<PAGE>
FIRST ALLMERICA FINANCIAL LIFE INSURANCE COMPANY
440 LINCOLN STREET
WORCESTER, MA 01653
[1-800-533-7881]
Group Policy No. [9999999]
Policyholder: [The ABC Employment Company]
Policy Delivered in and Governed by the Laws of New York
Date of Issue: [October 1, 2000]
[THE CERTIFICATE VALUE, WHEN BASED ON THE INVESTMENT PERFORMANCE OF THE VARIABLE
ACCOUNT, MAY INCREASE OR DECREASE AND IS NOT GUARANTEED AS TO A FIXED DOLLAR
AMOUNT. PLEASE REFER TO THE VARIABLE ACCOUNT SECTION FOR ADDITIONAL INFORMATION.
WE AGREE TO PAY THE BENEFITS OF THE CERTIFICATE IN ACCORDANCE WITH ITS TERMS.]
[The value in the Fixed Account will accumulate at a rate which will not be less
than 4% a year; [__%] on Certificate Value subject to a Preferred Loan.
Additional interest in excess of the guaranteed rate may be credited at our
discretion.]
THE AMOUNT OF THE DEATH BENEFIT AND THE LENGTH OF TIME A CERTIFICATE WILL REMAIN
IN FORCE MAY BE VARIABLE OR FIXED AS DESCRIBED IN THE BENEFIT PROVISION OF THE
CERTIFICATE. THE METHOD FOR DETERMINING THE AMOUNT OF THE DEATH BENEFIT IS FOUND
IN THE DEATH BENEFIT PROVISION.
RIGHT TO EXAMINE: You may return this Policy by mailing or delivering it to our
Principal Office or to our agent within ten days after receiving it. If
returned, the insurance shown in Certificate will be considered void from the
beginning, and you will receive a refund equal to the premiums paid.
This is a legal contract between the Policyholder and First Allmerica Financial
Life Insurance Company (the Company). The Company agrees, in accordance with the
provisions of this Policy, to pay benefits to the extent required by this
Policy, to those persons entitled to such benefits.
Executed at Worcester, Massachusetts
/s/ Charles F. Cronin /s/ Richard M. Reilly
------------------ ----------------------
Secretary President
GROUP FLEXIBLE PREMIUM VARIABLE LIFE INSURANCE POLICY
Death benefits payable in the event of an Insured's death prior to Final Payment
Date. Adjustable death benefits may be increased or decreased. Coverage may
expire prior to the Final Premium Payment Date if premiums paid or the earnings
credited are insufficient to continue coverage to such date. Coverage to the
Final Payment Date and Amount of Certificate Value Not Guaranteed. Some benefits
reflect investment results. Flexible premiums payable to Final Premium Payment
Date. Nonparticipating.
Form 1040P-00NY 1 Case ID [WG01]
<PAGE>
TABLE OF CONTENTS
Cover 1
Specifications Page 3
Riders/Endorsements
Charges 3B
Definitions 4
Eligibility 6
General Terms 6
Certificate Owner and the Beneficiary 8
Termination of Policy 9
Termination of Insurance Certificate 9
Premiums 10
Grace Period 11
Certificate Value 12
Variable Account 14
Fixed Account 17
Transfers of Value 18
Dollar Cost Averaging Option 19
Automatic Rebalancing Option 19
Certificate Loans 20
Surrender and Partial Withdrawals 20
Payments & Deferrals 21
Death Benefit 22
[Refund of Sales Load] 25
Payment of Benefits 25
Form 1040P-00NY 2 Case ID [WG01]
<PAGE>
SPECIFICATIONS PAGE
[EMPLOYER: The ABC Employment Company]
ELIGIBLE CLASSES OF [[EMPLOYEE]S]: [All full-time [Employee]s]
MINIMUM FACE AMOUNT: [$50,000]
MINIMUM INCREASE AMOUNT: [$1,000 - $10,000]
MINIMUM DECREASE AMOUNT: [$1,000 - $10,000]
MINIMUM PARTIAL WITHDRAWAL AMOUNT: [$500]
MORTALITY TABLE: 1980 CSO Mortality Table Age Last Birthday, [Smoker, Non-Smoker
or Unismoker, Male, Female or Unisex (Table B)] (or appropriate increases in
such tables for non-standard risks). For Insureds under age 18, [the mortality
table used is the 1980 CSO Mortality Table Age Last Birthday [Male, Female or
Unisex (Table B)] (or appropriate increases in such table for non-standard
risks).]
MINIMUM GUARANTEED INTEREST RATE: [4%] a year
MAXIMUM CERTIFICATE LOAN INTEREST RATE: [5.5%] a year in arrears
Form 1040P-00NY 3 Case ID [WG01]
<PAGE>
Variable ACCOUNT INVESTMENT PROVISION
Separate Accounts (s) _____
Sub-Accounts [1-5]:
Number of Notification Days: [15]
Investment Date: [any business day]
Liquidity Date(s): [last business day of each calendar quarter]
Availability of Funds: [15 business days after the Liquidity Date(s)]
Sub-Accounts [6-10]:
Number of Notification Days: [0]
Investment Date: [daily]
Liquidity Dates(s): [daily]
Availability of Funds: [1 business day after the Liquidity Date(s)]
Separate Accounts(s) ____
Sub-Accounts [11-15]:
Number of Notification Days: [0]
Investment Date: [daily]
Liquidity Date(s): [daily]
Availability of Funds: [2 business days after the Liquidity Date(s)]
Sub-Accounts [16-20]:
Number of Notification Days: [20]
Investment Date: [Monday of each week]
Liquidity Date(s): [last business day of each month]
Availability of Funds: [10 business days after the Liquidity Date(s)]
Form 1040P-00NY 3A Case ID [WG01]
<PAGE>
CHARGES
PREMIUM EXPENSE CHARGE: [13%]
[Includes the following:
[PREMIUM TAX CHARGE: [A charge calculated to approximate the
aggregate taxes imposed on the Company by the state in which the
[Policyholder's Home Office is located] [Certificate Owner
resides] [Insured resides] based on Certificate premium received
by the Company.]]
[FEDERAL TAX CHARGE: [1%]
DAC Tax Load: 3% of each Certificate premium payment received by
the Company to cover the cost of deferred acquisition cost tax
(DAC Tax) under Section 848 of the Internal Revenue Code of 1986,
as amended.
DAC Recapture:
Each Certificate premium payment will have a DAC recapture period
of 11 years. The first DAC recapture period for each Certificate
will begin on the later of the Certificate effective date or the
date of receipt of the first Certificate premium payment by the
Company.
a) For year 1 of the first DAC recapture period, on the first
Certificate anniversary, 5% of the DAC Tax Load will be
credited and allocated to the Variable Account or Fixed
Account as directed by the Certificate Owner according to
the most recent allocation. For year 1 of the subsequent DAC
recapture periods, on the Certificate anniversary which
occurs in such year of the DAC recapture period, 5% of the
DAC Tax Load will be credited and allocated to the Variable
Account or Fixed Account as directed by the Certificate
Owner according to the most recent allocation.
b) In year 2 through 10 of each DAC recapture period, on the
Certificate anniversary which occurs in each year of the DAC
recapture period, 10% of the DAC Tax Load will be credited
and allocated to the Variable Account or Fixed Account as
directed by the Certificate Owner according to the most
recent allocation.
c) In year 11 of each DAC recapture period, on the Certificate
anniversary which occurs in each such year of the DAC
recapture period, 5% of the DAC Tax Load will be credited
and allocated to the Variable Account or Fixed Account as
directed by the Certificate Owner according to the most
recent allocation.]
Form 1040P-00NY 3B Case ID [WG01]
<PAGE>
[DISTRIBUTION CHARGE: [10%]]]
[Year 1 through 5 - X%
Years 6 through 10 -Y%
Years 11 through 15 - Z%
Years 16 through 20 - A%
Years 21 and after - B%]]
MONTHLY COST OF INSURANCE CHARGES: [See Guaranteed Maximum Cost of Insurance
Charges Table]
ADMINISTRATIVE CHARGE: [$5] per month for each Certificate.
MONTHLY EXPENSE CHARGE: [varies by Certificate]
VARIABLE ACCOUNT MORTALITY AND EXPENSE RISK CHARGE: [The Owner will be assessed
a charge each month [based on the prior month's Variable Account Certificate
Value] not to exceed: (1) 1/12 of [0.75%] of the Variable Account Certificate
Value for the mortality and expense risks assumed by us during the first 120
months the Certificate is in force; (2) 1/12 of 0.50% of the Variable Account
Certificate Value for the mortality and expense risks assumed by us during the
next 120 months the Certificate is in force; and (3) 1/12 of 0.30% on an annual
basis thereafter.] [One-twelfth of the charge, currently [.90%] on an annual
basis, applied each month to the prior month's Sub-Account value. This charge
may not exceed [.90%] on an annual basis.]
[One-twelfth of the annual charge shall be deducted on the monthly processing
date of each Certificate from the Certificate values in the Variable Account(s).
The charge is determined based on the assets in the Variable Account(s) as of
the prior month's Variable Account Certificate Value. The Mortality and Expense
Risk Charges are shown in the Table below. This charge may not exceed [.53%] on
an annual basis.]
[CERTIFICATE YEARS ANNUALIZED MORTALITY &
EXPENSE RISK CHARGE
1 - 5 .53%
6-10 .48%
11-15 .43%
16-20 .38%
21 and after .33%]
ASSETS IN VARIABLE ACCOUNTS ANNUALIZED MORTALITY & EXPENSE RISK
CHARGE
$0 - $4,999,999 .53%
$5,000,000 - 14,999,999 .48%
$15,000,000 - 29,999,999 .43%
$30,000,000 - 49,999,999 .38%
$50,000,000+ .33%
Form 1040P-00NY 3C Case ID [WG01]
<PAGE>
PARTIAL WITHDRAWAL TRANSACTION CHARGES: We will deduct a 2% withdrawal
transaction charge (maximum $25) from the Certificate Value each time a partial
withdrawal is made.
TRANSFER CHARGE: Will not exceed $25[; no charge for the first twelve transfers
in any Certificate Year].
VARIABLE ACCOUNT ADMINISTRATIVE CHARGE: [One-twelfth of the charge currently
[.0%] on an annual basis applied each month to the prior month's Sub-Account
value. This charge may not exceed [.25%] on an annual basis, for up to [10]
Certificate Years.]
[ADDITIONAL BENEFITS PROVIDED BY RIDER
FORM NO. RIDER COST OF PAYABLE
INSURANCE TO
END 249P-94 OPTION TO ACCELERATE
DEATH BENEFITS
ENDORSEMENT
INSURED TERM RIDER]
Form 1040P-00NY 3D Case ID [WG01]
<PAGE>
GUARANTEED MAXIMUM COST OF INSURANCE CHARGES
PER $1,000 OF AMOUNT AT RISK
MONTHLY RATE MONTHLY RATE
AGE PER $1000 AGE PER $1000
[35 0.176 70 3.354
36 0.187 71 3.682
37 0.200 72 4.060
38 0.215 73 4.496
39 0.233 74 4.984
40 0.252 75 5.513
41 0.275 76 6.077
42 0.297 77 6.666
43 0.323 78 7.276
44 0.350 79 7.924
45 0.380 80 8.635
46 0.411 81 9.431
47 0.444 82 10.339
48 0.480 83 11.373
49 0.519 84 12.514
50 0.561 85 13.738
51 0.610 86 15.022
52 0.666 87 16.357
53 0.729 88 17.738
54 0.800 89 19.172
55 0.877 90 20.678
56 1.960 91 22.287
57 1.047 92 24.063
58 1.140 93 26.120
59 1.239 94 28.813
60 1.350 95 32.818
61 1.474 96 39.643
62 1.613 97 53.066
63 1.772 98 83.333
64 1.949 99 83.333]
65 2.143
66 2.351
67 2.573
68 2.809
69 3.065
[Male, Age 35, Preferred Non-Smoker Based on 1980 CSO Mortality Table Age Last
Birthday]
Form 1040P-00NY 3E Case ID [WG01]
<PAGE>
MINIMUM DEATH BENEFIT - OPTIONS 1 AND 2
GUIDELINE MINIMUM DEATH BENEFIT TABLE
AGE PERCENTAGE AGE PERCENTAGE
[Thru 40 250% 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 thru 90 105%
56 146% 91 104%
57 142% 92 103%
58 138% 93 102%
59 134% 94 101%
95-100 100%]
Form 1040P-00NY 3F Case ID [WG01]
<PAGE>
MINIMUM DEATH BENEFIT - OPTION 3
CASH VALUE ACCUMULATION TEST TABLE
PERCENTAGE VARIES BY CERTIFICATE
Form 1040P-00NY 3G Case ID [WG01]
<PAGE>
DEFINITIONS
[ACTIVELY AT WORK ON A FULL-TIME BASIS means the [Employee] is performing all
of the regular duties of the [Employee]'s occupation at the [Employee]'s
usual place of employment on a full-time work schedule which is in no way
curtailed or altered because of the [Employee]'s health.]
AGE means how old the Insured is on the last birthday prior to the
Certificate anniversary.
[AMOUNT AT RISK for each Certificate, means the total death benefit, including
the Insured Term Rider, if any, provided by the Certificate less its Certificate
Value.]
ASSIGNEE means the person to whom the Owner transfers ownership of the
Certificate.
BASE AMOUNT means the amount of insurance coverage the Owner elects to buy in
the application, not including the Insured Term Rider. The Base Amount is shown
in the Certificate Specifications Page.
CERTIFICATE means the individual Certificate issued for each Insured describing
the benefits to which the Owner is entitled under this Policy. In the event of
any change in the Policy affecting the benefits under a Certificate, a new
Certificate or Certificate rider will be issued to the Certificate Owner.
CERTIFICATE CHANGE means any change in the Face Amount, the underwriting class,
the addition or deletion of a rider, or a change in the Death Benefit Option.
CERTIFICATE DATE OR DATE OF ISSUE means, with respect to any Insured, the
effective date of that person's coverage. The Certificate Date is stated in the
Certificate Specifications Page for each Insured. Certificate months, years and
anniversaries are measured from this date.
CERTIFICATE OWNER OR OWNER means [the Policyholder.] [The person or entity named
in the Application Form.][Certificate Specifications Page.], or Your assignee.
CERTIFICATE VALUE means the sum of the values in the Variable Account and the
Fixed Account.
CERTIFICATE YEAR means a period of 12 months commencing on the same day of the
year as the Certificate Date.
COMPANY means First Allmerica Financial Life Insurance Company, also referred to
as we, our and us. Our telephone number is [1-800- ].
ELIGIBLE EMPLOYEE means an Employee who is in an eligible class as shown in the
Specification Pages.
EMPLOYEE means a person who is actively at work on a full-time basis for an
employer.
ENROLLMENT FORM OR APPLICATION means the form which is completed and signed by
the Owner and the Employee, if applicable, when applying for coverage under this
Policy.
EVIDENCE OF INSURABILITY means the information, including medical information,
satisfactory to us, that we use to decide the underwriting class for the person
Insured.
FACE AMOUNT means the sum of the Base Amount, plus the amount(s) under the
Insured Term Rider, if applicable. The Face Amount is shown on the Certificate
Specifications Page.
Form 1040P-00NY 4 Case ID [WG01]
<PAGE>
FINAL PAYMENT DATE OR FINAL PREMIUM PAYMENT DATE means the Certificate
anniversary nearest the Insured's [100th] birthday. No payments may be made
after this date.
[FULL-TIME WORK SCHEDULE means a normal week of at least [32] hours. If an
[Employee] is on approved leave (and not disabled) or on vacation, the
[Employee] is considered to be Actively at work.]
INSURED means the person on whose life a Certificate has been issued.
MONTHLY INSURANCE CHARGE means the amount of money we deduct from the
Certificate Value each month to pay for the insurance.
MONTHLY PROCESSING DATE means the date on which the monthly deduction is made
from the Certificate Value. This date is shown on the Specifications Page of the
Certificate.
OUTSTANDING LOAN means all unpaid Certificate loans plus interest due or accrued
on such loans.
POLICY YEAR means a period of 12 months commencing on the same day of the year
as the Policy date of issue.
PREMIUM means a payment which must be made to keep a Certificate in force.
PRINCIPAL OFFICE means our office located at 440 Lincoln Street, Worcester,
Massachusetts 01653.
PRO RATA refers to an allocation among the Sub-Accounts of the Variable Account
and the Fixed Account. A Pro-rata allocation will be in the same proportion that
the Certificate Value in each Sub-Account of the Variable Account and the
Certificate Value in the Fixed Account (other than value that is subject to
Outstanding Loan) have to the total unloaned Certificate Value.
RIDER means an optional benefit, which may be added to a Certificate [for an
additional charge.]
SPECIFICATIONS PAGE(S) means pages that contain information specific to the
Policy or the Certificate, as applicable, and are located after the Table of
Contents.
SUB-ACCOUNTS means subdivisions of the Variable Account investing exclusively in
the shares of one or more Funds, which the Certificate Owner chooses for their
investment allocations.
UNDERWRITING CLASS means the insurance risk classification that we assign to the
Insured based on the information in the application or Enrollment Form, if any,
and any other Evidence of Insurability we obtain. The Insured's underwriting
class affects the Monthly Insurance Charge, the Monthly Expense Charge and the
amount of the payments required to keep the Certificate in force.
WRITTEN NOTICE OF CLAIM means written notification of the death of the Insured
received in the Principal Office of the Company.
WRITTEN REQUEST means a request made by an Owner in writing in a form which is
satisfactory to us and which is filed at our Principal Office.
Form 1040P-00NY 5 Case ID [WG01]
<PAGE>
ELIGIBILITY
ELIGIBILITY - An Employee is eligible to elect insurance if the Employee is in
an eligible class.
ELECTION OF INSURANCE - To elect insurance, an eligible Employee must complete
the necessary Enrollment Form furnished by us and provide us with Evidence of
Insurability.
Insurance will become effective on the first monthly processing date following
the date the proposed Insured is accepted for insurance by us.
If there has been a material change in the proposed Insured's health between the
time of completion of the Enrollment Form for this coverage and the effective
date of coverage, new Evidence of Insurability will be required before such
proposed Insured's coverage will become effective.
Notwithstanding the above, in no event will new insurance become effective if
the Policy has been discontinued.
GENERAL TERMS
OUR RIGHT TO CONTEST THE POLICY IS LIMITED: The validity of this Policy shall
not be contested, except for non-payment of premiums, after it has been in force
for two years from the date of issue. Except for failure to pay premiums, each
Certificate issued under this Policy cannot be contested after the Certificate
for that Insured has been in force during the Insured's lifetime for two years
from the date of issue of the Certificate.
Except for failure to pay premiums, a requested increase in the Base Amount, a
change from Death Benefit Option 1 or 2 or an increase in the Amount at Risk as
a result of an additional Certificate premium payment which includes Evidence of
Insurability cannot be contested after the increased amount or change in Death
Benefit Option has been in force during the Insured's lifetime for two years
from its effective date.
ENTIRE CONTRACT: The entire contract consists of :
- this Policy, including any riders and endorsements attached
to this Policy, and
- a copy of the Policy application which is attached to this
Policy.
All statements by the Policyholder, Certificate Owner and any Insured person in
the application or Enrollment Form, if any, including any subsequent
applications, are considered representations and not warranties. The Company
will not use any statement to contest this Policy or any Certificate issued
under it or defend a claim unless the statement is in the application or
Enrollment Form, if any, and a copy of the instrument containing the statement
is or has been furnished to the Policyholder, Certificate Owner or beneficiary.
NONPARTICIPATING: No insurance dividends will be paid on this Policy.
ADJUSTMENT OF COST FACTORS: We determine the Monthly Insurance Charge and Fixed
Account interest rates which are used to calculate the Certificate Value,
subject to the guarantees noted in this Policy. Any changes in these charges and
rates will be made by underwriting class only, and will be based on changes in
our future expectations for such things as: our investment earnings, our
expenses, life expectancy rates, and how many [Certificate Owners] [Insureds
remain covered under] [continue] the Certificates.
Form 1060P-00NY 6 Case ID [WG01]
<PAGE>
SUICIDE EXCLUSION: If an Insured commits suicide, within two years of the
date the Certificate is issued, we will not pay a death benefit. The
beneficiary will receive only the total amount of payments made to us for the
insurance less any outstanding loan and loan interest due and amounts
withdrawn. If the face amount is increased at the Owner's request, and then
the Insured commits suicide, within two years, we will not pay the increased
amount. Instead the beneficiary will receive the Monthly Insurance Charges
paid for this increase, plus any net death benefit otherwise payable.
MISSTATEMENT OF AGE [OR SEX]: If an Insured's age [or sex, if applicable,] is
not correctly stated, we will adjust the net death benefit we will pay. The
amount will be:
- the Certificate Value, plus
- the Amount at Risk that would have been purchased by the
last Monthly Insurance Charge using the correct age [and
sex].
No adjustment will be made if:
- the Insured dies after the Final Payment Date.
PROTECTION OF BENEFITS: To the extent allowed by law, the benefits provided
by a Certificate cannot be reached by the beneficiary's creditors. No
beneficiary may assign, transfer, anticipate or encumber the Certificate
Value or benefit unless the Owner gives them this right.
[EXPERIENCE CREDITS: [Each year during which this Group Policy remains in force,
the Policyholder may be entitled to an experience rating refund in an amount
determined by Us, based on the experience under this Policy, including all the
Certificates issued thereunder. Each such refund will be paid in cash, or if the
Policyholder elects, left on deposit with the Company, and credited interest at
a rate of not less than 4%.]
[Claim Fluctuation Reserve: Part of the experience rating refund, if any,
allocated to this Policy will be set aside in a claims fluctuation reserve. This
is a Special Contingency Reserve whose purpose is to stabilize premiums. This
reserve will earn interest at a rate specified in our retrospective refund
formula. Upon termination of this Policy and all the Certificates thereunder,
any amount of this reserve not needed to provide for death benefits will be paid
as a refund as defined by the retrospective experience rating refund formula.]
PERIODIC REPORT: We will mail a report to each Owner at his or her last known
address at least once a year. This report will provide the following information
for each Certificate:
- death benefit;
- Certificate Values in each Sub-Account and in the Fixed Account;
- the value of the Certificate if it is surrendered;
- [changes in the Maximum Single Premium and the Maximum Level Premium;]
- [increases and decreases in the Face Amount;]
- Certificate payments made and monthly deductions by us since the last
report; and
- outstanding Certificate loans and any other information required by law.
Form 1040P-00NY 7 Case ID [WG01]
<PAGE>
CERTIFICATES: The Company will issue [a Certificate and Specifications Page(s)]
to each Certificate Owner setting forth the Insured's name and a description of
the benefits provided by the Policy.
OWNERSHIP OF ASSETS: The Company shall have exclusive and absolute ownership and
control of its assets, including the assets of the Variable Account(s).
MONEY PAYABLE: All money payable by or to the Company is to be paid in the
lawful currency of the United States of America.
ASSIGNMENT: The Policyholder may not assign this Policy.
PROJECTIONS: The Certificate Owner may request an illustration of future
benefits based on both the guaranteed and then future assumptions. [The Company
reserves the right to charge a fee for each projection requested; however, the
fee will not exceed $25.]
AUTHORITY: No change in the Policy or a Certificate will be valid until it is
approved by the President, a Vice President or Secretary of the Company. This
approval must be endorsed on or attached to the Policy or Certificate. Neither
an agent or other person has authority to accept representations or information
not in a written Enrollment Form, if any, or application, nor may that person
change this Policy or a Certificate or waive any of its provisions.
CHANGE IN POLICY: Subject to Policy guarantees, the Company has the right, at
any time and from time to time, to change the cost of insurance rates, interest
rates and any expenses shown in the Specifications Page(s).
The Policyholder may change the provisions of this Policy on any premium due
date if the change is approved by the Company. Written consent must be given for
any such change. The Company may change the provisions of this Policy on any
premium due date if the Policyholder agrees. The consent of [a Certificate
Owner,] is required to end, amend, modify or change this Policy. All changes to
this Policy will apply on the effective date of the change, and will not be
applied retroactively.
FACTS RELATING TO COVERAGE: At any reasonable time, the Company will have the
right to inspect any records of the Policyholder which relate to this Policy.
CONFORMITY WITH STATE STATUTES: If any provision of this Policy is in conflict
with any applicable statute, it is hereby amended to comply with the minimum
requirements of such statute.
CERTIFICATE OWNER AND THE BENEFICIARY
CERTIFICATE OWNER: The Policyholder is the Owner of the Certificate unless
another person is named as Owner in the application. The Owner may change the
ownership of the Certificate without the consent of any revocable beneficiary.
The Certificate Owner may exercise all other rights and options granted by this
Policy, subject to the consent of any irrevocable beneficiary.
ASSIGNMENT: The ownership of a Certificate may be changed by the Owner sending
us a written request. The written request must be received at our Principal
Office. An absolute assignment will transfer ownership of a Certificate to
another person called the assignee.
An Owner may also assign the Certificate as collateral to a collateral assignee.
The limitations on Ownership rights while a collateral assignment is in effect
are specified in the assignment.
Form 1040P-00NY 8 Case ID [WG01]
<PAGE>
An approved written assignment will take effect as of the date it is signed. Any
rights created by the assignment will be subject to any payments made or actions
taken by us before the change is received. We are not responsible for assuring
that any assignment or any assignee's interest is valid.
BENEFICIARY: The Owner names the beneficiary to receive the net death benefit.
The beneficiary's interest will be affected by any assignment. If a Certificate
is assigned as collateral, all or a portion of the net death benefit will first
be paid to the collateral assignee; any money left over from the amount due the
assignee will go to those otherwise entitled to it.
A beneficiary may be revocable or irrevocable. A revocable beneficiary may be
changed at any time by written request; but an irrevocable beneficiary must
agree to any change in writing. An irrevocable beneficiary's permission is also
needed to exercise other rights and options granted by the Certificate. Unless
otherwise indicated, the beneficiary will be revocable.
Any change of the beneficiary must be made while the Insured is living. This
change will take place on the date the request is signed, even if the Insured is
not living on the day we receive it. Any rights created by the change will be
subject to any payments made, or actions taken, before we receive the written
request.
[If a beneficiary dies before the Insured, his or her interest in the proceeds
will pass to any surviving beneficiaries in proportion to their share in the net
death benefit, unless requested otherwise. If all beneficiaries die before the
Insured, the net death benefit will pass to the Owner or the Owner's estate.]
TERMINATION OF POLICY
TERMINATION OF POLICY: This Policy may be terminated by the Company or the
Policyholder.
[The party who initiates the termination will send a notice to the Certificate
Owner of record, if other than the Policyholder, at the last known address for
the Owner, at least 15 days prior to the date of termination.]
No Enrollment Forms, if applicable, for new Insureds will be accepted on or
after the date notice of termination is received or sent by the Company,
whichever is applicable.
CONTINUATION OF INSURED'S COVERAGE AFTER TERMINATION OF THE POLICY: If this
Policy is terminated, any Certificate then in effect will remain in force under
the terminated Policy, provided it is not cancelled or surrendered by the
Certificate Owner.
TERMINATION OF INSURANCE CERTIFICATE
TERMINATION OF INSURANCE: Prior to an Insured's death, the Insured's Certificate
will terminate on the first to occur of the following:
- the Certificate lapses,
- the foreclosure date, or
- the surrender of the Certificate is requested.
[If the Insured ceases to be in an eligible class, the Certificate Owner may
continue the Certificate, but all future premiums must be allocated to the Fixed
Account.]
Form 1040P-00NY 9 Case ID [WG01]
<PAGE>
CONTINUATION OF INSURED'S COVERAGE AFTER TERMINATION OF THE POLICY: If this
Policy is terminated, Certificates, then in effect, may remain in force under
this terminated Policy, provided they are not cancelled or surrendered by the
Certificate Owner.
PREMIUMS
PREMIUMS: The Certificate premium is the premium paid by the Certificate Owner
for insurance coverage under this Policy. [The Policy and Certificates will not
be in force until the first premium is paid to us.] [Additional Certificate
premium payments may be made to us at any time before the Final Payment Date,
subject to the condition that Evidence of Insurability of the Insured is
provided which is satisfactory to us if the payment would increase the Amount at
Risk by more than the amount of the payment. Payments must be sent either to our
Principal Office or to our authorized representative.]
If requested in writing, we will send a signed receipt after payment. The
payment amount, which must be paid to keep the Certificate in force, is
described in the Certificate Grace Period and Certificate Lapse provision.
PREMIUM PAYMENT LIMITATIONS: [We may limit the amount of Certificate premium
payment received in any Certificate Year if the Death Benefit Option is either 1
or 2. [This limit will not be less than the guideline level premium; however,]
the sum of all payments made on each Certificate from the issue date, minus any
partial withdrawals, may not be more than the greater of:
- the guideline single premium, or
- the sum of the guideline level premiums to the date of payment.
The guideline premium amounts are shown on the Specifications Page of the
Certificate if Death Benefit Option 1 or 2 has been elected. These premium
limitations will not apply if they cause the Certificate to lapse.
Guideline premiums are determined according to rules in the federal tax law, and
will be adjusted as that law changes.
If the maximum payment limit applies to a Certificate, the excess payment will
be applied first to the outstanding loan and we will then return any balance to
the Owner within 60 days after the Certificate anniversary. We will pay interest
on each refund at the Fixed Account interest rate in effect on the date we
receive payment.
Subject to the limitations set forth above,] the Company will accept any
Certificate premium payment (or portion thereof) which does not increase the
Amount at Risk regardless whether Death Benefit Option 1, 2 or 3 is in effect;
see Required Minimum Amount of Death Benefit Provision. [Any Certificate premium
payment (or portion thereof) which would increase the Amount at Risk shall be
returned to the Owner by the Company. No additional Certificate premium payments
which increase the Amount at Risk will be accepted and no additional death
benefit shall be provided until the following conditions have been met:
- Evidence of Insurability has been received by the Company; and
- the Company has notified the Owner that the Insured is in a satisfactory
underwriting class. This notification shall include a copy of the
Enrollment Form, if applicable, containing the information relied on by the
Company in making its determination. The Owner may make Certificate premium
payments which increase the Amount at Risk for up to 60 days following the
date of such notification by the Company that the conditions have been met,
but not later than the Final Payment Date.]
Form 1040P-00NY 10 Case ID [WG01]
<PAGE>
NET PREMIUM: The net premium is equal to the premium less any premium expense
charge. The premium expense charge in effect on the Policy issue date is shown
on the Schedule Page(s) as "PREMIUM EXPENSE CHARGE." The premium expense charge
in effect on each Certificate issue date is shown in the Certificate Schedule
Page(s) as "PREMIUM EXPENSE CHARGE". It may be adjusted to reflect any increase
or decrease in the applicable state, local, or federal premium expense rate.
GRACE PERIOD
[POLICY PREMIUM GRACE PERIOD: If, prior to the due date of any Policy premium
after the first, the Owner has not previously given notice to the Company to
terminate the Policy, a grace period of 31 days will be granted for payment of
the Policy premiums. If any Policy premium is not paid by the end of this grace
period, the Policy will be discontinued at the end of such period. The Policy
will be discontinued before that date if the Policyholder has given to the
Company written notice in advance to discontinue it.]
CERTIFICATE GRACE PERIOD AND CERTIFICATE LAPSE: We will send the Owner a notice
if Certificate premium payments are not enough to keep the Certificate in force.
The Certificate will continue for 62 days, which is the grace period.
The first day of the grace period is called the date of default. We will send
the notice to the Owner's last known address, or to the person named to receive
this notice, showing the due date and the amount of premium which must be paid
to keep the Certificate in force.
[We also will send a notice to the Owner's last known address at least 15 and
not more than 45 days prior to the end of the grace period if the surrender
value is not adequate to prevent Certificate lapse.]
The grace period will begin if the Certificate Value less any outstanding loan
on a monthly processing date is less than the amount needed to pay the next
monthly deduction plus any outstanding loan interest accrued.
The death benefit during the grace period will be reduced by any overdue
charges. The Certificate will lapse if the amount shown in the notice remains
unpaid at the end of the grace period. The Certificate terminates on the date of
lapse.
REINSTATEMENT: If a Certificate has lapsed or foreclosed for failure to pay loan
interest, and has not been surrendered, it may be reinstated within three years
after the date of default or foreclosure. We will reinstate the Certificate on
the monthly processing date following the day we receive all of the following
items:
- a written application for reinstatement,
- Evidence of Insurability showing the Insured is insurable according to our
underwriting rules[,and
- a payment large enough to keep the Certificate in force for three months].
The Owner may repay or reinstate any outstanding loan on the date of default or
foreclosure.
The reinstatement premium will be allocated to the Fixed Account until we
approve the application, at which time we will transfer the reinstatement
premium, plus accrued interest, as directed in the most recent premium payment
allocation request.
Form 1040P-00NY 11 Case ID [WG01]
<PAGE>
The Certificate Value on the reinstatement date is:
- the payment to reinstate the Certificate, including the interest earned
from the date we received the payment; plus
- an amount equal to the Certificate Value less any outstanding loan on the
default date; less
- the monthly deduction due on the reinstatement date.
CERTIFICATE VALUE
PAYMENT AND ALLOCATION OF NEW PAYMENTS: Each payment made to us will be added to
the Certificate Value. The Certificate Value consists of all the money in the
Variable Account and the Fixed Account.
ALLOCATION OF PAYMENTS: If a Certificate Owner makes a payment with the
application or at any time before the date of issue, we will hold the payment in
the Fixed Account as of the day we receive it at our Principal Office. When the
Certificate has been issued, we will transfer any funds from the Fixed Account
(which were not allocated by the Owner to the Fixed Account) as directed by the
Owner in the application or by later request. All payments received thereafter
will be allocated in accordance with the most recent payment allocation request.
All percentage allocations must be in whole numbers, with the total allocation
to all selected accounts equaling 100%.
[Before the Right to Examine the Certificate expires, the Company may put the
net payment to be invested in the Separate Account(s) into the Sub-Account
investing in the [Money Market fund] on the date the proposed Insured is
accepted for insurance by the Company or on the date the payment is received at
the Company's Principal Office, whichever is later. The Company will transfer
the Certificate Value from the Fixed Account or the Sub-Account investing in the
[Money Market fund,] as applicable, as directed by the Certificate Owner
according to the Certificate Owner's most recent allocation, no later than the
expiration of the period during which the Certificate Owner may exercise his or
her Right to Examine the Certificate [subject to the Sub-Account Investment
Provision]. All net payments received thereafter will be allocated in accordance
with the Certificate Owner's most recent payment allocation request.]
[In addition, net premium paid at any time prior to the Final Premium Payment
Date will be placed in the Fixed Account, or in the Sub-Account investing in the
[Money Market fund,] as applicable, on the date it is received at the Principal
Office. Certificate Value will be transferred to the Sub-Account(s) in
accordance with the Certificate Owner's premium allocation no later than the
next applicable Investment Date following the receipt of the premium.]
MONTHLY DEDUCTION: The monthly deduction from each Certificate's Value is the
sum of the following charges:
- the Monthly Insurance Charges;
- monthly expense charge;
- administrative charge;
- the mortality and expense risk charge; [and
- [the variable account administrative charge; and]
- any monthly rider charge(s)].
Form 1040P-00NY 12 Case ID [WG01]
<PAGE>
Monthly deductions are made on the date of issue of the Certificate and on each
monthly processing date until the Final Payment Date. Thereafter, the mortality
and expense risk charge will be deducted on the Monthly Processing Date for the
life of the Insured.
The Owner may choose the Sub-Account from which the monthly deduction will be
made. If no choice is made, we will deduct the monthly deduction Pro-rata among
the Fixed Account and the Sub-Accounts. In the event any charge is greater than
the Value of a Sub-Account to which it relates on a monthly processing date, the
unpaid balance will be totaled and allocated Pro-rata among the other [liquid]
Sub-Accounts of the Separate Account; the Company will notify the Owner if this
occurs.
Charges allocated to the Fixed Account will be deducted on a last-in, first-out
basis. This means that we use the most recent payments to pay the fees.
INSURANCE CHARGES:
The Monthly Insurance Charge for each Certificate equals the sum of the charges
that apply to:
- the Base Amount, plus
- each increase in the Base Amount,
- plus any rider benefits.
We will determine the Monthly Insurance Charge each month. The actual charge for
the Insured Term Rider may be different than the charge for the Base Amount. Any
changes in these charges will be made by underwriting class. If the Face Amount
is decreased, we will adjust the Monthly Insurance Charge according to the
Benefit Change provision.
The Maximum Monthly Insurance Charge for the initial Face Amount will not be
more than (1) multiplied by (2) where:
- (1) is the insurance rate shown for the Insured's age in the Table in the
Specifications Page; and
- (2) is the initial Face Amount divided by 1,000.
For the purposes of this calculation, if one of the level death benefit options
is in effect, the initial Face Amount will be reduced by the Certificate Value,
minus charges for rider benefits, if applicable, at the beginning of the month,
but not less than zero.
If the Face Amount is increased, the Monthly Insurance Charge for the increase
will not be more than (3) multiplied by (4) where:
- (3) is the insurance rate applicable to the increased Face Amount for the
Insured's age; and
- (4) is the amount of the increase in the Face Amount divided by 1,000.
For purposes of this calculation, "age" means how old the Insured is on the last
birthday prior to the anniversary of the effective date of the increase. If one
of the level death benefit options is in effect and the Certificate Value, minus
charges for rider benefits, if applicable, at the beginning of the month, is
higher than the initial Base Amount, the excess Certificate Value will be used
to reduce any Insured Term Rider insurance benefit and increases in the Base
Amount in the order in which the Insured Term Rider insurance and increases in
the Base Amount were issued.
Form 1040P-00NY 13 Case ID [WG01]
<PAGE>
If the total death benefit is the minimum death benefit required for the
Certificate to qualify as life insurance under the federal tax law, the Monthly
Insurance Charge for the portion of the death benefit which exceeds the Face
Amount (i.e., initial Base Amount plus any Insured Term Rider insurance and
increases) will not be higher than (5) multiplied by (6) divided by 1,000 where:
- (5) is the insurance rate applicable to the initial Base Amount; and
- (6) is the death benefit less:
- the greater of the Face Amount or the Certificate Value if either of the
level death benefit options is in effect, or
- the Face Amount plus the Certificate Value, if the Death Benefit Option 2
is in effect.
INSURANCE RATES: [The cost of insurance rate for each Certificate may include an
expense factor and a mortality factor. The expense factor covers a portion of
our acquisition and distribution costs, tax and administrative expenses.] The
mortality factor is based on the Insured's:
- age,
- effective date of insurance coverage, including increases,
- sex, if applicable,
- underwriting class, and
- Base Amount.
The guaranteed rates will be no greater than the:
- the Commissioner's 1980 Standard Ordinary Mortality Table Age Last
Birthday, [ Male, Female, Unisex (Table B), Smoker, Non-Smoker, Unismoker],
and
- appropriate increases in such tables for rated risks.
[The insurance rates actually charged will usually be lower than, and never will
be higher than, the guaranteed rates. We will review the actual insurance rates
whenever we change these rates for new group flexible premium variable life
insurance policies. In any event, rates will be reviewed not more often than
once each year, but not less than once in a five-year period.]
VARIABLE ACCOUNT(S)
VARIABLE ACCOUNT: The Variable Account consists of one or more Separate
Accounts. The Value of a Certificate will vary if it is funded through
investments in the Sub-Accounts of the Separate Account(s). [A Separate Account
that is registered with the Securities and Exchange Commission ("SEC") under the
Investment Company Act of 1940 ("1940 Act") is referred to as a "registered
Separate Account." A Separate Account that is not registered under the 1940 Act
is referred to as a "non-registered Separate Account."] [The Policy provides for
two Separate Accounts, A and B.] The Separate Account(s) are separate from our
Fixed Account. We have exclusive and absolute ownership and control of all
assets, including those in the Separate Account(s). However, the portion of
assets in the Separate Account(s) equal to the reserves and liabilities of the
Certificates which are supported by the Separate Account(s) will not be charged
with liabilities that come from any other business we conduct.
Form 1040P-00NY 14 Case ID [WG01]
<PAGE>
[Separate Account A, which we established to support variable life insurance
certificates is called [______] and, is registered with the SEC as a unit
investment trust under the 1940 Act. [Separate Account B, which we established
to support variable life insurance certificates is called [ ], and is registered
with the SEC as a management investment company under the 1940 Act. The Separate
Account(s) are also governed by the laws of Massachusetts and New York.]
[Interests in the Separate Account(s) have not been registered under the
Securities Act of 1933 ("1933 Act"). Separate Account(s) A is not registered
under the 1940 Act in reliance on the exemption provided by Section 3(c)(1) of
the 1940 Act. Separate Account(s) B is not registered under the 1940 Act in
reliance on the exemption provided by Section 3(c)(7) of the 1940 Act.]
Each Separate Account(s) may have several Sub-Accounts. The Sub-Accounts in
which the Owner initially chose to invest are shown in the Allocation Form. Each
Sub-Account invests its assets in a separate series of an investment company
(called a "Fund") , which may or may not be registered under the 1940 Act, or in
other securities and investments. Funds that are registered under the 1940 Act
are referred to as "registered funds." Funds that are not registered under the
1940 Act are referred to as "non-registered funds."
[Sub-Account 1 of Separate Account(s) A will initially invest in (NAME) Fund,
which is not registered under the 1940 Act in reliance on the exemption provided
by Section 3(c)(1) of the 1940 Act. Sub-Account 1 of Separate Account(s) B will
initially invest in (NAME) Fund, which is not registered under the 1940 Act in
reliance on the exemption provided by Section 3(c)(7) of the 1940 Act]
[Sub-Account 2 of Separate Account(s) A will initially invest in the (name)
Fund, and Sub-Account 2 of Separate Account(s) B will initially invest in the
(name) Fund.]
We reserve the right, when the law allows, to change the name of the Separate
Account or any of its Sub-Accounts.
VARIABLE ACCOUNT CERTIFICATE VALUE: Certificate premium payments made, which are
allocated to the Sub-Accounts, will purchase units of the Sub-Accounts [on the
first Investment Date on or following receipt by the Company of such premiums at
its Principal Office].
The number of units purchased in each Sub-Account is equal to the portion of the
payment allocated to the Sub-Account, divided by the value of the applicable
unit as of the valuation date the payment is received at our Principal Office or
on the date value is transferred to the Sub-Account from another Sub-Account or
the Fixed Account.
The number of units will remain fixed unless (1) changed by a subsequent split
of unit value, or (2) reduced because of a transfer, Certificate loan, partial
withdrawal, transaction charges, monthly deduction or surrender allocated to the
Sub-Account. Any transaction described in (2) will result in the cancellation of
a number of units, which are equal in value to the amount of the transaction. On
each valuation date we will value the assets of each Sub-Account in which there
has been activity. The Certificate Value in a Sub-Account at any time is equal
to the number of units the Certificate then has in that Sub-Account multiplied
by the Sub-Account's unit value. The value of a unit for any Sub-Account for any
valuation period is determined by multiplying that Sub-Account's unit value for
the immediately preceding valuation period by the net investment factor for the
valuation period for which the unit value is being calculated. The unit value
will reflect the charges of the Sub-Account, if any, and the investment advisory
fee and other expenses incurred by the Funds.
Form 1040P-00NY 15 Case ID [WG01]
<PAGE>
NET INVESTMENT FACTOR: The net investment factor measures the investment
performance of a Sub-Account during the valuation period that has just ended.
The net investment factor for each Sub-Account is equal to 1.00 plus the result
from dividing (a) by (b) [and subtracting (c)] where:
- (a) is the investment income of the Sub-Account for the valuation period,
plus capital gains, realized or unrealized, credited during the valuation
period; minus capital losses, realized or unrealized, charged during the
valuation period; adjusted for provisions made for taxes, if any; and
- (b) is the value of that Sub-Account's assets at the beginning of the
valuation period[; and
- (c) is a charge equal to ___% on an annual basis of the daily value of the
Sub-Account's assets].
Since the net investment factor may be more or less than one, the unit value may
increase or decrease. The Owner bears the investment risk. We reserve the right
(subject to any required regulatory approvals) to change the method we use to
determine the net investment factor.
VALUATION DATES AND PERIODS: [The day that the Company values the assets of a
Sub-Account is the valuation date. For each Sub-Account of an unregistered
Separate Account, the valuation date will be at least monthly for the purpose of
determining the monthly deduction. For each Sub-Account of a registered Separate
Account, a Valuation Date is each day that the New York Stock Exchange (NYSE) is
open for business and any other day in which there is enough trading in the
Separate Account's underlying portfolio securities to materially affect the
value of the Separate Account. A valuation period is the period between
valuation dates.
ADDITION, DELETION OR SUBSTITUTION OF INVESTMENTS: We may not change the
investment policy of the Separate Account without the approval of the
Superintendent of Insurance for New York. The investment policy is on file with
the Superintendent.
We reserve the right, subject to compliance with applicable law, to add to,
delete from, or substitute for the shares of a Fund that are held by the
Separate Account or that the Separate Account may purchase. We reserve the right
to buy shares of other Funds for other series or classes of certificates, or to
cause a conversion between series or classes of certificates or contracts if
Owner(s) request it. We also reserve the right to eliminate the shares of any
Fund if they are no longer available for investment, or if we believe investing
more in any eligible Fund is no longer appropriate for the purposes of the
Separate Account. We will notify the Owner before we substitute any shares in
the Separate Account.
We reserve the right to establish other Sub-Accounts, and to make them available
to any class or series of certificates as we think appropriate. Each new
Sub-Account would invest in a new investment company or in shares of another
open-end investment company. We also reserve the right to eliminate or combine
existing Sub-Accounts of the Separate Account and to transfer the assets between
Sub-Accounts, when allowed by law. If we believe it is in the best interests of
our Certificate Owners, we may operate the Separate Account [as a management
company under the Investment Company Act of 1940,] or we may de-register it
under that Act if the registration is no longer required.] We may also combine
it with other separate accounts.
No material change in the underlying investment policy of a Sub-Account of the
Separate Account shall be made until 60 days have elapsed from the date such
change has been filed with the Superintendent of Insurance or such shorter
period as the Superintendent may permit. In the event of material change in the
investment policy of a Sub-Account of the Separate Account or of a Fund,
Certificate Owners will be notified of the change. If Certificate Values are in
that Sub-Account, we will transfer it without charge on written request to
another Sub-Account of the Separate Account or to the Fixed Account.
Form 1040P-00NY 16 Case ID [WG01]
<PAGE>
We must receive the written request within sixty (60) days of the later of (1)
the effective date of such change in the investment policy or (2) the receipt of
the notice of the Owner's right to transfer. The Owner may then change the
premium and deduction allocation percentages.
If we make any substitutions or changes in the Separate Account(s) that we
believe are necessary or appropriate, we may make changes in this Policy by
written notice to reflect the substitution or change.
FEDERAL TAXES: If we must pay taxes on the Separate Account, we will charge the
Certificate Owners for that tax. Although the account is not now taxable, we
reserve the right to make a charge for taxes if the account becomes taxable.
SPLITTING OF UNITS: We reserve the right to split the value of a unit, either to
increase or decrease the number of units. Any splitting of units will have no
material effect on Certificate benefits.
FIXED ACCOUNT
FIXED ACCOUNT: The Fixed Account is a part of our General Account. The General
Account consists of all assets owned by us, other than those in the Variable
Account and other separate accounts. Except as limited by law, we have sole
control over the investment of these General Account assets. Certificate Owners
do not share directly in the investment experience of the General Account, but
are allowed to allocate and transfer funds into the Fixed Account.
FIXED ACCOUNT INTEREST RATES: The interest rate credited to Certificate Value in
the Fixed Account is set by us but is guaranteed never to be less than that
described in the Specifications Page. We will review the non-guaranteed interest
rate from time to time, at least once a year.
The interest rate in effect on the day we receive the Certificate Owner's
payment at our Principal Office is guaranteed for one year unless the Owner
borrows money from that Certificate Value. The interest rate on Certificate
Value transferred from a Sub-Account of the Separate Account(s) to the Fixed
Account is not guaranteed. Certificate value which is within the first-year
guarantee period first will be used for payment of fees, charges, loans and
partial withdrawals on a last-in, first-out basis.
The interest rate in effect on a Certificate anniversary is guaranteed for one
year for those Certificate Values in the Fixed Account on the Certificate
anniversary so long as those values remain in the Fixed Account and are not
borrowed.
FIXED ACCOUNT CERTIFICATE VALUE: The Fixed Account Certificate Value on the date
of issue is the net premium less the first monthly deduction. On each monthly
processing date thereafter, the Certificate Value of the Fixed Account is:
- the Certificate Value in this account on the preceding monthly processing
date, if any, increased by one month's interest, plus
- payments received since the last monthly processing date which are
allocated to the Fixed Account plus the interest accrued from the date the
payments are received by us, plus
- Separate Account Certificate Value transferred to the Fixed Account from
any Sub-Accounts since the preceding monthly processing date, increased by
interest from the date the Certificate Value is transferred, minus
- Certificate Value transferred from the Fixed Account to a Sub-Account since
the preceding monthly processing date and interest accrued on these
transfers from the transfer date to the monthly processing date, minus
Form 1040P-00NY 17 Case ID [WG01]
<PAGE>
- partial withdrawals from the Fixed Account and partial withdrawal
transaction charges since the last monthly processing date, interest
accrued on these withdrawals and charges from the withdrawal date to the
monthly processing date, minus
- any transaction charges allocated to the Fixed Account for any changes in
the Face Amount since the last monthly processing date and interest accrued
on such charges to the monthly processing date, minus
- the portion of the monthly deduction allocated to the Certificate Value in
the Fixed Account.
During any Certificate month the Fixed Account Certificate Value will be
calculated on a consistent basis.
BASIS OF VALUE OF THE FIXED ACCOUNT: We base the minimum surrender value in the
Fixed Account on mortality no greater than the [Commissioner's 1980 Standard
Ordinary Mortality Table Age Last Birthday, Male, Female or Unisex (Table B)]
with interest at [4%] each year, compounded annually.
Actual Certificate Values are based on interest and insurance rates that we set.
If required, we have filed a detailed description of the way we determine this
value with the State Insurance Department. All values equal or exceed the
minimums required by law in the state in which the Certificate is delivered.
TRANSFERS OF VALUE
While the Certificate is in force, the Owner may transfer amounts between the
Fixed Account and the Sub-Accounts or among Sub-Accounts, on request either in
writing or by telephone transfer, if this option has been chosen.
Once during the first 24 months after the Certificate date of issue, and once
during the first 24 months after an increase in the Base Amount, the Owner may
transfer, without charge, all or part of the Certificate Value in the Separate
Account(s) to the Fixed Account [, based on the Liquidity Date(s) which next
occurs,] in order to convert to a Fixed Account only product. Thereafter, future
payments will be allocated to the Fixed Account unless specified otherwise. All
other transfers are subject to the following rules, and will be permitted with
our approval.
The minimum and maximum amounts that may be transferred from the Fixed Account
to the Separate Account shall be determined by us. [The minimum amount required
for a transfer will be no more than [$500.] The maximum transfer amount will not
be less than the lesser of [$100,000 or 25%] of the Certificate Value.]
There is no limit on the number of transfers between the Sub-Accounts of the
Separate Account and there is no limit on the number of transfers between the
Sub-Accounts of the Separate Account to the Fixed Account.
If a transfer would reduce the Certificate Value in a Sub-Account to less than
$100, we reserve the right to include the remaining value in the amount
transferred.
There will be no charge for the first [12] transfers in a Certificate Year, but
a transfer charge of up to [$25] may be made on each additional transfer. Any
transfer charge will be deducted from the amount that is transferred. Transfers
that result from a Certificate loan or repayment of a loan are not subject to
these rules.
The Company may at any time revoke, modify, or limit the transfer privilege.
Form 1040P-00NY 18 Case ID [WG01]
<PAGE>
DOLLAR COST AVERAGING OPTION
The certificate owner may elect automatic transfers of at least $100 to be made
from one sub-account (called the DCA sub-account in this provision) to one or
more of the other sub-accounts of the Variable Account. The Company will permit
the certificate owner designate the Money Market sub-account as the DCA
sub-account. Other sub-accounts of the Variable Account or the General Account
may be designated by the certificate owner as the DCA sub-account subject to the
Company's consent.
Automatic transfers may be made on a monthly, bi-monthly, quarterly, semi-annual
or annual frequency. The Dollar Cost Averaging Option will be treated as one of
the twelve free transfers permitted in a policy year without regard to how many
sub-accounts are elected or the transfer frequency. The Company reserves the
right to limit the number of sub-accounts that may be utilized and may
discontinue this option at any time upon advance written notice to the
certificate owner.
If automatic transfer reduces the balance in the DCA sub-account to less than
$100, the entire balance will be transferred proportionately to the chosen
Sub-Account(s).
The Dollar Cost Averaging Option will end:
- when the amount in the DCA sub-account is zero after an automatic transfer
has been made and not payments are allocated to the DCA sub-account before
the next DCA processing dates; or
- upon the certificate owner's request.
The Company will send the certificate owner a written notice when the Dollar
Cost Averaging Option ends. Payments allocated to the DCA sub-account after this
option has ended will not automatically reinstate the option; the certificate
owner must make a new election.
The Dollar Cost Averaging Option and the Automatic Rebalancing Option may not be
in effect at the same time.
AUTOMATIC REBALANCING OPTION
By electing this option the certificate owner may automatically rebalance the
sub-accounts of the Variable Account. The certificate owner may direct the
company to process such transfers on a monthly, bi-monthly, quarterly,
semi-annual or annual frequency. When the certificate owner elects this option
he will designate the percentage allocation for each of the Sub-Accounts chosen.
On each periodic transfer date the Company will review the percentage allocation
in the various Sub-Accounts and, as necessary, transfer funds in order to
re-establish the designated percentage allocation mix.
The Automatic Rebalancing Option will be treated as one of the twelve free
transfers permitted in a policy year without regard to how many sub-accounts are
elected or the transfer frequency. If the amount necessary to reestablish the
designated mix on any transfer is less than $100, no transfer will be made. The
arrangement may be terminated upon written request. The Company reserves the
right to limit the number of Sub-Accounts that may be utilized for automatic
rebalancing and to discontinue the option upon advance written notice to the
certificate owner.
The Dollar Cost Averaging Option and Automatic Rebalancing Option may not be in
effect at the same time.
Form 1040P-00NY 19 Case ID [WG01]
<PAGE>
CERTIFICATE LOANS
The Certificate will be the security for the loan.
AMOUNT AN OWNER MAY BORROW: The total amount the Owner may borrow is the loan
value. The loan value is 90% of the Certificate Value. Owners are advised to
consult with a tax advisor before making a Certificate loan.
If the Owner does not specify from which accounts to borrow, we will allocate
the loan Pro rata.
In order to secure the outstanding loan, we will transfer the Certificate Value
in each Sub-Account equal to the Certificate loan allocated to each Sub-Account
to the Fixed Account.
LOAN INTEREST: Interest is due on Certificate loans. Except as otherwise
provided in the Preferred Loan Option, the maximum rate of interest is set forth
in the Specifications Page(s). Interest accrues daily, and is payable at the end
of each Certificate Year. Any interest that is not paid on time will be added to
the loan principal and bear interest at the same rate. If this makes the
principal higher than the Certificate Value in the Fixed Account, we will offset
this shortfall by transferring funds from the Sub-Accounts to the Fixed Account.
We will allocate the transferred amount Pro rata among the Sub-Accounts in the
same proportion that the value in each Sub-Account has to the total value in all
of them.
REPAYING THE OUTSTANDING LOAN: The Owner may repay the outstanding loan at any
time before the Owner's Certificate lapses. When it is repaid, we will transfer
the Certificate Value securing the loan that is in the Fixed Account to the
various Sub-Accounts and increase the value in them. The Owner may tell us how
to allocate repayments, but if the Owner does not, we will allocate them
according to the most recent payment allocation choices made. Loan repayments
made to the Separate Account cannot be higher than the amounts transferred from
it to secure the outstanding loan.
FORECLOSURE: If at any time the Certificate Value less any outstanding loan is
insufficient to cover the monthly deduction, we will terminate the Certificate.
We will mail a notice of this termination to the last known address of the Owner
and any assignee. If the excess outstanding loan is not paid within 62 days
after this notice is mailed, the Certificate will terminate with no value. The
Owner may reinstate the Certificate according to the Reinstatement provision.
PREFERRED LOAN OPTION: All Certificate loans in effect after the tenth
Certificate Year will qualify as a preferred loan.
The annual interest rate charged to that portion of the Certificate loan is
guaranteed not to exceed 4.5%. The annual interest rate credited to Preferred
loans is guaranteed not to be less than 4%.
This option may be revoked by the Owner at any time.
SURRENDER AND PARTIAL WITHDRAWALS
SURRENDER: An Owner may cancel the Certificate and receive its surrender value
as long as the Insured is living on the date we receive the Owner's written
request in our Principal Office. The Certificate will be canceled on that day
The Owner may choose to receive the surrender value in a lump sum or under a
benefit option.
SURRENDER VALUE: The surrender value equals the Certificate Value minus any
outstanding loan [The Policyholder will receive all remaining DAC recapture not
yet credited to the Certificate].
Form 1040P-00NY 20 Case ID [WG01]
<PAGE>
PARTIAL WITHDRAWALS: Partial withdrawals are not allowed during the first
Certificate Year. After the first Certificate Year, an Owner may make a partial
withdrawal. Each partial withdrawal must be at least $500. We will deduct a 2%
partial withdrawal transaction charge, not to exceed $25, from the Certificate
Value each time a partial withdrawal is made.
If one of the Level Death Benefit Options is elected, the Face Amount and
Certificate Value will be reduced by the amount of the partial withdrawal, and
the Certificate Value will be further reduced by the partial withdrawal
transaction charge. The Face Amount will be decreased in the following order:
- first, the most recent increase in the Insured Term Rider, if any, or Base
Face Amount,
- second, the next most recent increases in the Insured Term Rider, if any,
or the Base Amount, in succession,
- the initial Insured Term Rider benefit, if any, and
- last, the initial Face Amount.
If the Death Benefit Option 2 is elected, the Certificate Value will be reduced
by the amount of the partial withdrawal and the partial withdrawal transaction
charge.
We will not permit a partial withdrawal if it reduces the Face Amount to less
than that described in the Specifications Page.
If the Owner does not allocate a partial withdrawal and the partial withdrawal
transaction charge among the Fixed Account and each Sub-Account, we will
allocate that amount Pro rata.
PAYMENTS AND DEFERRALS
POSTPONEMENT OF PAYMENT: We may postpone any transfer from the Separate Account
or payment of any amount payable on:
- surrender,
- partial withdrawal,
- transfer,
- Certificate loan, or
- death of the Insured.
[The postponement will continue during any period when:
- trading on the New York Stock Exchange (NYSE) is restricted as determined
by the SEC, or the NYSE is closed for days other than weekends and
holidays, or
- the SEC by order has permitted such suspension, or
- the SEC has determined that such an emergency exists that disposal of
portfolio securities or valuation of assets is not reasonably practical.]
Form 1040P-00NY 21 Case ID [WG01]
<PAGE>
We may also postpone any transfer from the Fixed Account or payment of any
portion of the amount payable on surrender, partial withdrawal or Certificate
loan from the Fixed Account for not more than six months from the day we receive
a written request and, if it is required, the Certificate. We will pay interest
if payment is not mailed or delivered within thirty days of the date a valid
request is made[; however, no interest shall be paid if such interest is less
than $25.] A "valid request" is made when all documentation necessary to
complete the transaction is received at the Home Office. The interest rate
credited will not be less than the minimum rate allowed by law. No payment will
be deferred to pay premiums on policies with the Company.
DEATH BENEFIT
NET DEATH BENEFIT: If an Insured dies on or before the Final Payment Date, we
will pay the net death benefit under the Certificate. The amount of the net
death benefit depends on which death benefit option is in effect for the
Certificate on the date of death. We will deduct from the death benefit any
outstanding loan, including interest due through the month in which the Insured
dies, and monthly deductions due and unpaid through the Certificate month in
which the Insured dies, as well as any rider charges, any partial withdrawals
and partial withdrawal transaction charges.
If the Insured dies after the Final Payment Date, we shall pay the Certificate
Value minus any outstanding loan as of the date we receive written notice of
claim. Except as otherwise provided, we will pay interest from the date the
Insured dies to the date the net death benefit is paid. For lump sum payments,
the interest rate will be at least 3% a year, or the minimum rate set by law,
whichever is greater. [If the Death Benefit Option 2 is in effect on the date of
the Insured's death, we will begin calculating interest on the Certificate Value
portion of the net death benefit on the date we receive written notice of claim.
Interest will be paid on the Amount at Risk and the Fixed Account portion of the
net death benefit, if any, from the date of death to the date that portion of
the net death benefit is paid. Interest will be paid on the Separate Account(s)
portion of the net death benefit from the Liquidity Date(s) next following the
date of death to the date the balance of the net death benefit is paid. The
payment date will be determined in accordance with the Sub-Account Investment
Provision in the Specifications Page(s).]
DEATH BENEFIT OPTIONS: An Owner has three options for determining the amount of
the death benefit. The option elected in the Owner's application is shown on the
Certificate Specifications Page(s). There are two level death benefit options:
Death Benefit Option 1 and 3.
Under the level death benefit options, the death benefit is:
- the Face Amount, or
- the minimum death benefit on the date of death, whichever is greater.
Under the Death Benefit Option 2, the death benefit is:
- the Face Amount, plus the Certificate Value on the date we receive written
notice of claim (we will refund monthly deductions taken from the
Certificate Value after the Insured's date of death), or
- the minimum death benefit, whichever is greater.
REQUIRED MINIMUM AMOUNT OF DEATH BENEFIT: In order to qualify as "life
insurance" under the federal tax law, a Certificate issued under this Policy
must provide a minimum death benefit. This is called the "guideline minimum sum
insured" in the tax code.
Form 1040P-00NY 22 Case ID [WG01]
<PAGE>
The minimum death benefit is obtained by multiplying the Certificate Value by a
percentage shown in the applicable Minimum Death Benefit Table for the Insured's
attained age and death benefit option. For the Death Benefit Options 1 and 2,
the table used is the Guideline Minimum Death Benefit Table. This table is
determined according to the guideline minimum death benefit test set forth in
the Federal tax laws.
For the Death Benefit Option 3, the Cash Value Accumulation Table is used. This
table is calculated to conform to the Cash Value Accumulation test set forth in
the federal tax laws.
The minimum death benefit will be determined as of the date of death. The
minimum death benefit will be adjusted to conform to any changes in the tax law.
DEATH BENEFIT OPTION CHANGES: If an Owner has selected Death Benefit Option 3,
he or she is not permitted to change the death benefit option. An Owner may
change the death benefit option only if he or she has selected either Death
Benefit Option 1 or 2.
An Owner may change the death benefit option by written request. Evidence of
Insurability may be required for a death benefit option change. The change will
be made on the next monthly processing date after we approve the request.
An Owner may not change the death benefit option more than once in any
Certificate Year or if the change reduces the Face Amount to less than the
Minimum Face Amount in the Specifications Page.
For a change from Death Benefit Option 1 to the Death Benefit Option 2, and if
the Company determines, based on the Evidence of Insurability, that the Insured
is an acceptable risk, the Face Amount under the Death Benefit Option 2 will be
equal to the death benefit under the Death Benefit Option 1, minus the
Certificate Value under Option 1 on the date of change. If the change is from
Option 2 to Option 1, the Face Amount will be equal to the death benefit under
Option 2 on the effective date of the change.
FACE AMOUNT: The Face Amount will be that selected by the Certificate Owner. The
Face Amount for each Insured is shown in the Certificate Specifications Page(s).
The death benefit option may not be changed if it reduces the Face Amount to
less than the Minimum Face Amount shown in the Certificate Schedule Page(s) for
each Insured.
BENEFIT CHANGE: An Owner may increase or decrease the Face Amount of insurance
by written request during the Insured's lifetime.
An Owner may not change the Face Amount if it does not meet the minimum death
benefit requirement set by federal tax law.
INCREASE: To increase the Base Amount:
- [the Owner must complete our application and provide us with Evidence of
Insurability for the Insured; and]
- the Insured must be under our maximum issue age for new insurance; and
- the Insured must be approved by us according to our underwriting rules; and
- the Owner must pay the amount which is necessary to keep the Certificate in
force for three months if the Certificate Value is less than this amount.
Form 1040P-00NY 23 Case ID [WG01]
<PAGE>
We will provide new Specification Pages, including a Supplemental Insurance
Charge Table. These pages will include the following information:
- effective date of the increase,
- amount of the increase,
- underwriting class, [and]
- Monthly Insurance Charge for the increase, [and
- new guideline premiums].
We reserve the right to set a limit on the minimum amount of an increase [and
the effective date of such increase] in the Base Amount. No increase may be less
than our minimum limit in effect on the date we receive the Owner's request.
The Certificate Owner may return the new Specification Pages to us within ten
days after receiving them [or 45 days after completion of the "Application Form"
which shows the amount of the increase.] If the Owner returns these pages, we
will consider the increase void from the beginning. We will add the charges back
to the Certificate Value unless requested otherwise.
DECREASE: A Certificate Owner may decrease the Face Amount of the Certificate at
any time. It will be effective on the first monthly processing date after we
receive the written request.
The Face Amount will be decreased or eliminated in the following order:
- first, the most recent increase in the Insured Term Rider, if any, or Base
Amount,
- second, the next most recent increases in succession, in the Insured Term
Rider, if any, or the Base Amount,
- next, the initial Insured Term Rider benefit, if any, and
- last, the initial Face Amount.
We will provide new Specification Pages. These pages will include the following
information:
- effective date of the decrease, [and]
- amount of the decrease and the Face Amount remaining in force, [, and
- new guideline premiums].
The Owner may not decrease the Base Amount or Insured Term Rider, if any, to
less than our minimum issue limit for this type of policy. We reserve the right
to establish a minimum limit on the amount of any decrease.
[DAC RECAPTURE: All remaining DAC recapture not yet credited to the Certificate
on all premiums paid up to the date of death of the Insured will be paid to the
Certificate Owner].
Form 1040P-00NY 24 Case ID [WG01]
<PAGE>
[REFUND OF SALES LOAD]
[REFUND OF SALES LOAD: If the Policyholder and Owner are a corporation, a
corporate grantor trust, or a corporate assignee in the case of a split dollar
arrangement, the Company will, upon written request, refund a portion of the
sales charge previously deducted from premiums paid under the following
conditions:
- The Policy and all Certificates thereunder are surrendered prior to
the end of the third Policy year;
- The original Owner of the Policy and Certificates thereunder is a
corporation or corporate grantor trust or an individual or trust under
a corporate sponsored collateral assignment split dollar agreement,
and the ownership has not been changed;
- The Policy and Certificates have not been exchanged to another
carrier.
REFUND AMOUNT: In the first Policy Year, the amount of the refund is [100%] of
the portion of the previously paid premium expense charges that exceeded our
local, state and federal tax expenses.
In the second Policy Year, the amount of the refund is [70%] of the portion of
the previously paid premium expense charges that exceeded our local, state and
federal tax expenses.
In the third Policy Year, the amount of the refund is [35%] of the portion of
the previously paid premium expense charges that exceeded our local, state and
federal tax expenses.
The amount of this refund will be calculated as of the date the written request
is received in the Principal Office and will be paid to the Owner or the
corporate assignee in the case of a corporate sponsored collateral assignment
split dollar arrangement.]
PAYMENT OF BENEFITS
PAYMENT OPTIONS: Upon written request, the surrender value or all or part of the
net death benefit may be placed under one or more of the payment options offered
by us at the time the request is made. If no election is made, we will pay the
benefit in a lump sum [, subject to the Sub-Account Investment Provision]. A
certificate will be provided to the payee describing the payment option
selected.
If a payment option is selected, the beneficiary, when filing proof of claim,
may pay us any amount that otherwise would be deducted from the net death
benefit.
The amounts payable under these options are paid from the General Account. The
options are not based on the investment experience of the Variable Account.
The amount applied under any one option for any one payee must be at least
$5,000. The periodic payment for any one payee must be at least $50.
Subject to the Owner and Beneficiary provisions, the Owner may change any option
selection before the net death benefit becomes payable. If no selection is made,
the beneficiary may select an option when the proceeds become payable.
Form 1040P-00NY 25 Case ID [WG01]
<PAGE>
ALLMERICA FINANCIAL LIFE INSURANCE AND ANNUITY COMPANY
Insured Term Rider
This rider is a part of the Certificate to which it is attached if it is shown
in the schedule of benefits and premiums. The Insured under the Certificate is
the Insured under this Rider.
BENEFIT
BENEFIT - The Company will pay the term insurance benefit upon receipt of due
proof that the Insured died prior to the final premium payment date while this
rider is in force. Unless otherwise requested, the term insurance benefit will
be paid to the beneficiary of the Certificate. The Specifications Page of the
Certificate shows the initial term insurance benefit.
Benefit Change Provisions
ELECTIVE CHANGE PROVISIONS - The Owner may change the amount of term insurance
if such request is made:
- during the lifetime of the Insured; and
- on written request while this Rider and Certificate are in force.
INCREASE - Any increase in the amount of term insurance is subject to:
- Evidence of Insurability;
- the Insured must be under age 86 and insurable according to the Company's
underwriting rules; and
- payment to the Company of the amount needed to keep the Certificate in force
if the surrender value of the Certificate is less than all charges due on the
Policy.
The effective date of the increased amount of term insurance will be:
- the date requested by the Certificate Owner and agreed upon by the Company;
otherwise
- the first monthly payment date on or following the date all the conditions
are met.
A supplemental Specifications Page will be issued. This Page will include the
following information for the additional amount of term insurance:
- the effective date of the increased term insurance;
- the amount of the increase in the term insurance; and
- the new guideline premiums and monthly charges.
No increase may be less than the Company's minimum limit in effect on the date
of the request.
65
<PAGE>
DECREASE - A request to decrease the amount of term insurance will be effective
on the monthly processing date following the date of the written request. Such
term insurance will be decreased or eliminated in the following order:
- first, the most recent increase;
- second, the next most recent increase successively; and
- finally, the original amount of term insurance.
A supplemental Specifications Page will be issued. This Page will include the
following information:
- the effective date of the decrease in the amount of term insurance; and
- the amount of the decrease in the term insurance and the benefit remaining in
force.
The Term insurance may not be reduced to less than the Company's minimum issue
limit.
The Company reserves the right to establish a minimum limit for the amount of
any decrease.
AUTOMATIC CHANGES - The Company may change the amount of term insurance
automatically in the following instances:
- Decreases - If the Certificate Owner changes the death benefit
option of the Certificate from Option 1 to Option 2, or elects to
decrease the Face Amount of the Certificate, the Company will reduce
the Face Amount on a last in, first out basis with term insurance being
reduced before the Base Amount where the Insured Term Rider and the
Certificate have the same effective date.
- Increases - If the Certificate Owner changes the death benefit
option of the Certificate from Option 2 to Option 1, the Company will
increase the term insurance to provide the increase in the Face Amount.
GENERAL
OWNER - The Owner of the Certificate is the owner of this rider.
INCONTESTABILITY - Except for failure to pay premiums, term insurance cannot be
contested after the expiration of the following time periods:
- the initial term insurance benefit cannot be contested after the term
insurance has been in force during the Insured's lifetime for two years from
the effective date; and
- an increase in the term insurance as a result of a request by the Certificate
Owner which includes Evidence of Insurability cannot be contested after the
increased amount has been in force during the Insured's lifetime for two
years from its effective date.
SUICIDE EXCLUSION - The risk of suicide of the Insured, while sane or insane,
within two years of the effective date of the initial term insurance is not
assumed. The beneficiary will receive the sum of the monthly charges paid for
this rider.
The risk of suicide of the Insured, while sane or insane, within two years of
the effective date of any increase in the term insurance amount as a result of a
request by the Certificate Owner which includes
66
<PAGE>
Evidence of Insurability is also not assumed to the extent of such increase. The
beneficiary will receive the monthly charges paid for such increase.
MISSTATEMENT OF AGE [OR SEX] - If the age [or sex, if applicable,] of the
Insured has been misstated, the amount payable under this rider will be such as
the charges paid on the last monthly processing date would have purchased at the
Insured's correct age [and sex].
CHARGES - Charges for this rider are payable as a part of the monthly deduction
due under this Certificate.
The maximum charges for each year for this rider are shown in the Specifications
Page(s).
TERMINATION - This rider will terminate on the first to occur of:
- the end of the grace period of a premium in default; or
- the termination of the Certificate; or
- the monthly processing date following a request for termination.
Except as otherwise provided, all conditions and provisions of the Certificate
apply to this rider.
Signed for the Company at Dover, Delaware
Secretary
President
67
<PAGE>
ALLMERICA FINANCIAL LIFE INSURANCE AND ANNUITY COMPANY
OPTION TO ACCELERATE DEATH BENEFITS ENDORSEMENT
This endorsement is part of the policy to which it is attached. The
insured under the certificate is the insured under this endorsement. This
endorsement does not apply to any benefits provided by rider.
BENEFIT X While this endorsement is in force, the owner may elect to
receive a portion of the death proceeds, called the "living benefit,"
prior to the insured's death under either the terminal illness option or
the nursing home option, subject to the definitions, conditions and
limitations in the endorsement.
DEFINITIONS X "Option amount" means that portion of the death benefit
which the owner elects to apply under this option. The option amount must
be at least $25,000 and may not exceed the lesser of:
- one-half of the death benefit on the date the option is elected; or
- the amount that would reduce the face amount to the Company's minimum
issue limit for the certificate; or
- $250,000.
"Option percentage" is the option amount divided by the death benefit.
"Living benefit" is the option amount which has been reduced for interest
and other factors. It is equal to the lump sum benefit under this
endorsement, and is the amount used to determine the monthly benefit. The
living benefit will not be less than the surrender value of the
certificate multiplied by the option percentage. The following factors
will be used to calculate the living benefit:
- age;
- sex, unless the certificate is issued on a unisex basis;
- life expectancy;
- certificate value;
- debt;
- rate of interest currently being credited to the certificate value
including those values which are subject to debt;
- face amount;
- current insurance charges;
- administrative charges; and
- death benefit option;
- an expense charge of [$150].
An amount equal to the debt multiplied by the option percentage will be deducted
from the living benefit. The remaining debt will continue in force.
The assumptions used by the Company to calculate the living benefit may change
from time to time. The factors used to compute the living benefit will be set
and changed only prospectively; that is, based on changes in future
expectations. The Company will not change these factors to recoup any prior
losses or distribute past gains under the endorsement.
68
<PAGE>
"Eligible nursing home" means an institution or special nursing unit of a
hospital which meets at least one of the following requirements:
it is Medicare - approved as a provider of skilled nursing care services; or
it is licensed as a skilled nursing home or as an intermediate care facility by
the state in which it is located; or
it meets all the requirements listed below:
/ / it is licensed as a nursing home by the state in which it is
located;
/ / its main function is to provide skilled, intermediate or
custodial nursing care;
/ / it is engaged in providing continuous room and board
accommodations to 3 or more persons;
/ / it is under the supervision of a registered nurse (RN) or
licensed practical nurse (LPN);
/ / it maintains a daily medical record of each patient; and
/ / it maintains control and records for all medications dispensed.
Institutions which primarily provide residential facilities are not eligible
nursing homes.
"Proof of claim satisfactory to us" will include:
/ / a request signed by the insured to disclose all facts concerning the
insured's health;
/ / records of the attending physician, including a prognosis of the insured;
and
/ / if requested by the Company, and at the Company's expense, a medical
examination of the insured, conducted by a physician chosen by the Company.
CONDITIONS / / Upon written request, the owner may elect to receive payment
under one of the accelerated death benefit options subject to the following
conditions:
/ / coverage under the policy is in force;
/ / a written consent has been given by any collateral assignee, irrevocable
beneficiary and the insured if other than the owner; and
/ / the insured qualifies for the option elected.
TERMINAL ILLNESS OPTION / / If the owner provides proof of claim satisfactory to
the Company that the insured's life expectancy is 12 months or less, the owner
may elect to receive equal monthly payments for 12 months. For each $1,000 of
living benefit, each payment will be at least [$85.21] This assumes an annual
interest rate of [5]%.
If the insured dies before all the payments have been made, the Company will pay
the beneficiary in one sum the present value of the remaining payments due under
this option calculated at the interest rate used by the Company to determine
those payments.
If the owner does not wish to receive monthly payments, the owner may elect to
receive an amount equal to the living benefit in a lump sum.
NURSING HOME OPTION / / If:
1. the insured is confined to an eligible nursing home and has been
confined there continuously for the preceding six months; and
69
<PAGE>
2. proof of claim satisfactory to the Company is provided that the
insured is expected to remain in the nursing home until death; then
the owner may elect level monthly payments for the number of years shown in the
table that follows. For each $1,000 of living benefit, each payment will be at
least the minimum amount shown in that table. The table assumes an annual
interest rate of [5]%.
If the insured dies before all the payments have been made, the Company will pay
the beneficiary in one sum the present value of the remaining payments under
this option calculated at the interest rate used by the Company to determine
those payments.
The owner may elect a longer payment period than that shown in the table. If the
owner does, monthly payments will be reduced so that the present value of the
monthly payment for the longer payment period is equal to the present value of
the payments for the period shown in the table, calculated at an interest rate
of at least [5]%.
The Company reserves the right to set a maximum monthly benefit, which will not
be less than $[5,000].
If the owner does not wish to receive monthly payments, the owner may elect to
receive an amount equal to the living benefit in a single sum.
<TABLE>
<CAPTION>
Payment Minimum Monthly Payment Payment Minimum Monthly payment Payment Minimum Monthly Payment
Period in for each Period in for each Period in for each
Years $1,000 of Living Benefit Years $1,000 of Living Benefit Years $1,000 of Living Benefit
<S> <C> <C> <C> <C> <C>
[1 $85.21 11 $9.77 21 $6.33
2 $43.64 12 $9.16 22 $6.17
3 $29.80 13 $8.64 23 $6.02
4 $22.89 14 $8.20 24 $5.88
5 $18.74 15 $7.82 25 $5.76
6 $15.99 16 $7.49 26 $5.65
7 $14.02 17 $7.20 27 $5.54
8 $12.56 18 $6.94 28 $5.45
9 $11.42 19 $6.71 29 $5.36
10 $10.51 20 $6.51 30 $5.28]
</TABLE>
EFFECT ON CERTIFICATE / / The death benefit of the certificate will be decreased
by the option amount. Such decrease will be effective on the monthly processing
date following the date of the written request. Existing insurance will be
decreased or eliminated in the following order:
/ / first, the most recent increase;
/ / second, the next most recent increases successively; and
/ / last, the initial face amount.
[A surrender charge applicable to the decrease in the face amount will be
waived. The amount of the charge which is waived will be:
/ / the surrender charge applicable to any increased face amount which is
eliminated in the order set forth above; plus
/ / a pro-rata share of the surrender charge applicable to a partial reduction
in an increase or in the original face amount.]
New specification pages will be issued. These pages will include the following
information:
70
<PAGE>
/ / the effective date of the decrease;
/ / the amount of the decrease and the benefit remaining in force;
[/ / the revised surrender charge;]
[/ / the revised minimum monthly factor, if any;] and
/ / the new maximum premiums.
The certificate value will be reduced in the same proportion as the
reduction in the face amount. Riders will continue in force.
EXCLUSION / / No benefit will be paid under this endorsement if a claim
results, directly or indirectly, from a suicide attempt or a
self-inflicted injury (while sane or insane) for any period during
which a suicide exclusion is applicable.
TERMINATION / / The coverage under this endorsement will terminate on
the first to occur of:
/ / the end of the grace period of a required premium in default; or
/ / the termination or maturity of the certificate while the insured
is alive; or
/ / the end of the certificate month following a request for
termination.
GENERAL / / The Certificate Schedule will show the effective date of
the endorsement.
The living benefit will be made available to the owner on a voluntary
basis only. Accordingly:
(a) If the owner is required by law to exercise this option to satisfy
the claim of creditors, whether in bankruptcy or otherwise, the
owner is not eligible for this benefit.
(b) If the owner is required by a government agency to exercise this
option in order to apply for, obtain, or retain a government
benefit or entitlement, the owner is not eligible for this
benefit.
Except as otherwise provided, all conditions and provisions of the policy apply
to this endorsement.
Executed at Worcester, Massachusetts
71
