METLIFE INSURANCE COMPANY OF CONNECTICUT
- [ 1300 HALL BOULEVARD, BLOOMFIELD, CT - 06002]
A STOCK COMPANY
If You have any questions concerning Your Contract, please contact Us at
[1-800-842-8573.]
We are pleased to provide You the benefits of this annuity Contract. Please read
all attached forms carefully.
This Contract is issued in consideration of the purchase payment. It is subject
to the terms and conditions stated on the attached pages, all of which are a
part of it.
RIGHT TO EXAMINE THIS CONTRACT
IF THIS CONTRACT IS RETURNED TO US AT OUR OFFICE OR TO OUR AGENT TO BE
CANCELED WITHIN 10 DAYS AFTER ITS DELIVERY TO YOU, WE WILL PAY YOU THE
MARKET ADJUSTED VALUE PLUS ANY PREMIUM TAX OR CONTRACT CHARGES WITHIN 10
DAYS AFTER ITS RETURN. AFTER THE CONTRACT IS RETURNED, IT WILL BE
CONSIDERED AS IF IT WERE NEVER IN EFFECT.
Executed at [Bloomfield, Connecticut]
[/s/ Michael Farrell]
President
This is a legal contract between You and Us. PLEASE READ YOUR CONTRACT CAREFULLY.
SINGLE PREMIUM INDIVIDUAL MODIFIED GUARANTEED ANNUITY CONTRACT
ELECTIVE OPTIONS NON-PARTICIPATING
THE CASH SURRENDER VALUE MAY INCREASE OR DECREASE IN ACCORDANCE WITH THE MARKET
VALUE ADJUSTMENT FORMULA ON THE CONTRACT SPECIFICATIONS PAGE. THE CASH SURRENDER
VALUE IS AVAILABLE WITHOUT APPLICATION OF THE MARKET VALUE ADJUSTMENT AT THE END
OF A GUARANTEE PERIOD.
The Market Value Adjustment formula will not be applied when You submit a
Written Request for a full or partial surrender at the end of any Guarantee
Period if We receive the request within the 30 day period prior to the end of
such Guarantee Period.
TABLE OF CONTENTS
[Contract Specifications Page 3
Definitions Page 5
Purchase Payment Page 6
Contract Control Provisions Page 6
Crediting of Interest and Guarantee Periods Page 7
Market Value Adjustment Page 7
Transfer Between Guarantee Periods Page 7
Termination Provisions Page 8
Settlement Provisions Page 8
General Provisions Page 11
Life Annuity Tables Page 13 - 14]
Any Riders or Endorsements follow the Life Annuity Tables.
Page 2
CONTRACT SPECIFICATIONS
CONTRACT OWNER [JOHN DOE]
[JOINT CONTRACT OWNER] [JOHN DOE]
ANNUITANT [JOHN DOE]
[CONTINGENT ANNUITANT] [JOHN DOE]
CONTRACT NUMBER [SPECIMEN] [12/01/07] CONTRACT DATE
[12/01/2026] ANNUITY COMMENCEMENT DATE
PURCHASE PAYMENT $[10,000.00]
INITIAL GUARANTEE PERIOD [7 YEARS]
INITIAL INTEREST RATE [5.00%]
MINIMUM GUARANTEED INTEREST RATE [3.00%]
PURCHASE PAYMENT/TERMINATION AMOUNT:
Minimum Purchase Payment Amount: [$5,000]
Maximum Purchase Payment Amount: [$1,000,000] unless We consent to a larger amount
Termination Amount: $2,000
MARKET VALUE ADJUSTMENT FORMULA:
A Market Value Adjustment will be applied when a surrender occurs prior to the
end of a Guarantee Period. The Market Value Adjustment is the difference between
the Account Value and the Market Adjusted Value.
Market Adjusted Value = (Maturity Value) x [ 1/(1 + ic)] (t/365)
ic = the current Guaranteed Interest Rate (straight line interpolation between
whole years) that We are then crediting for a Guarantee Period of t days on this
class of Contract(s). The Guaranteed Interest Rate will not be less than the
minimum guaranteed interest rate shown above.
t = the number of days remaining in the Guarantee Period adjusting for leap
years.
SURRENDER CHARGE:
During the first seven years after a purchase payment is applied under the
Contract, the surrender charge may be deducted from any amount surrendered. This
charge is a percentage of the Cash Value surrendered from a Contract.
CONTRACT YEARS
SINCE PAYMENT
WAS APPLIED SURRENDER CHARGE
-------------- ----------------
1 7%
2 6%
3 5%
4 4%
5 3%
6 2%
7 1%
THEREAFTER 0%
No surrender charge will apply at the end of an initial Guarantee Period of at
least three years. Initial Guarantee Periods of one or two years are subject to
a surrender charge for a period of five years.
Page 3
FREE WITHDRAWAL AMOUNT:
Interest credited in the previous Contract Year may be withdrawn without a
Market Value Adjustment or a surrender charge.
ANNUITY COMMENCEMENT DATE:
If no Annuity Commencement Date is specified, the automatic Annuity Commencement
Date will be the greater of when the Annuitant reaches Age 90 or ten years after
the Contract Date. Additionally, to the extent permitted by law, at least 30
days before the original Annuity Commencement Date, You may change the Annuity
Commencement Date by Written Request to any time prior to the Annuitant's 90th
birthday, or ten years after the Contract Date, or, if we agree, to a later date
not to exceed the Annuitant's 95th birthday, subject to the laws and regulations
then in effect.
AUTOMATIC RENEWAL GUARANTEE PERIOD:
A [one year] Guarantee Period.
SEPARATE ACCOUNT:
MetLife of CT Separate Account MGA
Page 4
DEFINITIONS
(a) ACCOUNT VALUE - The sum of the purchase payment and all interest credited
to that date, less the sum of all partial surrenders, surrender charges,
and applicable premium tax deducted to that date.
(b) ANNUITANT - The person on whose life this Contract is issued and on whose
life the annuity payments are made.
(c) ANNUITY COMMENCEMENT DATE - The date shown on the Contract Specifications
page, but in no instance shall the Annuity Commencement Date be later than
ten years after the Contract Date, or, if we agree, to a later date not to
exceed the Annuitant's 95th birthday, subject to the laws and regulations
then in effect.
(d) BENEFICIARY(IES) - The person(s) entitled to receive benefits after Your
Death or the death of the Annuitant.
(e) CASH SURRENDER VALUE - The Cash Value less surrender charges and any
applicable premium tax.
(f) CASH VALUE - The Account Value at the end of a Guarantee Period or the
Market Adjusted Value before the end of a Guarantee Period.
(g) CONTRACT - The Contract provided to You, the Contract Owner, which
describes the benefits, rights, and obligations of You and Us.
(h) CONTRACT DATE - The date shown on the Contract Specifications page on which
the Contract is issued.
(i) CONTRACT YEAR(S) - The twelve month period(s) beginning with the Contract
Date.
(j) DUE PROOF OF DEATH - A copy of a certified death certificate; a copy of a
certified decree of a court of competent jurisdiction as to the finding of
death; a written statement by a medical doctor who attended the deceased;
or any other proof satisfactory to Us.
(k) GUARANTEED INTEREST RATE - The annual effective interest rate credited to a
purchase payment during the Guarantee Period as described in the Crediting
of Interest and Guarantee Periods section.
(l) GUARANTEE PERIOD - The period for which either an initial or subsequent
Guarantee Interest Rate is credited.
(m) MARKET ADJUSTED VALUE - Reflects the relationship on the Surrender Date
between the current Guaranteed Interest Rate for the duration remaining in
the Guarantee Period and the Guaranteed Interest Rate that applies to Your
Contract.
(n) MARKET VALUE ADJUSTMENT - The difference between the Account Value and the
Market Adjusted Value.
(o) MATURITY VALUE - The accumulated value of a purchase payment at the
Guaranteed Interest Rate at the end of the Guarantee Period selected less
any partial surrenders, surrender charges, and applicable premium tax
previously deducted.
(p) OUR OFFICE - the Home Office of MetLife Insurance Company of Connecticut or
any other office which We may designate for the purpose of administering
this Contract. All correspondence regarding this Contract should be sent to
Our mailing address stated on the cover page of this Contract.
(q) SURRENDER DATE - The date We receive Your Written Request for a surrender
or the date You request the surrender to be effective, if later.
(r) WE, US, OUR - MetLife Insurance Company of Connecticut.
(s) WRITTEN REQUEST - written information including requests for Contract,
beneficiary, ownership, transfers, surrenders or other changes sent to Us
in a form and content satisfactory to Us and received in good order at Our
Office. Requests for changes are subject to any action taken prior to our
receipt of the written information.
(t) YOU, YOUR - the contract owner, including any joint contract owner as named
on the Contract Specifications Page.
Page 5
PURCHASE PAYMENT PROVISIONS
PURCHASE PAYMENT
The purchase payment is a payment You make to this Contract for the benefits it
provides. A lump sum purchase payment must be made to the Contract and is due
and payable before the Contract becomes effective. The purchase payment is
payable to Us at Our Office; the minimum and maximum purchase payment amounts
are shown in the Contract Specifications.
SEPARATE ACCOUNT
Purchase payments made to this Contract are invested in the Separate Account
shown on the contract specifications page. We have exclusive and absolute
ownership and control of the assets of the Separate Account. It is a
non-unitized separate account and, to the extent such assets are attributable to
Your purchase payments, it is not chargeable with liabilities arising out of any
other business that We may conduct. You do not share in the investment
performance of assets allocated to the Separate Account. Income, gains and
losses, whether or not realized, from assets allocated to the Separate Account
shall be charged against the Separate Account without regard to Our other
income, gains or losses. The obligations under this Contract are independent of
the investment performance of the Separate Account and are Our obligations.
We will maintain assets with an aggregate market value at least equal to the
greatest of:
(i) an amount equal to the aggregate cash surrender values of the
contracts funded by the Account (as adjusted by the market-value
adjustment formula)
(ii) an amount equal to the reserves of the contracts funded by the Account
(iii) an amount of assets deemed by the qualified actuary to be sufficient
to make good provision for the contract liabilities.
If the aggregate market value of such assets in the Separate Account should fall
below such amount, We will establish a liability payable to the Account so that
the aggregate market value for the Account's assets is at least equal to such
amount.
PREMIUM TAX
The premium tax is the amount of tax, if any, charged by the state or
municipality on a purchase payment, on the Cash Value upon surrender, or on the
amount applied to elect an annuity option. We will deduct any applicable premium
tax from the Cash Value either upon death, surrender, annuitization or at the
time the purchase payment is made, but no earlier than when We have a tax
liability under law.
ALLOCATION OF PURCHASE PAYMENT
The purchase payment (less applicable premium tax, if any) will be allocated to
an account established for You by Us. Account Values will be determined in
accordance with the terms of this Contract.
CONTRACT CONTROL PROVISIONS
OWNER
This Contract belongs to You or to any person subsequently named in a Written
Request of "Transfer of Ownership" as provided below. As Contract owner, You
have sole power during the Annuitant's lifetime to exercise any rights and to
receive all benefits given in this Contract, provided You have not named an
irrevocable beneficiary and provided the Contract is not assigned.
You will be the recipient of all payments while the Annuitant is alive unless
You direct them to an alternate recipient by Written Request. An alternate
recipient does not become the owner. An alternate payment directive is revocable
by You at any time by giving Us 30 days advance notice by Written Request.
JOINT CONTRACT OWNERS
Joint Contract owners may be named in a Written Request prior to the Contract
Date. All rights of Contract ownership must be exercised by joint action. Joint
Contract owners own equal shares of any benefits accruing or payments made to
them. All rights of a joint Contract owner end at death if another joint
Contract owner survives. The entire interest of the deceased joint Contract
owner in this Contract will pass to the surviving joint Contract owner, unless
the deceased joint Contract owner was also the Annuitant.
If a joint Contract owner dies before payment of an annuity option begins and is
survived by the Annuitant, any surviving joint Contract owner is the "designated
beneficiary" referred to in Section 72(s) of the Code, and his or her rights
pre-empt those of the beneficiary named in a Written Request. Upon the death of
a joint Contract owner who is the Annuitant, the entire interest will pass to
the beneficiary(ies).
Page 6
TRANSFER OF OWNERSHIP
You may transfer ownership by Written Request, subject to Our approval. You may
not revoke any transfer of ownership after the effective date of such transfer.
The transfer of owner will take effect as of the date of your Written Request,
subject to any payments made or other actions taken by us before its receipt.
Until a new beneficiary is designated, a transfer of ownership does not affect
the interest of any beneficiary designated prior to the effective date of the
transfer.
A transfer of ownership may have tax consequences to You; please consult Your
tax advisor.
ASSIGNMENT
To the extent permitted by law, You may collaterally assign ownership of all or
a portion of this Contract by Written Request without the approval of any
beneficiary unless irrevocably named. You may not exercise any rights of
ownership while the assignment remains in effect without the approval of the
collateral assignee. We are not responsible for the validity of any assignment.
The collateral assignment will take effect as of the date of your Written
Request, subject to any payments made or other actions taken by Us before the
Written Request is received.
If a claim is made based on an assignment, We may require proof of interest of
the claimant. An assignment takes precedence over any rights of a beneficiary.
Any amounts due under an assignment will be paid in a single sum.
An assignment may have adverse tax consequences to You; please consult Your tax
advisor.
CREDITOR CLAIMS
To the extent permitted by law, no right or benefit of the owner or beneficiary
under this Contract shall be subject to the claims of creditors or any legal
process except as may be provided by an assignment.
BENEFICIARY
The Beneficiary is the party named in a Written Request. The Beneficiary has the
right to receive any remaining Contract benefits upon the death of the
Annuitant, or under certain circumstances, upon the death of the Contract Owner.
If there is more than one Beneficiary surviving the Annuitant, the Beneficiaries
will share equally in benefits unless different shares are received by Us by
Written Request prior to the death of the Annuitant.
If a Joint Contract Owner dies before payment of an Annuity Option begins and is
survived by the Annuitant, any surviving Joint Contract Owner is the "designated
beneficiary" referred to in Section 72(s) of the Code, and his or her rights
pre-empt those of the Beneficiary named in a Written Request.
Unless an irrevocable Beneficiary has been named, You have the right to change
any Beneficiary by Written Request during the lifetime of the Annuitant and
while the Contract continues.
A change in Beneficiary will take effect as of the date of the Written Request,
subject to any payments made or other actions taken by Us before We receive the
Written Request.
If no Beneficiary has been named by You, or if no Beneficiary is living when the
Annuitant dies, the interest of any Beneficiary will pass:
a) if You are living, to You; or
b) if You have died and there is a surviving Joint Contract Owner, to the
Joint Contract Owner; or
c) if You have died and there is not a Joint Contract Owner surviving, to
Your estate.
ANNUITANT
The Annuitant is the individual shown on the Contract Specifications page on
whose life the annuity payments are made. The Annuitant may not be changed after
the Contract Date.
CONTINGENT ANNUITANT
You may name one individual as a contingent Annuitant by Written Request prior
to the Contract Date, provided the owner is not a trust. A contingent Annuitant
may not be changed, deleted or added to the Contract after the Contract Date.
Page 7
If the Annuitant (who is not the owner) dies prior to the Maturity Date while
this Contract is in effect and while the contingent Annuitant is living:
a. the death benefit will not be payable upon the Annuitant's death;
b. the contingent Annuitant becomes the Annuitant; and
c. all other rights and benefits provided by this Contract will continue
in effect.
When a contingent Annuitant becomes the Annuitant, the Maturity Date remains the
same as previously in effect, unless otherwise provided.
CREDITING OF INTEREST AND GUARANTEE PERIODS
The purchase payment (less surrenders made and less applicable premium tax, if
any) will earn interest at the initial Guaranteed Interest Rate during the
initial Guarantee Period. The initial Guaranteed Interest Rate will never be
less than the amount shown on the Contract Specifications page. All interest
earned will be credited daily. This compounding effect is reflected in the
Guaranteed Interest Rates.
Within 60 days of the end of any Guarantee Period, We will notify You about
selecting a subsequent Guarantee Period. If no election is made, the automatic
renewal guarantee period as stated on the Contract Specifications page will
commence, unless You have:
a. submitted a Written Request for a full surrender which we receive
within 30 days prior to the end of the current Guarantee Period; or
b. elected by Written Request a Guarantee Period of a different duration
from among those offered by Us 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, We will automatically
establish a subsequent Guarantee Period that will end nearest to the
Annuity Commencement Date then in effect, unless You elect by Written
Request a subsequent Guarantee Period of shorter duration.
At any time during the automatic renewal guarantee period, You may transfer to a
Guarantee Period of a different duration without incurring a surrender charge or
Market Value Adjustment.
The Account Value at the beginning of any subsequent Guarantee Period will be
equal to the Account Value at the end of the Guaranteed Period just ending. The
Account Value will earn interest at the subsequent Guaranteed Interest Rate
during the subsequent Guarantee Period. There is a minimum renewal Guaranteed
Interest Rate that will not be less then the minimum Guaranteed Interest Rate
shown on the Contract Specifications pages. However, this rate will be at least
equal to the initial Guaranteed Interest Rate being credited to purchase
payments for new Contracts at the time the subsequent Guaranteed Interest Rate
is determined. In the event that current Guaranteed Interest Rates can no longer
be determined for this class of Contracts, the procedure used to derive the
current Guaranteed Interest Rate used in the Market Value Adjustment formula
will consider the then current yield of a Treasury Security which possesses the
same duration as that remaining until the end of the current guarantee period.
Though the procedure will consider the then current yields of Treasury
Securities, current Guaranteed Interest Rates will be set at Our discretion.
However, current Guaranteed Interest Rates will never be less than the minimum
Guaranteed Interest Rate shown on the Contract Specifications pages. The
procedure referenced above is on file with the New York Insurance Department.
Any change in this procedure will be filed with the New York Insurance
Department prior to implementation.
MARKET VALUE ADJUSTMENT
This Contract contains a Market Value Adjustment formula. The formula will
result in upward or downward adjustments in the amount payable on any full or
partial surrender made prior to the end of any Guarantee Period. Details of the
Market Value Adjustment formula are described on the Contract Specifications
page.
The Market Value Adjustment formula will not be applied when You submit a
Written Request for:
a. a full or partial surrender at the end of any Guarantee Period if We
receive the request within the 30 day period prior to the end of such
Guarantee Period; or
b. any interest credited during the previous Contract Year.
c. a transfer to a Guarantee Period of a different duration, during the
automatic renewal period.
Page 8
d. payments that satisfy the maximum requirement for the minimum
distribution program, if You participate in Our minimum distribution
program. Additionally, these payments through the minimum distribution
program will not be subject to a surrender charge.
We will send a notice to You at least 15 but not more than 45 days prior to the
beginning of the 30 day period in which You may request a full or partial
surrender without imposition of a Market Value Adjustment.
TRANSFER BETWEEN GUARANTEE PERIODS
Once each Contract Year after the first Contract Year, You may elect by Written
Request to transfer out of the current Guarantee Period and into a Guarantee
Period of a different duration. At that time, a new Guarantee Period will be
established for the duration You choose, and the Account Value at the beginning
of the new Guarantee Period will equal the Market Adjusted Value for the current
Guarantee Period at the time of the transfer. There is no surrender charge for
this transfer.
Surrender charges will continue to be based on the appropriate Contract Year as
determined from the original Contract Date.
TERMINATION PROVISIONS
GENERAL SURRENDERS
Full and partial surrenders may be made under this Contract at any time except
to the extent described in the qualification rider as attached. A surrender
charge may be assessed on surrenders as stated on the Contract Specifications
page.
SPECIAL SURRENDERS
No surrender charges will apply at the end of an initial Guarantee Period of at
least three years. Initial Guarantee Periods of one or two years are subject to
surrender charge for a period of five years. No surrender charge will be applied
upon annuitization, provided that annuitization occurs after the first Contract
Year. A request for a surrender at the end of a Guarantee Period must be
received by Written Request within the 30 day period prior to the end of such
Guarantee Period. The resulting income will never be less than the Account Value
applied to current purchase rates.
In addition, if You notify Us by Written Request, We will send you any interest
credited during the previous Contract Year. No surrender charge or Market Value
Adjustment will be imposed on such interest payments.
TERMINATION OF THIS CONTRACT
We reserve the right to terminate this Contract if the Account Value is less
than the termination amount shown on the Contract Specifications page after the
completion of three Contract Years. Termination will not occur until 31 days
after We have mailed notice of termination to You at Your last known address. If
the Contract is terminated, We will pay You the Account Value, if any.
TERMINATION AFTER THE ANNUITY COMMENCEMENT DATE
This Contract may not be surrendered after the commencement of annuity payments.
PAYMENT UPON SURRENDER - DEFERRAL OF PAYMENT
We may defer payment of a partial or full surrender request for up to six months
from the date of the Written Request. If payment is deferred for more than 10
working days, We will continue to credit interest in the same manner as it would
have been credited had the surrender request not been received until the date We
make the payment.
DEATH BENEFIT
If You die prior to the Annuity Commencement Date, the death benefit will be
payable to the Beneficiary as determined under the Control Provisions and under
the tax qualification requirements described in the attached rider. The death
benefit equals the Account Value as of the date We receive 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 Our receipt of Due Proof of Death.
The death benefit may be taken in one sum or under any of the annuity options
then being offered by Us.
SETTLEMENT PROVISIONS
ANNUITY BENEFIT
On the Annuity Commencement Date, unless directed otherwise, We will apply the
Account Value, or any part thereof, less any applicable premium tax, to purchase
the monthly income payments according to the annuity option elected. The annuity
option
Page 9
may be subject to the tax qualification limits described in the attached
qualification rider. In the absence of such election, We will pay You the first
of a series of periodic annuity payments based on the life of the Annuitant, in
accordance with annuity Option 2, with 120 monthly payments assured.
Election of any annuity option must be made by Written Request and received by
Us at least 30 days prior to the date such election is to become effective. Such
election must be made at least thirteen months after the Contract Date. 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 annuity
payments. The resulting income will never be less than the Account Value applied
to current purchase rates.
You may change the Annuity Commencement Date at any time, subject to the
distribution requirements described in the attached rider and the conditions
described in the Contract Specifications page, as long as such change is made by
Written Request and is received by Us at least 30 days prior to the scheduled
Annuity Commencement Date.
You, or in the event You have not done so, the Beneficiary, may elect, in lieu
of payment in one sum, that any amount due under this Contract be applied under
any of the annuity options described below. The election by the Beneficiary must
be made within one year after Your death by Written Request to Our Office, with
the exception of the sixth annuity option. The sixth annuity option must be
elected at the time Due Proof of Death is provided to Us.
DEATH OF ANNUITANT
In the event of Your death after annuity payments commence, 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
Your death.
ANNUITY OPTIONS
Option 1. 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.
Option 2. Life Annuity with 120, 180, or 240 Monthly Payments Certain - An
annuity providing monthly income to the Annuitant for a guaranteed period of 120
months, 180 months, or 240 months (as selected), and for as long thereafter as
the Annuitant shall live.
Option 3. 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 Cash Value applied on the Annuity Commencement Date under this
option; and (b) is the dollar amount of annuity payments already paid.
Option 4. Joint and Last Survivor 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.
Option 5. Payments for a Designated Period - An amount payable monthly for the
guaranteed number of years selected which may be from 5 to 30 years.
Option 6. Annuity Proceeds Settlement Option - Proceeds from the death benefit
can be left with Us for a period not to exceed five years from the date of Your
death prior to the Annuity Commencement Date. The proceeds will remain in the
same Guarantee Period and continue to earn the same Guaranteed Interest Rate in
effect at the time of death as long as this option is elected at the time Due
Proof of Death is provided to Us. If the Guarantee Period ends before the end of
the five year period, the Beneficiary may elect a new Guarantee Period with a
duration but not to exceed the time remaining in the period of five years from
the date of Your death. If no election is made, the Contract will automatically
renew for a period of one year, provided that the five year period is not
exceeded. Full or partial surrenders may be made at any time. A Market Value
Adjustment will be applied to all surrenders except those occurring at the end
of a Guarantee Period or if the previous Contract Year's interest is being
surrendered. This option is only available to Beneficiaries.
Option 7. We will make any other arrangements for annuity payments as may be
mutually agreed by You and Us.
ANNUITY TABLES
The attached tables show the dollar amount of the monthly payments for each
$1000 of proceeds applied under the five annuity options. Under options 1, 2 or
3, the amount of each payment will depend upon the age of the Annuitant at the
time the first payment is due. Under option 4, the amount of each payment will
depend upon the ages of the Annuitant and the secondary payee at the time the
first payment is due.
Page 10
BETTERMENT OF RATES
If at the due date of the first annuity payment, We have declared a higher rate
per $1,000 of proceeds applied under an annuity option or used to purchase any
single consideration immediate annuity offered by Us or one of Our affiliates,
then the annuity payments will be based on the higher rates.
Annuity payments will not be less than those that would be provided by the
application of the Cash Value to purchase a single consideration immediate
annuity contract of the same type as the settlement option elected, which is
offered by Us or our affiliates on the Maturity Date to the same class of
annuitants.
MINIMUM AMOUNT
The minimum amount that can be placed under an annuity option is $2,000 unless
We consent to a lesser amount.
MINIMUM PAYMENT
The annuity option elected must result in a payment of at least $20.00. If at
any time payments are less than $20.00, We have 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, We may make other arrangements that are
equitable to the Annuitant.
DATE OF PAYMENT
The first payment under any annuity option shall be made on the Annuity
Commencement Date. Subsequent payments shall be made on the same day of each
month in accordance with the manner of payment selected.
GENERAL PROVISIONS
THE CONTRACT
The entire Contract between You and Us consists of the Contract, and any
attached Amendments, Riders, or Endorsements.
CONTRACT CHANGES
The only way this Contract may be changed is by a written endorsement signed by
one of Our officers.
MISSTATEMENT
We may require proof of age of You or Your Beneficiary before making any
payments under this Contract that are measured by Your life or Your
Beneficiary's. If the age or sex of the measuring life has been misstated, the
amount payable will be the amount that the Account Balance would have provided
at the correct age.
Once annuity payments have begun, the amount of any overpayments or
underpayments, with interest at [6%] per annum, will be, as appropriate,
deducted from or added to the payment or payments made after the adjustment.
INCONTESTABILITY
We will not contest this Contract from its Contract Date.
REQUIRED REPORTS
We will provide a report to You as often as required by law, but at least once
in each Contract Year before the due date of the first annuity payment. The
report will show the Cash Value, the Market Adjusted Value, the Cash Surrender
Value and the Death Benefit of this Contract as of the date of the report.
MORTALITY AND EXPENSES
Our actual mortality and expense experience will not affect the amount of any
annuity payments or any other values under this Contract.
NON-PARTICIPATING
This Contract does not share in Our surplus earnings, so You will receive no
dividends under it.
CONFORMITY WITH STATE AND FEDERAL LAWS
This Contract is governed by the law of the state in which it is issued for
delivery. Any paid-up annuity, Cash Surrender Value or death benefit available
under this Contract will not be less than the minimum benefits required by the
statutes of that state.
Page 11
We may, at any time, make any changes, including retroactive changes, in this
Contract to the extent that the change is required to meet the requirements of
any law or regulation issued by any governmental agency to which We or You are
subject. Any change made by endorsement or rider will be subject to the prior
approval of the Superintendent of the State of New York.
Page 12
LIFE ANNUITY TABLES
GUARANTEED AMOUNT OF MONTHLY ANNUITY PAYMENTS
PURCHASED WITH EACH $1,000 OF PROCEEDS APPLIED
THIS TABLE WILL BE USED FOR QUALIFIED CONTRACTS
OPTIONS 1, 2, AND 3 - SINGLE LIFE ANNUITIES
NUMBER OF MONTHLY
MALE OR FEMALE PAYMENTS GUARANTEED
ADJUSTED ------------------------- CASH
AGE NONE 120 180 240 REFUND
-------------- ---- ---- ---- ---- ------
45 3.72 3.71 3.69 3.66 3.62
46 3.78 3.76 3.74 3.70 3.66
47 3.83 3.8 3.79 3.75 3.70
48 3.89 3.87 3.84 3.80 3.75
49 3.95 3.92 3.89 3.85 3.80
50 4.01 3.98 3.95 3.90 3.85
51 4.08 4.05 4.01 3.95 3.90
52 4.15 4.11 4.07 4.00 3.96
53 4.22 4.18 4.13 4.06 4.02
54 4.30 4.26 4.20 4.12 4.08
55 4.38 4.33 4.27 4.18 4.14
56 4.47 4.41 4.34 4.24 4.21
57 4.56 4.50 4.42 4.30 4.28
58 4.66 4.59 4.50 4.37 4.35
59 4.76 4.68 4.58 4.43 4.43
60 4.87 4.78 4.67 4.50 4.51
61 4.99 4.89 4.76 4.57 4.59
62 5.11 5.00 4.85 4.64 4.68
63 5.24 5.12 4.95 4.71 4.78
64 5.39 5.24 5.04 4.77 4.87
65 5.54 5.37 5.14 4.84 4.98
66 5.70 5.50 5.25 4.91 5.09
67 5.88 5.64 5.35 4.97 5.20
68 6.06 5.79 5.46 5.03 5.32
69 6.26 5.95 5.56 5.09 5.45
70 6.47 6.11 5.67 5.14 5.58
71 6.70 6.27 5.78 5.19 5.72
72 6.95 6.45 5.88 5.24 5.87
73 7.22 6.62 5.98 5.28 6.02
74 7.50 6.81 6.08 5.32 6.18
75 7.81 6.99 6.17 5.36 6.36
The listed above dollar amounts of the monthly annuity payments for the first,
second, third options are based on the equally blended male and female 1983
Individual Annuitant Mortality Table A with ages set back one year and a net
investment rate of 3% per annum. The adjusted age of the person on whose life
the life annuity is based is determined from the actual age last birthday on the
due date of the first annuity payment in the following manner:
CALENDAR YEAR IN WHICH
FIRST PAYMENT IS DUE 2001 - 2010 2011 - 2020 2021 and later
---------------------- ----------- ----------- --------------
ADJUSTED AGE IS
ACTUAL AGE MINUS 1 MINUS 2 MINUS 3
Page 13
LIFE ANNUITY TABLES
GUARANTEED DOLLAR AMOUNT OF MONTHLY ANNUITY PAYMENTS
PURCHASED WITH EACH $1,000 APPLIED
THIS TABLE WILL BE USED FOR QUALIFIED CONTRACTS
OPTION 4 - JOINT AND LAST SURVIVOR LIFE ANNUITY
ADJUSTED
AGES 45 50 55 60 65 70 75
-------- ---- ----- ---- ---- ---- ---- ----
45 3.36 3.45 3.52 3.58 3.63 3.66 3.68
50 3.45 3.57 3.67 3.77 3.84 3.90 3.94
55 3.52 .3.67 3.82 3.97 4.09 4.18 4.26
60 3.58 3.77 3.97 4.17 4.35 4.51 4.64
65 3.63 3.84 4.09 4.35 4.63 4.88 5.10
70 3.66 3.90 4.18 4.51 4.88 5.27 5.62
75 3.68 3.94 4.26 4.64 5.10 5.62 6.17
The listed above dollar amounts of the monthly annuity payments for the fourth
option are based on the equally blended male and female 1983 Individual
Annuitant Mortality Table A with ages set back one year and a net investment
rate of 3 % per annum. The adjusted age of the person on whose life the life
annuity is based is determined from the actual age last birthday on the due date
of the first annuity payment in the following manner:
CALENDAR YEAR IN WHICH
FIRST PAYMENT IS DUE 2001 - 2010 2011 - 2020 2021 and later
---------------------- ----------- ----------- --------------
ADJUSTED AGE IS
ACTUAL AGE MINUS 1 MINUS 2 MINUS 3
Page 14
LIFE ANNUITY TABLES
GUARANTEED AMOUNT OF MONTHLY ANNUITY PAYMENTS
PURCHASED WITH EACH $1,000 OF PROCEEDS APPLIED
THIS TABLE WILL BE USED FOR NONQUALIFIED CONTRACTS
OPTIONS 1, 2, AND 3 - SINGLE LIFE ANNUITIES
NUMBER OF MONTHLY
MALE PAYMENTS GUARANTEED
ADJUSTED ------------------------- CASH
AGE NONE 120 180 240 REFUND
-------- ---- ---- ---- ---- ------
45 3.87 3.85 3.82 3.77 3.72
46 3.93 3.90 3.87 3.82 3.77
47 3.99 3.96 3.92 3.87 3.82
48 4.05 4.02 3.98 3.92 3.87
49 4.12 4.09 4.04 3.97 3.92
50 4.19 4.15 4.10 4.03 3.98
51 4.27 4.22 4.17 4.08 4.04
52 4.34 4.30 4.30 4.20 4.16
53 4.43 4.37 4.30 4.20 4.16
54 4.51 4.45 4.37 4.26 4.23
55 4.60 4.54 4.45 4.32 4.30
56 4.70 4.62 4.53 4.39 4.37
57 4.80 4.72 4.61 4.45 4.44
58 4.91 4.82 4.69 4.51 4.52
59 5.03 4.92 4.78 4.58 4.61
60 5.28 5.14 4.96 4.71 4.79
61 5.28 5.27 5.06 4.78 4.88
62 5.43 5.27 5.06 4.78 4.88
63 5.58 5.39 5.16 4.84 4.98
64 5.74 5.53 5.26 4.90 5.09
65 5.91 5.66 5.36 4.96 5.20
66 6.10 5.81 5.46 5.02 5.32
67 6.30 5.96 5.56 5.08 5.44
68 6.51 6.12 5.66 5.13 5.56
69 6.73 6.28 5.77 5.18 5.70
70 6.97 6.44 5.86 5.23 5.84
71 7.23 6.61 5.96 5.27 5.99
72 7.51 6.79 6.05 5.31 6.14
73 7.80 6.96 6.14 5.34 6.30
74 8.12 7.14 6.23 5.37 6.47
75 8.43 7.32 6.31 5.40 6.65
The listed above dollar amounts of the monthly annuity payments for the first,
second and third options are based on the 1983 Individual Annuitant Mortality
Table A for males with ages set back one year and a net investment rate of 3%
per annum. The adjusted age of the person on whose life the life annuity is
based is determined from the actual age last birthday on the due date of the
first annuity payment in the following manner:
CALENDAR YEAR IN WHICH
FIRST PAYMENT IS DUE 2001 - 2010 2011 - 2020 2021 - 2030 2031 and later
---------------------- ----------- ----------- ----------- --------------
ADJUSTED AGE IS
ACTUAL AGE MINUS 1 MINUS 2 MINUS 3 MINUS 4
Page 15
LIFE ANNUITY TABLES
GUARANTEED AMOUNT OF MONTHLY ANNUITY PAYMENTS
PURCHASED WITH EACH $1,000 OF PROCEEDS APPLIED
THIS TABLE WILL BE USED FOR NONQUALIFIED CONTRACTS
OPTIONS 1, 2, AND 3 - SINGLE LIFE ANNUITIES
FEMALE
ADJUSTED CASH
AGES NONE 120 180 240 REFUND
-------- ---- ---- ---- ---- ------
45 3.59 3.58 3.57 3.55 3.52
46 3.64 3.63 3.61 3.59 3.56
47 3.68 3.67 3.66 3.63 3.60
48 3.74 3.72 3.71 3.68 3.64
49 3.79 3.78 3.81 3.77 3.73
50 3.85 3.83. 3.81 3.77 3.73
51 3.90 3.89 3.86 3.82 3.78
52 3.97 3.95 3.92 3.88 3.84
53 4.03 4.01 3.98 3.93 3.89
54 4.10 4.08 4.04 3.99 3.95
55 4.18 4.15 4.11 4.05 4.01
56 4.25 4.22 4.18 4.11 4.07
57 4.34 4.30 4.25 4.17 4.14
58 4.42 4.38 4.32 4.23 4.20
59 4.52 4.47 4.40 4.30 4.28
60 4.61 4.56 4.48 4.37 4.35
61 4.72 4.66 4.57 4.44 4.43
62 4.83 4.76 4.66 4.51 4.52
63 4.95 4.87 4.75 4.58 4.61
64 5.08 4.98 4.85 4.65 4.70
65 5.21 5.10 4.95 4.72 4.80
66 5.36 5.22 5.05 4.79 4.90
67 5.51 5.36 5.16 4.86 5.01
68 5.67 5.50 5.26 4.93 5.12
69 5.85 5.65 5.38 5.00 5.25
70 6.04 5.80 5.49 5.06 5.37
71 6.25 5.97 5.60 5.12 5.51
72 6.47 6.14 5.71 5.18 5.65
73 6.71 6.32 5.83 5.23 5.80
74 6398 6.50 5.94 5.28 5.96
75 7.26 6.69 6.04 5.32 6.13
The listed above dollar amounts of the monthly annuity payments for the first,
second and third options are based on the 1983 Individual Annuitant Mortality
Table A for females with ages set back one year and a net investment rate of 3%
per annum. The adjusted age of the person on whose life the life annuity is
based is determined from the actual age last birthday on the due date of the
first annuity payment in the following manner:
CALENDAR YEAR IN WHICH
FIRST PAYMENT IS DUE 2001 - 2010 2011 - 2020 2021 and later
---------------------- ----------- ----------- --------------
ADJUSTED AGE IS
ACTUAL AGE MINUS 1 MINUS 2 MINUS 3
Page 16
LIFE ANNUITY TABLES
GUARANTEED DOLLAR AMOUNT OF MONTHLY ANNUITY PAYMENTS
PURCHASED WITH EACH $1,000 APPLIED
THIS TABLE WILL BE USED FOR NONQUALIFIED CONTRACTS
OPTION 4 - JOINT AND LAST SURVIVOR LIFE ANNUITY
ADJUSTED FEMALE
AGES ----------------------------------------------
MALE 45 50 55 60 65 70 75
-------- ---- ---- ---- ---- ---- ---- ----
45 3.36 3.46 3.56 3.64 3.71 3.76 3.80
50 3.42 3.56 3.69 3.82 3.93 4.01 4.08
55 3.47 3.64 3.82 3.99 4.16 4.29 4.40
60 3.51 3.70 3.92 4.15 4.39 4.61 4.79
65 3.54 3.75 4.00 4.29 4.61 4.94 5.24
70 3.56 3.78 4.07 4.41 4.80 5.25 5.70
75 3.57 3.81 4.11 4.48 4.95 5.51 6.15
Dollar amounts of the monthly annuity payments for the fourth option are based
on the 1983 Individual Annuitant Mortality Table A for males and females with
ages set back one year and a net investment rate of 3 % per annum. The adjusted
age of the person on whose life the life annuity is based is determined from the
actual age last birthday on the due date of the first annuity payment in the
following manner:
CALENDAR YEAR IN WHICH
FIRST PAYMENT IS DUE 2001 - 2010 2011 - 2020 2021 and later
---------------------- ----------- ----------- --------------
ADJUSTED AGE IS
ACTUAL AGE MINUS 1 MINUS 2 MINUS 3
Page 17
ANNUITY TABLES
GUARANTEED DOLLAR AMOUNT OF THE MONTHLY ANNUITY PAYMENTS
PURCHASED WITH EACH $1,000 OF PROCEEDS APPLIED
THIS TABLE WILL BE USED FOR NONQUALIFIED AND QUALIFIED CONTRACTS
OPTION 5 - PAYMENTS FOR A DESIGNATED PERIOD
MONTHLY MONTHLY
NUMBER OF PAYMENT NUMBER OF PAYMENT
YEARS AMOUNT YEARS AMOUNT
--------- ------- --------- -------
5 17.91 18 5.96
6 15.14 19 5.73
7 13.16 20 5.51
8 11.68 21 5.32
9 10.53 22 5.15
10 9.61 23 4.99
11 8.86 24 4.84
12 8.24 25 4.71
13 7.71 26 4.59
14 7.26 27 4.47
15 6.87 28 4.37
16 6.53 29 4.27
17 6.23 30 4.18
The dollar amounts of the monthly annuity payments for the fifth option are
based on a net investment rate of 3% per annum.
Page 18
THIS PAGE LEFT INTENTIONALLY BLANK.
SINGLE PREMIUM INDIVIDUAL MODIFIED GUARANTEED ANNUITY CONTRACT
NON-PARTICIPATING
RIDERS
ENDORSEMENTS