and any other variable life policies supported by the Account.
The assets of the Account will be available to cover the liabilities of our
general account only to the extent that the assets of the Account exceed the
liabilities of the Account arising under the variable life policies supported by
the Account.
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5.2 THE SUBACCOUNTS
The Account has several Subaccounts. We list those available on the policy date
on the schedule pages. The available Subaccounts may change after the policy
date. Any changes will be disclosed by the Prospectus. You determine, using
percentages, how the net premium will be allocated among the Subaccounts. You
may choose to allocate nothing to a particular Subaccount. You may not choose a
fractional percent. The allocations to the Subaccounts along with allocations to
the Fixed Account must total 100%. The assets of each Subaccount will be used to
buy shares in a corresponding portfolio of the funding vehicles designated on
the schedule pages. See Section 5.5. Income and realized and unrealized gains or
losses from the assets of each Subaccount of the Account are credited to or
charged against that Subaccount without regard to income, gains or losses in the
other Subaccounts of the Account, our general account or any other separate
accounts.
5.3 VALUATION OF ASSETS
We will determine the value of the assets of each Subaccount at the end of each
valuation date.
5.4 TRANSFER AMONG SUBACCOUNTS
You may transfer amounts among Subaccounts as often as you wish in a policy
year. The transfer will take effect on the later of the date designated in the
request or on the valuation date following receipt of the written request at our
Home Office.
Each transfer must be for a minimum of $250 or the balance in the Subaccount, if
less. The first 15 transfers per policy year will be allowed free of charge.
Thereafter, a $10 transfer charge may be deducted from the accumulation value.
The minimum amount which can remain in a Subaccount and/or in the Fixed Account
as a result of a transfer is $100. Any amount below this minimum must be
included in the amount transferred.
Transfers may be subject to additional restrictions by the Funds.
5.5 THE FUNDS
The word Funds, where we use it in this policy without qualification, means the
funding vehicles designated on the schedule pages. The available Funds may
change. Any changes will be disclosed in the Prospectus. The Funds are
registered with the SEC under the Investment Company Act of 1940 as diversified
open-end management investment companies. The Funds bear their own expenses. The
Funds have several portfolios; there is a portfolio that corresponds to each of
the Subaccounts of the Account. We list those available on the policy date on
the schedule pages.
5.6 PORTFOLIO CHANGES
A portfolio of the Funds might, in our judgment, become unsuitable for
investment by a Subaccount. This might happen because of a change in investment
policy, because of a change in laws or regulations, because the shares are no
longer available for investment, or for some other reason. If that occurs, we
have the right to substitute another portfolio of the Funds, or to invest in
another fund. But we would first notify and receive approval from the SEC and
the New York Insurance Department. This approval process is on file with the
insurance commissioner of the state where this policy is delivered. Any
portfolio changes will be disclosed in the Prospectus. If the SEC requires that
such action receive approval from a majority of the policyholders in the
Account, then you will be notified of your right to vote. You will be notified
of any material change in the investment policy of any portfolio in which you
have an interest. If you are dissatisfied with any change, you always have the
option to transfer all or a portion of your accumulation value to the Fixed
Account (See Section 6.2) or to one of the other available Subaccounts (See
Section 5.4).
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SECTION 6. THE FIXED ACCOUNT
6.1 THE FIXED ACCOUNT
Net premiums allocated to and transfers to the Fixed Account under this policy
become part of the general account assets of First Ameritas Life Insurance Corp.
of New York which support annuity and insurance obligations. The Fixed Account
includes all of First Ameritas Life Insurance Corp. of New York's assets, except
those assets segregated in separate accounts. First Ameritas Life Insurance
Corp. of New York maintains the sole discretion to invest the assets of the
Fixed Account, subject to applicable law.
You determine, using percentages, how the premium will be allocated to the Fixed
Account. You may choose to allocate nothing to the Fixed Account. The minimum
allocation must be at least 1%; you may not choose a fractional percentage. The
allocations to the Fixed Account along with allocations to the Subaccounts must
total 100%.
6.2 TRANSFERS AMONG THE FIXED ACCOUNT AND THE SUBACCOUNTS
You may transfer into the Fixed Account from the Subaccounts at any time during
the policy year.
You may make one transfer out of the Fixed Account to any of the other
Subaccounts only during the 30 day period following each policy anniversary.
The allowable transfer amount out of the Fixed Account is limited to the greater
of:
a. 25% of the Fixed Account balance; or
b. any Fixed Account transfer out of the Fixed Account which occurred
during the prior 13 months; or
c. $1,000.
Transfers into or from the Fixed Account will be subject to the same transfer
charges and minimums that are applied to transfers among the Subaccounts. See
Section 5.4.
SECTION 7. ACCUMULATION VALUE
7.1 HOW ACCUMULATION VALUE OF THE POLICY IS DETERMINED
The accumulation value of this policy on the issue date is:
a. The net premiums received by us on or before the issue date; minus
b. Any monthly deductions due on or before the issue date.
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The accumulation value of this policy on a valuation date is equal to the total
of the values in each Subaccount and the Fixed Account, plus the accumulation
value impaired by policy debt which is held in the general account, plus any net
premium received on that valuation date but not yet allocated.
7.2 ACCUMULATION VALUE OF THE SUBACCOUNTS
To compute the accumulation value held in the Subaccounts on any valuation date,
we multiply each Subaccount's unit value (defined in Section 7.4 below) by the
number of Subaccount units allocated to this policy.
The number of Subaccount units will increase when:
a. Net premiums are credited to that Subaccount;
b. Transfers from other Subaccounts or the Fixed Account are credited to that
Subaccount;
c. Policy debt (principal or interest) is repaid and allocated to the
Subaccount, or interest is credited from the amount held in the general
account to secure the policy debt; or
d. that portion of the net cash surrender value bonus, if any, is credited to
that Subaccount.
The number of Subaccount units will decrease when:
a. A policy loan is taken from that Subaccount;
b. A partial withdrawal is taken from that Subaccount;
c. A portion of the monthly deduction is taken from that Subaccount;
d. A transfer, and its charge, is made from that Subaccount to other
Subaccounts or the Fixed Account;
e. Policy loan interest not paid when due is taken from that Subaccount; or
f. A portion of any transfer charge is taken from that Subaccount.
Each transaction above will increase or decrease the number of Subaccount units
allocated to this policy by an amount equal to the dollar value of the
transaction divided by the current unit value.
7.3 NET ASSET VALUE
The net asset value of the shares of each portfolio of the Fund is determined
once daily as of the close of business of the New York Stock Exchange on days
when the Exchange is open for business. The net asset value is determined by
adding the values of all securities and other assets of the portfolio,
subtracting liabilities and expenses and dividing by the number of outstanding
shares of the portfolio. Expenses, including the investment advisory fee, are
accrued daily.
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7.4 SUBACCOUNT UNIT VALUE
For each Subaccount, the value of an accumulation unit (unit value) was set when
the Subaccount was established. The unit value of each Subaccount reflects the
investment performance of that Subaccount. The unit value may increase or
decrease from one valuation date to the next.
The unit value of each Subaccount on any valuation date shall be calculated as
follows:
a. The per share net asset value of the corresponding Fund portfolio on the
valuation date times the number of shares held by the Subaccount, before
the purchase or redemption of any shares on that date; minus
b. A daily charge for administrative expenses, called the asset based daily
administrative charge, shown on the schedule page; minus
c. A daily charge for mortality and expense risk shown on the schedule page;
minus
d. Any taxes payable by the Separate Account; divided by
e. The total number of units held in the Subaccount on the valuation date
before the purchase or redemption of any units on that date.
When transactions are made, the actual dollar amounts are converted to
accumulation units. The number of accumulation units for a transaction is found
by dividing the dollar amount of the transaction by the current unit value.
7.5 ACCUMULATION VALUE OF THE FIXED ACCOUNT
The accumulation value of the Fixed Account on a valuation date is equal to:
a. The net premiums credited to the Fixed Account; plus
b. Any transfers from the Subaccounts credited to the Fixed Account; plus
c. Any policy debt (principal or interest) repaid and allocated to the Fixed
Account, or interest credited from the amount held in the general account
to secure the policy debt; minus
d. Any policy loan taken from the Fixed Account; minus
e. Any partial withdrawal and its charge taken from the Fixed Account; minus
f. The portion of the monthly deduction taken from the Fixed Account; minus
g. Any transfer made from the Fixed Account; minus
h. The portion of any transfer charge taken from the Fixed Account; minus
i. Any policy loan interest not paid when due taken from the Fixed Account;
plus
j. that portion of the net cash surrender value bonus, if any, that is
credited to the Fixed Account; plus
k. Interest credits.
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7.6 NET CASH SURRENDER VALUE BONUS
We will credit an additional amount (bonus) to your accumulation value each
policy year if the policy has been in force at least 21 years and if the net
cash surrender value is at least $500,000. The bonus will be a percentage of
your net cash surrender value. The policy must be in force for the bonus to be
credited. This bonus will be credited to the Subaccounts and/or the Fixed
Account based on the premium allocation percentages in effect at that time. We
reserve the right to change the bonus from time to time.
7.7 INTEREST CREDITS
We guarantee that the accumulation value in the Fixed Account will be credited
with an effective annual interest rate of at least 3.5%. We may, at our
discretion, credit a higher current rate of interest.
7.8 ADMINISTRATIVE EXPENSE CHARGE
On each monthly activity date, one-twelfth of an annual charge called the
administrative expense charge will be deducted from the accumulation value. The
maximum administrative expense charge is shown on the schedule pages. We have
the option of charging a current administrative expense charge, which can be
less than the maximum.
7.9 COST OF INSURANCE
The cost of insurance will be figured each month. It is the cost of insurance
for the basic policy (including any increases in the specified amount) plus the
cost for any riders. The cost for this policy is equal to:
a. the death benefit on the monthly activity date, discounted at the
guaranteed rate of interest for the Fixed Account for one month;
b. less the accumulation value on the monthly activity date, after all
monthly deductions have been taken except for the cost of insurance;
c. the above result multiplied by the monthly cost per $1,000 of insurance
(as described below in the Cost of Insurance Rates section);
d. divided by $1,000.
The charge made during the policy year will be shown on the annual report.
7.10 COST OF INSURANCE RATES
For the initial specified amount, the cost of insurance rates will not exceed
those shown on the SCHEDULE OF GUARANTEED ANNUAL COST OF INSURANCE RATES in the
schedule pages. To calculate the monthly rates divide by 12 and round to the
nearest five decimal places.
Each year, the annual cost of insurance rates will be declared for the next
policy year. These rates will be based on the Insured's issue age and sex, the
Insured's tobacco usage, the specified amount and policy year. The rates will be
adjusted for any table rating and/or flat extra rating. Part of the Cost of
Insurance charge may be used to recover acquisition expenses arising from the
issuance of the policy. The expense recovery is higher in early policy years.
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If this policy is rated at issue with extra premiums, the guaranteed rates shown
are a multiple of the guaranteed rates for a standard issue. This multiple
factor is shown on the schedule pages. Any flat extra rating is shown on the
schedule pages and has been included in the cost of insurance rates.
Any change in the current cost of insurance rates will apply to all policies
having the same issue age, specified amount, policy year, sex, plan, issue
month, issue year, rating class and guaranteed cost of insurance rates as this
policy.
7.11 MONTHLY DEDUCTION
The monthly deduction is made each policy month against the accumulation value
allocated to the Account and to the Fixed Account. Monthly deductions will be
deducted from the Subaccounts and the Fixed Account in the same proportion as
the balances held in the Subaccounts and the Fixed Account. The monthly
deduction is equal to:
a. The administrative expense charge; plus
b. The cost of insurance for the current policy month, including the cost for
any rider.
Refer to the SCHEDULE OF GUARANTEED ANNUAL COST OF INSURANCE RATES and the
SCHEDULE OF CHARGES on the schedule pages for further details.
7.12 ANNUAL REPORT
Each year the Owner will be mailed an annual report within 45 days of the close
of the end of the year and within 13 months of the last statement. This report
will show for the last policy year:
a. premiums paid;
b. expense charges, if any;
c. interest credits;
d. cost of insurance;
e. outstanding debt;
f. total charges for riders, if any;
g. partial withdrawals or policy loan activity including the amount of the
loan interest and withdrawal charge identified separately;
h. the accumulation value and net cash surrender value at the beginning and
end of the period, including any bonus credited, if applicable;
i. the amount of the death benefit at the beginning and end of the period;
j. the projected current interest rate(s) as of the statement date;
k. the expiry date of coverage assuming no further premium payments or policy
changes are made; and
l. any other information required by the Superintendent of Insurance.
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7.13 ILLUSTRATIVE REPORTS
The Owner may request a report illustrating future values of this policy under
both guaranteed and current assumptions at any time. The first report requested
in a policy year is free. If allowed by state law, a reasonable fee not to
exceed $50 may be charged for each report after the first report.
7.14 CHANGES IN NON-GUARANTEED COST FACTORS
Any adjustments to non-guaranteed cost factors (interest credits, administrative
expense charge, administration charge, mortality and expense risk charges, cost
of insurance charges, and net cash surrender value bonus) will be by class and
based on changes in future expectations of such elements as mortality,
persistency, investment earnings, expenses and taxes. Any changes in policy cost
factors will be determined in accordance with procedures and standards on file
with the Superintendent of Insurance. Cost factors will be reviewed for in force
policies for adjustments not more often than once per year nor less often than
once every five years.
7.15 OPTION TO TRANSFER TO FIXED ACCOUNT
Each year, at any time within ten days after the policy anniversary, you have
the option to transfer all funds to the Fixed Account and receive guaranteed
reduced paid up benefits. The amount of the guaranteed reduced paid up benefits
will be that amount which the funds will purchase based on the mortality table
on which the guaranteed rates are calculated and the guaranteed interest rate.
SECTION 8. POLICY SURRENDER
AND PARTIAL WITHDRAWALS
8.1 SURRENDER OF THE POLICY
This policy may be surrendered before the maturity date at any time during the
Insured's life for its net cash surrender value.
8.2 NET CASH SURRENDER VALUE
The amount payable upon surrender is the accumulation value on the valuation
date we receive your written request, less any surrender charges, and less any
outstanding policy debt. The net cash surrender value is payable in one lump sum
or under one of the payment options. See Section 12.
8.3 SURRENDER CHARGE
The surrender charge is based on the initial specified amount of insurance at
issue and any increase in specified amount.
Refer to the SCHEDULE OF CHARGES on the schedule pages for the surrender charge
on the initial specified amount of insurance.
If the specified amount is increased, the surrender charge will be a composite
of all charges which apply for each year. Refer to the SCHEDULE OF SURRENDER
CHARGES FOR INCREASES on the schedule pages for further details.
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8.4 PARTIAL WITHDRAWAL
A partial withdrawal of this policy may be made for any amount of at least $500
subject to the following rules:
a. The net cash surrender value remaining after a partial withdrawal must be
at least $1,000 or an amount sufficient to maintain this policy in force
for the next 12 months.
b. A partial withdrawal is irrevocable.
c. The request must be made to us in writing on a form approved by us.
d. A partial withdrawal will not be allowed if the resulting specified amount
after the withdrawal is less than:
i. For Insureds in the preferred rating class; $100,000
ii. For Insureds in all other rating classes;
(1) In the second and third policy year; $50,000
(2) After the third policy year; $35,000.
e. A withdrawal charge will be deducted from the amount withdrawn. The charge
will not exceed the lesser of $25 or 5% of the amount withdrawn.
Partial withdrawals will affect other policy values. The accumulation value will
be reduced by the amount of the partial withdrawal. If Death Benefit Option A is
in effect on the date of a partial withdrawal, the specified amount will be
reduced by the amount of the partial withdrawal. These reductions will also
reduce the death benefits. See Section 9. The withdrawal will affect the net
policy funding used to determine if the Guaranteed Death Benefit is to remain in
effect. See Section 2.3.
You may tell us how to allocate the partial withdrawal among the Subaccounts
and/or the Fixed Account, provided that the minimum amount remaining in a
Subaccount and/or the Fixed Account as a result of the allocation is $100. If
you do not, or if there is not enough value in any Subaccount or in the Fixed
Account, the partial withdrawal will be allocated among the Subaccounts and the
Fixed Account in the same proportion as the balances held in each Subaccount and
the Fixed Account on the date we receive the request in our Home Office.
8.5 POSTPONEMENT OF PAYMENTS
We will usually pay any amounts payable from the Subaccounts as a result of
surrender, partial withdrawals, and policy loans within seven (7) days after we
receive written request in our Home Office on a form satisfactory to us. We can
postpone such payments or any transfers of amounts between Subaccounts if:
a. The New York Stock Exchange is closed other than customary weekend and
holiday closings or trading on the New York Stock Exchange is restricted
as determined by the SEC; or
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b. The SEC by order permits the postponement for the protection of
policyowners; or
c. An emergency exists as determined by the SEC, as a result of which disposal
of securities is not reasonable, practicable, or it is not reasonable or
practicable to determine the value of the net assets of the Account.
We may defer the payment of a full surrender, partial withdrawals and policy
loans from the Fixed Account for up to six months from the date we receive your
written request.
SECTION 9. DEATH BENEFIT
9.1 DEATH BENEFIT PROCEEDS
The death benefit proceeds payable to the beneficiary upon our receipt of
satisfactory proof of the death of the Insured while this policy is in force
will equal:
a. The death benefit; plus
b. Any additional life insurance proceeds provided by any rider; minus
c. Any outstanding policy debt; minus
d. Any overdue monthly deductions including the deduction for the month of
death.
9.2 INTEREST ON PROCEEDS
Death benefit proceeds that are paid in one lump sum will include interest if we
do not pay the proceeds within 30 days of receiving satisfactory proof of death.
The rate of interest will be the greater of:
a. 3% per annum.
b. the current rate of interest payable on death benefit proceeds.
c. the rate required by state law.
Interest will accrue from the date we receive satisfactory proof of death to the
date of payment of the death benefit proceeds.
9.3 DEATH BENEFIT
Subject to the provisions of this policy, the death benefit at any time prior to
the maturity date shall be either Option A or Option B. The initial death
benefit option is shown on the schedule pages. It may be changed as described in
Section 10.1.
Option A: Basic Coverage
The death benefit will be the greater of:
a. The current specified amount; or
b. A percentage of the accumulation value on the date of death, where the
applicable percentage is determined from the table shown below.
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Option B: Basic Coverage Plus Accumulation Value
The death benefit will be the greater of:
a. The current specified amount plus the accumulation value on the date of
death; or
b. A percentage of the accumulation value on the date of death, where the
applicable percentage is determined from the table shown below.
Insured's Applicable Insured's Applicable
Age * Percentage Age * Percentage
--------- ---------- --------- ----------
40 or less 250% 60 130%
41 243 61 128
42 236 62 126
43 229 63 124
44 222 64 122
45 215 65 120
46 209 66 119
47 203 67 118
48 197 68 117
49 191 69 116
50 185 70 115
51 178 71 113
52 171 72 111
53 164 73 109
54 157 74 107
55 150 75-90 105
56 146 91 104
57 142 92 103
58 138 93 102
59 134 95-100 100
*Insured's Age means the attained age at the beginning of the policy year.
9.4 POSTPONEMENT OF PAYMENT
We will usually pay any death benefit proceeds within seven (7) days after we
receive satisfactory proof of death.
SECTION 10. POLICY CHANGES
AND EXCHANGE OF POLICY
10.1 CHANGE IN DEATH BENEFIT OPTIONS
You may change the death benefit option which is shown on the schedule pages and
is referred to in Section 9. The death benefit option may not be changed in the
first policy year and may only be changed once a year thereafter. The change
will become effective on the first monthly activity date on or next following
the date we approve your requested change.
If you change from Option A to Option B, the specified amount after the change
will equal the death benefit prior to the change, less the accumulation value as
of the date of change. A change from Option B to Option A will change the
specified amount to an amount equal to the death benefit as of the date of
change.
5118 21
<PAGE>
10.2 CHANGE IN THE SPECIFIED AMOUNT
After this policy has been in effect for one year, you can increase or decrease
the specified amount. To make a change, send a written request to our Home
Office. Any change will be effective on the monthly activity date on or next
following the date we approve the request, unless you specify a later date. You
may only change the specified amount once a year.
10.3 DECREASING THE SPECIFIED AMOUNT
A decrease in the specified amount is subject to the following conditions:
a. A decrease may not be made during the first policy year nor during the
first 12 policy months following an increase in specified amount except
for a decrease which was the result of a partial withdrawal.
b. The specified amount in effect after any decrease may not be less than:
i. For Insureds in the preferred rating class; $100,000
ii. For Insureds in all other rating classes;
(1) In the second and third policy year; $50,000
(2) After the third policy year; $35,000.
c. The resulting specified amount after a decrease may not affect the tax
qualifications of this policy as described in Section 7702 of the Internal
Revenue Code, as amended.
d. A decrease in the specified amount will not lower the Guaranteed Death
Benefit Premium that was in effect prior to the decrease.
A decrease in the specified amount will reduce the specified amount in the
following order:
a. The specified amount provided by the most recent increase;
b. the next most recent increases successively; and
c. the initial specified amount.
10.4 INCREASING THE SPECIFIED AMOUNT
Any increase of the specified amount is subject to the following conditions:
a. An increase may not be made in the first policy year.
b. A supplemental application for the increase and satisfactory evidence of
insurability of the Insured must be received.
c. The minimum amount of any increase is $25,000.
d. An increase cannot be made if the Insured's age nearest birthday is over
80.
5118 22
<PAGE>
e. If an increase occurs during the Guaranteed Death Benefit Period, an
additional premium may be required on the date of change in order to meet
the new Guaranteed Death Benefit Premium. The Guaranteed Death Benefit
requirement will reflect the change in the Guaranteed Death Benefit
premium from the date of change.
f. At the time of the increase, the accumulation value, less any surrender
charges less any outstanding policy debt must be at least equal to 12
times the current month's monthly deduction reflecting the increase in
specified amount. If this value is not sufficient to support these monthly
deductions for at least one year beyond the effective date of the
increase, additional premiums may be required. You will be notified of any
additional premium due.
g. If the increase is approved by us but in a rating class different than the
original specified amount or any prior increase, the Guaranteed Death
Benefit Period may be adjusted. The expiration date will be shown on a new
schedule page provided to you.
10.5 SURRENDER CHARGE FOR INCREASES
An additional surrender charge will be imposed under this policy in the event of
each requested increase in specified amount. The surrender charge is an amount
per $1000 of increased specified amount based on the attained age and sex of the
Insured at the time of the increase. We may charge an amount less than the
surrender charge amount. The additional surrender charge will be deducted upon
the surrender of this policy at any time during the 15 years following the
increase. This surrender charge will be determined at the time of each increase
and will grade down to zero at the end of 15 years based on the following
schedule:
YEAR FROM DATE % OF SURRENDER CHARGE
OF INCREASE AT TIME OF INCREASE
1 100%
2 100%
3 100%
4 100%
5 100%
6 90%
7 80%
8 70%
9 60%
10 50%
11 40%
12 30%
13 20%
14 10%
15 0
See the SCHEDULE OF SURRENDER CHARGES FOR INCREASES on the schedule pages for
further information.
SECTION 11. LOAN BENEFITS
This policy has loan benefits that are described below. The amount of
outstanding loans plus accrued interest is called outstanding policy debt. Any
outstanding policy debt will be deducted from proceeds payable at the Insured's
death, on maturity, or on surrender.
5118 23
<PAGE>
11.1 MAKING A POLICY LOAN
After the first policy anniversary, you may obtain a policy loan from us. This
policy is the only security required. The maximum available loan amount is equal
to the net cash surrender value at the time of the loan less the guaranteed
monthly deductions remaining for the balance of the policy year, less interest
on the policy debt including the requested loan to the next policy anniversary
date.
11.2 INTEREST
The maximum interest rate on any loan is 5.5% per year. We have the option of
charging less. Interest accrues daily and becomes a part of the policy debt.
Interest payments are due on each anniversary date. If interest is not paid when
due, it will be added to the policy debt and will bear interest at the rate
charged on the loan.
11.3 REDUCED LOAN INTEREST RATE
The loan interest rate will be reduced to a maximum of 4% for eligible loan
amounts. This reduced loan interest rate is available on and after the 10th
policy anniversary. During each policy year, the eligible loan amount for a
reduced loan interest rate will be 10% of the net cash surrender value as of the
most recent policy anniversary. If a regular loan is in effect on the policy
anniversary, it will be converted to a loan with the reduced loan interest rate
up to the eligible amount. Loan interest accrued on loans with a reduced loan
interest rate will also accrue at the reduced loan rate.
11.4 OTHER BORROWING RULES
When a policy loan is made, or when interest is not paid when due, an amount
sufficient to secure the policy debt is transferred out of the Account and the
Fixed Account and into our general account. You may tell us how to allocate that
accumulation value among the Subaccounts and/or the Fixed Account provided that
the amount remaining in a Subaccount or the Fixed Account as a result of the
allocation is $100. Without specific direction, the accumulation value will be
allocated among the Subaccounts and/or the Fixed Account in the same proportion
that the policy's accumulation value in each Subaccount and the Fixed Account
bears to the total accumulation value in all Subaccounts and the Fixed Account
on the date we make the loan.
Accumulation value transferred into the general account to secure policy debt
will be credited with 3.5% interest annually. The interest earned will be
allocated to the Subaccounts and/or the Fixed Account in the same manner as net
premiums.
If the policy debt exceeds the accumulation value less any accrued expenses and
charges, you must pay the excess. We will send you a notice of the amount you
must pay. If you do not pay this amount within 61 days after we send notice,
this policy will terminate without value unless the Guaranteed Death Benefit is
in effect. We will send the notice to you and to any assignee of record at our
Home Office.
Any loan transaction will permanently affect the values of this policy.
11.5 REPAYING A POLICY DEBT
You can repay a policy debt in part or in full anytime during the Insured's life
prior to the maturity date while this policy is in force. Repayment must be
specifically identified as such by you. When a loan repayment is made,
accumulation value in the general account related to that payment will be
transferred into the Subaccounts and/or the Fixed Account in the same proportion
that net premiums are being allocated.
5118 24
<PAGE>
SECTION 12. PAYMENT OPTIONS
Life insurance proceeds, the net cash surrender value, or benefits at maturity
will be paid in one lump sum if no option is chosen. Subject to the rules stated
below, all or part of the proceeds can be paid under a payment option. During
the Insured's life, you can choose a payment option. A beneficiary can choose a
payment option if you have not chosen one at the Insured's death.
12.1 PAYMENT OPTION RULES
There are several important payment option rules:
a. An association, corporation, partnership or fiduciary can only receive a
lump sum payment or a payment under Option b.
b. If this policy is assigned, any amount due to the assignee will first be
paid in one sum. The balance, if any, may be applied under any payment
option.
c. If the payments under any option come to less than $100 each, we have the
right to make payments at less frequent intervals.
d. The rate of interest payable under Options ai, aii and b is guaranteed at
3% compounded annually. Payments under Option c and d are based on the
1983 Individual Annuity Tables projected 17 years with an interest rate of
3 1/2%.
To choose an option, you must send a written request satisfactory to us to our
Home Office.
12.2 DESCRIPTION OF OPTIONS
Option ai
Interest Payment Option. We will hold any amount applied under this option.
Interest on the unpaid balance will be paid or credited each month at a rate
determined by us.
Option aii
Fixed Amount Payable Option. Each payment will be for an agreed fixed amount.
Payments continue until the amount we hold runs out.
Option b
Fixed Period Payment Option. Equal payments will be made for any period
selected, up to 20 years.
Option c
Lifetime Payment Option. Equal monthly payments are based on the life of a named
person. Payments will continue for the lifetime of that person. Variations
provide for guaranteed payments for a period of time or a lump sum refund.
Option d
Joint Lifetime Payment Option. Equal monthly payments are based on the lives of
two named persons. While both are living, one payment will be made each month.
When one dies, payments will continue for the lifetime of the other. Variations
provide for a reduced amount of payment during the lifetime of the surviving
person.
5118 25
<PAGE>
SECTION 13. NOTES ON OUR COMPUTATIONS
13.1 BASIS OF COMPUTATION
In our computations, we assume that the minimum values and reserves held for
benefits guaranteed in the Fixed Account will earn interest at an annual rate of
3.5%. We use mortality rates from the Commissioners 1980 Standard Ordinary
Smoker and Nonsmoker, Male and Female Continuous Function Mortality Tables in
computing minimum values and reserves for this policy. The nonsmoker values from
these Tables are used when the Insured is a non-tobacco user and the smoker
values from these Tables are used when the Insured is a tobacco user. The male
values from these Tables are used when the Insured is a male. The female values
from these Tables are used when the Insured is a female.
13.2 METHODS OF COMPUTING VALUES
We have filed a detailed statement of the method we use to compute policy values
and benefits with the Superintendent of Insurance. All these values and benefits
are not less than those required by the laws of that state.
Reserves are calculated in accordance with the Standard Non-Forfeiture Law and
Valuation Law of the state in which this policy is delivered. In no instance
will reserves be less than the net cash surrender values.
5118 26
<PAGE>
THIS PAGE LEFT INTENTIONALLY BLANK.
<PAGE>
<TABLE>
<CAPTION>
TABLES OF SETTLEMENT OPTIONS
TABLE B (OPTION B) TABLE D (OPTION D)
MONTHLY INSTALLMENTS FOR MONTHLY INSTALLMENTS FOR EACH $1,000 OF NET PROCEEDS
EACH $1,000 OF NET PROCEEDS
MALE & MALE & MALE & MALE& MALE &
AGE FEMALE YEARS MONTHLY
-------------------------------------------------------------------------------------------------
<S> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C>
1 84.47 11 8.86 40 3.56 50 3.94 60 4.60 70 5.88 80 8.76
2 42.86 12 8.24 41 3.59 51 3.99 61 4.69 71 6.07 81 9.21
3 28.99 13 7.71 42 3.62 52 4.04 62 4.78 72 6.27 82 9.71
4 22.06 14 7.26 43 3.65 53 4.10 63 4.89 73 6.50 83 10.25
5 17.91 15 6.87 44 3.69 54 4.16 64 5.00 74 6.74 84 10.81
--------------------------- --------------------------------------------------------------
6 15.14 16 6.53 45 3.72 55 4.22 65 5.12 75 7.01 85 11.51
7 13.16 17 6.23 46 3.76 56 4.29 66 5.25 76 7.30
8 11.68 18 5.96 47 3.80 57 4.36 67 5.39 77 7.62
9 10.53 19 5.73 48 3.84 58 4.43 68 5.54 78 7.96
10 9.61 20 5.51 49 3.89 59 4.51 69 5.70 79 8.34
---------------------------- --------------------------------------------------
</TABLE>
INCOME FOR PAYMENTS OTHER THAN MONTHLY WILL BE FURNISHED BY THE HOME OFFICE
UPON REQUEST.
TABLE D VALUES FOR COMBINATIONS OF AGES NOT SHOWN AND VALUES FOR 2 MALES OR
2 FEMALES WILL BE FURNISHED BY THE HOME OFFICE UPON REQUEST.
<TABLE>
<CAPTION>
TABLE C (OPTION C) MONTHLY INSTALLMENTS FOR EACH $1,000 OF NET PROCEEDS
MALE FEMALE
LIFE MONTHS CERTAIN CASH LIFE MONTHS CERTAIN CASH
AGE ONLY 60 120 180 240 Ref. AGE ONLY 60 120 180 240 REF.
---------------------------------------- ------------------------------------------------
<S> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C>
40 3.84 3.84 3.83 3.82 3.80 3.77 40 3.64 3.64 3.63 3.63 3.62 3.60
41 3.88 3.88 3.87 3.86 3.83 3.81 41 3.67 3.67 3.66 3.66 3.65 3.63
42 3.93 3.93 3.92 3.90 3.87 3.84 42 3.70 3.70 3.70 3.69 3.68 3.66
43 3.98 3.97 3.96 3.94 3.91 3.88 43 3.74 3.74 3.73 3.73 3.71 3.70
44 4.02 4.02 4.01 3.99 3.95 3.92 44 3.78 3.78 3.77 3.76 3.75 3.73
--------------------------------------------- ------------------------------------------
45 4.08 4.07 4.06 4.03 3.99 3.97 45 3.82 3.82 3.81 3.80 3.78 3.77
46 4.13 4.13 4.11 4.08 4.04 4.01 46 3.86 3.86 3.85 3.84 3.82 3.80
47 4.19 4.18 4.16 4.13 4.09 4.06 47 3.90 3.90 3.89 3.88 3.86 3.84
48 4.25 4.24 4.22 4.18 4.13 4.11 48 3.95 3.95 3.94 3.93 3.90 3.88
49 4.31 4.30 4.28 4.24 4.18 4.16 49 4.00 4.00 3.99 3.97 3.95 3.93
--------------------------------------------- ------------------------------------------
50 4.37 4.37 4.34 4.30 4.23 4.21 50 4.05 4.05 4.04 4.02 3.99 3.97
51 4.44 4.43 4.40 4.36 4.29 4.27 51 4.10 4.10 4.09 4.07 4.04 4.02
52 4.51 4.50 4.47 4.42 4.34 4.32 52 4.16 4.16 4.15 4.12 4.09 4.07
53 4.59 4.58 4.54 4.48 4.40 4.38 53 4.22 4.22 4.20 4.18 4.14 4.12
54 4.67 4.66 4.62 4.55 4.45 4.45 54 4.29 4.28 4.26 4.23 4.19 4.17
--------------------------------------------- ------------------------------------------
55 4.76 4.74 4.70 4.62 4.51 4.52 55 4.35 4.35 4.33 4.30 4.24 4.23
56 4.85 4.83 4.78 4.70 4.57 4.59 56 4.42 4.42 4.40 4.36 4.30 4.29
57 4.94 4.92 4.87 4.77 4.64 4.66 57 4.50 4.49 4.47 4.43 4.36 4.35
58 5.04 5.02 4.96 4.85 4.70 4.74 58 4.58 4.57 4.54 4.50 4.42 4.42
59 5.15 5.13 5.06 4.94 4.76 4.82 59 4.67 4.66 4.62 4.57 4.48 4.48
--------------------------------------------- ------------------------------------------
60 5.27 5.24 5.16 5.02 4.83 4.90 60 4.76 4.74 4.71 4.65 4.55 4.56
61 5.39 5.36 5.27 5.11 4.89 4.99 61 4.85 4.84 4.80 4.73 4.62 4.63
62 5.52 5.49 5.38 5.20 4.95 5.08 62 4.95 4.94 4.89 4.81 4.68 4.71
63 5.66 5.62 5.50 5.30 5.02 5.18 63 5.06 5.05 4.99 4.90 4.75 4.80
64 5.81 5.77 5.63 5.39 5.08 5.29 64 5.18 5.16 5.10 4.99 4.82 4.89
--------------------------------------------- ------------------------------------------
65 5.98 5.92 5.76 5.49 5.14 5.39 65 5.30 5.28 5.21 5.08 4.89 4.98
66 6.15 6.09 5.90 5.59 5.20 5.51 66 5.44 5.41 5.33 5.18 4.96 5.08
67 6.33 6.26 6.04 5.69 5.26 5.62 67 5.58 5.55 5.45 5.28 5.03 5.19
68 6.53 6.45 6.19 5.79 5.32 5.75 68 5.73 5.70 5.59 5.39 5.10 5.30
69 6.74 6.64 6.34 5.89 5.37 5.88 69 5.90 5.86 5.73 5.50 5.17 5.42
--------------------------------------------- ------------------------------------------
70 6.96 6.85 6.50 5.99 5.42 6.02 70 6.07 6.03 5.87 5.61 5.24 5.54
71 7.20 7.06 6.66 6.09 5.46 6.16 71 6.26 6.21 6.03 5.72 5.30 5.67
72 7.46 7.29 6.83 6.18 5.51 6.31 72 6.47 6.40 6.19 5.83 5.36 5.81
73 7.73 7.53 7.00 6.28 5.54 6.47 73 6.69 6.62 6.36 5.94 5.42 5.96
74 8.02 7.79 7.17 6.36 5.58 6.63 74 6.94 6.84 6.54 6.05 5.47 6.11
--------------------------------------------- ------------------------------------------
75 8.32 8.05 7.34 6.45 5.61 6.81 75 7.20 7.08 6.72 6.16 5.51 6.28
76 8.66 8.34 7.52 6.53 5.64 6.99 76 7.48 7.34 6.91 6.27 5.56 6.45
77 9.01 8.63 7.69 6.60 5.66 7.19 77 7.78 7.61 7.10 6.37 5.59 6.64
78 9.39 8.94 7.87 6.67 5.68 7.39 78 8.11 7.90 7.30 6.46 5.63 6.83
79 9.80 9.27 8.04 6.74 5.70 7.60 79 8.47 8.21 7.50 6.55 5.65 7.03
--------------------------------------------- ------------------------------------------
80 10.23 9.61 8.20 6.79 5.71 7.83 80 8.85 8.54 7.70 6.63 5.68 7.25
81 10.70 9.96 8.37 6.85 5.72 8.06 81 9.27 8.89 7.90 6.71 5.70 7.48
82 11.20 10.32 8.52 6.89 5.73 8.31 82 9.72 9.26 8.09 6.78 5.71 7.72
83 11.72 10.69 8.67 6.93 5.74 8.57 83 10.21 9.64 8.28 6.84 5.73 7.98
84 12.29 11.07 8.81 6.97 5.75 8.84 84 10.74 10.05 8.46 6.89 5.74 8.25
85 12.89 11.46 8.95 7.00 5.75 9.13 85 11.32 10.47 8.63 6.94 5.74 8.53
--------------------------------------------- ------------------------------------------
</TABLE>
INCOME FOR PAYMENTS OTHER THAN MONTHLY WILL BE FURNISHED BY THE HOME OFFICE UPON
REQUEST.
TABLE C VALUES FOR AGES BELOW 40 AND ABOVE 85, AND VALUES FOR 300 AND 360 MONTHS
CERTAIN WILL BE FURNISHED BY THE HOME OFFICE UPON REQUEST.
5118 28
<PAGE>
THIS PAGE LEFT INTENTIONALLY BLANK.
<PAGE>
FLEXIBLE PREMIUM VARIABLE LIFE INSURANCE POLICY. NET CASH SURRENDER VALUE
IF ANY, PAYABLE AT MATURITY. DEATH BENEFIT PROCEEDS PAYABLE AT
DEATHOF INSURED PRIOR TO MATURITY DATE. FLEXIBLE PREMIUMS
PAYABLE DURING LIFETIME OF INSURED UNTIL MATURITY DATE (AGE 100).
SOME BENEFITS REFLECT INVESTMENT RESULTS. NON-PARTICIPATING.
FORM 5118
<PAGE>
FIRST AMERITAS LIFE INSURANCE CORP. OF NEW YORK LOGO
UNISEX ENDORSEMENT
The policy to which this endorsement is attached is amended to a sex-neutral
basis as follows:
"Misstatement of Age or Sex" in "Section 2. General Provisions" is amended so
that all references to sex are omitted.
"Cost of Insurance Rates" in "Section 7. Accumulation Value" is amended so
that all references to sex are omitted.
"Description of Options" in "Section 12. Payment Options" is amended so the
reference to the Individual Annuity Table specifies "based on male lives".
"Basis of Computation" in "Section 13. Notes on Our Computations" is amended.
Section 13.1 should be deleted and the following section inserted as follows:
SECTION 13.1 BASIS OF COMPUTATION
We use mortality rates from the Commissioners 1980 Standard Ordinary
Smoker & Nonsmoker Mortality Tables in computing minimum values and
reserves for this policy. The nonsmoker values from these Tables are
used when the Insured is a non-tobacco user and the smoker values from
these tables are used where the Insured is a tobacco user.
For minimum cash values and guaranteed cost of insurance rates, we use
the sex-neutral 1980 CSO-B Table which assumes a blend of the 1980 CSO
Table (M) and the 1980 CSO Table (F), 80 percent male and 20 percent
female.
For reserves, we use the sex-distinct CSO Tables. The male values from
these Tables are used where the Insured is male. The female values from
these Tables are used where the Insured is female.
FIRST AMERITAS LIFE INSURANCE CORP. OF NEW YORK
/s/ Donald R. Stading /s/ Mitch Politzer
-------------------------- -----------------------
Secretary President
Form UNI 5118
<PAGE>
FIRST AMERITAS LIFE INSURANCE CORP. OF NEW YORK LOGO
ACCIDENTAL DEATH BENEFIT
CONSIDERATION
This rider is issued in consideration of the application and the payment of its
cost of insurance. A copy of the application is attached to the policy. The cost
of insurance for this rider is deducted from the accumulation value at the same
time and in the same manner as the cost of insurance for the policy.
DEFINITIONS
ACCIDENTAL DEATH: Accidental death as covered by this rider means death which:
1. results directly from accidental bodily injuries incurred before this
rider terminates, and independently of all other causes, and
2. Occurs within 91 days after such injuries were sustained.
COUNTRY: Means any government or any coalition of countries or governments
through an international organization or otherwise.
EFFECTIVE DATE: The effective date of coverage under this rider shall be as
follows:
1. The policy date shall be the effective date for all coverage provided in
the original application.
2. For any rider issued after the policy date, the effective date shall be
the date shown on a supplement to the policy schedule pages.
3. For any insurance that has been reinstated, the effective date shall be
the monthly anniversary date that falls on or next follows the date we
approve the reinstatement.
EXPIRATION DATE: This date is shown on the schedule page. It is the date on
which this rider is no longer effective.
MILITARY SERVICE: Means service in the armed forces of any country.
PARTICIPATING OR ENGAGING: Means promoting, inciting, conspiring to promote or
incite, aiding, abetting, and all forms of taking part. It will not include
actions taken in defense of public or private property, or actions taken in
defense of the person of the Insured, if such actions of defense are not taken
against persons seeking to maintain or restore law and order including but not
limited to police officers and firemen.
RIDER SPECIFIED AMOUNT OF INSURANCE: This is shown on the schedule page. It is
the amount of the proceeds payable if this rider is in force on the date of the
Insured's accidental death.
AD 5901
<PAGE>
RIOT: Includes all forms of public violence, disorder, or disturbance of the
public peace, by three or more persons assembled together, whether or not acting
with a common intent and whether or not damage to person or property or unlawful
act or acts is the intent or consequence of such disorder.
WAR: Means declared or undeclared war or conflict between the armed forces of
countries.
BENEFITS
If the Insured dies of an accidental death while the policy and this rider are
in force, we will pay the rider specified amount of insurance to the
beneficiary. Satisfactory proof of the accidental death is required. The amount
will be paid with the death benefit of the basic policy.
GENERAL PROVISIONS
INCONTESTABILITY: While the Insured is alive, the validity of this rider cannot
we contested after it has been in force for a period of 2 years from the
effective date of this rider, or from the date of reinstatement.
REINSTATEMENT: Coverage under this rider may be reinstated with the policy if no
more than 3 years have passed since the beginning of the policy grace period.
Reinstatement must occur before the expiration date of this rider. The
requirements for reinstatement are:
1. Receipt by us of satisfactory evidence of insurability.
2. Payment of the minimum cost of insurance sufficient to keep the rider in
force for 3 months.
EXCLUSIONS: No rider proceeds will be payable if the Insured's death results
directly or indirectly from any of these causes:
1. Insurrection or war or any act attributable to war, whether or not the
Insured is in military service.
2. Injury sustained outside the states of the United states or its territories,
the District of Columbia, and Canada while the Insured is in military
service for any country at war.
3. Participating or engaging in a riot.
4. An act of suicide.
5. Bodily or mental infirmity, disease of any kind or medical or surgical
treatment thereof.
6. Committing or attempting to commit an assault or felony.
7. Voluntary :
a. Asphyxiation from inhalation of gas, whether conscious or unconscious,
except in the course of the Insured's job; or
b. Taking of any poison (except for food poisoning), hallucinogen, drug or
sedative unless taken on the advice of a physician.
AD 5901
<PAGE>
8. Operating or riding in or descending from any kind of aircraft if the
Insured:
a. Is a pilot, officer or member of the crew of such aircraft; or
b. Is giving or receiving any kind of training or instruction; or
c. Has any duties aboard such aircraft; or
d. Is being flown for the purpose of descent from such aircraft while in
flight.
RIGHT OF AUTOPSY: Where it is not forbidden by law, we will have the right to
require an autopsy.
TERMINATION OF RIDER: This rider will automatically terminate on the earliest of
these conditions:
1. The policy anniversary nearest the Insured's 70th birthday.
2. When the policy matures or expires, whichever occurs first.
3. On the monthly activity date on or next following the date we receive your
written request.
4. The surrender of this rider to us.
5. The expiration date of this rider.
NONPARTICIPATING: This rider is nonparticipating.
COST OF INSURANCE DEDUCTIONS AFTER RIDER TERMINATION DATE: We will not be liable
for the cost of insurance deductions on this rider after it terminates except to
return them.
INCORPORATION OF POLICY PROVISIONS INTO RIDER: The provisions of the policy are
hereby referred to and made a part of this rider unless otherwise specified in
this rider.
FIRST AMERITAS LIFE INSURANCE CORP. OF NEW YORK
/s/ Donald R. Stading /s/ Mitch Politzer
-------------------------- -----------------------
Secretary President
AD 5901
<PAGE>
FIRST AMERITAS LIFE INSURANCE CORP. OF NEW YORK LOGO
AVIATION EXCLUSION RIDER
The policy to which this rider is attached is hereby amended as follows:
GENERAL DEFINITIONS AND PROVISIONS
"INSURED" may be the insured under the base policy ("Base Insured") or may be an
insured with coverage under a rider ("Covered Insured") attached to the base
policy. The "Insured(s)" whose benefits may be limited by the provisions of this
rider are identified on the policy schedule page.
1. This rider is made part of the policy to which it is attached and is
effective on the policy date for the "Base Insured" or on the rider
effective date for the "Covered Insured".
2. This rider will be included in any policy to which the policy or rider
may be changed or converted.
3. The contestability provisions of the policy and/or riders are amended
to add the following language:
"Any defense by us under the provisions of this Aviation Exclusion Rider will
not constitute a violation of this provision."
RISKS NOT COVERED
This policy is issued under the express condition that the death benefit
proceeds of this policy and/or any attached riders are not payable if the death
of the Insured results from operating, riding in, or descending from any kind of
aircraft if the Insured:
1. is a pilot, or member of the crew; or
2. is being flown for the purpose of descent from such aircraft while in
flight; or
3. is giving or receiving any kind of training or instructions; or
4. is on an aircraft which is being flown for experimental or test purposes;
or
5. has any duties aboard such aircraft.
LIMITATIONS OF LIABILITY
If the death of the Base Insured results from one of the risks not covered, the
Company's liability will be limited to the greater of:
(a) the accumulation value for the policy; or
AER 5901
<PAGE>
(b) the total premiums paid without interest, less any previous partial
withdrawals;
less any outstanding policy debt.
If the death of a Covered Insured results from one of the risks not covered, the
Company's liability will be limited to the total cost of insurance deductions or
premiums paid, without interest, for the "Covered Insured" rider.
FIRST AMERITAS LIFE INSURANCE CORP. OF NEW YORK
/s/ Donald R. Stading /s/ Mitch Politzer
-------------------------- -----------------------
Secretary President
AER 5901
<PAGE>
FIRST AMERITAS LIFE INSURANCE CORP. OF NEW YORK LOGO
AVIATION EXCLUSION RIDER
The policy to which this rider is attached is hereby amended as follows:
GENERAL DEFINITIONS AND PROVISIONS
"INSURED" may be the insured under the base policy ("Base Insured") or may be an
insured with coverage under a rider ("Covered Insured") attached to the base
policy. The "Insured(s)" whose benefits may be limited by the provisions of this
rider are identified on the policy schedule page.
1. This rider is made part of the policy to which it is attached and is
effective on the policy date for the "Base Insured" or on the rider
effective date for the "Covered Insured".
2. This rider will be included in any policy to which the policy or rider may
be changed or converted.
3. The Contestability provisions of the policy and/or riders are amended to
add the following language:
"Any defense by us under the provisions of this Military Aviation Exclusion
Rider will not constitute a violation of this provision."
4. "Armed Forces" mean the military, naval or air forces of any country,
international organization or combination of countries (including the
reserve and civilian components of such forces, and also including
National Guard units).
RISKS NOT COVERED
This policy is issued under the express condition that the death benefit
proceeds of this policy and/or any attached riders are not payable if the death
of the Insured while a member of the armed forces results from operating, riding
in, or descending from any kind of aircraft if the Insured:
1. is a pilot, or member of the crew; or
2. is being flown for the purpose of descent from such aircraft while in
flight; or
3. is giving or receiving any kind of training or instructions; or
4. is on an aircraft which is being flown for experimental or test purposes;
or
5. has any duties aboard such aircraft.
AER-M 5901
<PAGE>
LIMITATIONS OF LIABILITY
If the death of the Base Insured results from one of the risks not covered, the
Company's liability will be limited to the greater of:
(a) the accumulation value for the policy; or
(b) the total premiums paid without interest, less any previous partial
withdrawals;
less any outstanding policy debt.
If the death of a Covered Insured results from one of the risks not covered, the
Company's liability will be limited to the total cost of insurance deductions or
premiums paid, without interest, for the "Covered Insured" rider.
FIRST AMERITAS LIFE INSURANCE CORP. OF NEW YORK
/s/ Donald R. Stading /s/ Mitch Politzer
-------------------------- -----------------------
Secretary President
AER-M 5901
<PAGE>
FIRST AMERITAS LIFE INSURANCE CORP. OF NEW YORK LOGO
TERM RIDER FOR COVERED INSURED
CONSIDERATION
This rider is issued in consideration of the application and the payment of its
cost of insurance. A copy of the application is attached to the policy. The cost
of insurance for this rider is deducted from the accumulation value at the same
time and in the same manner as the cost of insurance for the policy.
DEFINITIONS
BENEFICIARY: The term "beneficiary" in this rider means only the beneficiary for
the benefit payable at the Covered Insured's death. The term "beneficiary" in
other provisions of the policy means only the beneficiary for the benefits
payable at the Insured's death.
You will be the beneficiary for the benefit payable at the Covered Insured's
death, unless another beneficiary has been named and is living at the Covered
Insured's death.
While the Covered Insured is living, you may change the beneficiary by written
request in a form satisfactory to us. The change will take effect on the date we
record it in the Home Office.
COVERED INSURED: Covered Insured means each person so named in an application or
supplemental application, if approved by us, and shown on the Schedule Pages.
EFFECTIVE DATE: The effective date of coverage under this rider shall be as
follows:
1. The policy date shall be the effective date for all coverage provided in
the original application.
2. For any rider issued after the policy date or for any coverage on another
Covered Insured, the effective date shall be the date shown on a
supplement to the schedule pages.
3. For any insurance that has been reinstated, the effective date shall be
the monthly activity date that falls on or next follows the date we
approve the reinstatement.
EXPIRATION DATE: This date is also shown in the schedule pages. It is the date
on which this rider is no longer effective.
RIDER CONVERSION OPTION EXPIRATION DATE: The date ten years from the rider
effective date for each Covered Insured.
RIDER SPECIFIED AMOUNT OF INSURANCE: The rider specified amount of insurance for
a Covered Insured is shown for that Covered Insured on the schedule pages.
CIR 5901
<PAGE>
BENEFITS
We agree to pay the rider specified amount of insurance to the beneficiary upon
receipt of due proof of the death of any Covered Insured. Death must occur while
this rider is in force with respect to the Covered Insured. Payment is subject
to the provisions of the policy and this rider.
COST OF INSURANCE
The annual cost of insurance for each Covered Insured upon renewal for this
rider will be the rate per thousand at the attained age of that Covered Insured
multiplied by the rider specified amount of insurance in thousands. The Maximum
Guaranteed Cost of Insurance Rates per $1000 is attached. We have the option of
charging less than the maximum. Each year, the current annual cost of insurance
rates will be declared for the next policy year. If the rider for any Covered
Insured was issued with a rating, renewal premiums computed on a consistent
basis will be charged on the renewed rider. The rating factor is shown in the
schedule pages for each Covered Insured.
CONVERSION OF THIS RIDER
While the policy and this rider are in force, you may convert it for a permanent
policy on the life of the Covered Insured. You may do this at any time during
the first 10 years from the rider effective date for that Covered Insured.
Evidence of insurability will not be required, except for additional benefits.
If the policy terminates prior to the rider conversion option expiration date
due to the death of the insured under the basic policy, the Covered Insured may
still convert within 60 days of the date of death.
The new policy will have a specified amount of insurance no more than the rider
specified amount of insurance in effect on the date of conversion for that
Covered Insured.
The policy date of the new policy will be date of conversion. The new policy
will be subject to our then current rules as to the amount and the kind of
policy issued and premiums charged. If this rider was issued with extra premiums
for the Covered Insured on whom coverage is being converted, extra premiums will
be charged on the new policy. Any restrictions found in this rider will also be
found in the new policy. Incontestability and Suicide Provisions of the
converted policy will be effective from the effective date of this rider.
Application must be made and the first premium for the new policy paid to us
before this rider terminates for the Covered Insured on whom coverage is being
converted. In addition, the Covered Insured on whom coverage is being converted
must be alive on the policy date of the new policy.
TERMINATION OF RIDER: This rider will automatically terminate for each Covered
Insured on the earliest of these conditions:
1. On the expiration date of this rider for each Covered Insured;
2. On the monthly activity date on or next following the date we receive your
written request;
CIR 5901
<PAGE>
3. On surrender of this rider to us;
4. On termination of this policy; or
5. On the policy maturity date.
GENERAL PROVISIONS
REINSTATEMENT: This rider may be reinstated with the policy if no more than 3
years have passed since the date of termination. Reinstatement must occur before
the expiration date of this rider. The requirements for reinstatement are:
1. Receipt by us of evidence of insurability of the Covered Insured for whom
coverage is being reinstated. This evidence must be satisfactory to us.
2. Payment of the minimum cost of insurance sufficient to keep the rider in
force for 3 months.
SUICIDE: If any Covered Insured commits suicide within 2 years from the
effective date of this rider or any reinstatement of this rider with respect to
that Covered Insured, the total liability shall be the cost of insurance for
that Covered Insured.
INCONTESTABILITY: While a Covered Insured is alive, the validity of this rider
cannot be contested for that Covered Insured after it has been in force for a
period of 2 years from the rider effective date for that Covered Insured.
COST OF INSURANCE DEDUCTIONS AFTER RIDER EXPIRATION DATE: We will not be liable
for the cost of insurance deductions on this rider for any Covered Insured after
it terminates except to return them.
INCORPORATION OF POLICY PROVISIONS INTO RIDER: The Provisions of the policy are
hereby referred to and made a part of this rider unless otherwise specified in
this rider.
This rider has no cash or loan value.
NONPARTICIPATING: This rider is nonparticipating.
FIRST AMERITAS LIFE INSURANCE CORP. OF NEW YORK
/s/ Donald R. Stading /s/ Mitch Politzer
-------------------------- -----------------------
Secretary President
CIR 5901
<PAGE>
<TABLE>
<CAPTION>
MAXIMUM GUARANTEED COST OF INSURANCE RATES
PER $1000 APPLICABLE UPON RENEWAL
MALE RATES FEMALE RATES MALE RATES FEMALE RATES
AGES NON-SMOKER SMOKER NON-SMOKER SMOKER AGES NON-SMOKER SMOKER NON-SMOKER SMOKER
-----------------------------------------------------------------------------------------------------
<S> <C> <C> <C> <C> <C> <C> <C>
0 4.18 2.89 35 2.42 4.10 2.35 2.76
1 2.52 2.20 36 2.45 4.15 2.36 2.81
2 2.52 2.20 37 2.58 4.19 2.41 2.86
3 2.52 2.20 38 2.75 4.22 2.48 2.94
4 2.52 2.20 39 2.93 4.48 2.57 3.02
5 2.52 2.20 40 3.13 4.76 2.66 3.13
6 2.52 2.20 41 3.34 5.09 2.78 3.33
7 2.52 2.20 42 3.55 5.45 2.93 3.64
8 2.52 2.20 43 3.79 5.83 3.13 3.96
9 2.52 2.20 44 4.03 6.22 3.37 4.28
10 2.52 2.20 45 4.27 6.60 3.64 4.61
11 2.52 2.20 46 4.54 7.15 3.91 4.95
12 2.52 2.20 47 4.81 7.78 4.20 5.31
13 2.52 2.20 48 5.10 8.45 4.50 5.68
14 2.52 2.20 49 5.40 9.12 4.81 6.08
15 2.52 2.20 50 5.72 9.88 5.15 6.54
16 2.50 2.22 51 6.13 10.75 5.33 7.00
17 2.46 2.23 52 6.56 11.72 5.71 7.52
18 2.42 2.26 53 7.01 12.72 6.12 8.13
19 2.39 2.27 54 7.49 13.80 6.54 8.75
20 2.36 3.90 2.28 2.62 55 8.04 15.14 7.30 9.40
21 2.36 3.90 2.28 2.62 56 8.65 16.59 7.78 10.05
22 2.36 3.90 2.28 2.62 57 9.49 18.09 8.28 10.67
23 2.36 3.90 2.28 2.62 58 10.42 19.69 8.82 11.25
24 2.36 3.90 2.28 2.62 59 11.47 21.35 10.30 11.85
25 2.36 3.90 2.28 2.62 60 12.64 23.19 10.87 12.51
26 2.36 3.90 2.28 2.62 61 13.94 25.26 11.47 13.36
27 2.36 3.90 2.28 2.62 62 15.42 27.59 12.13 14.39
28 2.36 3.90 2.28 2.62 63 17.11 30.23 12.97 15.78
29 2.36 3.90 2.28 2.62 64 19.02 33.14 13.81 17.33
30 2.36 3.90 2.28 2.62 65 21.13 36.29 14.84 19.07
31 2.36 3.95 2.28 2.63 66 23.40 39.57 16.08 20.79
32 2.38 4.00 2.29 2.65 67 25.86 43.01 17.64 22.58
33 2.39 4.03 2.32 2.69 68 28.50 46.55 19.44 24.20
-----------------------------------------------------------------------------------------------------
34 2.41 4.07 2.34 2.72 69 31.38 50.32 21.43 26.02
</TABLE>
CIR 5901
<PAGE>
FIRST AMERITAS LIFE INSURANCE CORP. OF NEW YORK LOGO
CHILDREN'S PROTECTION RIDER
LEVEL TERM INSURANCE
CONSIDERATION
This rider is issued in consideration of the application and the payment of its
cost of insurance. A copy of the application is attached to the policy. The cost
of insurance for this rider is deducted from the accumulation value at the same
time and in the same manner as the cost of insurance for this policy.
DEFINITIONS
COST OF INSURANCE: The cost of insurance for this rider is shown on the schedule
page.
DEPENDENT CHILD: A dependent child is a child born of a marriage, a stepchild, a
legally adopted child of the Insured or any child for which the Insured is
legally responsible. To qualify as a dependent child, the child must be at least
15 days of age and have not yet reached the rider anniversary nearest his or her
25th birthday. The child must either:
1. Be named in the application and the date of such application must be
before the child's 18th birthday; or
2. Qualify as a dependent child after the date of the application but before
the child's 18th birthday.
EFFECTIVE DATE: The effective date of coverage under this rider shall be as
follows:
1. The policy date shall be the effective date for all coverage provided in
the original application.
2. For any rider issued after the policy date, the effective date shall be
the date shown on a supplement to the schedule page.
3. For any insurance that has been reinstated, the effective date shall be
the monthly activity date that falls on or next follows the date we
approve the reinstatement.
EXPIRATION DATE: The date is also shown on the schedule page. It is the date on
which this rider is no longer effective.
RIDER BENEFICIARY: Unless otherwise provided, the owner will be the rider
beneficiary. If the owner is not living, then the beneficiary will be the
owner's spouse. If the spouse becomes the beneficiary and then dies, the
beneficiary will be the estate of the spouse. If there is no spouse when the
owner dies, the beneficiary will be the estate of the owner.
RIDER OWNER: The owner of the policy is the owner of this rider unless otherwise
provided. If the owner dies, the owner's spouse will become the owner. If the
spouse becomes the owner, and then dies, ownership will pass to the spouse's
estate. If there is no spouse at the owner's death, then ownership will pass to
the owner's estate.
RIDER SPECIFIED AMOUNT OF INSURANCE: The rider specified amount of insurance is
the insurance payable under this rider. The amount is shown on the schedule
page.
CPR 5901
<PAGE>
BENEFITS
We agree to pay the rider specified amount of insurance if a dependent child
dies while the policy and this rider are in force. The rider beneficiary will
receive the proceeds. Satisfactory proof of death of the dependent child is
required.
GENERAL PROVISIONS
INCONTESTABILITY: While the Insured and any dependent children covered are
alive, the validity of this rider cannot be contested after it has been in force
for a period of 2 years from the effective date of the rider or from the date of
reinstatement.
REINSTATEMENT: This rider may be reinstated with the policy if no more than 3
years have passed since the beginning of the grace period. Reinstatement must
occur before the expiration date of this rider. The requirements for
reinstatement are:
1. Receipt by us of satisfactory evidence of insurability of the Insured and
of each dependent child for whom coverage is being reinstated.
2. Payment of the minimum cost of insurance sufficient to keep the rider in
force for 3 months.
DEATH OF THE INSURED: On the death of the Insured, the insurance under this
rider becomes paid-up term insurance. It will expire for each dependent child on
the earliest of the expiration date of this rider or the rider anniversary
nearest the child's 25th birthday.
The paid-up insurance may be surrendered for any or all of the dependent
children. It may be surrendered for its cash value which is the present value of
future guaranteed benefits. If surrender is within 30 days after a rider
anniversary, the cash value will not be less than the value on that anniversary.
The amounts will be furnished by the company on request.
SUICIDE PROVISION: If any dependent child covered under this rider commits
suicide within 2 years of the effective date of this rider or any reinstatement
of this rider, the total liability shall be the cost of insurance for such
child.
Payment under this provision will not affect the coverage of any other dependent
child under this rider. The cost of insurance for this rider will not be
increased.
If the Insured commits suicide this rider will become paid-up for each covered
dependent child as provided in "Death of the Insured".
TERMINATION OF RIDER: This rider will automatically terminate for all dependent
children on the earliest of these conditions:
1. The expiration date of this rider,
2. The monthly activity date on or next following the date we receive your
written request.
3. The surrender of this rider to us,
4. Termination of this policy; or
5. The policy maturity date.
Coverage under this rider will terminate for each dependent child on the
earliest of these conditions:
1. The rider anniversary nearest the dependent child's 25th birthday.
2. On conversion of this coverage. See "Conversion".
CPR 5901
<PAGE>
CONVERSION
While the policy and this rider are in full force, this rider may be converted
(exchanged) for a different policy. Evidence of insurability will not be
required.
Conversion can be made to a permanent nonpension policy subject to the following
rules:
1. No riders may be added to the new policy without satisfactory evidence of
insurability.
2. Application must be made and the first premium for the new policy paid to
us before this rider terminates for the dependent child on whom coverage
is being converted.
3. The dependent child on whom coverage is being converted must be alive on
the policy date of the new policy (the date of conversion).
4. The policy date of the new policy will be the date of conversion.
5. The new policy must be subject to our then current rules as to the amount
and the kind of policy issued and premiums charged.
CPR 5901
<PAGE>
Coverage under this rider for each dependent child may be converted at any time:
a. on or before the expiration date of this rider; or
b. the rider anniversary nearest the child's 25th birthday, whichever occurs
first.
The amount of the new policy will depend on when this rider is converted.
If coverage under this rider is converted before the termination of the rider
for a dependent child, the new policy will be for a face amount of insurance not
greater than the rider face amount of insurance. If coverage is converted at the
time of termination, the new policy will be for a face amount of insurance not
greater than 5 times the rider face amount of insurance.
NONPARTICIPATING: This rider is nonparticipating.
COST OF INSURANCE DEDUCTIONS AFTER RIDER TERMINATION DATE: We will not be liable
for the cost of insurance payments paid on this rider after it terminates except
to return them.
INCORPORATION OF POLICY PROVISIONS INTO RIDER: The provisions of the policy are
hereby referred to and made a part of this rider unless otherwise specified in
this rider.
FIRST AMERITAS LIFE INSURANCE CORP. OF NEW YORK
/s/ Donald R. Stading /s/ Mitch Politzer
-------------------------- -----------------------
Secretary President
CPR 5901
<PAGE>
FIRST AMERITAS LIFE INSURANCE CORP. OF NEW YORK LOGO
DISABILITY BENEFIT RIDER
CONSIDERATION
This rider is issued in consideration of the application and payment of its cost
of insurance. A copy of the application is attached to the policy. The cost of
insurance for this rider is deducted from the accumulation value at the same
time and in the same manner as the cost of insurance for the policy.
DEFINITIONS
DISABILITY BENEFIT: For purposes of this rider, the disability benefit is an
amount shown on the schedule pages, selected by you on the application.
EFFECTIVE DATE: The effective date of all coverage under this rider shall be as
follows:
1. The policy date shall be the effective date for all coverage provided in
the original application.
2. For any rider issued after the policy date, the effective date shall be
the date shown on a supplement to the schedule pages.
3. For any insurance that has been reinstated, the effective date shall be
the monthly activity date on or next following the date we approve the
reinstatement.
EXPIRATION DATE: This date is also shown on the schedule pages. It is the date
on which this rider is no longer effective.
TOTAL DISABILITY: Total disability must begin after the effective date of this
rider as shown in the schedule pages and before the policy anniversary nearest
the Insured's 60th birthday. It must result from bodily injury which occurs or
sickness which first manifests itself while this rider is in force.
Total Disability means:
1. Total loss of the sight of both eyes. This loss must be irrecoverable; or
2. Total loss of the use of both hands, both feet, or one hand and one foot.
This loss must be irrecoverable; or
3. The incapacity of the Insured to engage in any substantial duties of his
or her occupation for at least six consecutive months. (Substantial duties
includes managerial or supervisory functions.)
During the first 24 months of total disability, occupation means the usual
work, employment, business or profession in which the Insured was engaged
immediately before the date of disability. This includes attendance at
school or college as a full-time student. After 24 months of total
disability an Insured who is engaged in any occupation for remuneration or
profit will not be considered totally disabled.
DBR 5901
<PAGE>
BENEFITS
While the Insured is totally disabled, the disability benefit will be applied as
premium. The premium will be credited as of the last monthly activity date,
prior to the approval date of the claim and will be credited annually
thereafter, during continuance of total disability. In addition, while the
Insured is totally disabled, the cost of insurance for this rider will not be
deducted from the accumulation value. All other monthly deductions will apply.
If total disability begins after the grace period, no benefits under this rider
will be paid.
GENERAL PROVISION
NOTICE OF DISABILITY: To receive this benefit, written notice of claim must be
received at the Home Office. It must be received: (a) while the Insured is
living; (b) while the Insured is totally disabled; and (c) as soon as reasonably
possible.
PROOF OF TOTAL DISABILITY: Approval of the initial notice of claim will be
granted after we receive satisfactory written proof that the Insured is totally
disabled. Proof must be presented at the Home Office: (a) while the Insured is
living; (b) before total disability has ended or been interrupted; and (c)
within 12 months after we receive the notice of total disability. Forms approved
by us must be used.
Similar proof that the total disability is continuing may be required at
reasonable intervals. If the Insured fails to furnish such proof, the disability
benefit will cease.
INCONTESTABILITY: While the Insured is alive, the validity of this rider cannot
be contested after it has been in force for a period of 2 years from the
effective date of this rider.
REINSTATEMENT: Coverage under this rider may be reinstated with the policy if no
more than 3 years have passed since the date of termination. Reinstatement must
occur before the expiration date of this rider. Such reinstatement may occur any
time before the policy anniversary nearest the Insured's 60th birthday. The
requirements for reinstatement are:
1. Receipt of evidence of insurability satisfactory to us.
2. Payment of the minimum cost of insurance sufficient to keep the rider in
force for 3 months.
EXCLUSIONS: The Insured will not be eligible for the disability benefit if the
total disability on which the claim is based results from:
1. Self-inflicted bodily injury, other than accidental injury; or
2. War or any act of war, whether declared or not, regardless of whether the
Insured is in the military, naval or air forces.
DBR 5901
<PAGE>
TERMINATION OF RIDER: This rider will automatically terminate on the earliest of
these conditions:
1. On the expiration date of this rider unless a disability benefit is being
provided on that date;
2. On the monthly activity date on or next following the date we receive your
written request;
3. On surrender of this rider to us;
4. On termination of this policy unless a disability benefit is being
provided on that date; or
5. On the policy maturity date.
CHANGE OF POLICY: Once the disability benefit commences, you cannot change the
specified amount of insurance (except for any increase(s) which result from
exercising options under any Guaranteed Insurability Rider), the death benefit
option, the mode of the planned periodic premium payments, or change the policy
to another form of insurance.
NONPARTICIPATING: This rider is nonparticipating.
COST OF INSURANCE DEDUCTIONS AFTER THE RIDER HAS TERMINATED: We will not be
liable for the cost of insurance deductions on this rider after it terminates
except to return them.
INCORPORATION OF POLICY PROVISIONS INTO RIDER: The provisions of the policy are
hereby referred to and made a part of this rider.
FIRST AMERITAS LIFE INSURANCE CORP. OF NEW YORK
/s/ Donald R. Stading /s/ Mitch Politzer
-------------------------- -----------------------
Secretary President
DBR 5901
<PAGE>
FIRST AMERITAS LIFE INSURANCE CORP. OF NEW YORK LOGO
GUARANTEED INSURABILITY RIDER
CONSIDERATION
This rider is issued in consideration of the application and payment of its cost
of insurance. A copy of the application is attached to the policy. The cost of
insurance for this rider is deducted from the accumulation value at the same
time and in the same manner as the cost of insurance for the policy.
BENEFITS
You may buy additional insurance on the life of the Insured by increasing the
specified amount of insurance of the policy, subject to the provisions below.
Evidence of insurability is not required. The amount of the increase is equal to
the election amount. The policy and this rider must be in force during the
option period before an option can be effective.
DEFINITIONS
ELECTION AMOUNT: The election amount is the amount of the additional insurance
which is issued as an increase in the specified amount of insurance of the
policy. You must choose the election amount at the time this rider is issued.
The election amount you have chosen and the regular option dates are shown on
the schedule pages.
REGULAR OPTION DATES: The regular option dates are the policy anniversaries on
which the Insured's age at nearest birthday is 25, 28, 31, 34, 37 and 40.
ALTERNATE OPTION DATES: You may also choose an alternate option date in lieu of
a regular option date after:
1. a marriage of the Insured after the effective date of this rider; or
2. a child born to the Insured, or for which the Insured is legally
responsible; or
3. the legal adoption of a child by the Insured.
Only one alternate option date may be chosen between the effective date of the
rider and the first regular option date and between each pair of successive
regular option dates.
Election of an alternative option will replace the next regular option date.
Therefore, the next regular option cannot be elected.
OPTION PERIOD: The option period is the time during which you may choose to
elect an option. For a regular option date, the option period is the 31 day
period on either side of such date. For an alternate option date, the option
period is the 60 days immediately after such date.
GIR 5901
<PAGE>
EFFECTIVE DATE: The effective date of coverage under this rider shall be as
follows:
1. The policy date shall be the effective date for all coverage provided in
the original application.
2. For any insurance that has been reinstated, the effective date shall be
the monthly activity date that falls on or next follows the date we
approve the reinstatement.
EXPIRATION DATE: This date is shown on the schedule page. It is the date on
which this rider is no longer effective.
CONDITIONS
Options elected under this rider are subject to the following conditions:
1. The increased specified amount will be subject to any ratings and
restrictions under the policy.
2. If any rider which provides total and permanent disability benefits is
attached to the policy, the disability benefits may be increased to cover
the increased specified amount without evidence of insurability. No other
riders may be added without satisfactory evidence of insurability.
3. If an option is effective while disability benefits are currently being
provided by a rider,
the disability benefit will be increased. This increase in disability benefits
will reflect any necessary higher minimum premium requirements for the policy
as if the increased insurance were issued as a separate policy at the attained
age of the Insured.
4. If a regular option is chosen, the effective date of the increased
specified amount will be the later of the regular option date or the
effective date of the election. If an alternate option is chosen, the
effective date will be the effective date of the election.
5. The election of an option will be effective when any required premium is
paid and written application signed by both you and the Insured is made to
us during an option period.
6. The Insured must be alive on the effective date.
7. The increase in specified amount will be treated in the same manner as an
increase granted under the terms of the policy to which this rider is
attached, except that the requirement of evidence of insurability will be
waived. Please see the Death Benefit provision in the policy for more
information.
GIR 5901
<PAGE>
GENERAL PROVISIONS
REINSTATEMENT: Coverage under this rider may be reinstated with the policy if no
more than 3 years have passed since the beginning of the policy grace period.
Reinstatement must occur before the expiration date of this rider. Such
reinstatement may occur any time before the last regular option date. The
requirements for reinstatement are:
1. Receipt by us of satisfactory evidence of insurability for the Insured.
2. Payment of the minimum cost of insurance sufficient to keep the rider in
force for 3 months.
RIDER TERMINATION DATE: This rider will terminate on the earliest of these
conditions:
1. The expiration date of this rider which is the policy anniversary nearest
the Insured's 40th birthday.
2. The effective date of an alternate option if between ages 37 and 40.
3. The surrender of this rider to us.
4. On the monthly activity date on or next following the date we receive
written request from you.
5. The termination of the policy.
NONPARTICIPATING: This rider is nonparticipating.
COST OF INSURANCE DEDUCTIONS AFTER RIDER TERMINATION DATE: We will not be liable
for the cost of insurance deductions on this rider after it terminates except to
return them.
INCORPORATION OF POLICY PROVISIONS INTO RIDER: The provisions of the policy are
hereby referred to and made a part of this rider unless otherwise specified in
this rider.
FIRST AMERITAS LIFE INSURANCE CORP. OF NEW YORK
/s/ Donald R. Stading /s/ Mitch Politzer
-------------------------- -----------------------
Secretary President
GIR 5901
<PAGE>
FIRST AMERITAS LIFE INSURANCE CORP. OF NEW YORK LOGO
PAYOR WAIVER OF MONTHLY
DEDUCTIONS ON
DISABILITY OF A COVERED PERSON
CONSIDERATION
This rider is issued in return for the application and payment of its cost of
insurance. A copy of the application is attached to the policy. The cost of
insurance for this rider is deducted from the accumulation value at the same
time and in the same manner as the cost of insurance for the policy.
COST OF INSURANCE
The calculation of the monthly cost of insurance for this rider is described in
the attached table.
DEFINITIONS
DISABILITY BENEFIT: For purposes of this rider, the disability benefit refers to
the monthly deduction on each monthly activity date for the base policy and any
riders and is equal to:
1. the current cost of insurance for the base policy and any riders;
2. the expense charges; and
3. the charges for specified amount increases, if any.
TOTAL DISABILITY: Total disability must begin after the effective date and
before the expiration date of this rider. It must result from bodily injury
which occurs or sickness which first manifests itself while this rider is in
force.
Total Disability means:
1. Total loss of the sight of both eyes. This loss must be irrecoverable; or
2. Total loss of the use of both hands, both feet, or one hand and one foot.
This loss must be irrecoverable; or
3. The incapacity of the Covered Person to engage in any substantial duties
of his or her occupation for at least six consecutive months. (Substantial
duties includes managerial or supervisory functions.)
During the first 24 months of total disability, occupation means the usual
work, employment, business or profession in which the Covered Person was
engaged immediately before the date of disability. This includes
attendance at school or college as a full-time student. After 24 months of
total disability a Covered Person who is engaged in any occupation for
remuneration or profit will not be considered totally disabled.
PDIS 5901
<PAGE>
COVERED PERSON: The Covered Person is the person on whom disability benefit
coverage is being offered. The applicant is the Covered Person until the
automatic substitution date. On and after this date, the Insured is the Covered
Person.
AUTOMATIC SUBSTITUTION DATE: The automatic substitution date is the policy
anniversary nearest the Insured's 23rd birthday.
ELECTION PERIOD: The election period begins on the policy anniversary nearest
the Insured's 18th birthday and ends on the automatic substitution date.
EFFECTIVE DATE: The effective date of coverage under this rider shall be as
follows:
1. The policy date shall be the effective date for all coverage provided in
the original application.
2. For any rider issued after the policy date, the effective date shall be
the date shown on a supplement to the schedule pages.
3. For any insurance that has been reinstated, the effective date shall be
the monthly activity date on or next following the date we approve the
reinstatement.
EXPIRATION DATE: This date is also shown on the schedule pages. It is the date
on which this rider is no longer effective.
BENEFITS
While the Covered Person is totally disabled, the disability benefit will not be
deducted from the accumulation value. During this time, the policy and any
rider(s) will continue to be in force.
Monthly deductions falling due before we approve a claim for benefits will
continue to be deducted from the accumulation value. However, after total
disability has continued for six (6) consecutive months and we approve the
claim, any disability benefit which otherwise could have been paid under the
provisions of this rider will be credited to the accumulation value.
If total disability begins after the grace period, no benefit under this rider
will be paid.
COVERAGE CHANGES
We will provide disability benefit coverage on the applicant until the automatic
substitution date. At that time, the coverage automatically shifts to the
Insured. During the election period, on written request, coverage may be shifted
from the applicant to the Insured. This will be subject to evidence of
insurability of the Insured. This election, once we accept it, is irrevocable
(it cannot be changed).
If the applicant is the Covered Person and becomes totally disabled, the
disability benefit continues during a period of total disability until the
automatic substitution date. At that time, the Insured automatically becomes the
Covered Person. The disability benefit will cease and we will resume deducting
the cost of insurance for this rider from the accumulation value. If the Insured
is the Covered Person and becomes totally disabled, the disability benefit
continues so long as the disability continues. If the Insured becomes totally
disabled before the automatic substitution date, the disability benefit will
begin as of that date. It will continue as long as the disability continues.
PDIS 5901
<PAGE>
If the applicant dies before the beginning of the election period, no benefits
will be payable except that the disability benefit will not be deducted from the
accumulation value until the first day of the election period. At that time, the
Insured automatically becomes the Covered Person. If the applicant dies during
the election period, the Insured automatically becomes the Covered Person.
GENERAL PROVISIONS
NOTICE OF DISABILITY: To receive this benefit, written notice of claim must be
received at the Home Office. It must be received: (a) while the Covered Person
is living; (b) while the Covered Person is totally disabled; and (c) as soon as
reasonably possible.
PROOF OF TOTAL DISABILITY: The disability benefit will not commence until we
receive satisfactory written proof that the Covered Person is totally disabled.
Proof must be presented at the Home Office: (a) while the Covered Person is
living; (b) before total disability has ended or been interrupted; and (c)
within 12 months after we receive the notice of total disability. Forms approved
by us must be used.
Similar proof that the total disability is continuing may be required at
reasonable intervals. If the Covered Person fails to furnish such proof, the
disability benefit will cease.
INCONTESTABILITY: While the Covered Person is alive, the validity of this rider
cannot be contested after it has been in force for a period of 2 years from the
effective date of the rider.
REINSTATEMENT: This rider may be reinstated with the policy subject to the
policy reinstatement provision. Reinstatement must occur before the expiration
date of this rider. Such reinstatement may occur before the policy anniversary
nearest the Covered Person's 60th birthday. The requirements for reinstatement
are:
1. Evidence of insurability is required on both the applicant and the
Insured, if the applicant is the Covered Person. Otherwise, evidence of
insurability will be required only on the Insured. This evidence must be
satisfactory to us.
2. Payment of the minimum cost of insurance sufficient to keep this rider in
force for 3 months.
EXCLUSIONS: The Covered Person will not be eligible for the disability benefit
if the total disability on which the claim is based results from:
1. Self-inflicted bodily injury, other than accidental injury; or
2. War or any act of war, whether declared or not, regardless of whether the
Covered Person is in the military, naval or air service.
TERMINATION OF RIDER: This rider will automatically terminate on the earliest of
these conditions:
1. On the expiration date of this rider unless a disability benefit is being
provided on that date;
2. On the monthly activity date on or next following the date we receive your
written request;
PDIS 5901
<PAGE>
3. On surrender of this rider to us;
4. On termination of the policy unless a disability benefit is being provided
on that date;
5. On assignment of the policy; or
6. On the policy maturity date.
TERM RIDERS: If a renewable and convertible term rider is attached to the policy
during a benefit period, the cost of insurance for that rider will be waived
until the expiration date. If the Owner elects to convert that term rider, no
benefits will be paid under this rider on the conversion policy.
CHANGE OF POLICY: Once the disability benefit commences, you cannot change the
specified amount of insurance (except for any increases(s) which result from
exercising options under any Guaranteed Insurability Rider), the death benefit
option, the mode of the planned periodic premium payments, or change the policy
to another form of insurance.
NONPARTICIPATING: This rider is nonparticipating.
COST OF INSURANCE PAYMENTS AFTER THE RIDER HAS TERMINATED: We will not be liable
for the cost of insurance payments on this rider after it terminates except to
return them.
INCORPORATION OF POLICY PROVISIONS INTO RIDER: The provisions of the policy are
hereby referred to and made a part of this rider.
FIRST AMERITAS LIFE INSURANCE CORP. OF NEW YORK
/s/ Donald R. Stading /s/ Mitch Politzer
-------------------------- -----------------------
Secretary President
PDIS 5901
<PAGE>
COST OF INSURANCE TABLE
On each monthly activity date, the monthly cost of insurance for this rider is
equal to the product of A times B where:
A is a factor based on the attained age, sex and tobacco use of the Covered
Person and is shown in the table below. (Note: If this rider is issued with a
special rating, this factor will be increased based on that rating. Any
special rating will be shown on the schedule pages).
B is the monthly deduction for the policy, including any table ratings and any
riders attached to the policy except for this rider.
<TABLE>
<CAPTION>
-----------------------------------------------------------------------------------------------------
MALE RATES FEMALE RATES MALE RATES FEMALE RATES
AGES NON-TOBACCO TOBACCO NON-TOBACCO TOBACCO AGES NON-TOBACCO TOBACCO NON-TOBACCO TOBACCO
USE USE USE USE USE USE USE USE
<S> <C> <C> <C> <C> <C> <C> <C> <C> <C>
0 0.0508 0.0509 0.0555 0.0555 30 0.0487 0.0419 0.0514 0.0471
1 0.0508 0.0509 0.0555 0.0555 31 0.0489 0.0420 0.0513 0.0469
2 0.0528 0.0529 0.0573 0.0574 32 0.0492 0.0423 0.0512 0.0466
3 0.0531 0.0532 0.0580 0.0580 33 0.0492 0.0421 0.0512 0.0464
4 0.0539 0.0540 0.0587 0.0587 34 0.0492 0.0419 0.0506 0.0457
5 0.0553 0.0555 0.0590 0.0591 35 0.0492 0.0420 0.0509 0.0460
6 0.0565 0.0567 0.0601 0.0601 36 0.0507 0.0427 0.0524 0.0468
7 0.0584 0.0587 0.0605 0.0606 37 0.0562 0.0467 0.0573 0.0505
8 0.0598 0.0601 0.0613 0.0614 38 0.0593 0.0486 0.0600 0.0522
9 0.0607 0.0610 0.0617 0.0618 39 0.0624 0.0506 0.0627 0.0539
10 0.0613 0.0618 0.0623 0.0624 40 0.0655 0.0523 0.0652 0.0552
11 0.0604 0.0609 0.0622 0.0623 41 0.0679 0.0535 0.0670 0.0558
12 0.0584 0.0590 0.0614 0.0616 42 0.0708 0.0552 0.0691 0.0571
13 0.0549 0.0557 0.0607 0.0609 43 0.0735 0.0567 0.0716 0.0586
14 0.0514 0.0525 0.0593 0.0596 44 0.0765 0.0584 0.0742 0.0603
15 0.0487 0.0434 0.0583 0.0558 45 0.0794 0.0602 0.0770 0.0622
16 0.0463 0.0405 0.0573 0.0547 46 0.0825 0.0625 0.0801 0.0645
17 0.0445 0.0384 0.0563 0.0535 47 0.0866 0.0656 0.0838 0.0676
18 0.0434 0.0370 0.0554 0.0522 48 0.0915 0.0696 0.0881 0.0713
19 0.0422 0.0357 0.0543 0.0510 49 0.0974 0.0745 0.0935 0.0760
20 0.0413 0.0346 0.0530 0.0498 50 0.1054 0.0812 0.1000 0.0817
21 0.0403 0.0332 0.0516 0.0482 51 0.1148 0.0892 0.1082 0.0893
22 0.0419 0.0352 0.0526 0.0495 52 0.1266 0.0994 0.1187 0.0987
23 0.0427 0.0361 0.0528 0.0496 53 0.1405 0.1112 0.1305 0.1095
24 0.0437 0.0370 0.0523 0.0492 54 0.1579 0.1258 0.1465 0.1238
25 0.0448 0.0382 0.0525 0.0493 55 0.1778 0.1428 0.1649 0.1404
26 0.0458 0.0394 0.0521 0.0487 56 0.2034 0.1647 0.1896 0.1626
27 0.0466 0.0402 0.0521 0.0484 57 0.2234 0.1818 0.2106 0.1816
28 0.0475 0.0411 0.0518 0.0482 58 0.2460 0.2007 0.2362 0.2046
29 0.0481 0.0416 0.0517 0.0478 59 0.2684 0.2211 0.2633 0.2295
-----------------------------------------------------------------------------------------------------
</TABLE>
PDIS 5901
<PAGE>
FIRST AMERITAS LIFE INSURANCE CORP. OF NEW YORK LOGO
PAYOR DISABILITY RIDER
CONSIDERATION
This rider is issued in consideration of the application and payment of its cost
of insurance. A copy of the application is attached to the policy. The cost of
insurance for this rider is deducted from the accumulation value at the same
time and in the same manner as the cost of insurance for the policy.
DEFINITIONS
AUTOMATIC SUBSTITUTION DATE: The automatic substitution date is the policy
anniversary nearest the Insured's 23rd birthday.
COVERED PERSON: The Covered Person is the person on whom disability benefit
coverage is being offered. The applicant is the Covered Person until the
automatic substitution date unless an election is made during an election
period. On and after this date, the Insured is the Covered Person.
DISABILITY BENEFIT: For purposes of this rider, the disability benefit is an
amount shown on the schedule pages, selected by you on the application.
EFFECTIVE DATE: The effective date of coverage under this rider shall be as
follows:
1. The policy date shall be the effective date for all coverage provided in
the original application.
2. For any rider issued after the policy date, the effective date shall be
the date shown on a supplement to the schedule pages.
3. For any insurance that has been reinstated, the effective date shall be
the monthly activity date on or next following the date we approve the
reinstatement.
ELECTION PERIOD: The election period begins on the policy anniversary nearest
the Insured's 18th birthday and ends on the automatic substitution date.
EXPIRATION DATE: This date is also shown on the schedule pages. It is the date
on which this rider is no longer effective.
TOTAL DISABILITY: Total disability covered by this rider must begin after the
effective date and before the expiration date of this rider. Total disability
must result from bodily injury which occurs or sickness which first manifests
itself while this rider is in force.
Total Disability means:
1. Total loss of the sight of both eyes. This loss must be irrecoverable; or
2. Total loss of the use of both hands, both feet, or one hand and one foot.
This loss must be irrecoverable; or
PDR 5901
<PAGE>
3. The incapacity of the Covered Person to engage in any substantial duties
of his occupation for at least six consecutive months. (Substantial duties
includes managerial or supervisory functions).
During the first 24 months of total disability, occupation means the usual
work, employment, business or profession in which the Covered Person was
engaged immediately before the date of disability. This includes
attendance at school or college as a full-time student. After 24 months of
total disability a Covered Person who is engaged in any occupation for
remuneration or profits will not be considered totally disabled.
BENEFITS
While the Covered Person is totally disabled, the disability benefit will be
applied as premium. The premium will be credited as of the last monthly activity
date prior to the approval date of the claim and will be credited annually
thereafter during continuance of total disability. In addition, while the
Covered Person is totally disabled, the cost of insurance for this rider will
not be deducted from the accumulation value. All other monthly deductions will
apply.
We will provide disability benefit coverage on the applicant until the automatic
substitution date. At that time, the coverage automatically shifts to the
Insured. During the election period, on written request, coverage may be shifted
from the applicant to the Insured. This will be subject to evidence of
insurability of the Insured. This election, once we accept it, is irrevocable
(it cannot be changed). If the applicant is the Covered Person and becomes
totally disabled, the disability benefit continues during a period of total
disability until the automatic substitution date. At that time, the Insured
automatically becomes the Covered Person. The disability benefit will cease and
we will resume deducting the cost of insurance for this rider from the
accumulation value. If the Insured is the Covered Person and becomes totally
disabled, the disability benefit continues as long as the disability continues
until the rider expiration date. If the Insured becomes totally disabled before
the automatic substitution date, the disability benefit will begin as of that
date. It will continue as long as the disability continues until the rider
expiration date.
If the applicant dies before the beginning of the election period, no benefits
will be payable except that the cost of insurance for this rider will not be
deducted from the accumulation value until the first day of the election period.
At that time, the Insured automatically becomes the Covered Person. If the
applicant dies during the election period, the Insured automatically becomes the
Covered Person.
If total disability begins after the grace period, no benefit under this rider
will be paid.
GENERAL PROVISIONS
NOTICE OF DISABILITY: To receive this benefit, written notice of claim must be
received at the Home Office. It must be received: (a) while the Covered Person
is living; (b) while the Covered Person is totally disabled; and (c) as soon as
reasonably possible.
PDR 5901
<PAGE>
PROOF OF TOTAL DISABILITY: Approval of the initial notice of claim will be
granted after we receive satisfactory written proof that the Covered Person is
totally disabled. Proof must be presented at the Home Office: (a) while the
Covered Person is living; (b) before total disability has ended or been
interrupted; and (c) within 12 months after we receive the notice of total
disability. Forms approved by us must be used.
Similar proof that the total disability is continuing may be required at
reasonable intervals. If the Covered Person fails to furnish such proof, the
disability benefit will cease.
INCONTESTABILITY: While the Insured is alive, the validity of this rider cannot
be contested after it has been in force for a period of 2 years from the
effective date of the rider.
REINSTATEMENT: This rider may be reinstated with the policy if no more than 3
years have passed since the date of termination. Reinstatement must occur before
the expiration date of this rider. Such reinstatement may occur before the
policy anniversary nearest the Covered Person's 60th birthday. The requirements
for reinstatement are:
1. Evidence of insurability is required on both the applicant and the
Insured, if the applicant is the Covered Person. Otherwise, evidence of
insurability will be required only on the Insured. This evidence must be
satisfactory to us.
2. Payment of the minimum cost of insurance sufficient to keep this rider in
force for 3 months.
EXCLUSIONS: The Covered Person will not be eligible for the disability benefit
if the total disability on which the claim is based results from:
1. Self-inflicted bodily injury, other than accidental injury; or
2. War or any act of war, whether declared or not, regardless of whether the
Covered Person is in the military, naval or air forces.
TERMINATION OF RIDER: This rider will automatically terminate on the earliest of
these conditions:
1. On the expiration date of this rider unless a disability benefit is being
provided on that date;
2. On the monthly activity date on or next following the date we receive your
written request;
3. On surrender of this rider to us;
4. On termination of the policy unless a disability benefit is being provided
on that date;
5. On assignment of the policy; or
6. On the policy maturity date.
PDR 5901
<PAGE>
CHANGE OF POLICY: Once the disability benefit commences, you cannot change the
specified amount of insurance (except for any increase(s) which result from
exercising options under any Guaranteed Insurability Rider), the death benefit
option, the mode of the planned periodic premium payments, or change the policy
to another form of insurance.
NONPARTICIPATING: This rider is nonparticipating.
COST OF INSURANCE DEDUCTIONS AFTER THE RIDER HAS TERMINATED: We will not be
liable for the cost of insurance deductions on this rider after it terminates
except to return them.
INCORPORATION OF POLICY PROVISIONS INTO RIDER: The provisions of the policy are
hereby referred to and made a part of this rider.
FIRST AMERITAS LIFE INSURANCE CORP. OF NEW YORK
/s/ Donald R. Stading /s/ Mitch Politzer
-------------------------- -----------------------
Secretary President
PDR 5901
<PAGE>
FIRST AMERITAS LIFE INSURANCE CORP. OF NEW YORK LOGO
WAIVER OF MONTHLY DEDUCTIONS ON
DISABILITY
CONSIDERATION
This rider is issued in return for the application and payment of its cost of
insurance. A copy of the application is attached to the policy. The cost of
insurance for this rider is deducted from the accumulation value at the same
time and in the same manner as the cost of insurance for the policy.
COST OF INSURANCE
The calculation of the monthly cost of insurance for this rider is described in
the attached table.
DEFINITIONS
DISABILITY BENEFIT: For purposes of this rider, the disability benefit refers to
the monthly deduction on each monthly activity date for the base policy and any
riders and is equal to:
1. the current cost of insurance for the base policy and any riders;
2. the expense charges; and
3. the charges for specified amount increases, if any.
TOTAL DISABILITY: Total disability must begin after the effective date and
before the expiration date of this rider. It must result from bodily injury
which occurs or sickness which first manifests itself while this rider is in
force.
Total Disability means:
1. Total loss of the sight of both eyes. This loss must be irrecoverable; or
2. Total loss of the use of both hands, both feet, or one hand and one foot.
This loss must be irrecoverable; or
3. The incapacity of the Insured to engage in any substantial duties of his
or her occupation for at least six consecutive months. (Substantial duties
includes managerial or supervisory functions.)
During the first 24 months of total disability, occupation means the usual
work, employment, business or profession in which the Insured was engaged
immediately before the date of disability. This includes attendance at school
or college as a full- time student. After 24 months of total disability, an
Insured who is engaged in any occupation for remuneration or profit will not
be considered totally disabled.
WDIS 5901
<PAGE>
EFFECTIVE DATE: The effective date of coverage under this rider shall be as
follows:
1. The policy date shall be the effective date for all coverage provided in
the original application.
2. For any rider issued after the policy date, the effective date shall be
the date shown on a supplement to the schedule pages.
3. For any insurance that has been reinstated, the effective date shall be
the monthly activity date on or next following the date we approve the
reinstatement.
EXPIRATION DATE: This date is also shown on the schedule pages. It is the date
on which this rider is no longer effective.
BENEFITS
While the Insured is totally disabled, the disability benefit will not be
deducted from the accumulation value. During this time, the policy and any
rider(s) will continue to be in force.
Monthly deductions falling due before we approve a claim for benefits will
continue to be deducted from the accumulation value. However, after total
disability has continued for six (6) consecutive months and we approve the
claim, any disability benefit which otherwise could have been paid under the
provisions of this rider will be credited to the accumulation value.
If total disability begins after the grace period, no benefit under this rider
will be paid.
GENERAL PROVISIONS
NOTICE OF DISABILITY: To receive this benefit, written notice of claim must be
received at the Home Office. It must be received: (a) while the Insured is
living; (b) while the Insured is totally disabled; and (c) as soon as reasonably
possible.
PROOF OF TOTAL DISABILITY: The disability benefit will commence once we receive
satisfactory written proof that the Insured is totally disabled. Proof must be
presented at the Home Office: (a) while the Insured is living; (b) before total
disability has ended or been interrupted; and (c) within 12 months after we
receive the notice of total disability. Forms approved by us must be used.
Similar proof that the total disability is continuing may be required at
reasonable intervals. If the Insured fails to furnish such proof, the disability
benefit will cease.
INCONTESTABILITY: While the Insured is alive, the validity of this rider cannot
be contested after it has been in force for a period of 2 years from the
effective date of this rider.
WDIS 5901
<PAGE>
REINSTATEMENT: Coverage under this rider may be reinstated with the policy
subject to the policy reinstatement provision. Reinstatement must occur before
the expiration date of this rider. Such reinstatement may occur any time before
the policy anniversary nearest the Insured's 60th birthday. The requirements for
reinstatement are:
1. Receipt of satisfactory evidence of insurability.
2. Payment of the minimum cost of insurance sufficient to keep this rider in
force for 3 months.
EXCLUSIONS: The insured will not be eligible for the disability benefit if the
total disability on which the claim is based results from:
1. Self-inflicted bodily injury, other than accidental injury; or
2. War or any act of war, whether declared or not, regardless of whether the
Insured is in the military, naval or air service.
TERMINATION OF RIDER: This rider will automatically terminate on the earliest of
these conditions:
1. On the expiration date of this rider unless a disability benefit is being
provided on that date;
2. On the monthly activity date on or next following the date we receive your
written request;
3. On surrender of this rider to us;
4. On termination of this policy unless a disability benefit is being
provided on that date; or
5. On the policy maturity date.
TERM RIDERS: If a renewable and convertible term rider is attached to the policy
during a benefit period, the cost of insurance for that rider will be waived
until the expiration date. If the Owner elects to convert that term rider, no
benefits will be paid under this rider on the conversion policy.
CHANGE OF POLICY: Once the disability benefit commences, you cannot change the
specified amount of insurance (except for any increase(s) which result from
exercising options under any Guaranteed Insurability Rider), the death benefit
option, the mode of the planned periodic premium payments, or change the policy
to another form of insurance.
NONPARTICIPATING: This rider is nonparticipating.
WDIS 5901
<PAGE>
COST OF INSURANCE PAYMENTS AFTER THE RIDER HAS TERMINATED: We will not be liable
for the cost of insurance payments on this rider after it terminates except to
return them.
INCORPORATION OF POLICY PROVISIONS INTO RIDER: The provisions of the policy are
hereby referred to and made a part of this rider.
FIRST AMERITAS LIFE INSURANCE CORP. OF NEW YORK
/s/ Donald R. Stading /s/ Mitch Politzer
-------------------------- -----------------------
Secretary President
WDIS 5901
<PAGE>
COST OF INSURANCE TABLE
On each monthly activity date, the monthly cost of insurance for this rider is
equal to the product of A times B where:
A is a factor based on the attained age, sex and tobacco use of the Insured and
is shown in the table below. (Note: If this rider is issued with a special
rating, this factor will be increased based on that rating. Any special
rating will be shown on the schedule pages).
B is the monthly deduction for the policy, including any table ratings and any
riders attached to the policy except for this rider.
<TABLE>
<CAPTION>
-----------------------------------------------------------------------------------------------------
MALE RATES FEMALE RATES MALE RATES FEMALE RATES
AGES NON-TOBACCO TOBACCO NON-TOBACCO TOBACCO AGES NON-TOBACCO TOBACCO NON-TOBACCO TOBACCO
USE USE USE USE USE USE USE USE
<S> <C> <C> <C> <C> <C> <C> <C> <C> <C>
15 0.0487 0.0434 0.0583 0.0558 40 0.0655 0.0523 0.0652 0.0552
16 0.0463 0.0405 0.0573 0.0547 41 0.0679 0.0535 0.0670 0.0558
17 0.0445 0.0384 0.0563 0.0535 42 0.0708 0.0552 0.0691 0.0571
18 0.0434 0.0370 0.0554 0.0522 43 0.0735 0.0567 0.0716 0.0586
19 0.0422 0.0357 0.0543 0.0510 44 0.0765 0.0584 0.0742 0.0603
20 0.0413 0.0346 0.0530 0.0498 45 0.0794 0.0602 0.0770 0.0622
21 0.0403 0.0332 0.0516 0.0482 46 0.0825 0.0625 0.0801 0.0645
22 0.0419 0.0352 0.0526 0.0495 47 0.0866 0.0656 0.0838 0.0676
23 0.0427 0.0361 0.0528 0.0496 48 0.0915 0.0696 0.0881 0.0713
24 0.0437 0.0370 0.0523 0.0492 49 0.0974 0.0745 0.0935 0.0760
25 0.0448 0.0382 0.0525 0.0493 50 0.1054 0.0812 0.1000 0.0817
26 0.0458 0.0394 0.0521 0.0487 51 0.1148 0.0892 0.1082 0.0893
27 0.0466 0.0402 0.0521 0.0484 52 0.1266 0.0994 0.1187 0.0987
28 0.0475 0.0411 0.0518 0.0482 53 0.1405 0.1112 0.1305 0.1095
29 0.0481 0.0416 0.0517 0.0478 54 0.1579 0.1258 0.1465 0.1238
30 0.0487 0.0419 0.0514 0.0471 55 0.1778 0.1428 0.1649 0.1404
31 0.0489 0.0420 0.0513 0.0469 56 0.2034 0.1647 0.1896 0.1626
32 0.0492 0.0423 0.0512 0.0466 57 0.2234 0.1818 0.2106 0.1816
33 0.0492 0.0421 0.0512 0.0464 58 0.2460 0.2007 0.2362 0.2046
34 0.0492 0.0419 0.0506 0.0457 59 0.2684 0.2211 0.2633 0.2295
35 0.0492 0.0420 0.0509 0.0460
36 0.0507 0.0427 0.0524 0.0468
37 0.0562 0.0467 0.0573 0.0505
38 0.0593 0.0486 0.0600 0.0522
39 0.0624 0.0506 0.0627 0.0539
-----------------------------------------------------------------------------------------------------
</TABLE>
WDIS 5901
