CONTRACT DATA PAGE
Contract Information
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Contract Number: [P9999999999] | | Contract Date: [February 2, 2021] | | Contract Type: [Non-Qualified] |
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Owner: [JOHN DOE] | | [Date of Birth: [March 1, 1976] | | Age at Issue: [44]] |
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[Joint Owner: [JANE DOE] | | Date of Birth: [June 10, 1977] | | Age at Issue: [43]] |
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Annuitant: [JOHN DOE] | | Date of Birth: [March 1, 1976] | | Age at Issue: [44] |
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[Joint Annuitant: [JANE DOE] | | Date of Birth: [June 10, 1977] | | Age at Issue: [43]] |
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[Beneficiary: [As named by You on the Application]] | | |
Single Purchase Payment Information
Single Purchase Payment: [$25,000.00]
Purchase Payment Allocation Information
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Strategy Account Option(s) Purchase Payment Allocation: | | |
[1yr PTP S&P 500 10% Buffer with Cap:] | | [50%] |
[1yr PTP S&P 500 10% Buffer with Trigger:] | | [30%] |
[6yr PTP S&P 500 10% Buffer with Participation & Cap:] | | [10%] |
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Fixed Account Option Purchase Payment Allocation: | | [10%] |
Interest Crediting Period: | | [One (1) Contract Year(s)] |
Initial Annual Interest Rate: | | [1.00%] |
Guaranteed Minimum Interest Rate: | | [0.25%] |
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Renewal Window: | | [The Renewal Window is [20] calendar days prior to and including the Term End Date.] |
If You have questions about your annuity contract, You may call Us, or You may call Your state insurance department
at [1(XXX) XXX-XXXX].
CONTRACT DATA PAGE (continued)
Withdrawal Information
Minimum Withdrawal Value Percentage: [87.5%]
Interest Rate for Minimum Withdrawal Value: [1.00%]
Withdrawal Charge Schedule:
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| Contract Year | | 1 | | | 2 | | | 3 | | | 4 | | | 5 | | | 6 | | | 7+ | |
| Withdrawal Charge Percentage | | | 8 | % | | | 8 | % | | | 7 | % | | | 6 | % | | | 6 | % | | | 4 | % | | | 0 | % |
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See Page [10] of the Contract for Withdrawal Provisions.
Minimum Partial Withdrawal Amount: [$1,000]
Maximum Penalty-Free Withdrawal Percentage: [Each Contract Year You have up to 10.00% of the Contract Value as of the previous Contract Anniversary]
Maximum Penalty-Free Withdrawal Eligibility Date: [Permitted after the first Contract Year]
Minimum Contract Value Remaining After a Partial Withdrawal: [$2,500]
Minimum Transfer Amount: [$100]
Minimum Strategy Account Option Value Remaining After a Transfer: [$100]
Annuity Income Payment Information
Earliest Date to Start an Income Plan: [Two years]
Latest Annuity Date: [The Contract Anniversary following Your [95th] birthday]
Actuarial Basis of Computation:
The actuarial basis for the Income Payment Options is the [2012 IAR Mortality Table with a one-year age setback plus an additional year setback for every 4 years after 2012], and a guaranteed interest rate of [0.25%]. The annuity rates pertaining to the Actuarial Basis of Computation will be furnished upon Your request.
Option 5 – Fixed Payments for a Specified Period Certain:
Fixed payments payable to the Payee for any specified period of time is for [five (5)] years or more, but not exceeding [thirty (30)] years as selected at the time an Income Plan commences.[ If an Income Plan begins prior to [five (5)] years from the Contract Date, the minimum fixed amount payment period is [ten (10)] years. After [five (5)] years from the Contract Date, the minimum fixed amount payment period is [five (5)] years.] The specified period options may be limited by federal tax law.
CONTRACT DATA PAGE (continued)
Income Payment Option 5 - Table of Monthly Installments Per
Fixed Payment for a Specified Period Certain
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Number of Years | | Monthly Payment | | | Number of Years | | Monthly Payment | | | Number of Years | | Monthly Payment | | | Number of Years | | Monthly Payment | |
| | | | | | 10 | | | 8.44 | | | 17 | | | 5.01 | | | 24 | | | 3.58 | |
| | | | | | 11 | | | 7.68 | | | 18 | | | 4.73 | | | 25 | | | 3.44 | |
[5 | | | 16.77 | | | 12 | | | 7.05 | | | 19 | | | 4.49 | | | 26 | | | 3.31 | |
6 | | | 13.99 | | | 13 | | | 6.51 | | | 20 | | | 4.27 | | | 27 | | | 3.19 | |
7 | | | 12.01 | | | 14 | | | 6.06 | | | 21 | | | 4.07 | | | 28 | | | 3.08 | |
8 | | | 10.52 | | | 15 | | | 5.66 | | | 22 | | | 3.89 | | | 29 | | | 2.98 | |
9 | | | 9.36 | | | 16 | | | 5.31 | | | 23 | | | 3.73 | | | 30 | | | 2.88 | ] |
Misstatement of Age or Sex Interest Rate: [0.25%]
Rider and/or Endorsement Information
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| | Non-Optional Elections: | | | | |
| [Market Value Adjustment Rider | | See Attached Form] |
| [Extended Care Rider | | See Attached Form] |
| [Terminal Illness Rider | | See Attached Form] |
| [Buffer with Participation and Cap Strategy Account Option(s) Rider | | See Attached Form] |
| [Buffer with Cap Secure Rate Strategy Account Option(s) Rider | | See Attached Form] |
| [Buffer with Trigger Performance Strategy Account Option(s) Rider | | See Attached Form] |
| [Buffer Dual Direction with Cap Strategy Account Option(s) Rider | | See Attached Form] |
| [Lock with Buffer Strategy Account Option(s) Rider | | See Attached Form] |
| [Performance Lock Rider | | See Attached Form] |
| Optional Elections: | | |
| [Return of Purchase Payment Death Benefit Rider | | See Attached Form] |