<PAGE>
EXHIBIT 4(d)
Peoples Benefit Life Insurance Company
A Stock Company
Home Office located at: 4333 Edgewood Road N.E., Cedar Rapids, Iowa 52499
(Hereafter called the Company, we, our or us) (800)-866-6007
ANNUITANT:
OWNER(S):
POLICY NUMBER:
POLICY DATE:
WE AGREE
. To provide annuity payments as set forth in Section 10 of this policy,
. Or to pay Withdrawal benefits in accordance with Section 5 of this policy,
. Or to pay death proceeds in accordance with Section 9 of this policy.
Withdrawals, Transfers and amounts applied to a Payment Option may be subject to
an Excess Interest Adjustment in accordance with Sections 5, 8, and 10,
respectively, of this policy.
These agreements are subject to the provisions of this policy. This policy is
issued in consideration of the application, or information provided in lieu
thereof, and payment of the initial premium. This policy may be applied for and
issued to qualify as a tax-qualified annuity under the applicable sections of
the Internal Revenue Code.
20 DAY RIGHT TO CANCEL
You may cancel this policy by delivering or mailing a written notice or sending
a telegram to us. You must return the policy before midnight of the twentieth
day after the day You receive it. Notice given by mail and return of the policy
by mail are effective on being postmarked, properly addressed and postage
prepaid.
We will pay You an amount equal to the sum of:
. the premiums paid; and
. the accumulated gains or losses, if any, in the Separate Account on the date
of cancellation; unless otherwise required by law.
Signed for us at our home office.
/s/ Craig D. Vermie /s/ Bart Herbert, Jr.
SECRETARY PRESIDENT
This policy is a legal contract between the policyowner and the Company.
READ YOUR POLICY CAREFULLY
Flexible Premium Deferred Variable Annuity
Income Payable At Annuity Commencement Date
Benefits Based On The Performance Of The Separate Account
Are Variable And Are Not Guaranteed As To Dollar Amount
(See Sections 6 and 10C)
Non-Participating
AV515 101 130 600
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INDEX
<TABLE>
<CAPTION>
Page Page
<S> <C> <C> <C>
Accumulation Units..................................9 Guaranteed Periods.....................................10
Age or Sex Corrections.............................22 Incontestability.......................................22
Annuity Commencement Date..........................23 Modification of Policy.................................22
Annuity Payments...................................15 Non-participating......................................22
Adjusted Policy Value...............................5 Partial Withdrawals.....................................7
Assignment.........................................23 Payee..................................................15
Beneficiary........................................23 Payment of Premiums.....................................5
Cash Value..........................................6 Payment Option Tables...............................18-21
Contract...........................................22 Policy Data Page........................................3
Death Proceeds.....................................12 Policy Value............................................5
Definitions.........................................4 Proof of Age...........................................15
Dollar Cost Averaging Option.......................11 Protection of Proceeds.................................23
Evidence of Survival...............................22 Right to Cancel.........................................1
Excess Interest Adjustment..........................6 Rights of Owner........................................22
Fixed Account......................................10 Separate Account........................................8
Guaranteed Minimum Death Benefit...................12 Service Charge..........................................6
Guaranteed Return of Fixed Account..................8 Settlement.............................................22
Premium Payments....................................5 Transfers..............................................11
</TABLE>
Page 2
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SECTION 1 - POLICY DATA
POLICY NUMBER: ANNUITANT:
INITIAL PREMIUM
PAYMENT: ISSUE AGE/SEX:
POLICY DATE: OWNER(S):
ANNUITY
COMMENCEMENT
DATE: BENEFICIARY:
DEATH BENEFIT
OPTION:
Fixed Account Guaranteed Minimum Effective Annual Interest Rate: 3%
Before the Annuity Commencement Date:
Return of Premium Death Benefit Option
Mortality and Expense Risk Fee and Administrative Charge: .60%
6 Year Step-Up Death Benefit Option
Mortality and Expense Risk Fee and Administrative Charge: .65%
Double Enhanced Death Benefit Option
Mortality and Expense Risk Fee and Administrative Charge: .75%
After the Annuity Commencement Date:
Mortality and Expense Risk Fee and Administrative Charge: .60%
Page 3
<PAGE>
SECTION 2 - DEFINITIONS
ADJUSTED POLICY VALUE - The Policy Value increased or decreased by any Excess
Interest Adjustment.
ANNUITANT - The person to whom annuity payments will be made, unless another
Payee is named.
ANNUITY COMMENCEMENT DATE - The Date the Annuitant will begin receiving payments
from this policy, which may not be later than the last day of the policy month
starting after the Annuitant attains age 85, except as expressly allowed by us
(within state restrictions), but in no event later than the last day of the
month in which the Annuitant attains age 98.
CASH VALUE - Amount, defined in Section 5, that can be withdrawn if the annuity
is Surrendered.
CUSTODIAL CARE - Care designed essentially to help a person with the activities
of daily living which does not require the continuous attention of trained
medical or paramedical personnel.
DISTRIBUTION - A Withdrawal or disbursement of funds from the Policy Value or
Cash Value. Policy Value or Cash Value will be reduced by any Distribution.
HOSPITAL - An institution which 1) is operated pursuant to the laws of the
jurisdiction in which it is located, 2) operates primarily for the care and
treatment of sick and injured persons on an inpatient basis, 3) provides 24-hour
nursing service by or under the supervision of registered graduate professional
nurses, 4) is supervised by a staff of one or more licensed Physicians, and 5)
has medical, surgical and diagnostic facilities or access to such facilities.
INVESTMENT OPTIONS - Any of the Guaranteed Period Options of the Fixed Account,
the Dollar Cost Averaging Fixed Account Option, and any of the Subaccounts of
the Separate Account.
NURSING FACILITY - A facility which 1) is operated pursuant to the laws of the
jurisdiction in which it is located, 2) provides Nursing Care or Custodial Care,
3) primarily provides Nursing Care under the direction of a licensed Physician,
registered graduate professional nurse, or licensed vocational nurse, except
when receiving Custodial Care, and 4) is not other than incidentally a Hospital,
a home for the aged, a retirement home, a rest home, a community living center
or a place mainly for the treatment of alcoholism, mental illness or drug abuse.
NURSING CARE - Care prescribed by a Physician and performed or supervised by a
registered graduate nurse. Such care includes nursing and rehabilitation
services available 24 hours.
PAYEE - The person to whom annuity payments will be made.
PAYMENT OPTIONS - Options through which the Distribution of the Adjusted Policy
Value can be directed.
PHYSICIAN - Doctor of Medicine or Doctor of Osteopathy who is licensed as such
and operating within the scope of the license.
POLICY ANNIVERSARY - The anniversary of the Policy Date for each year the policy
remains in force.
POLICY DATE - The date shown on page 3 of this policy and the date on which this
policy becomes effective.
POLICY YEAR - The 12-month period following the Policy Date shown on the Policy
Data page. The first Policy Year starts on the Policy Date. Each subsequent year
starts on the anniversary of the Policy Date.
SEPARATE ACCOUNT - The separate investment account established by us, as
described in Section 6.
SUBACCOUNT - A division of the Separate Account, as described in Section 6.
SURRENDER - A Distribution of funds from the Policy Value or Cash Value. Policy
Value or Cash Value will be reduced by any Surrender.
TERMINAL CONDITION - A condition resulting from an accident or illness which, as
determined by a Physician, has reduced life expectancy to not more than 12
months, despite appropriate medical care.
WITHDRAWAL - A partial Distribution of funds from the Policy Value or Cash
Value. Policy Value or Cash Value will be reduced by any Withdrawal.
YOU, YOUR - The owner of this policy. Unless otherwise specified on the Policy
Data page, the Annuitant and the owner shall be one and the same person.
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SECTION 3 - PREMIUM PAYMENTS
PAYMENT OF PREMIUMS
Premium payments may be made any time while this policy is in force before the
Annuity Commencement Date. You may start or stop, increase or decrease, or skip
any premium payments.
MAXIMUM AND MINIMUM PREMIUM PAYMENT
The premium payments may not be more than the amount permitted by law if this is
a tax-qualified annuity. The minimum initial premium payment is $10,000. If this
policy is being used as a tax-qualified annuity, the minimum initial premium is
$1,000, except that no minimum initial premium payment will be required for
403(b) annuities. The minimum subsequent premium payment we will accept is $500,
or $25 if it is a tax-qualified annuity. The maximum total premium payments
which we will accept without prior Company approval is $1,000,000.
PREMIUM PAYMENT DATE
The premium payment date is the date on which the premium payment is credited to
the policy. The initial premium payment less any applicable premium taxes will
be credited to the policy within two business days of receipt of the premium
payment and the information needed. Subsequent additional premium payments will
be credited to the policy as of the business day when the premium payment and
required information are received. A business day is any day that the New York
Stock Exchange is open for trading.
SYSTEMATIC PREMIUM PAYMENTS
Beginning in the first Policy Year, Systematic Premium Payments can be made on a
monthly, quarterly, semi-annual or annual basis. These premium payments must
meet minimum premium requirements, and must be sent through electronic funds
transfer. Systematic Premium Payments may be stopped or started at any time;
however, 30 days' written notice is required to stop them.
ALLOCATION OF PREMIUM PAYMENTS
Premium payments may be applied to various Investment Options which we make
available. You must indicate what percent of each premium payment to allocate to
various Investment Options. Each percent may be either zero or any whole number;
however, the allocation among all accounts must total 100%.
CHANGE OF ALLOCATION
You may change the allocation of premium payments to various Investment Options.
You must tell us in a notice You sign which gives us the facts that we need.
Premium payments received after the date on which we receive Your notice will be
applied on the basis of the new allocation.
PREMIUM TAXES
Your state may impose a premium tax. It may be imposed either when a premium
payment is made, on the Annuity Commencement Date, on the date of death, or on
the date of full Surrender. When permitted by state law, we will not deduct the
premium tax until the Annuity Commencement Date, date of death, or date of full
Surrender.
SECTION 4 - POLICY VALUE
POLICY VALUE
On or before the Annuity Commencement Date, the Policy Value is equal to Your:
(a) premium payments; minus
(b) Gross Partial Withdrawals (as defined in Section 5); plus
(c) interest credited to the Fixed Account (see Section 7); plus
(d) accumulated gains in the Separate Account (see Section 6); minus
(e) accumulated losses in the Separate Account (see Section 6); minus
(f) service charges, premium taxes, transfer fees, and rider fees, if any.
ADJUSTED POLICY VALUE
The Adjusted Policy Value is the Policy Value increased or decreased by any
Excess Interest Adjustment. You may use the Adjusted Policy Value on the Annuity
Commencement Date to provide lifetime income or income for a period of no less
than 60 months under the Payment Options in Section 10.
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SECTION 4 - POLICY VALUE - CONT
SERVICE CHARGE
On each Policy Anniversary and at the time of Surrender during any Policy Year
before the Annuity Commencement Date, we reserve the right to assess a service
charge up to $30 for policy administration expenses. The Service Charge will be
deducted from each Investment Option in proportion to the portion of Policy
Value (prior to such charge) in each Investment Option. In no event will the
Service Charge exceed 2% of the Policy Value on the Policy Anniversary or at the
time of Surrender.
The Service Charge will not be deducted on a Policy Anniversary or at the time
of Surrender if, at either of these times, (1) the sum of all premium payments
less the sum of all Withdrawals taken is at least $50,000; (2) the Policy Value
equals or exceeds $50,000, or (3) the policy is tax-qualified.
SECTION 5 - CASH VALUE AND PARTIAL WITHDRAWALS
CASH VALUE
On or before the Annuity Commencement Date, the Cash Value is equal to the
Adjusted Policy Value. Information on the current amount of Your policy's Cash
Value is available upon request. The Cash Value may be partially withdrawn or
will be paid in the event of a full Surrender of the policy. We must receive
Your written partial Withdrawal or Surrender request before the Annuity
Commencement Date.
There is no Cash Value once an Annuity Payment Option has been selected.
EXCESS INTEREST ADJUSTMENT
Full Surrenders, Partial Withdrawals, Transfers, and amounts applied to a
Payment Option from the Fixed Account Guaranteed Period Options described in
Section 7 will be subject to an Excess Interest Adjustment except as provided
for in the Partial Withdrawals provision below.
An Excess Interest Adjustment applies in the following situations:
1) When You withdraw or transfer all or any portion of Your Cash Value,
2) When You exercise an Annuity Payment Option,
3) When death proceeds are calculated. However, death proceeds will not be
reduced as a result of any Excess Interest Adjustment.
The Excess Interest Adjustment is only applied to transactions affecting the
Guaranteed Period Options of the Fixed Account (see Section 7) and is based on
any change in interest rates from the time the affected Guaranteed Period(s)
started until the time the Excess Interest Adjustment occurs. The Excess
Interest Adjustment is applied as follows:
1) The Excess Interest Adjustment is only applied when the transactions occur
prior to the end of any Guaranteed Period Option;
2) Transfers to the Guaranteed Period Options of the Fixed Account are
considered Premium Payments for purposes of determining the Excess
Interest Adjustment;
3) The Excess Interest Adjustment may affect the death proceeds defined in
Section 9;
4) If interest rates have decreased from the time the affected Guaranteed
Period(s) started until the time the transaction occurs, the Excess
Interest Adjustment will result in additional funds available to You;
5) If interest rates have increased from the time the affected Guaranteed
Period(s) started until the time the transaction occurs, the Excess
Interest Adjustment will result in a decrease in the funds available to
You.
6) Certain amounts are not subject to the Excess Interest Adjustment as
provided in Sections 5, 7 and 8.
The formula for determining the amount of the Excess Interest Adjustment is as
follows:
Excess Interest Adjustment = Sx(G-C)x(M/12)
where: S is the gross (that is, before premium taxes, if any) amount
being Surrendered, partially withdrawn, transferred, or applied
to a Payment Option that is subject to the Excess Interest
Adjustment.
G is the guaranteed interest rate for the Guaranteed Period
applicable to S.
M is the number of months remaining in the Guaranteed Period for S,
rounded up to the next higher whole number of months.
C is the current guaranteed interest rate then being offered on new
Premium Payments for the next longer Guaranteed Period than "M".
If this policy form or such a Guaranteed Period Option is no
longer offered, "C" will be the U.S. Treasury rate for the next
longer maturity (in whole years) than "M" on the 25th day of the
previous calendar month, plus up to 2%.
<PAGE>
SECTION 5 - CASH VALUE AND PARTIAL WITHDRAWALS- CONT
Upon full Surrender, the Excess Interest Adjustment (EIA) for each Guaranteed
Period Option will not reduce the Adjusted Policy Value for that Guaranteed
Period Option below the amount paid into, less any prior Withdrawals and
transfers from, that Guaranteed Period Option, plus interest at the 3%
guaranteed effective annual interest rate.
PARTIAL WITHDRAWALS
We will pay You a portion of the Cash Value as a Partial Withdrawal provided we
receive Your written request while the policy is in effect and before the
Annuity Commencement Date. When You request a Partial Withdrawal You must tell
us how it is to be allocated from among the Investment Options. If Your request
for a Partial Withdrawal from any Investment Option is less than or equal to the
Cash Value in that option, we will pay the amount of Your request. However, if
Your request for a Partial Withdrawal from any Investment Option is greater than
the Cash Value in that option, we will pay You the Cash Value of that Investment
Option.
The Gross Partial Withdrawal is the total amount which will be deducted from
Your Policy Value as a result of each Partial Withdrawal. The Gross Partial
Withdrawal may be more or less than Your requested Partial Withdrawal amount,
depending on whether Excess Interest Adjustments apply at the time You request
the Partial Withdrawal.
The formula for determining the Gross Partial Withdrawal is as follows:
Gross Partial Withdrawal = R - E
where: R is the requested Partial Withdrawal; and
E is the Excess Interest Adjustment.
If any Partial Withdrawal reduces the Cash Value below $500, we reserve the
right to pay the full Cash Value and terminate the policy.
We may delay payment of the Cash Value from the Fixed Account for up to 6 months
after we receive the request. If the owner dies after we receive the request,
but before the request is processed, the request will be processed before the
death proceeds are determined.
Partial Withdrawals may be made free from Excess Interest Adjustments as
follows:
LUMP SUM
Beginning in the first Policy Year, Partial Withdrawals are available as
Lump Sum Distributions in one or more Withdrawals during a Policy Year.
Any of these Withdrawals taken from the Fixed Accounts in excess of 10% of
the cumulative premium payments immediately prior to the Partial
Withdrawal will be subject to an Excess Interest Adjustment. The minimum
Withdrawal is $500.
SYSTEMATIC PAYOUT OPTION
Beginning in the first Policy Year, a Systematic Payout Option (SPO) is
available on a monthly, quarterly, semi-annual or annual basis. SPO
payouts must be at least $50 and may not exceed 10% of the cumulative
premium payments at the time a SPO payout is made divided by the number of
payouts made per year (e.g. 12 for monthly). No Excess Interest Adjustment
will apply to the SPO payout. Monthly and quarterly payouts must be sent
through electronic funds transfer directly to Your checking or savings
account. You may start or stop SPO payouts at any time; however, 30 days'
written notice is required to stop SPO payouts. Once stopped, You must
wait until the first day of the next Policy Year to begin a new SPO.
Once You have elected a SPO, You must wait a minimum time before the first
SPO payment:: 1 month for a monthly SPO, 3 months for quarterly, 6 months
for semi-annual, or 12 months for annual.
MINIMUM REQUIRED DISTRIBUTION
For tax-qualified plans, Partial Withdrawals taken to satisfy minimum
Distribution requirements under Section 401(a)(9) of the Internal Revenue
Code (IRC) are available with no Excess Interest Adjustments. The amount
available from this policy with respect to the minimum Distribution
requirement is based solely on this policy.
The owner must be at least 70 1/2 years old in the calendar year of
Distribution, must submit a written request to us and must take the
Distribution before year-end. If the owner attains age 70 1/2 in the
calendar year of Distribution, a written request which is postmarked no
later than the end of the current calendar year must be submitted to us.
Systematic minimum Distributions must be at least $50 or a lump sum
Distribution is available if minimum required Distributions are less than
$50.
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SECTION 5 - CASH VALUE AND PARTIAL WITHDRAWALS- CONT
Any amount requested in excess of the (IRC) minimum required Distribution
will have the appropriate Excess Interest Adjustments applied, unless the
excess Distribution qualifies as Excess Interest Adjustment-free under any
additional options provided.
NURSING CARE AND TERMINAL CONDITION WITHDRAWAL OPTION
Beginning in the first Policy Year, if the owner or owner's spouse
(Annuitant or Annuitant's spouse if the owner is not a natural person) has
been 1) confined in a Hospital or Nursing Facility for 30 consecutive days
or 2) diagnosed as having a Terminal Condition, You may elect to withdraw
all or a portion of the Policy Value without an Excess Interest
Adjustment. The minimum Withdrawal under this option is $1000.
For Nursing Care, we must receive each Withdrawal request and proof of
eligibility with each request no later than 90 days following the date
that confinement has ceased, unless it can be shown that it was not
reasonably possible to provide the notice and proof within the above time
period and that the notice and proof were given as soon as reasonably
possible. However, in no event, except the absence of legal capacity,
shall the notice and proof be provided later than one year following the
date that confinement has ceased. For a Terminal Condition, we must
receive each Withdrawal request and the applicable proof of eligibility no
later than one year following diagnosis of the Terminal Condition. Proof
of a Terminal Condition is required only with the initial Withdrawal
request and must be furnished by the Annuitant, Annuitant's spouse, owner,
or owner's spouse's Physician. Proof of confinement may be a Physician's
statement or a statement from a Hospital or Nursing Facility
administrator.
UNEMPLOYMENT WAIVER
Beginning in the first Policy Year, You may withdraw all or a portion of
the Policy Value free of any Excess Interest Adjustment if the owner or
owner's spouse (Annuitant or Annuitant's spouse, if the owner is not a
natural person) becomes unemployed. In order to qualify, You 1) must have
been employed full-time for at least two years prior to Your becoming
unemployed, 2) must have been employed full-time on Your Policy Date, 3)
must have been unemployed for at least 60 consecutive days at the time of
Withdrawal and 4) must have a minimum Cash Value of $5000 at the time of
Withdrawal. Proof of unemployment will consist of providing us with a
determination letter from the applicable State's Department of Labor which
verifies that You qualify for and are receiving unemployment benefits at
the time of Withdrawal. The determination letter must be received by us no
later than 15 days following the date of the Withdrawal request
GUARANTEED RETURN OF FIXED ACCOUNT PREMIUM PAYMENTS
Upon full Surrender of the policy, You will always receive at least the premium
payments made to, less prior Withdrawals and transfers from, the Fixed Account.
MINIMUM VALUES
Benefits available under this policy are not less than those required by any
statute of the state in which the policy is delivered.
SECTION 6 - SEPARATE ACCOUNT
SEPARATE ACCOUNT
We have established and will maintain a Separate Account, under the laws of the
state of Iowa. Any realized or unrealized income, net gains and losses from the
assets of the Separate Account are credited to or charged against it without
regard to our other income, gains or losses. Assets are put in the Separate
Account for this policy, as well as for other variable annuity policies. Any
Separate Account may invest assets in shares of one or more mutual fund
portfolios, or in the case of a managed Separate Account, direct investments in
stocks or other securities as permitted by law. Fund Shares refer to shares of
underlying mutual funds or prorata ownership of the assets held in a Subaccount
of a managed Separate Account. Fund shares are purchased, redeemed and valued on
behalf of the Separate Account.
The Separate Account is divided into Subaccounts. Each Subaccount invests
exclusively in shares of one of the portfolios of an underlying mutual fund. We
reserve the right to add or remove any Subaccount of the Separate Account.
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SECTION 6 - SEPARATE ACCOUNT - CONT
The assets of the Separate Account are our property. These assets will equal or
exceed the reserves and other contract liabilities of the Separate Account.
These assets will not be chargeable with liabilities arising out of any other
business we conduct. We reserve the right, subject to regulations governing the
Separate Account, to transfer assets of a Subaccount, in excess of the reserves
and other contract liabilities with respect to that Subaccount, to another
Subaccount or to our General Account.
We will determine the fair market value of the assets of the Separate Account in
accordance with a method of valuation which we establish in good faith.
Valuation Period means the period of time from one determination of the value of
each Subaccount to the next. Such determinations are made when the value of the
assets and liabilities of each Subaccount is calculated. This is generally the
close of business on each day on which the New York Stock Exchange is open.
We also reserve the right to transfer assets of the Separate Account, which we
determine to be associated with the class of policies to which this policy
belongs, to another Separate Account. If this type of transfer is made, the term
"Separate Account", as used in the policy, shall then mean the Separate Account
to which the assets were transferred.
We also reserve the right, when permitted by law to:
(a) deregister the Separate Account under the Investment Company Act of 1940;
(b) manage the Separate Account under the direction of a committee at any time;
(c) restrict or eliminate any voting rights of policy owners or other persons
who have voting rights as to the Separate Account;
(d) combine the Separate Account with one or more other Separate Accounts;
(e) create new Separate Accounts;
(f) add new Subaccounts to or remove existing Subaccounts from the Separate
Account, or combine Subaccounts; and
(g) add new underlying mutual funds, remove existing mutual funds, or substitute
a new fund for an existing fund.
The Net Asset Value of a fund share is the per-share value calculated by the
mutual fund or, in the case of a managed Separate Account, by the Company. The
Net Asset Value is computed by adding the value of the Subaccount's investments,
cash and other assets, subtracting its liabilities, and then dividing by the
number of shares outstanding. Net Asset Values of fund shares reflect investment
advisory fees and other expenses incurred in managing a mutual fund or a managed
Separate Account.
CHANGE IN INVESTMENT OBJECTIVE OR POLICY OF A MUTUAL FUND
If required by law or regulation, an investment policy of the Separate Account
will only be changed if approved by the appropriate insurance official of the
state of Iowa or deemed approved in accordance with such law or regulation. If
so required, the process for obtaining such approval is filed with the insurance
official of the state or district in which this policy is delivered.
CHARGES AND DEDUCTIONS
The Mortality and Expense Risk Fee and the Administrative Charge are each
deducted both before and after the Annuity Commencement Date to compensate for
changes in mortality and expenses not anticipated by the mortality and
administration charges guaranteed in the policy.
The Service Charge is deducted prior to the Annuity Commencement Date only.
If the Mortality and Expense Risk Fee is more than sufficient, the Company will
retain the balance as profit or may reduce this fee in the future.
ACCUMULATION UNITS
The Policy Value in the Separate Account before the Annuity Commencement Date is
represented by accumulation units. The dollar value of accumulation units for
each Subaccount will change from day to day reflecting the investment experience
of the Subaccount.
Premium Payments allocated to and any amounts transferred to the Subaccounts
will be applied to provide accumulation units in those Subaccounts. The number
of accumulation units purchased in a Subaccount will be determined by dividing
the amount allocated to or transferred to that Subaccount, by the value of an
accumulation unit for that Subaccount on the premium payment or transfer date.
The number of accumulation units withdrawn or transferred from the Subaccounts
will be determined by dividing the amount withdrawn or transferred by the value
of an accumulation unit for that Subaccount on the Withdrawal or transfer date.
The value of an accumulation unit on any business day is determined by
multiplying the value of that unit at the end of the immediately preceding
valuation period by the net investment factor for the valuation period.
Page 9
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SECTION 6 - SEPARATE ACCOUNT - CONT
The net investment factor used to calculate the value of an accumulation unit in
each Subaccount for the Valuation Period is determined by dividing (a) by (b)
and subtracting (c) from the result, where:
(a) is the result of:
(1) the net asset value of a fund share held in that Subaccount
determined as of the end of the current valuation period; plus
(2) the per share amount of any dividend or capital gain Distributions
made by the fund for shares held in that Subaccount if the
ex-dividend date occurs during the valuation period; plus or minus
(3) a per share credit or charge for any taxes reserved for, which we
determine to have resulted from the investment operations of that
Subaccount.
(b) is the net asset value of a fund share held in that Subaccount determined
as of the end of the immediately preceding valuation period.
(c) is a factor representing the Mortality and Expense Risk Fee and
Administrative Charge before the Annuity Commencement Date. This factor is
less than or equal to, on an annual basis, the percentage shown on page 3
of the daily net asset value of a fund share held in that Subaccount.
Since the net investment factor may be greater or less than one, the
accumulation unit value may increase or decrease.
SECTION 7 - FIXED ACCOUNT
FIXED ACCOUNT
Premium payments applied to and any amounts transferred to the Fixed Account
will reflect a fixed interest rate. The interest rates we set will be credited
for increments of at least one year measured from each premium payment or
transfer date. These rates will never be less than an effective annual interest
rate of 3%.
GUARANTEED PERIODS
We may offer optional Guaranteed Period Options, into which premium payments may
be paid or amounts transferred. The current interest rate we set for funds
entering each Guaranteed Period Option (GPO) is guaranteed until the end of that
option's Guaranteed Period. At that time, the premium payment made or amount
transferred into the GPO, less any Withdrawals or transfers from that GPO, plus
accrued interest, will be rolled into a new GPO or may be transferred to any
Subaccount(s) within the Separate Account(s).
You may choose the Investment Option(s) You want the funds rolled into by giving
us a written notice within 30 days before the end of the expiring option's
Guaranteed Period. However, any Guaranteed Period elected may not extend beyond
the maximum Annuity Commencement Date defined in Section 11. In the absence of
such election, the funds will be rolled into a new GPO which is the same as the
expiring GPO unless that GPO is no longer offered, in which case, the next
shorter GPO offered will be used. You will be mailed a notice of completion of
the rollover with the new interest rate applicable. The new GPO will be deemed
as accepted if we do not receive a written rejection within 30 days from the
postmark date of the completion notice.
We reserve the right for new premium payments, transfers, or rollovers to offer
or not to offer any GPO, except that we will always offer at least a one-year
GPO.
For purposes of crediting interest when funds are withdrawn from or transferred
into a GPO, the amount of the oldest premium payment or rollover into that GPO
is considered to be withdrawn first. If the amount withdrawn exceeds this
amount, the next oldest premium payment or rollover is considered to be
withdrawn next, and so on until the most recent premium payment or rollover is
considered to be withdrawn (this is a "First-In, First-Out" or FIFO procedure).
Premium payment(s) or rollover(s) are deemed to be withdrawn first, then
credited interest.
Partial Withdrawals, Surrenders, transfers, and amounts applied to a Payment
Option from the Guarantee Period Option(s) are subject to an Excess Interest
Adjustment as described in Section 5.
DOLLAR COST AVERAGING FIXED ACCOUNT OPTION
We may offer a Dollar Cost Averaging (DCA) Fixed Account Option separate from
the Guaranteed Period Options. This option will have a one-year interest rate
guarantee. The current interest rate we set for the DCA Fixed Account may differ
from the rates credited on the one-year GPO in the Fixed Account. In addition,
the current interest rate we credit may vary on different portions of the DCA
Fixed Account. The credited interest rate will never be less than the minimum
effective annual interest rate of 3%. The DCA Fixed Account Option will only be
available under a Dollar Cost Averaging program as described in Section 8.
Page 10
<PAGE>
SECTION 8 - TRANSFERS
A. TRANSFERS BEFORE THE ANNUITY COMMENCEMENT DATE
Prior to the Annuity Commencement Date, You may transfer the value of the
accumulation units from one Investment Option to another. You must sign a notice
to transfer which gives us the facts that we need.
Transfers of Policy Value from the Guaranteed Period Options (GPO) of the Fixed
Account prior to the end of that GPO are subject to an Excess Interest
Adjustment. If the Excess Interest Adjustment at the time of such Policy Value
transfer is a negative adjustment, then the maximum Policy Value transfer is 25%
of that GPO's Policy Value, less Policy Values previously transferred out of
that GPO during the current Policy Year. If the Excess Interest Adjustment at
the time of such Policy Value transfer is a positive adjustment, no maximum will
apply to such Policy Values transferred from the GPO. No Excess Interest
Adjustment will apply to Policy Value transfers at the end of a Guaranteed
Period.
Transfers of interest credited in the GPOs to other Investment Options are
allowed on a "First-In, First-Out" basis. Such transfers may be made monthly,
quarterly, semi-annually, or annually. Each such transfer must be at least $50
and will not be subject to an Excess Interest Adjustment.
Transfers of Policy Value from the Separate Account are subject to a minimum of
$500 or the entire Subaccount Policy Value, if less. However, if the remaining
Subaccount Policy Value is less than $500, we reserve the right to include that
amount as part of the transfer.
You may choose which GPO to transfer to or from, however, any GPO elected may
not extend beyond the maximum Annuity Commencement Date defined in Section 11.
No transfers will be allowed out of the Dollar Cost Averaging Fixed Account
Option except through the Dollar Cost Averaging Option.
We reserve the right to limit transfers to no more than 12 in any one Policy
Year. Any transfers in excess of 12 per Policy Year may be charged a $10 per
transfer fee. Transfers among multiple Investment Options will be treated as one
transfer in determining the number of transfers that have occurred. We also
reserve the right to prohibit transfers to the Fixed Account if we are crediting
an effective annual interest rate of 3%.
DOLLAR COST AVERAGING OPTION
Prior to the Annuity Commencement Date, You may instruct us to automatically
transfer a specified amount from the Money Market Subaccount or the Dollar Cost
Averaging (DCA) Fixed Account Option to any other Subaccount(s) of the Separate
Account. The automatic transfers can occur monthly or quarterly. If the Dollar
Cost Averaging request is received prior to the 28th day of any month, the first
transfer will occur on the 28th day of that month. If the Dollar Cost Averaging
request is received on or after the 28th day of any month, the first transfer
will occur on the 28th day of the following month. Changes to the Subaccounts to
which these transfers are allocated are not restricted. Transfers must be
scheduled for at least 6, but not more than 24 months or for at least 4, but not
more than 8 quarters each time the Dollar Cost Averaging program is started or
restarted following termination of the program for any reason.
Dollar Cost Averaging from the Dollar Cost Fixed Account
Prior to the Annuity Commencement Date, no transfers, (except through Dollar
Cost Averaging) will be allowed from a DCA Fixed Account. Transfers will
continue until the DCA Fixed Account value is depleted. The amount transferred
each time must be at least $500. All transfers from the DCA account will be the
same amount as the initial transfer. Changes to the amount transferred will only
be allowed when additional premium is allocated or a new amount is transferred
into the DCA Fixed Account. The Dollar Cost Averaging option from the DCA Fixed
Account may be discontinued after satisfying the minimum number of required
transfers by sending written notice to us.
Dollar Cost Averaging from the Money Market Account
Transfers from the Money Market Account will continue until Your original
request is met. If on any transfer date, the value in the Money Market Account
is equal to or less than the amount You have elected to have transferred, We
will transfer the entire amount and the option will end. The amount transferred
each time must be at least $500. All transfers from the Money Market Account
will be the same amount as the initial transfer. Changes to the amount
transferred are allowed once each Policy Year provided we receive written notice
at least seven days prior to the next transfer date. The Dollar Cost Averaging
option may be discontinued at any time provided we receive written notice at
least seven days prior to the next transfer date.
Page 11
<PAGE>
SECTION 8 - TRANSFERS - CONT
Dollar Cost Averaging results in the purchase of more accumulation units when
the value of the accumulation unit is low, and fewer accumulation units when the
value of the accumulation unit is high. However, there is no guarantee that the
Dollar Cost Averaging program will result in higher Policy Values or will
otherwise be successful. While Dollar Cost Averaging is in effect, Asset
Rebalancing is not available.
ASSET REBALANCING
Prior to the Annuity Commencement Date, You may instruct us to automatically
transfer amounts among the Subaccounts of the Separate Account on a regular
basis to maintain a desired allocation of the Policy Value among the various
Subaccounts offered. Rebalancing will occur on a monthly, quarterly, semi-annual
or annual basis, beginning on a date selected by You. You must select the
percentage of the Policy Value desired in each of the various Subaccounts
offered (totaling 100%). Any amounts in the Fixed Account are ignored for the
purposes of Asset Rebalancing. Rebalancing can be started, stopped or changed at
any time. Asset Rebalancing is not available while Dollar Cost Averaging is in
effect. Rebalancing will cease as soon as we receive a request for any other
transfer.
B. TRANSFERS AFTER THE ANNUITY COMMENCEMENT DATE
After the Annuity Commencement Date, You may transfer the value of the variable
annuity units from one Subaccount to another within the Separate Account or to
the Fixed Account. If You want to transfer the value of the variable annuity
units, You must tell us in a signed notice which gives us the facts that we
need. We reserve the right to limit transfers between the Subaccounts or to the
Fixed Accounts to once per Policy Year.
The minimum amount which may be transferred is the lesser of $10 monthly income
or the entire monthly income of the variable annuity units in the Subaccount
from which the transfer is being made. If the monthly income of the remaining
units in a Subaccount is less than $10, we have the right to include the value
of those variable annuity units as part of the transfer.
After the Annuity Commencement Date, no transfers may be made from the Fixed
Account to any other Investment Options.
SECTION 9 - DEATH PROCEEDS
A. DEATH PROCEEDS PRIOR TO ANNUITY COMMENCEMENT DATE
The amount of death proceeds will be the greatest of (a), (b) or (c) where:
(a) is the Policy Value on the date we receive due proof of death and an
election of a method of settlement;
(b) is the Cash Value on the date we receive due proof of death and an election
of a method of settlement, and;
(c) is the Guaranteed Minimum Death Benefit (GMDB), if any, plus any additional
premium payments received, less any Gross Partial Withdrawals from the date
of death to the date of payment of death proceeds.
If You have not selected a payment option by the date of death, the beneficiary
may make such election within one year of the date we receive due proof of the
owner's or Annuitant's death as described in C below. The beneficiary may elect
to receive the death proceeds as a lump sum payment or may use the death
proceeds to provide any of the annuity Payment Options described in Section 10.
Interest on death proceeds will be paid as required by law.
B. GUARANTEED MINIMUM DEATH BENEFIT
The amount of the Guaranteed Minimum Death Benefit (GMDB) is based on the death
benefit option shown on page 3. You may not change the GMDB option after the
policy is issued.
Option: Return of Premium Death Benefit
This GMDB is equal to the total premiums paid for this policy, less any
Adjusted Partial Withdrawals (as described below), as of the date of death.
Available for issue ages 0-85.
Option: 6 Year Step-Up Death Benefit
This GMDB is the higher of the initial premium or the Adjusted Policy Value
on the 6th, 12th, 18th, etc., Policy Anniversary prior to the earlier of the
date of death or the Annuitant's 81st birthday plus premiums paid, less partial
Withdrawals subsequent to the date of the 6th Policy Anniversary with the
largest Policy Value. Available for issue ages 0-75.
Page 12
<PAGE>
SECTION 9 - DEATH PROCEEDS - CONT
Option: Double Enhanced Death Benefit
This GMDB is the greater of (1) and (2) where:
(1) is a 5% annually compounding death benefit, equal to the cumulative
Premium Payments, minus Adjusted Partial Withdrawals, plus interest
accumulated at 5% per annum from the payment or Withdrawal date to the
earlier of the Annuitant's date of death or the Annuitant's 81st
birthday, and
(2) is an annual Step-Up Death Benefit, equal to the largest Policy Value
on the Policy Date or on any Policy Anniversary prior to the earlier of
the Annuitant's date of death or the Annuitant's 81st birthday, plus
any Premium Payments (minus Adjusted Partial Withdrawals) since the
date of the Policy Anniversary with the largest Policy Value. Available
for issue ages 0-79.
If the owner is a non-natural person, or if the owner has elected to have the
death proceeds paid upon the death of the Annuitant, the GMDB will be based upon
the Annuitant's age.
A Partial Withdrawal taken as provided in Section 5 will reduce the Guaranteed
Minimum Death Benefit by an amount referred to as the "Adjusted Partial
Withdrawal". The Adjusted Partial Withdrawal may be a different amount than the
Gross Partial Withdrawal described in Section 5. The Adjusted Partial Withdrawal
is the total amount deducted from the GMDB as a result of a Partial Withdrawal
as used in the GMDB provision. It is equal to the Gross Partial Withdrawal
described in Section 5, multiplied by an Adjustment Factor. The Adjustment
Factor is equal to the amount of the death proceeds prior to the Partial
Withdrawal divided by the Policy Value prior to the Partial Withdrawal.
C. DEATH PRIOR TO ANNUITY COMMENCEMENT DATE
Death proceeds are payable contingent upon the relationships between the owner,
Annuitant, owner's designated beneficiary and beneficiary as outlined below. The
policy must be Surrendered upon settlement or on proof of death.
I. Annuitant and owner are the same.
When we have due proof that the owner died before the Annuity Commencement
Date, we will provide the death proceeds to the beneficiary.
a) Beneficiary is the deceased owner's surviving spouse. The beneficiary
may elect to continue this policy as owner and Annuitant rather than
receiving the death proceeds. If the policy is continued, an amount
equal to the excess, if any, of the Guaranteed Minimum Death Benefit,
if any, over the Policy Value will then be added to the Policy Value.
This is a one-time only Policy Value adjustment applied at the time the
policy is continued, and the Guaranteed Minimum Death Benefit will
continue on as applicable. If this beneficiary elects to have the death
proceeds paid, the death proceeds must be distributed:
(1) by the end of 5 years after the date of the deceased owner's
death, or
(2) payments must begin no later than one year after the deceased
owner's death and must be made for a period certain or for this
beneficiary's lifetime, so long as any period certain does not
exceed this beneficiary's life expectancy.
b) Beneficiary is not the deceased owner's surviving spouse. The death
proceeds must be distributed as provided in I.a)(1) or I.a)(2) above.
c) Death proceeds which are not paid to or for the benefit of a natural
person must be distributed by the end of 5 years after the date of the
deceased owner's death.
II. Annuitant and owner are different and the Annuitant dies.
When we have due proof that the Annuitant dies prior to the Annuity
Commencement Date, the owner will become the new Annuitant and no death
proceeds are payable. If the owner is also the deceased Annuitant's
surviving spouse, an amount equal to the excess, if any, of the Guaranteed
Minimum Death Benefit, if any, value over the Policy Value will then be
added to the Policy Value. This is a one-time only Policy Value adjustment
applied at the time the policy is continued, and the Guaranteed Minimum
Death Benefit will continue on as applicable.
However, in lieu of becoming the new Annuitant, the owner may elect to have
the death proceeds distributed to the Annuitant's beneficiary on the death
of the Annuitant. This election must be in writing and must be received by
us prior to the Annuitant's death. In such case, when we have due proof
that the Annuitant died prior to the Annuity Commencement Date, we will
provide the death proceeds to the Annuitant's beneficiary.
Page 13
<PAGE>
SECTION 9 - DEATH PROCEEDS - CONT
a) If the owner has elected to have the death proceeds paid as a lump
sum, the beneficiary must, within 60 days' of our receipt of due
proof of the Annuitant's death, either:
1) receive the lump sum proceeds; or
2) elect to receive annuity payments. Such payments must begin
within one year of our receipt of due proof of the
Annuitant's death and must be made for a period certain or for
this beneficiary's lifetime, so long as any period certain does
not exceed this beneficiary's life expectancy.
b) Death proceeds which are not paid to or for the benefit of a
natural person must be distributed by the end of 5 years after the
date of the Annuitant's death.
III. Annuitant and owner are different and the owner dies.
If the owner dies prior to the Annuity Commencement Date and before the
entire interest in the policy is distributed, the owner's designated
beneficiary will become the new owner. The remaining portion of any
interest in the policy must be distributed to the extent provided below in
III.a), III.b), III.c), or III.d).
a) Owner designated beneficiary is the deceased owner's surviving
spouse. The owner designated beneficiary may elect to continue this
policy rather than receive the Adjusted Policy Value. If the owner
designated beneficiary elects to receive the Adjusted Policy Value,
the Adjusted Policy Value must be distributed:
(1) by the end of 5 years after the date of the deceased owner's
death, or
(2) payments must begin no later than one year after the deceased
owner's death and must be made for a period certain or for the
owner designated beneficiary's lifetime, so long as any period
certain does not exceed the owner designated beneficiary's life
expectancy.
b) Owner designated beneficiary is not the deceased owner's surviving
spouse. The Adjusted Policy Value must be distributed as provided in
III.a)(1) or III.a)(2) above.
c) Owner designated beneficiary is not a natural person. The Adjusted
Policy Value must be distributed as provided in III.a)(1) above.
d) No owner designated beneficiary survives the deceased owner. The
deceased owner's estate will become the new owner (or the estate may
name a new owner). The Executor or Administrator must be named in a
form acceptable to us. The Adjusted Policy Value must be distributed
by the end of 5 years after the date of the deceased owner's death.
IV. More than one Owner.
If there is more than one owner, then the death of any owner will be
treated the same as the death of the owner.
D. DEATH ON OR AFTER THE ANNUITY COMMENCEMENT DATE
The death proceeds on or after the Annuity Commencement Date depend on the
payment option selected. If any owner dies on or after the Annuity Commencement
Date, but before the entire interest in the policy is distributed, the remaining
portion of such interest in the policy will be distributed to the beneficiary at
least as rapidly as under the method of distribution being used as of the date
of that owner's death.
E. AN OWNER IS NOT AN INDIVIDUAL
In the case of a non tax-qualified annuity, if any owner or beneficial owner, is
not an individual, then for purposes of the federal income tax mandatory
Distribution provisions in subsection C or D above, (1) the primary Annuitant
will be treated as the owner of the policy, and (2) if there is any change in
the primary Annuitant, such a change will be treated as the death of the owner.
Page 14
<PAGE>
SECTION 10 - ANNUITY PAYMENTS
A. GENERAL PAYMENT PROVISIONS
Payment
If this policy is in force on the Annuity Commencement Date, we will use the
Fixed Account portion and/or the Separate Account portion of the Adjusted Policy
Value to make annuity payments to the Payee under Option 3 and/or 3-V,
respectively, with 10 years certain, or if elected, under one or more of the
other options described in this section. However, the option(s) elected must
provide for lifetime income or income for a period of at least 60 months. You
will become the Annuitant at the Annuity Commencement Date. Payments will be
made at 1, 3, 6 or 12 month intervals. We reserve the right to change the
frequency of payments to avoid making payments of less than $50.00.
Before the Annuity Commencement Date, if the death proceeds become payable or if
You Surrender this policy, we will pay any proceeds in one sum, or if elected,
all or part of these proceeds may be placed under one or more of the options
described in this section. If we agree, the proceeds may be placed under some
other method of payment instead.
Adjusted Age
Payments under Options 3 and 5 and the first payment under Options 3-V and 5-V
are determined based on the adjusted age of the Annuitant. The adjusted age is
the Annuitant's actual age on the Annuitant's nearest birthday, at the Annuity
Commencement Date, adjusted as follows:
Annuity
Commencement Date Adjusted Age
----------------- ------------
Before 2010 Actual Age
2010 - 2019 Actual Age minus 1
2020 - 2026 Actual Age minus 2
2027 - 2033 Actual Age minus 3
2034 - 2040 Actual Age minus 4
After 2040 Determined by us
Election of Optional Method of Payment
Before the Annuity Commencement Date You can elect or change a payment option.
You may elect, in a notice You sign which gives us the facts that we need,
annuity payments that may be either variable, fixed, or a combination of both.
If You elect a combination, You must also tell us what part of the policy
proceeds on the Annuity Commencement Date are to be applied to provide each type
of payment. (You must also specify which Subaccounts.) The amount of a combined
payment will be the sum of the variable and fixed payments. Payments under a
variable payment option will reflect the investment performance of the selected
Subaccount of the Separate Account.
Payee
Unless You specify otherwise, the Payee shall be the Annuitant, or the
beneficiary as defined in the Beneficiary provision.
Proof of Age
We may require proof of the age of any person who has an annuity purchased under
Options 3, 3-V, 5 and 5 -V of this section before we make the first payment.
Minimum Proceeds
If the proceeds are less than $2,000, we reserve the right to pay them out as a
lump sum instead of applying them to a payment option.
Premium Tax
We may be required by law to pay premium tax on the amount applied to a payment
option. If so, we will deduct the premium tax before applying the proceeds.
Supplementary Contract
Once proceeds become payable and a payment option has been selected, this policy
will terminate and we will issue a supplementary contract to reflect the terms
of the selected option. The contract will name the Payee(s) and will describe
the payment schedule.
B. FIXED ACCOUNT PAYMENTS
Guaranteed Payment Options
The fixed account payment is determined by multiplying each $1,000 of policy
proceeds allocated to a fixed payment option by the amounts shown on page 18 for
the option You select. Options 1, 2 and 4 are based on a guaranteed interest
rate of 3%.
Options 3 and 5 are based on a guaranteed interest rate of 3% and the "Annuity
2000" (male, female, and unisex if required by law) mortality table projected
for improvement using projection scale G.
Option 1 - Interest Payments
We will pay the interest on the amount we use to provide annuity payments in
equal payments or this amount may be left to accumulate for a period of time we
and You agree to. We and You will agree on Withdrawal rights when You elect this
option. The interest rate we declare for this option may be different than the
interest rate(s) credited prior to the Annuity Commencement Date.
Option 2 - Income for a Specified Period
We will make level payments only for the fixed period You choose. In the event
of the death of the person receiving payments prior to the end of the fixed
period elected, payments will be continued to that person's beneficiary or their
present value may be paid in a single sum. No funds will remain at the end.
Page 15
<PAGE>
SECTION 10 - ANNUITY PAYMENTS - CONT
Option 3 - Life Income - You may choose between:
1. "No Period Certain" - We will make level payments only during the
Annuitant's lifetime.
2. "10 Years Certain" - We will make level payments for the longer of the
Annuitant's lifetime or ten years.
3. Guaranteed Return of Policy Proceeds - We will make level payments for the
longer of the Annuitant's lifetime or until the total dollar amount of
payments we made to You equals the amount applied to this option.
Option 4 - Income of a Specified Amount
Payments are made for any specified amount until the amount applied to this
option, with interest, is exhausted. This will be a series of level payments
followed by a smaller final payment. In the event of the death of the person
receiving payments prior to the time proceeds with interest are exhausted,
payments will be continued to that person's beneficiary or their present value
may be paid in a single sum.
Option 5 - Joint and Survivor Annuity
Payments are made during the joint lifetime of the Payee and a joint Payee of
Your selection. Payments will be made as long as either person is living.
Current Payment Options
The amounts shown in the tables on page 18 are the guaranteed amounts. Current
amounts offered to individuals of the same class may be obtained from us.
C. VARIABLE ACCOUNT PAYMENT OPTIONS
Variable Annuity Units
The policy proceeds You tell us to apply to a variable payment option will be
used to purchase variable annuity units in Your chosen Subaccounts. The dollar
value of variable annuity units in Your chosen Subaccounts will increase or
decrease reflecting the investment experience of Your chosen Subaccounts. The
value of a variable annuity unit in a particular Subaccount on any business day
is equal to (a) multiplied by (b) multiplied by (c), where:
(a) is the variable annuity unit value for that Subaccount on the immediately
preceding business day;
(b) is the net investment factor for that Subaccount for the Valuation Period;
and
(c) is the Assumed Investment Return adjustment factor for the Valuation
Period.
The Assumed Investment Return adjustment factor for the valuation period is the
product of discount factors of .99986634 per day to recognize the 5.0% effective
annual Assumed Investment Return.
The net investment factor used to calculate the value of a variable annuity unit
in each Subaccount for the Valuation Period is determined by dividing (a) by (b)
and subtracting (c) from the result, where:
(a) is the net result of:
(1) the net asset value of a fund share held in that Subaccount
determined as of the end of the current valuation period; plus
(2) the per share amount of any dividend or capital gain Distributions made
by the fund for shares held in that Subaccount if the ex-dividend date
occurs during the Valuation Period; plus or minus
(3) a per share credit or charge for any taxes reserved for, which we
determine to have resulted from the investment operations of the
Subaccount.
(b) is the net asset value of a fund share held in that Subaccount
determined as of the end of the immediately preceding Valuation Period.
(c) is a factor representing the Mortality and Expense Risk Fee and
Administrative Charge applicable after the Annuity Commencement Date. This
factor is less than or equal to, on an annual basis, the percentage shown
on page 3 of the daily net asset value of a fund share held in the Separate
Account for that Subaccount.
Determination of the First Variable Payment
The amount of the first variable payment is determined by multiplying each
$1,000 of policy proceeds allocated to a variable payment option by the amounts
shown on page 20 for the variable option You select. The tables are based on a
5% effective annual Assumed Investment Return and the "Annuity 2000" (male,
female, and unisex if required by law) mortality table projected for improvement
using projection scale G.
Option 3-V - Life Income An election may be made between:
1. "No Period Certain" - Payments will be made during the lifetime of the
Annuitant.
2. "10 Years Certain" - Payments will be made for the longer of the
Annuitant's lifetime or ten years. In the event of the death of the person
receiving payments prior to the end of the guarantee period for which the
election was made, payments will be continued to that person's beneficiary
or their present value may be paid in a single sum.
Page 16
<PAGE>
SECTION 10 - ANNUITY PAYMENTS - CONT
Option 5-V - Joint and Survivor Annuity
Payments are made as long as either the Annuitant or the joint Annuitant is
living.
Determination of Subsequent Variable Payments
The amount of each variable annuity payment after the first will increase or
decrease according to the value of the variable annuity units which reflect the
investment experience of the selected Subaccounts. Each variable annuity payment
after the first will be equal to the number of variable annuity units in the
selected Subaccounts multiplied by the variable annuity unit value on the date
the payment is made. The number of variable annuity units in each selected
Subaccount is determined by dividing the first variable annuity payment
allocated to the Subaccount by the variable annuity unit value of that
Subaccount on the Annuity Commencement Date.
Page 17
<PAGE>
GUARANTEED FIXED ACCOUNT PAYMENT OPTIONS
The amounts shown in these tables are the guaranteed amounts for each $1,000
of the proceeds. Higher current amounts may be available at the time of
settlement.
<TABLE>
<CAPTION>
-------------------------------------------------------------------------------------------------------------------------------
Option 2, Table I Option 3, Table II Option 3, Table III Option 3, Table IV
-------------------------------------------------------------------------------------------------------------------------------
Number of Amount of
Years Monthly Monthly Installment For Monthly Installment For Life Monthly Installment For Life
Payable Installment Life No Period Certain 10 Years Certain Guaranteed Return Of Proceeds
-------------------------------------------------------------------------------------------------------------------------------
Age* Male Female Unisex Male Female Unisex Male Female Unisex
-------------------------------------------------------------------------------------------------------------------------------
<S> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C>
50 $3.82 $3.70 $3.74 $3.80 $3.69 $3.72 $3.70 $ 3.62 $3.65
51 3.89 3.76 3.80 3.86 3.74 3.78 3.75 3.67 3.70
52 3.95 3.81 3.86 3.92 3.80 3.84 3.81 3.72 3.75
53 4.02 3.88 3.92 3.99 3.86 3.90 3.87 3.78 3.80
5 $17.91 54 4.10 3.94 3.99 4.06 3.92 3.96 3.93 3.83 3.86
6 15.14 55 4.18 4.01 4.06 4.13 3.99 4.03 3.99 3.89 3.92
7 13.16 56 4.26 4.08 4.14 4.21 4.06 4.10 4.06 3.95 3.98
8 11.68 57 4.35 4.16 4.22 4.29 4.13 4.18 4.13 4.02 4.05
9 10.53 58 4.44 4.24 4.30 4.38 4.21 4.26 4.20 4.08 4.12
10 9.61 59 4.54 4.33 4.39 4.47 4.29 4.35 4.27 4.16 4.19
11 8.86 60 4.64 4.42 4.49 4.57 4.38 4.44 4.36 4.23 4.27
12 8.24 61 4.76 4.52 4.59 4.67 4.47 4.53 4.44 4.31 4.35
13 7.71 62 4.88 4.63 4.70 4.78 4.57 4.63 4.53 4.39 4.43
14 7.26 63 5.01 4.74 4.82 4.89 4.67 4.74 4.62 4.48 4.52
15 6.87 64 5.15 4.86 4.94 5.01 4.78 4.85 4.72 4.57 4.62
16 6.53 65 5.30 4.98 5.08 5.14 4.89 4.97 4.83 4.67 4.72
17 6.23 66 5.46 5.12 5.22 5.27 5.02 5.09 4.94 4.78 4.82
18 5.96 67 5.63 5.27 5.37 5.41 5.14 5.22 5.05 4.89 4.94
19 5.73 68 5.81 5.42 5.54 5.55 5.28 5.36 5.17 5.00 5.05
20 5.51 69 6.00 5.59 5.71 5.70 5.42 5.51 5.30 5.13 5.18
70 6.21 5.78 5.90 5.86 5.58 5.66 5.43 5.26 5.31
71 6.43 5.97 6.11 6.02 5.74 5.82 5.58 5.39 5.45
72 6.66 6.19 6.33 6.18 5.90 5.99 5.72 5.54 5.59
73 6.91 6.42 6.56 6.35 6.08 6.16 5.88 5.70 5.75
74 7.18 6.67 6.82 6.53 6.26 6.34 6.05 5.86 5.92
75 7.46 6.94 7.09 6.70 6.45 6.53 6.22 6.04 6.09
76 7.77 7.23 7.39 6.88 6.65 6.72 6.40 6.22 6.27
77 8.10 7.55 7.71 7.07 6.85 6.91 6.60 6.42 6.47
78 8.45 7.89 8.05 7.25 7.05 7.11 6.80 6.63 6.68
79 8.83 8.26 8.43 7.43 7.26 7.31 7.01 6.85 6.90
80 9.23 8.66 8.83 7.61 7.46 7.51 7.24 7.08 7.13
81 9.66 9.10 9.27 7.79 7.66 7.70 7.47 7.33 7.37
82 10.13 9.57 9.74 7.97 7.86 7.89 7.72 7.59 7.63
83 10.62 10.09 10.24 8.13 8.05 8.07 7.98 7.86 7.90
84 11.15 10.64 10.79 8.29 8.23 8.25 8.26 8.15 8.18
85 11.72 11.24 11.38 8.44 8.40 8.41 8.55 8.45 8.48
86 12.32 11.89 12.02 8.59 8.56 8.56 8.85 8.77 8.80
87 12.97 12.59 12.70 8.72 8.70 8.71 9.17 9.11 9.12
88 13.65 13.33 13.42 8.84 8.83 8.83 9.50 9.45 9.47
89 14.38 14.11 14.19 8.95 8.95 8.95 9.85 9.82 9.83
90 15.16 14.94 15.00 9.06 9.05 9.05 10.22 10.19 10.20
91 15.97 15.80 15.85 9.15 9.15 9.15 10.61 10.59 10.59
92 16.84 16.70 16.74 9.23 9.23 9.23 11.01 11.00 11.00
93 17.75 17.63 17.67 9.31 9.31 9.31 11.45 11.42 11.43
94 18.72 18.60 18.64 9.37 9.37 9.37 11.92 11.88 11.89
95 19.77 19.62 19.66 9.43 9.43 9.43 12.42 12.36 12.38
-------------------------------------------------------------------------------------------------------------------------------
</TABLE>
Page 18
<PAGE>
<TABLE>
<CAPTION>
Option 5, Table V
-----------------
Monthly Installment For Joint and Full Survivor
-------------------------------------------------------------------------------------------------------------------------------
Age of Age of Female Annuitant*
------------------------------------------------------------------------------------------------------------
Male 15 Years 12 Years 9 Years 6 Years 3 Years Same As 3 Years
Less Than Less Than Less Than Less Than Less Than Male More Than
Annuitant* Male Male Male Male Male Male
-------------------------------------------------------------------------------------------------------------------------------
<S> <C> <C> <C> <C> <C> <C> <C>
50 $3.06 $3.12 $3.19 $3.25 $3.31 $3.38 $3.44
55 3.20 3.27 3.35 3.44 3.52 3.61 3.69
60 3.37 3.47 3.57 3.68 3.79 3.91 4.02
65 3.59 3.72 3.86 4.01 4.16 4.32 4.47
70 3.88 4.06 4.25 4.45 4.67 4.89 5.11
-------------------------------------------------------------------------------------------------------------------------------
Monthly Installment For Unisex Joint and Full Survivor
-------------------------------------------------------------------------------------------------------------------------------
Age of Age of Joint Annuitant*
------------------------------------------------------------------------------------------------------------
First 15 Years 12 Years 9 Years 6 Years 3 Years Same As 3 Years
Less Than Less Than Less Than Less Than Less Than First More Than
Annuitant* First First First First First First
-------------------------------------------------------------------------------------------------------------------------------
50 $3.07 $3.13 $3.19 $3.25 $3.31 $3.37 $3.43
55 3.20 3.28 3.36 3.44 3.52 3.60 3.67
60 3.38 3.48 3.58 3.68 3.79 3.89 4.00
65 3.61 3.73 3.87 4.01 4.16 4.30 4.44
70 3.90 4.07 4.26 4.46 4.66 4.86 5.05
-------------------------------------------------------------------------------------------------------------------------------
*Adjusted Age as defined in Section 10.A.
-------------------------------------------------------------------------------------------------------------------------------
</TABLE>
Dollar amounts of monthly, quarterly, semi-annual, and annual installments not
shown in the above tables will be calculated on the same basis as those shown
and may be obtained from the Company.
Page 19
<PAGE>
VARIABLE PAYMENT OPTIONS
BASED ON ASSUMED INVESTMENT RETURN
The amounts shown in these tables are the initial payment amounts based on a
5.0% Assumed Investment Return for each $1,000 of the proceeds.
<TABLE>
<CAPTION>
-------------------------------------------------------------------------------------------------------------------------------
Option 3-V, Table II Option 3-V, Table III
-------------------------------------------------------------------------------------------------------------------------------
Monthly Installment for Life Monthly Installment for Life
No Period Certain 10 Years Certain
-------------------------------------------------------------------------------------------------------------------------------
<S> <C> <C> <C> <C> <C> <C>
Age* Male Female Unisex Male Female Unisex
50 $5.07 $4.93 $4.98 $5.04 $4.92 $4.95
51 5.13 4.99 5.03 5.09 4.96 5.00
52 5.19 5.04 5.08 5.15 5.01 5.05
53 5.26 5.10 5.14 5.21 5.07 5.11
54 5.33 5.16 5.21 5.27 5.12 5.17
55 5.40 5.22 5.27 5.34 5.18 5.23
56 5.48 5.29 5.35 5.41 5.25 5.30
57 5.57 5.36 5.42 5.49 5.32 5.37
58 5.66 5.44 5.50 5.57 5.39 5.44
59 5.75 5.52 5.59 5.66 5.47 5.52
60 5.85 5.61 5.68 5.75 5.55 5.61
61 5.97 5.70 5.78 5.85 5.63 5.70
62 6.09 5.81 5.89 5.95 5.72 5.79
63 6.21 5.91 6.00 6.06 5.82 5.89
64 6.35 6.03 6.13 6.17 5.92 6.00
65 6.50 6.16 6.26 6.29 6.03 6.11
66 6.66 6.29 6.40 6.42 6.15 6.23
67 6.83 6.43 6.55 6.55 6.27 6.36
68 7.01 6.59 6.71 6.69 6.40 6.49
69 7.21 6.76 6.89 6.83 6.54 6.63
70 7.41 6.94 7.08 6.98 6.69 6.77
71 7.63 7.14 7.28 7.13 6.84 6.93
72 7.87 7.35 7.50 7.28 7.00 7.09
73 8.12 7.58 7.74 7.45 7.17 7.25
74 8.39 7.83 8.00 7.61 7.34 7.42
75 8.68 8.11 8.28 7.78 7.52 7.60
76 8.99 8.40 8.58 7.95 7.71 7.78
77 9.32 8.72 8.90 8.12 7.90 7.97
78 9.68 9.07 9.25 8.29 8.09 8.16
79 10.06 9.45 9.63 8.47 8.29 8.34
80 10.47 9.85 10.04 8.64 8.48 8.53
81 10.91 10.30 10.48 8.80 8.67 8.71
82 11.38 10.78 10.96 8.97 8.86 8.89
83 11.88 11.30 11.47 9.12 9.04 9.06
84 12.42 11.87 12.03 9.27 9.21 9.23
85 12.99 12.48 12.63 9.41 9.37 9.38
86 13.60 13.13 13.27 9.54 9.51 9.52
87 14.26 13.84 13.96 9.67 9.65 9.65
88 14.95 14.59 14.70 9.78 9.77 9.77
89 15.69 15.39 15.48 9.89 9.88 9.88
90 16.47 16.23 16.30 9.98 9.98 9.98
91 17.29 17.10 17.16 10.07 10.07 10.07
92 18.16 18.01 18.05 10.15 10.15 10.15
93 19.07 18.95 18.98 10.22 10.22 10.22
94 20.05 19.92 19.96 10.28 10.28 10.28
95 21.09 20.94 20.99 10.34 10.33 10.33
-------------------------------------------------------------------------------------------------------------------------------
</TABLE>
Page 20
<PAGE>
<TABLE>
<CAPTION>
Option 5V, Table V
------------------
Monthly Installment For Joint and Full Survivor
-------------------------------------------------------------------------------------------------------------------------------
Age of Age of Female Annuitant*
------------------------------------------------------------------------------------------------------------
Male 15 Years 12 Years 9 Years 6 Years 3 Years Same As 3 Years
Less Than Less Than Less Than Less Than Less Than Male More Than
Annuitant* Male Male Male Male Male Male
-------------------------------------------------------------------------------------------------------------------------------
<S> <C> <C> <C> <C> <C> <C> <C>
50 $4.37 $4.42 $4.46 $4.51 $4.56 $4.62 $4.67
55 4.48 4.54 4.60 4.67 4.74 4.81 4.88
60 4.62 4.70 4.79 4.88 4.98 5.08 5.18
65 4.81 4.92 5.04 5.17 5.31 5.46 5.61
70 5.07 5.23 5.40 5.59 5.79 6.00 6.22
-------------------------------------------------------------------------------------------------------------------------------
Monthly Installment For Unisex Joint and Full Survivor
-------------------------------------------------------------------------------------------------------------------------------
Age of Age of Joint Annuitant*
------------------------------------------------------------------------------------------------------------
First 15 Years 12 Years 9 Years 6 Years 3 Years Same As 3 Years
Less Than Less Than Less Than Less Than Less Than First More Than
Annuitant* Male Male Male Male Male First
-------------------------------------------------------------------------------------------------------------------------------
50 $4.38 $4.42 $4.47 $4.51 $4.56 $4.61 $4.66
55 4.48 4.54 4.60 4.67 4.73 4.80 4.87
60 4.63 4.70 4.79 4.88 4.97 5.07 5.16
65 4.82 4.93 5.05 5.17 5.30 5.44 5.57
70 5.09 5.24 5.41 5.59 5.78 5.97 6.16
-------------------------------------------------------------------------------------------------------------------------------
*Adjusted Age as defined in Section 10.A
-------------------------------------------------------------------------------------------------------------------------------
</TABLE>
Dollar amounts of monthly, quarterly, semi-annual, and annual installments not
shown in the above tables will be calculated on the same basis as those shown
and may be obtained from the Company.
Page 21
<PAGE>
SECTION 11 - GENERAL PROVISIONS
THE CONTRACT
The entire contract consists of this policy, including any riders or
endorsements.
MODIFICATION OF POLICY
No change in this policy is valid unless made in writing by us and approved by
one of our officers. No Registered Representative has authority to change or
waive any provision of Your policy.
TAX QUALIFICATION
This policy is intended to qualify as an annuity contract for federal income tax
purposes. The provisions of this policy are to be interpreted to maintain such
qualification, notwithstanding any other provisions to the contrary. To maintain
such tax qualification, we reserve the right to amend this policy to reflect any
clarifications that may be needed or are appropriate to maintain such tax
qualification or to conform this policy to any applicable changes in the tax
qualification requirements. We will send You a copy in the event of any such
amendment. If You refuse such an amendment it must be by giving us written
notice, and Your refusal may result in adverse tax consequences.
NON-PARTICIPATING
This policy will not share in our surplus earnings.
AGE OR SEX CORRECTIONS
If the age or sex of the Annuitant has been misstated, the benefits will be
those which the premiums paid would have purchased for the correct age and sex.
If required by law to ignore differences in the sex of the Annuitant, the
annuity payments will be determined using the unisex factors in Section 10.
Any underpayment made by us will be paid with the next payment. Any overpayment
made by us will be deducted from future payments. Any underpayment or
overpayment, will include interest at 5% per year, from the date of the wrong
payment to the date of the adjustment.
INCONTESTABILITY
This policy shall be incontestable from the Policy Date.
EVIDENCE OF SURVIVAL
We have the right to require satisfactory evidence that a person was alive if a
payment is based on that person being alive. No payment will be made until we
receive the evidence.
SETTLEMENT
Any payment by us under this policy is payable at our Home Office.
RIGHTS OF OWNER
The owner may, while the Annuitant is living:
1. Assign this policy.
2. Surrender the policy to us.
3. Amend or modify the policy with our consent.
4. Receive annuity payments or name a Payee to receive the payments,
5. Exercise, receive and enjoy every other right and benefit contained in
the policy.
The use of these rights may be subject to the consent of any assignee or
irrevocable beneficiary; and of the spouse in a community or marital property
state.
Unless we have been notified of a community or marital property interest in this
policy, we will rely on our good faith belief that no such interest exists and
will assume no responsibility for inquiry.
OWNER DESIGNATED BENEFICIARY
An owner designated beneficiary can be named in the application, or information
provided in lieu thereof, or in a notice You sign which gives us the facts that
we need. The owner designated beneficiary will become the new owner when You
die, if You die before the Annuitant. If no owner designated beneficiary
survives You and You die before the Annuitant, Your estate will become the new
owner.
CHANGE OF OWNERSHIP
In the case of a non-tax qualified annuity, You can change the owner of this
policy, from yourself to a new owner, in a notice You sign which gives us the
facts that we need. When this change takes effect, all rights of ownership in
this policy will pass to the new owner.
A change of owner or owner designated beneficiary will not be effective until it
is recorded in our records. After it has been so recorded, the change will take
effect as of the date You signed the notice. However, if the Annuitant dies
before the notice has been so recorded, it will not be effective as to those
proceeds we have paid before the change was recorded in our records.
We may require that the change be endorsed in the policy. Changing the owner or
naming a new owner designated beneficiary cancels any prior choice of owner
designated beneficiary, but does not change the beneficiary or the Annuitant.
A change of ownership may result in adverse tax consequences.
Page 22
<PAGE>
SECTION 11 - GENERAL PROVISIONS - CONT
ANNUITY COMMENCEMENT DATE
The Annuity Commencement Date is the date annuity payments begin. This date may
not be later than the last day of the policy month starting after the Annuitant
attains age 85, except as expressly allowed by us (within state restrictions),
but in no event later than the last day of the policy month following the month
in which the Annuitant attains age 98. You may change the Annuity Commencement
Date at any time before the Annuity Commencement Date by giving us 30 days'
written notice.
ASSIGNMENT
(a) In the case of a non tax-qualified annuity, this Policy may be assigned.
The assignment must be in writing and filed with us.
(b) We assume no responsibility for the validity of any assignment. Any claim
made under an assignment shall be subject to proof of interest and the
extent of the assignment.
(c) This policy may be applied for and issued to qualify as a tax-qualified
annuity under certain sections of the Internal Revenue Code. Ownership of
this policy is then restricted so that it will comply with provisions of
the Internal Revenue Code.
Assignment of this policy may result in adverse tax consequences.
BENEFICIARY
Death proceeds, when payable in accordance with Section 9, are payable to the
designated beneficiary or beneficiaries. Such beneficiary(ies) must be named in
the application, or information provided in lieu thereof, and may be changed
without consent (unless irrevocably designated or required by law) by notifying
us in writing on a form acceptable to us. The change will take effect upon the
date You sign it, whether or not You are living when we receive it. The notice
must have been postmarked (or show other evidence of delivery that is acceptable
to us) on or before the date of death. Your most recent change of beneficiary
notice will replace any prior beneficiary designations. No change will apply to
any payment we made before the written notice was received. If an irrevocable
beneficiary dies, You may designate a new beneficiary.
You may direct that the beneficiary shall not have the right to withdraw, assign
or commute any sum payable under an option. In the absence of such election or
direction, the beneficiary may change the manner of payment or make an election
of any option.
If any primary or contingent beneficiary dies before the Annuitant, that
beneficiary's interest in this policy ends with that beneficiary's death. Only
those beneficiaries living at the time of the Annuitant's death will be eligible
to receive their share of the Death Proceeds. In the event no contingent
beneficiaries have been named and all primary beneficiaries have died before the
death proceeds become payable, the owner(s) will become the beneficiary(ies)
unless elected otherwise in accordance with Section 9. If both primary and
contingent beneficiaries have been named, payment will be made to the named
primary beneficiaries living at the time the death proceeds become payable. If
there is more than one beneficiary and You failed to specify their interest,
they will share equally. Payment will be made to the named contingent
beneficiary(ies) only, if all primary beneficiaries have died before the death
proceeds become payable. If any primary beneficiary is alive at the time the
death proceeds become payable, but dies before receiving their payment, their
share will be paid to their estate.
In cases where the Annuitant dies and the owner (who is not the Annuitant)
elected to receive the death benefit in accordance with Section 9, if the
Annuitant's estate has been named as beneficiary, then payment will be made to
the owner.
PROTECTION OF PROCEEDS
Unless You so direct by filing written notice with us, no beneficiary may assign
any payments under this policy before the same are due. To the extent permitted
by law, no payments under this policy will be subject to the claims of creditors
of any beneficiary.
DEFERMENT
We will pay any Partial Withdrawals or Surrender proceeds from the Separate
Account within 7 days after we receive all requirements that we need. However,
it may happen that the New York Stock Exchange is closed for trading (other than
the usual weekend or holiday closings), or the Securities and Exchange
Commission restricts trading or determines that an emergency exists. If so, it
may not be practical for us to determine the investment experience of the
Separate Account. In that case, we may defer transfers among the Subaccounts and
to the Fixed Account, and determination or payment of Partial Withdrawals or
Surrender proceeds.
Page 23
<PAGE>
SECTION 11 - GENERAL PROVISIONS - CONT
When permitted by law, we may defer paying any Partial Withdrawals or Surrender
proceeds from the Fixed Account for up to 6 months from the date we receive Your
request. If the owner dies after the request is received, but before the request
is processed, the request will be processed before the death proceeds are
determined. Interest will be paid on any amount deferred for 30 days or more.
This rate will be 3% per year unless otherwise required by law.
REPORTS TO OWNER
We will give You an annual report at least once each Policy Year. This report
will show the number and value of the accumulation units held in each of the
Subaccounts as well as the value of the Fixed Account. It will also give You the
Death Benefit, Cash Value, and any other facts required by law or regulation.
Page 24
<PAGE>
Peoples Benefit Life Insurance Company
Home Office located at 4333 Edgewood Road N.E., Cedar Rapids, Iowa 52499
Flexible Premium Variable Annuity
Income Payable At Annuity Commencement Date
Benefits Based On The Performance Of The
Separate Account Are Variable And Are Not Guaranteed As To Dollar Amount
(See Sections 6 and 10C.)
Non-Participating
