[LOGO]
ITT HARTFORD
This notice is to advise you that should any complaints arise regarding this
annuity contract, you may contact the following:
ITT Hartford Life Insurance Companies
P.O. Box 2999
Hartford, CT 06104-2999
Telephone: (800) 862-6668
If the problem is not resolved, you may write to the Illinois Insurance
Department at the following address:
Illinois Department of Insurance
Consumer Division
320 West Washington Street
Springfield, Illinois 62767
HL-A13885-1
IMPORTANT
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PLEASE SIGN AND RETURN THE
ENCLOSED ANNUITY CONFIRMATION FORM
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Please take a few minutes to look over your
enclosed annuity contract and confirm that it
accurately reflects your decisions.
It is important that we have certain key
information to properly establish this contract
and that your signature be added to your
contract record. Therefore, we ask that you
complete, sign and return the enclosed
ANNUITY CONFIRMATION FORM in the
postage-paid envelope.
If you have any questions about the form or any
of the information requested, you may call your
local registered representative or contact ITT
Hartford Customer Service staff toll-free at
1-800-862-6668 week days between 8:00 AM
and 7:00 PM (Eastern Time).
PLEASE NOTE: If this form is not signed and
returned, a signature guarantee will be required
prior to processing any provision in your
contract, including withdrawals.
Thank you
HARTFORD ANNUITY CONFIRMATION FORM
DEAR ANNUITY CONTRACT OWNER(S) OR PARTICIPANT(S):
1. PLEASE FILL-IN YOUR DESIGNATED BENEFICIARY(IES) BELOW,
2. CORRECT YOUR SOCIAL SECURITY NUMBER BELOW, IF NEEDED,
3. SIGN AND DATE THE BOTTOM OF THIS FORM,
4. ENCLOSE THIS COMPLETED FORM IN THE POSTAGE-PAID ENVELOPE
AND DROP IT IN THE U.S. MAIL AT YOUR EARLIEST CONVENIENCE.
RE: ANNUITY CONTRACT/CERTIFICATE NUMBER: 12000 / 196530
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ANNUITANT: DR MARIAMMA ABRAHAM
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OWNER SOCIAL SECURITY (TAX ID) NUMBER: (X ###-##-####
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SS # CORRECTION - -
--- --- --- --- --- --- --- --- ---
BENEFICIARY: PLEASE NOTE THE DESIGNATED BENEFICIARY(IES) FOR THIS
ANNUITY BELOW IF OTHER THAN THE ESTATE OF THE OWNER/PARTICIPANT:
NAME(S) RELATIONSHIP PERCENTAGE
PRIMARY DR JOSHY ABRAHAM SPOUSE
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CONTINGENT BAI JUABRAHAM CHILD
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PLEASE USE REVERSE SIDE OR THE ENCLOSED CHANGE REQUEST FORM TO
PROVIDE ADDITIONAL BENEFICIARIES OR ANY OTHER ADDITIONS/CORRECTIONS
YOU WISH TO MAKE TO THIS ANNUITY NOW.
I CERTIFY THAT MY SOCIAL SECURITY/TAX I.D. NUMBER IS CORRECT AS
NOTED ABOVE AND AFFIRM THAT THIS ANNUITY IS NOT A REPLACEMENT OF
ONE OR MORE ANNUITY OR LIFE INSURANCE CONTRACTS.
- -----------------------------------
CONTINGENT ANNUITANT, IF ANY
X
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OWNER/PARTICIPANT SIGNATURE -- DR MARIAMMA ABRAHAM
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X
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JOINT OWNER/PARTICIPANT, IF ANY, --
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DATE:
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IF YOU HAVE ANY QUESTIONS OR REQUIRE ANY ASSISTANCE IN COMPLETING
THIS FORM, PLEASE CONTACT YOUR LOCAL REGISTERED REPRESENTATIVE, OR
CALL THE HARTFORD'S TOLL FREE CUSTOMER SERVICE LINE: 1-800-862-6668.
THANK YOU FOR SELECTING A HARTFORD ANNUITY, COMPLETING THIS FORM,
AND MAILING IT BACK TO US IN THE POSTAGE-PAID ENVELOPE PROVIDED.
Please forward to
Hartford Life Insurance Companies ANNUITY CHANGE REQUEST
Attn: Individual Annuity Operations
P.O. Box 2999
Hartford, CT 06104-2999
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ITT HARTFORD
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Annuitant Name Account No.
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NAME CHANGE/REVISION
/ / Annuitant / / Contract Owner(s)/ / / Contingent Beneficiary
Participant(s) (Include Relationship)
/ / Agent / / Contingent Annuitant / / Beneficiary
(Include Relationship)
*NOTE: The designated annuitant and contingent annuitant cannot be changed.
The space provided is for name corrections only.
From:
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To:
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ADDRESS CHANGE
/ / Annuitant / / Contract Owner(s)/ / / Agent / / Broker-Dealer Firm
Participant(s)
From:
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To:
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SOCIAL SECURITY CHANGE/TAX I.D. NUMBER CHANGE
/ / Annuitant / / Contract Owner/ / / Joint Owner/Participant
Participant
/ / Beneficiary / / Contingent Beneficiary
From:
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To:
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DATE OF BIRTH CHANGE
/ / Annuitant / / Contract Owner/Participant / / Joint Owner/Participant
From:
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To:
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(Signature of Contract (Signature of Joint Owner/ (Date)
Owner/Participant) Participant, if applicable)
Form HL-12524 Printed in U.S.A.
INDIVIDUAL SINGLE PREMIUM DEFERRED ANNUITY CONTRACT
HARTFORD LIFE INSURANCE COMPANY
P.O. BOX 2999
HARTFORD, CONNECTICUT 06104-2999
(A stock life insurance company, herein after called the Company)
The Company agrees with the Contract Owner to provide the benefits as described
in this contract.
Signed for the Company
/s/ Bruce D. Gardner /s/ Lowndes A. Smith
Bruce D. Gardner, Secretary Lowndes A. Smith, President
READ THIS CONTRACT CAREFULLY
This is a legal contract between the Contract Owner and the Company.
MARKET VALUE ADJUSTMENT FORMULA
This contract contains a Market Value Adjustment formula. The formula may result
in both upward and downward adjustments in the Gross Surrender Value. Details of
the Market-Value Adjustment are described on page 9.
The Market-Value Adjustment formula will not be applied when the Contract Owner
requests, In Writing:
a) a full or partial surrender at the end of any Guarantee Period if the
Company receives the request during the 30 day period preceding the end of
such Guarantee Period; or
b) any interest credited during the twelve month period prior to the written
request.
NONPARTICIPATING
RIGHT TO EXAMINE CONTRACT
The Company wants the Contract Owner to be satisfied with this contract. The
Company urges the Contract Owner to examine it closely. If for any reason the
Contract Owner is not satisfied with this contract, the Contract Owner may
surrender the contract by returning the contract within ten days after it was
purchased. A written request to surrender the contract must accompany the
contract. In such event the Company will pay the Contract Owner an amount equal
to the sum of a) Account Value on the date of surrender multiplied by the Market
Value Adjustment formula and b) any charges deducted from the purchase payment.
Form HL-12511 Printed in U.S.A.
TABLE OF CONTENTS
Page
Contract Specifications 3
Definitions 4
Purchase Payment 5
Contract Control Provisions 5
General Provisions 8
Crediting of Interest and Guarantee Periods 8
Termination Provisions 8
Settlement Provisions 10
Annuity Tables 12
Form HL-12511 Printed in U.S.A
Page 2
DEFINITIONS The definitions in this section apply to the following words and
phrases whenever and wherever they appear in this contract.
ACCOUNT VALUE -- The sum of the Purchase Payment and all interest
earned to that date; less the sum of the Gross Surrender Value of
any surrenders made to that date; and less the sum of the Annual
Contract Maintenance fees deducted to that date.
ANNUAL CONTRACT MAINTENANCE FEE -- An amount which is deducted
from the Account Value at the end of the Contract Year or on the
date of full surrender, if earlier. The amount is shown on Page 3.
ANNUITANT -- The person on whose life this contract is issued.
ANNUITY COMMENCEMENT DATE -- The date shown on page 3.
BENEFICIARY -- The person entitled to receive benefits as per the
terms of the contract in case of the death of the Annuitant or the
Contract Owner or joint Contract Owner as applicable.
COMPANY -- The Hartford Life Insurance Company.
CONTINGENT ANNUITANT -- The person designated by the Contract
Owner who, upon the Annuitant's death prior to the Annuity
Commencement Date, becomes the Annuitant.
CONTRACT DATE -- The date shown on Page 3. Contract Years are
measured from the Contract Date.
CONTRACT OWNER -- The owner(s) of the contract.
CURRENT RATE -- The applicable interest rate contained in a
schedule of rates established by the Company from time to time
for various durations.
DUE PROOF OF DEATH -- A certified copy of the death certificate,
an order of a court of competent jurisdiction, a statement from a
physician who attended the deceased, or any other proof acceptable
to the Company.
GROSS SURRENDER VALUE -- The portion of the Account Value
specified by the Contract Owner for a full or partial surrender.
GUARANTEE PERIOD --The period for which either an initial or
Subsequent Guarantee Rate is credited.
HOME OFFICE OF THE COMPANY -- Currently located at 200 Hopemeadow
St., Simsbury, CT. All correspondence concerning this contract
should be sent to our mailing address at P.O. Box 2999, Att:
Individual Annuity Operations, Hartford CT 06104-2999.
INITIAL GUARANTEE RATE -- The rate of interest credited to a
Purchase Payment as described in the Crediting of Interest and
Guarantee Periods section. This rate of interest is specified on
page 3.
IN WRITING -- A written form satisfactory to the Company and
received at their Home Office as defined.
Page 4
DEFINITIONS NET SURRENDER VALUE -- The amount payable to the Contract Owner on
(CONTINUED) full surrender or partial surrender under this contract after the
application of any contract charges and/or Market Value Adjustment.
It is described in the General Surrenders section of the
Termination Provisions.
PREMIUM TAX -- The amount of tax, if any, charged by the state or
municipality on purchase payments, from Gross Surrender Value upon
Surrender, or from the amount applied to effect an annuity.
SUBSEQUENT GUARANTEE RATE -- The rate of interest established by
the Company for the applicable Subsequent Guarantee Period, but
in no event less than 3%.
SURRENDER DATE -- The date the Company receives the Contract
Owner's written request for a surrender or the date requested
for surrender by the Contract Owner, if later.
PURCHASE
PAYMENT PURCHASE PAYMENT -- The Purchase Payment is shown on Page 3.
Purchase Payments are payable at the designated office(s) of the
Company. The Company reserves the right to limit the amount of the
Purchase Payment which will be accepted.
CONTRACT ALLOCATION OF PURCHASE PAYMENT
CONTROL
PROVISIONS The Purchase Payment (less applicable Premium Taxes, if any)
will be allocated to an account established by the Company for
the Contract Owners of those contracts. A Contract Owner's
Account Value will be determined in accordance with the terms of
this contract.
ANNUITANT, CONTINGENT ANNUITANT, AND PARTICIPANT
The Annuitant may not be changed
The designations of Contract Owner and Contingent Annuitant will
remain in effect until changed by the Contract Owner. Changes in
the designation of the Contract Owner may be made during the
lifetime of the Annuitant by written notice to the Company. Changes
in the designation of the Contingent Annuitant may be made at any
time prior to the Annuity Commencement Date by written notice to
the Company. Notwithstanding the foregoing, if no Contingent
Annuitant has been named and the Contract Owner/Annuitant's spouse
is the Beneficiary, it will be assumed that the Contract
Owner/Annuitant's spouse is the Contingent Annuitant.
The Contract Owner has the sole power to exercise all rights,
options and privileges granted by this contract or permitted by
The Company and to agree with the Company to any change in or
amendment to the contract. The rights of the Contract Owner shall
be subject to the rights of any assignee of record with the Company
and of any irrevocably designated Beneficiary. In the case of joint
Contract Owners, each Contract Owner alone may exercise all rights,
options and privileges, except with respect to Termination
Provisions.
Form HL-12514 Printed in U.S.A
Page 5
BENEFICIARY
GENERAL The Designated Beneficiary will remain in effect until changed by
CONTROL the Contract Owner. Changes in the designated Beneficiary may be
PROVISIONS made during the lifetime of the Annuitant by written notice to the
(CONTINUED) Company. If the designated Beneficiary has been designated
irrevocably, however, such designation cannot be changed or
revoked without such Beneficiary's written consent. Upon receipt
of such notice and written consent, if required, at the Home
Office of the Company, the new designation will take effect as of
the date the notice is signed, whether or not the Annuitant or
Contract Owner is alive at the time of receipt of such notice.
The change will be subject to any payments made or other action
taken by the Company before the receipt of the notice.
In the event of the death of the Annuitant when there is no
surviving Contingent Annuitant the Beneficiary will be as follows.
If the Annuitant is a joint Contract Owner and the death of the
Annuitant occurs prior to the Annuity Commencement Date, the
Beneficiary shall be the surviving Contract Owner, notwithstanding
that the Designated Beneficiary may be different. Otherwise, the
Beneficiary will be the Designated Beneficiary then in effect. If
there is no Designated Beneficiary in effect or if the Designated
Beneficiary is no longer living, the Contract Owner will be the
Beneficiary. If the Annuitant is the sole Contract Owner and there
is no Designated Beneficiary in effect, the Annuitant's estate will
be the Beneficiary.
In the event of the death of the Contract Owner prior to the
Annuity Commencement Date, the Beneficiary will be as follows.
Upon the death of the joint Contract Owner, the Beneficiary
will be the surviving joint Contract Owner, notwithstanding
that the Designated Beneficiary may be different. If the Contract
Owner was the sole Contract Owner, the Beneficiary shall be the
Designated Beneficiary then in effect. If no Beneficiary
designation is in effect or if the Designated Beneficiary has
predeceased the Contract Owner, the Contract Owner's estate will
be the beneficiary. At the first death of a joint Contract
Owner prior to the Annuity Commencement Date, the Beneficiary
shall be the surviving Contract Owner notwithstanding that the
Designated Beneficiary may be different.
GENERAL
PROVISIONS
THE CONTRACT
The contract, endorsements and application, if any, constitute the
entire contract.
MINIMUM VALUE STATEMENT
Any values available under the Termination or Surrender Provisions
of this contract equal or exceed those required by the state in
which the contract is delivered.
Page 6
MODIFICATION
GENERAL The only way the contract may be modified is by a written agreement
PROVISIONS with the Contract Owner signed by our President, or one of our Vice
(CONTINUED) Presidents, Secretaries, or Assistant Secretaries. No modification
will affect the amount or term of any annuity begun prior to the
modification unless it is required to conform the contract to any
Federal or State statute. No modification of the contract will
affect the method by which the Contract Owners' Account Value will
be determined.
MISSTATEMENT OF AGE AND SEX
If the age and/or sex of the Annuitant is incorrectly stated, death
benefits or annuity payments will be adjusted to the payment which
would have been provided at the correct age and sex adjusted for
any overpayments or underpayments which had been made. The adjusted
annuity payment or death benefit will include interest of 3-1/2% in
the event of an underpayment or will deduct interest of 3-1/2% in
the event of an overpayment.
INCONTESTIBILITY
We cannot contest this contract from the date of issue.
CHANGE OF ANNUITY COMMENCEMENT DATE
The Contact Owner may change the Annuity Commencement Date provided
the Company is notified In Writing 30 days before the proposed
Annuity Commencement Date; and the proposed date selected is on or
before the Annuitant's attained age 90.
NON-PARTICIPATING
This contract is nonparticipating. It does not earn dividends.
ANNUAL REPORT
The Contract Owner will receive a report once each Contract Year
showing the Account Value of this contract and any other
information required by the Department of Insurance.
TRANSFER BETWEEN GUARANTEE PERIODS
Once each Contract Year, the Contract Owner may elect, In Writing
to transfer out of the current Guarantee Period and into a
Guarantee Period of different duration. At that time, a new
Guarantee Period will be established for the duration chosen by the
Contract Owner, and the Account Value at the beginning of the new
Guarantee Period will equal the Account Value for the current
Guarantee Period multiplied by the Market Value Adjustment for the
current Guarantee Period. The Company reserves the right to charge
for any such transfer by reducing the Account Value at the
beginning of the new Guarantee Period by an amount not to exceed
$50.00.
Form HL-12569 Printed in U.S.A
Page 7
GENERAL
PROVISIONS Surrender charges will continue to be based on the appropriate
(CONTINUED) Contract Year as determined from the original Contract Date.
CREDITING OF
INTEREST
AND GUARANTEE
PERIODS The Purchase Payment (less the Gross Surrender Value of all
surrenders made and less applicable Premium Taxes, if any) will
earn interest at the Initial Guarantee Rate, compounded annually,
during the Initial Guarantee Period.
At the end of any Guarantee Period, a subsequent Guarantee Period
of the same duration will commence, unless the Contract Owner has:
a) requested, In Writing, a surrender within 30 days prior to
the end of the current Guarantee Period; or
b) elected, In Writing, a Guarantee Period of a different
duration from among those offered by the Company at any time
within 30 days prior to the end of the current Guarantee
Period; or
c) selected a subsequent Guarantee Period that extends beyond
the Annuity Commencement Date then in effect. In this case,
the Company will automatically establish a subsequent
Guarantee Period that will end nearest to the Annuity
Commencement Date then in effect, unless the Contract Owner
elects, In Writing, for a subsequent Guarantee Period of
shorter duration.
The Account Value at the beginning of any subsequent Guarantee
Period will be equal to the Account Value at the end of the
Guarantee Period just ending. The Account Value will earn interest
at the Subsequent Guarantee Rate, compounded annually, in the
subsequent Guarantee Period. This rate will be at least equal to
the Initial Guarantee Rates being credited to Purchase Payments
for new contracts at the time the Subsequent Guarantee Rate is
determined.
The initial Guarantee Rate and the Subsequent Guarantee Rate
will never be less than 3%. Surrenders made during a Guarantee
Period will be subject to a Market Value Adjustment.
TERMINATION
PROVISIONS GENERAL SURRENDERS
Full surrenders may be made under this contract at any time.
Partial surrenders may only be made if:
a) The Gross Surrender Value is at least $1,000; and
b) the remaining Account Value after the Gross Surrender Value
has been deducted is at least $5,000.
Page 8
TERMINATION
PROVISIONS In the case of all surrenders, the Account Value will be reduced
(CONTINUED) by the Gross Surrender Value on the Surrender Date and the Net
Surrender Value will be payable to the Contract Owner. Except as
provided for in the Special Surrender Section, the Net Surrender
Value is calculated by the Company on a daily basis as follows:
(A - B) X C, where:
A = the Gross Surrender Value reduced by any applicable Annual
Contract Maintenance Fee;
B = The surrender charge, shown on Page 3, plus any unpaid
Premium Taxes;
C = the Market Value Adjustment described below.
MARKET VALUE ADJUSTMENT
The formula which will be used to determine the Market Value
Adjustment is calculated by the Company on a daily basis as
follows:
_ _ N/12
| 1 + I |
| ----- |
|_ 1 + J _|
I = Guarantee Rate in effect for the Current Guarantee Period
(expressed as a decimal, e.g., - 1% = .01).
J = The Current Rate (expressed as a decimal, e.g. - 1% = .01) in
effect for durations equal to the number of years remaining in
the current Guarantee Period (years are rounded to the next
highest number of years). If not available, the Company will
utilize a rate equal to the most recent Moody's Corporate Bond
Yield Average - Monthly Average Corporates (for the applicable
duration) as published by Moody's Investors Service, Inc. In
the event the Moody's Corporate Bond Yield Average - Monthly
Average Corporates is no longer available, a suitable
replacement index, subject to the approval of the Insurance
Department, would be utilized.
N = The number of complete months from the Surrender Date to the
end of the current Guarantee Period.
SPECIAL SURRENDERS
A full or partial surrender made at the end of a Guarantee Period
may be subject to a surrender charge as set forth on page 3. A
Market Value Adjustment will not be applied. A request for a
surrender at the end of a Guarantee Period must be received In
Writing during the 30 day period preceding the end of such
Guarantee Period.
In addition, if the Contract Owner notifies the Company, In
Writing, the Company will send the Contract Owner any interest
credited during the twelve month period prior to the written
request. No Surrender Charge or Market Value Adjustment will be
imposed on such interest payments.
TERMINATION AFTER THE ANNUITY COMMENCEMENT DATE
This contract may not be surrendered after the commencement of
annuity payments.
Form HL-12517 Printed in U.S.A
Page 9
PAYMENT UPON SURRENDER -- DEFERRAL OF PAYMENT
TERMINATION
PROVISIONS The Company may defer payment of a partial or full surrender
(CONTINUED) request for up to six months from the date of the request. If
payment is deferred for more than 10 days from the date the request
is received, the Company will pay interest of 4-1/2% or the
interest rate currently being paid on proceeds left under the
interest settlement option, whichever is higher, on the amount
deferred.
DEATH BENEFIT
If the Annuitant dies prior to the Annuity Commencement Date and
there is no designated Contingent Annuitant surviving, or if the
Contract Owner dies before the Annuity Commencement Date, the death
benefit will be payable to the Beneficiary as determined under the
Control Provisions. The death benefit equals the Account Value as
of the date the Company receives written notification of Due Proof
of Death.
The death benefit will be due and payable within a reasonable
period of time (not to exceed 6 months) after the date of the
Company's receipt of Due Proof of Death. The death benefit may be
taken in one sum or under any of the settlement options then being
offered by the Company provided, however, that, in the event of a
Contract Owner's Death, any settlement option must provide that any
amount payable as a death benefit will commence upon notification
of Due Proof of Death and be completed within five years of the
date of death or, if the benefit is payable over a period not
extending beyond the life expectancy of the Beneficiary or over the
life of the Beneficiary, such distribution must commence within one
year of the date of death. Notwithstanding the foregoing, in the
event of the Contract Owner's death where the sole Beneficiary is
the spouse of the Contract Owner and the Annuitant or Contingent
Annuitant is living, such spouse may elect, in lieu of receiving
the death benefit, to be treated as the Contract Owner.
SETTLEMENT
PROVISIONS ANNUITY BENEFIT
On the Annuity Commencement Date, unless directed otherwise, the
Company will apply the Contract Owner's Account Value multiplied by
the Market Value Adjustment, if any, less any applicable Premium
Taxes, to purchase the monthly income payments according to the
Annuity Option elected. If the Annuity Commencement Date coincides
with the end of any Guarantee Period, no Market Value Adjustment
will be applied in the determination of the monthly income
payments. No surrender charge will be applied upon annuitization.
In no event will the annuity benefit, at the time of its
commencement, be less than that which would be provided by applying
the greater of the Net Surrender Value or 95 percent of what the
Net Surrender Value would be with no surrender charge, to purchase
a single premium immediate annuity contract offered by the Company
at that time to the same class of annuitants.
Page 10
ELECTION OF ANNUITY OPTIONS
SETTLEMENT
PROVISIONS The Contract Owner may elect any of the Annuity Options described
(CONTINUED) below or any other Annuity Option being offered by the Company at
the time of Annuitization. In the absence of such election, the
second option providing a life annuity with 120 monthly payments
certain will apply.
Election of any of these options must be made In Writing to the
Company at least 30 days prior to the date such election is to
become effective.
DATE OF PAYMENT
The first payment under any option shall be made on the tenth day
of the month following the Annuity Commencement Date. Subsequent
payments shall be made on the tenth day of each month in accordance
with the manner of payment selected.
The Contract Owner, or in the event the Contract Owner has not done
so, the Beneficiary after the death of the Annuitant, may elect, in
lieu of payment in one sum, any amount or part thereof due by the
Company under this contract to the Beneficiary will be applied
under any of the options described below. Such election must be
made within one year after the death of the Annuitant by written
notice to the offices of the Company.
DEATH OF ANNUITANT
In the event of the death of the Annuitant while receiving annuity
payments, the present values of the current dollar amount on the
date of death of any remaining guaranteed number of payments, or
any then remaining balance of proceeds under the Fifth Option will
be paid in one sum to the Beneficiary unless other provisions shall
have been made and approved by the Company. However, if the
Contract Owner was also the Annuitant, any method of distribution
must provide that any amount payable as a death benefit will be
distributed at least as rapidly as under the method of distribution
in effect at the Contract Owner's death. Calculations of such
present value of the guaranteed payments remaining will be based on
the interest rate that is used by the Company to determine the
amount of each certain payment.
ANNUITY OPTIONS
FIRST OPTION -- Life Annuity -- An annuity payable monthly during
the lifetime of the Annuitant, ceasing with the last payment due
prior to the death of the Annuitant.
SECOND OPTION -- Life Annuity -- with 120, 180, or 240 Monthly
Payments Certain - An annuity providing monthly income to the
Annuitant for a fixed period of 120 months, 180 months, or 240
months (as selected), and for as long thereafter as the Annuitant
shall live.
THIRD OPTION -- Cash Refund Life Annuity -- An annuity payable
monthly during the lifetime of the Annuitant, ceasing with the last
payment due prior to the death of the Annuitant provided that, at
the death of the Annuitant the beneficiary will receive an
additional payment equal to the excess, if any, of (a) over (b)
where: (a) is the Account Value applied on the Annuity Commencement
Date under this option; and (b) is the dollar amount of annuity
payments already paid.
Form HL-12519 Printed in U.S.A
Page 11
SETTLEMENT
PROVISIONS
(CONTINUED) FOURTH OPTION -- Joint and Last Survivor Life Annuity -- An annuity
payable monthly during the joint lifetime of the Annuitant and a
secondary payee, and thereafter during the remaining lifetime of
the survivor, ceasing with the last payment prior to the death of
the survivor.
FIFTH OPTION -- Payments for a designated Period -- An amount
payable monthly for the number of years selected which may be from
5 to 30 years.
ANNUITY
TABLES The attached tables show the dollar amount of the monthly payments
for each $1,000 applied under the five options. Under the First,
Second, or Third Options, the amount of each payment will depend
upon the age and sex of the Annuitant at the time the first payment
is due. Under the Fourth Option, the amount of each payment will
depend upon the sex of both payees and their ages at the time the
first payment is due.
MINIMUM PAYMENT
The option elected must result in a payment of at least $20.00. If
at any time payments are less than $20.00, the Company has the
right to change the frequency to an interval resulting in a payment
of at least $20.00. If any amount due is less than $20.00 per year,
the Company may make other arrangements that are equitable to the
Annuitant.
DESCRIPTION OF TABLES
The tables for the First, Second, Third and Fourth Options are
based on the 1983a Individual Annuity Mortality table with ages
set back one year and a net investment rate of 4% per annum. The
Table for the Fifth Option is based on a net investment rate of 4%
per annum.
Page 12