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SPECIFICATIONS (SUPPLEMENT)
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Certificate Type: Non-qualified Certificate Number: zz00000000
Owner: John Doe Owner Date of Birth: 01/01/1960
Joint Owner: Jack Doe Joint Owner Date of Birth: 01/01/1960
Annuitant: Mary Doe Annuitant Date of Birth: 01/01/1950
Joint Annuitant: Michael Doe Joint Annuitant Date of Birth: 01/01/1950
Beneficiary(ies):
Primary: Surviving Joint Owner, if any
1st Contingent: Michael Doe
2nd Contingent: Mary Doe
Payee: John Doe and Jack Doe
Payee Address: 1 Main Street, Anywhere, USA 00000
Annuity Date: 01/01/2025
Expiration of 90-Day Period: 04/01/2025
Annuity Benefit Payment Option: Joint with 2/3 Survivor Option
Survivor Annuity Benefit Percentage: 66 2/3%
Percentage under a Fixed Annuity Option: 30%
Percentage under a Variable Annuity Option: 70%
Assumed Investment Return: [3%, 5%]
Annuity Benefit Payment Change Frequency: Annual
Annuity Benefit Payment Frequency: Monthly
Variable Allocation on Annuity Date:
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Sub-Accounts:
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[AIT Equity Index Fidelity VIP Eq. Inc
AIT Money Market Fidelity VIP Growth
AIT Select Aggr. Growth Fidelity VIP High Inc.
AIT Select Capital Appr. Fidelity VIP II Contrafund
AIT Select Emerging Markets Fidelity VIP III Growth[nb]& Income
AIT Select Growth and Income Fidelity VIP III Mid Cap
AIT Select International Equity
AIT Select Investment Grade Income Franklin Small Cap
AIT Select Strategic Growth Mutual Shares Securities
AIT Select Strategic Income Templeton Pacific Growth Securities
AIT Select Value Opportunity
Invesco VIF Dynamics
AIM VI Aggressive Growth Invesco VIF Health Sciences
AIM VI Blue Chip Fund
AIM VI Value Fund Janus Aspen Aggressive Growth
Janus Aspen Growth
Alliance Premier Growth Janus Aspen Growth and Income
Alliance Growth and Income Janus Aspen International Growth
Deutsche VIT EAFE Equity Index KSV Dreman Financial Services Portfolio
Deutsche VIT Small Cap Index Kemper Technology Growth
T. Rowe Price Int'l]
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SPECIFICATIONS (supplement)
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Present Value Withdrawal Amount: 100% of Present Value of remaining guaranteed annuity benefit payments if the Payments
Guaranteed for a Specified Number of Years annuity option is selected.
Mortality and Expense Risk Charge: 1.25% on an annual basis of the daily value of the Sub-Account assets.
Administrative Charge: .15% on an annual basis of the daily value of the Sub-Account assets.
Principal Office: 440 Lincoln Street, Worcester, Massachusetts 01653 (1-800-782-8380)
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