1
Exhibit 99.1.(5)(a)
- ------------------------------------------------------------------------------------------------------------------------------------
FLEXIBLE PREMIUM
VARIABLE LIFE
INSURANCE POLICY
-------------------------------------------------- ----------------------------------------------
Variable and/or Fixed Death Benefit Guarantee
Accumulation Values ----------------------------------------------
-------------------------------------------------- Death Benefit Options
Flexible Premiums Payable to ----------------------------------------------
Age 100 of the Insured Nonparticipating
-------------------------------------------------- ----------------------------------------------
Adjustable Face Amount
--------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
NOTICE Right to Return Policy
Read this policy carefully. If for any the the policy void from the start and refund to
policy void from the start and reason you do you all premiums paid.
not want it, you may refund to you all
premiums paid return it to us or the agent If you return this policy later than 10 days
who sold it to you and ask us to cancel it. after you receive it, the Total Surrender
provision of the policy will apply.
If you return this policy within 10 days
after you receive it, we will consider
- ------------------------------------------------------------------------------------------------------------------------------------
We will pay the proceeds defined in the Death STAYS IN FORCE WILL DEPEND ON THE INVESTMENT
Benefits portion of the Summary of Benefits PERFORMANCE OF THE VARIABLE ACCOUNT, INTEREST
on page 3, if we receive written proof that CREDITED TO THE NET PREMIUMS ALLOCATED TO THE
the Insured died while this policy was in FIXED ACCOUNT, THE AMOUNT OF PREMIUS YOU PAY,
force. This policy also provides other AND ANY PARTIAL WITHDRAWLS, LOANS, AND
benefits and rights. We issue this policy in CHARGES MADE AGAINST THIS POLICY. IF YOU KEEP
consideration of the application and payment A DEATH BENEFIT GUARANTEE IN EFFECT, WE
of the initial premium. GUARANTEE THIS POLICY WILL STAY IN FORCE
DURING THE DEATH BENEFIT GUARANTEE PERIOD
THE AMOUNT OF THE PROCEEDS PAYABLE AT THE SHOWN ON THE POLICY DATA PAGE.
DEATH OF THE INSURED WILL BE AT LEAST EQUAL
TO THE FACE AMOUNT OF THE POLICY IF THIS THE VARIABLE ACCUMULATION VALUE WILL INCREASE
POLICY IS IN FORCE AND THERE IS NO LOAN OR DECREASE REFLECTING THE INVESTMENT
AMOUNT AND NO UNPAID MONTHLY DEDUCTIONS AND PERFORMANCE OF THE VARIABLE ACCOUNT.
THERE HAVE BEEN NO PARTIAL WITHDRAWLS.
THE PERIOD OF TIME THIS LIFE INSURANCE
- ------------------------------------------------------------------------------------------------------------------------------------
[RELIASTAR LOGO] RELIASTAR LIFE INSURANCE COMPANY Executed at our Home Office
OF NEW YORK ----------------------------------------------
James R. Gelder President
1000 Woodbury Road, Suite 102 ----------------------------------------------
P.O. Box 9004 /s/ James R. Gelder
Woodbury, New York 11797 ----------------------------------------------
Susan M. Bergen Secretary
----------------------------------------------
/s/ Susan M. Bergen
----------------------------------------------
- --------------------
Page 1 86-025
- --------------------
2
- --------------------------------------------------------------------------------
INDEX PAGE
Accumulation Value ..................................11
Age and Sex .........................................27
Allocation of Premiums .............................. 7
Amendment ...........................................29
Annual Statement ....................................28
Beneficiary .........................................21
Cash Surrender Value ................................18
Cash Value ..........................................18
Changes in Face Amount .............................. 6
Changes in Death Benefit Option ..................... 7
Claims ..............................................30
Control of Policy ...................................25
Conversion Right ....................................28
Death Benefit ....................................... 6
Definitions ......................................... 4
Death Benefit Guarantee ............................. 9
Fixed Accumulation Value ............................11
General Provisions ..................................26
Grace Period ........................................10
Incontestability ....................................27
Insured ............................................. 1
Monthly Deductions ..................................13
Net Premium ......................................... 7
Nonforfeiture Provisions ............................17
Ownership ...........................................25
Partial Withdrawal ..................................19
Payment of Proceeds .................................22
Policy Data Page .................................... A
Policy Loans ........................................20
Premiums ............................................ 7
Right to Return Policy .............................. 1
Reinstatement .......................................10
Settlement Options ..................................22
Suicide .............................................27
Summary of Benefits ................................. 3
Termination .........................................27
Transfers ...........................................15
Variable Accumulation Value .........................11
Voting of Mutual Fund Shares ........................26
Additional benefits and restrictions, if any, are listed on
the Policy Data Page.
- --------------------------------------------------------------------------------
- ----------------
Page 2 5770
- ----------------
3
POLICY DATA PAGE DATE PRINTED
POLICY NUMBER: S9-999-999 JANUARY 1, 2000
- ----------------------------------------------------------------------------------------------------------------------
POLICY INFORMATION OWNER John Doe
POLICY DATE January 1, 2000
ISSUE DATE January 1, 2000
EFFECTIVE DATE January 1, 2000
INSURED James Doe
SEX, ISSUE AGE Male, 40
RATE CLASS Preferred No Tobacco
RATE CLASS RATING FACTOR 100%
EXTRA COST OF INSURANCE RATE 1 $00.00 per $1000 for 0 years
EXTRA COST OF INSURANCE RATE 2 $00.00 per $1000 for 0 years
- ----------------------------------------------------------------------------------------------------------------------
DEATH BENEFITS INITIAL FACE AMOUNT $100,000
CURRENT FACE AMOUNT $100,000
MINIMUM FACE AMOUNT $100,000
DEATH BENEFIT OPTION Level Amount Option
CORRIDOR PERCENTAGE TABLE
Attained Age Corridor Percent
------------ ----------------
0-40 250%
45 215
50 185
55 150
60 130
65 120
70 115
75-90 105
95+ 100
Percentages grade uniformly between ages shown.
- ----------------------------------------------------------------------------------------------------------------------
PREMIUMS INITIAL PREMIUM $1,462.00
PLANNED PERIODIC PREMIUM
AMOUNT $1,462.00
FREQUENCY Annual
BASIC DEATH BENEFIT
GUARANTEE PERIOD 5 Years
BASIC
MINIMUM MONTHLY PREMIUM $68.00
EXTENDED DEATH BENEFIT
GUARANTEE PERIOD 20 Years
EXTENDED
MINIMUM MONTHLY PREMIUM $121.83
- ----------------------------------------------------------------------------------------------------------------------
Form Numbers 86-025 - 86-041
A
4
POLICY DATA PAGE DATE PRINTED
POLICY NUMBER: S9-999-999 JANUARY 1, 2000
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
NONFORFEITURE ITEMS MORTALITY TABLE 1980 Commissioner's Standard
Ordinary Mortality Table for
Nonsmokers, Age Nearest Birthday
INTEREST RATE 4.00%
MAXIMUM PARTIAL 0% in policy year 1;
WITHDRAWAL PERCENT 20% per policy year in policy years
2-10;
100% thereafter
- ----------------------------------------------------------------------------------------------------------------------
SETTLEMENT OPTION ITEMS MORTALITY TABLE Annuity 2000 Table with
Projection Scale G
INTEREST RATE 2.00%
----------------------------------------------------------------------------------------
OPTION 3 TABLE
MONTHLY PAYMENTS
PER $1000
NUMBER OF YEARS OF PROCEEDS
-------------------------------------- ------------------------------------------------
5 $17.49
10 $9.18
15 $6.42
20 $5.04
25 $4.22
- ----------------------------------------------------------------------------------------------------------------------
PREMIUM ALLOCATION
Fixed Account xx% Neuberger&Berman Limited
Alger American Growth Portfolio xx% Maturity Bond Portfolio xx%
Alger American MidCap Growth Portfolio xx% Neuberger&Berman Partners
Alger American Small Capitalization Portfolio xx%
Portfolio xx% Northstar Growth Fund xx%
Fidelity Contrafund Portfolio xx% Northstar High Yield Bond Fund xx%
Fidelity Equity-Income Portfolio xx% Northstar Income and Growth Fund xx%
Fidelity Growth Portfolio xx% Northstar International Value Fund xx%
Fidelity High Income Portfolio xx% Northstar Multi-Sector Bond Fund xx%
Fidelity Index 500 Portfolio xx% OCC Equity Portfolio xx%
Fidelity Investment Grade Bond Portfolio xx% OCC Global Equity Portfolio xx%
Fidelity Money Market Portfolio xx% OCC Managed Portfolio xx%
Janus Aggressive Growth Portfolio xx% OCC Small Cap Portfolio xx%
Janus International Growth Portfolio xx% Putnam VT Diversified Income
Fund xx%
Janus Worldwide Growth Portfolio xx% Putnam VT Growth & Income Fund xx%
Putnam VT Voyager Fund xx%
INITIAL PREMIUM SUB-ACCOUNT: Fidelity Money Market Portfolio (FMM)
INITIAL PREMIUM TRANSFER DATE January 21, 2000
- ----------------------------------------------------------------------------------------------------------------------
FIXED ACCOUNT INTEREST MINIMUM ANNUAL INTEREST RATE 4.00%
RATES MINIMUM MONTHLY INTEREST RATE 0.3274%
LOAN INTEREST RATE 5.66% payable in advance
PREFERRED LOAN INTEREST RATE 3.85% payable in advance
B
5
POLICY DATA PAGE DATE PRINTED
POLICY NUMBER: S9-999-999 JANUARY 1, 2000
- ----------------------------------------------------------------------------------------------------------------------
DEDUCTIONS AND PREMIUM EXPENSE CHARGE
CHARGES PERCENT PREMIUM RATE 5.00% Years 1-10
4.00% Years 11+
MONTHLY EXPENSE CHARGE
MAXIMUM MONTHLY
ADMINISTRATIVE CHARGE $10.00 per month
MONTHLY AMOUNT CHARGE RATE $0.2389 per $1,000
MONTHLY AMOUNT CHARGE TERM 10 years
MAXIMUM VARIABLE
ACCUMULATION VALUE
CHARGE RATE 0.40%
SERVICE CHARGES
MAXIMUM PER TRANSFER $25.00
MAXIMUM PER PARTIAL WITHDRAWAL $25.00
MAXIMUM PER ADDITIONAL STATEMENT $50.00
MAXIMUM PER PROJECTION REPORT $50.00
- ----------------------------------------------------------------------------------------------------------------------
TABLE OF SURRENDER CHARGES
0 $781.00
1 $702.90 6 $312.40
2 $624.80 7 $234.30
3 $546.70 8 $156.20
4 $468.60 9 $78.10
5 $390.50 10 $0.00
Surrender Charges grade uniformly by policy
month between the consecutive years shown
above. The Surrender Charge will not be more
than the total of premiums paid.
IMPORTANT NOTICE: IT IS POSSIBLE THAT COVERAGE WILL EXPIRE WHERE EITHER NO
PREMIUMS ARE PAID FOLLOWING THE INITIAL PREMIUM, OR SUBSEQUENT PREMIUMS ARE
INSUFFICIENT TO CONTINUE COVERAGE. THE PERIOD FOR WHICH THE POLICY AND COVERAGE
WILL CONTINUE IN FORCE WILL DEPEND ON: (1) THE AMOUNT, TIMING, AND FREQUENCY OF
PREMIUM PAYMENTS; (2) CHANGES IN THE FACE AMOUNT AND THE DEATH BENEFIT OPTION;
(3) CHANGE IN INTEREST RATES CREDITED TO THE FIXED ACCOUNT AND IN THE INVESTMENT
PERFORMANCE OF THE SUB-ACCOUNTS; (4) CHANGES IN THE MONTHLY COST OF INSURANCE
DEDUCTIONS FROM THE ACCUMULATION VALUE OF THIS POLICY AND ANY BENEFITS PROVIDED
BY RIDERS TO THIS POLICY; AND (5) LOAN AND PARTIAL WITHDRAWAL ACTIVITY.
ADDITIONAL AMOUNTS ARE NOT GUARANTEED AND WE HAVE THE RIGHT TO CHANGE THE AMOUNT
OF INTEREST CREDITED TO THE POLICY AND THE AMOUNT OF COST OF INSURANCE OR OTHER
EXPENSE CHARGES DEDUCTED UNDER THE POLICY WHICH MAY REQUIRE MORE PREMIUM TO BE
PAID THAN WAS ILLUSTRATED OR THE CASH VALUES MAY BE LESS THAN THOSE ILLUSTRATED.
C
6
POLICY DATA PAGE DATE PRINTED
POLICY NUMBER: S9-999-999 JANUARY 1, 2000
- ----------------------------------------------------------------------------------------------------------------------
ADDITIONAL BENEFITS The cost of the Rider Benefits increases the
Monthly Deduction of the Policy
----------------------------------------------------------------------------------------
TERM RIDER (TR)
ISSUE AGE AND SEX 40 Male
TR RATE CLASS Preferred No Tobacco
TR RATE CLASS RATING FACTOR 100%
EXTRA TR COST OF INSURANCE $00.00 per $1000 for 0 years
RATE
TR FACE AMOUNT $100,000
TR MONTHLY AMOUNT CHARGE $0.0735
RATE
TR MONTHLY AMOUNT CHARGE 10 Years
TERM
RIDER EFFECTIVE DATE January 1, 2000
RIDER EXPIRY DATE January 1, 2040
- ----------------------------------------------------------------------------------------------------------------------
D
7
- ------------------------------------------------------------------------------------------------------------------------------------
POLICY DATA PAGE TABLE OF MONTHLY GUARANTEED COST
OF INSURANCE RATES PER $1,000
MALE - NONSMOKERS
------------------------------------------------------------------------------------------------------
ATTAINED ATTAINED ATTAINED
AGE RATE AGE RATE AGE RATE
------------------------ --------------------------- ---------------------------
0 .34900 35 .14094 70 2.93268
1 .08921 36 .14762 71 3.30181
2 .08254 37 .15680 72 3.61779
3 .08170 38 .16682 73 4.04199
4 .07920 39 .17851 74 4.52073
------------------------ --------------------------- ---------------------------
5 .07503 40 .19103 75 5.03724
6 .07169 41 .20607 76 5.59039
7 .06669 42 .22110 77 6.17549
8 .06336 43 .23865 78 6.78686
9 .06169 44 .25619 79 7.44038
------------------------ --------------------------- ---------------------------
10 .06085 45 .27709 80 8.16249
11 .06419 46 .29966 81 8.97320
12 .07086 47 .32391 82 9.89813
13 .08254 48 .34984 83 10.95204
14 .09588 49 .37912 84 12.11846
------------------------ --------------------------- ---------------------------
15 .10756 50 .41009 85 13.37460
16 .11924 51 .44963 86 14.69860
17 .12842 52 .48965 87 16.08129
18 .13343 53 .53742 88 17.49682
19 .13844 54 .59276 89 18.96601
------------------------ --------------------------- ---------------------------
20 .14011 55 .65401 90 20.51212
21 .13927 56 .72203 91 22.16549
22 .13677 57 .79429 92 23.98724
23 .13427 58 .87251 93 26.06643
24 .13093 59 .96090 94 28.78427
------------------------ --------------------------- ---------------------------
25 .12675 60 1.05949 95 32.81758
26 .12342 61 1.16916 96 39.64294
27 .12175 62 1.29417 97 53.06605
28 .12008 63 1.43714 98 83.33333
29 .12008 64 1.59899 99 83.33333
------------------------ --------------------------- ---------------------------
30 .12008 65 1.77812
31 .12258 66 1.97123
32 .12509 67 2.18097
33 .12926 68 2.40660
34 .13427 69 2.65338
------------------------ ---------------------------
- ---------------
86-046
- ---------------
8
- ------------------------------------------------------------------------------------------------------------------------------------
POLICY DATA PAGE TABLE OF MONTHLY GUARANTEED COST
OF INSURANCE RATES PER $1,000
MALE - SMOKERS
------------------------------------------------------------------------------------------------------
ATTAINED ATTAINED ATTAINED
AGE RATE AGE RATE AGE RATE
------------------------ --------------------------- ---------------------------
15 .13760 45 .52401 75 7.26414
16 .15597 46 .57096 76 7.92842
17 .17099 47 .62212 77 8.60587
18 .18018 48 .67584 78 9.28569
19 .18853 49 .73631 79 9.98835
------------------------ --------------------------- ---------------------------
20 .19270 50 .80018 80 10.74534
21 .19437 51 .87419 81 11.57692
22 .19187 52 .95668 82 12.50906
23 .18853 53 1.05105 83 13.55162
24 .18435 54 1.15734 84 14.66820
------------------------ --------------------------- ---------------------------
25 .17851 55 1.27051 85 15.82369
26 .17350 56 1.39312 86 16.98122
27 .17183 57 1.52015 87 18.12337
28 .17016 58 1.65583 88 19.38671
29 .17183 59 1.79682 89 20.65144
------------------------ --------------------------- ---------------------------
30 .17517 60 1.95335 90 21.93652
31 .18101 61 2.12977 91 23.26852
32 .18686 62 2.32876 92 24.70635
33 .19604 63 2.55476 93 26.58833
34 .20690 64 2.80452 94 29.07200
------------------------ --------------------------- ---------------------------
35 .21943 65 3.07567 95 32.81758
36 .23447 66 3.35886 96 39.64294
37 .25369 67 3.65683 97 53.06605
38 .27542 68 3.96448 98 83.33333
39 .30050 69 4.29327 99 83.33333
------------------------ --------------------------- ---------------------------
40 .32893 70 4.65747
41 .36239 71 5.06279
42 .39670 72 5.52571
43 .43604 73 6.04980
44 .47708 74 6.62444
------------------------ ---------------------------
- ----------------
86-047
- ----------------
9
- ------------------------------------------------------------------------------------------------------------------------------------
POLICY DATA PAGE TABLE OF MONTHLY GUARANTEED COST
OF INSURANCE RATES PER $1,000
FEMALE - NONSMOKERS
------------------------------------------------------------------------------------------------------
ATTAINED ATTAINED ATTAINED
AGE RATE AGE RATE AGE RATE
------------------------ --------------------------- ---------------------------
0 .24115 35 .12258 70 1.78407
1 .07253 36 .13009 71 1.96612
2 .06753 37 .13927 72 2.19207
3 .06586 38 .14929 73 2.46823
4 .06419 39 .16098 74 2.79421
------------------------ --------------------------- ---------------------------
5 .06336 40 .17350 75 3.16450
6 .06085 41 .18853 76 3.57271
7 .06002 42 .20356 77 4.01324
8 .05835 43 .21860 78 4.48657
9 .05752 44 .23363 79 5.00641
------------------------ --------------------------- ---------------------------
10 .05668 45 .24951 80 5.59571
11 .05752 46 .26622 81 6.27546
12 .06002 47 .28461 82 7.06752
13 .06252 48 .30468 83 7.98847
14 .06669 49 .32558 84 9.02014
------------------------ --------------------------- ---------------------------
15 .07003 50 .34984 85 10.16441
16 .07336 51 .37578 86 11.40375
17 .07670 52 .40507 87 12.74961
18 .07920 53 .43939 88 14.19103
19 .08170 54 .47457 89 15.75519
------------------------ --------------------------- ---------------------------
20 .08421 55 .51227 90 17.44624
21 .08504 56 .55083 91 19.30510
22 .08671 57 .58941 92 21.39679
23 .08754 58 .62632 93 23.84043
24 .09004 59 .66577 94 26.92636
------------------------ --------------------------- ---------------------------
25 .09088 60 .71195 95 31.31011
26 .09338 61 .76656 96 38.50479
27 .09505 62 .83550 97 52.27571
28 .09755 63 .92216 98 83.33333
29 .10006 64 1.02492 99 83.33333
------------------------ --------------------------- ---------------------------
30 .10339 65 1.13624
31 .10589 66 1.25614
32 .10923 67 1.37789
33 .11257 68 1.50066
34 .11841 69 1.63207
------------------------ ---------------------------
- -------------
86-048
- -------------
10
- ------------------------------------------------------------------------------------------------------------------------------------
POLICY DATA PAGE TABLE OF MONTHLY GUARANTEED COST
OF INSURANCE RATES PER $1,000
FEMALE - SMOKERS
------------------------------------------------------------------------------------------------------
ATTAINED ATTAINED ATTAINED
AGE RATE AGE RATE AGE RATE
------------------------ --------------------------- ---------------------------
15 .07837 45 .38498 75 3.97231
16 .08254 46 .41344 76 4.43318
17 .08671 47 .44358 77 4.91927
18 .09088 48 .47457 78 5.42834
19 .09422 49 .50808 79 5.97677
------------------------ --------------------------- ---------------------------
20 .09672 50 .54664 80 6.58859
21 .09839 51 .58521 81 7.28491
22 .10089 52 .62884 82 8.08683
23 .10256 53 .68004 83 9.00541
24 .10589 54 .73211 84 10.09637
------------------------ --------------------------- ---------------------------
25 .10756 55 .78673 85 11.19977
26 .11174 56 .84138 86 12.46983
27 .11507 57 .89354 87 13.71056
28 .11841 58 .94237 88 15.13413
29 .12342 59 .99290 89 16.50860
------------------------ --------------------------- ---------------------------
30 .12926 60 1.04853 90 18.11827
31 .13427 61 1.12021 91 19.86655
32 .14011 62 1.20715 92 21.81429
33 .14595 63 1.32461 93 24.07436
34 .15513 64 1.45577 94 26.92636
------------------------ --------------------------- ---------------------------
35 .16181 65 1.60323 95 31.31011
36 .17433 66 1.74923 96 38.50479
37 .19020 67 1.90143 97 52.27571
38 .20774 68 2.03939 98 83.33333
39 .22779 69 2.19463 99 83.33333
------------------------ --------------------------- ---------------------------
40 .25034 70 2.35955
41 .27792 71 2.57362
42 .30384 72 2.83977
43 .33060 73 3.16536
44 .35737 74 3.54671
------------------------ ---------------------------
- -------------
86-049
- -------------
11
- ------------------------------------------------------------------------------------------------------------------------------------
POLICY DATA PAGE TABLE OF MONTHLY GUARANTEED COST
OF INSURANCE RATES PER $1,000
UNISEX - NONSMOKERS
------------------------------------------------------------------------------------------------------
ATTAINED ATTAINED ATTAINED
AGE RATE AGE RATE AGE RATE
------------------------ --------------------------- ---------------------------
0 .31137 35 .13427 70 2.52905
1 .08337 36 .14178 71 2.83203
2 .07753 37 .15096 72 3.11619
3 .07586 38 .16098 73 3.48780
4 .07420 39 .17266 74 3.91313
------------------------ --------------------------- ---------------------------
5 .07086 40 .18519 75 4.37719
6 .06753 41 .20022 76 4.87881
7 .06419 42 .21525 77 5.41241
8 .06169 43 .23196 78 5.97499
9 .06002 44 .24867 79 6.58142
------------------------ --------------------------- ---------------------------
10 .05919 45 .26706 80 7.25602
11 .06169 46 .28796 81 8.01942
12 .06669 47 .31053 82 8.89686
13 .07586 48 .33395 83 9.90371
14 .08587 49 .36071 84 11.02168
------------------------ --------------------------- ---------------------------
15 .09422 50 .38917 85 12.23766
16 .10339 51 .42181 86 13.53129
17 .11007 52 .46033 87 14.90086
18 .11424 53 .50306 88 16.32565
19 .11841 54 .55167 89 17.82935
------------------------ --------------------------- ---------------------------
20 .12091 55 .60451 90 19.42703
21 .12008 56 .66241 91 21.15397
22 .11924 57 .72287 92 23.07224
23 .11758 58 .78589 93 25.28101
24 .11674 59 .85736 94 28.12943
------------------------ --------------------------- ---------------------------
25 .11424 60 .93732 95 32.28750
26 .11257 61 1.02830 96 39.24335
27 .11257 62 1.13371 97 52.78868
28 .11257 63 1.25699 98 83.33333
29 .11340 64 1.39736 99 83.33333
------------------------ --------------------------- ---------------------------
30 .11424 65 1.55320
31 .11674 66 1.72035
32 .11924 67 1.89887
33 .12342 68 2.08883
34 .12842 69 2.29457
------------------------ ---------------------------
- -------------
86-050
- -------------
12
- ------------------------------------------------------------------------------------------------------------------------------------
POLICY DATA PAGE TABLE OF MONTHLY GUARANTEED COST
OF INSURANCE RATES PER $1,000
UNISEX - SMOKERS
------------------------------------------------------------------------------------------------------
ATTAINED ATTAINED ATTAINED
AGE RATE AGE RATE AGE RATE
------------------------ --------------------------- ---------------------------
15 .11674 45 .47541 75 6.09791
16 .13009 46 .51563 76 6.68991
17 .14178 47 .55922 77 7.29846
18 .14929 48 .60534 78 7.91660
19 .15513 49 .65653 79 8.56373
------------------------ --------------------------- ---------------------------
20 .15931 50 .71111 80 9.26815
21 .16098 51 .77328 81 10.05166
22 .16014 52 .84222 82 10.93605
23 .15847 53 .92132 83 11.93378
24 .15680 54 1.00807 84 13.04182
------------------------ --------------------------- ---------------------------
25 .15346 55 1.10081 85 14.17835
26 .15179 56 1.19955 86 15.37591
27 .15179 57 1.30009 87 16.55365
28 .15179 58 1.40582 88 17.87507
29 .15513 59 1.51506 89 19.17920
------------------------ --------------------------- ---------------------------
30 .15931 60 1.63546 90 20.58123
31 .16432 61 1.77557 91 22.06318
32 .17016 62 1.93462 92 23.68300
33 .17851 63 2.12209 93 25.70058
34 .18853 64 2.33047 94 28.31554
------------------------ --------------------------- ---------------------------
35 .19939 65 2.55733 95 32.28750
36 .21358 66 2.79249 96 39.24335
37 .23113 67 3.03860 97 52.78868
38 .25202 68 3.28625 98 83.33333
39 .27542 69 3.55364 99 83.33333
------------------------ --------------------------- ---------------------------
40 .30133 70 3.84616
41 .33311 71 4.18412
42 .36406 72 4.57680
43 .39921 73 5.03019
44 .43521 74 5.53546
------------------------ ---------------------------
- -----------
86-051
- -----------
13
- -----------------------------------------------------------------------------------------------------------------------------------
SUMMARY OF BENEFITS LIVING BENEFITS
While the insured is alive, subject to this pol- 6.
icy's provisions, you may: Surrender this policy for its Cash Surrender
Value;
1.
Change the amount and frequency of your 7.
premium payments; Make a Partial Withdrawal;
2. 8.
Change the allocation of your premiums; Take a Policy Loan;
3. 9.
Change the Face Amount; Assign this policy as collateral;
4. 10.
Change the Death Benefit Option; Change the beneficiary;
5. 11.
Make transfers between accounts; Transfer ownership; and
12.
Exercise any other rights this policy allows.
-----------------------------------------------------------------------------------------------------
DEATH BENEFITS
If we receive written proof that the Insured 3.
died while this policy was in force, the pro- Plus a refund of any policy loan interest we
ceeds payable are: have charged but not earned;
1. 4.
The Death Benefit then in force; Minus any Loan Amount; and
2. 5.
Plus any additional amounts provided by Minus any unpaid Monthly Deductions.
rider;
- -----------------------------------------------------------------------------------------------------------------------------------
THE CONTRACT This policy is a legal contract. Read your pol- All statements made by or on behalf of any-
icy carefully! You rely on us to provide its one covered by this policy are representations
benefits; we rely on you to pay its premiums. and not warranties. No statement can be
The entire contract is this policy and all ap- used to cancel this policy or can be used in
plications, Policy Data Pages, riders, and our defense if we refuse to pay a claim, un-
amendments attached at time of issue or less it is found in an application, rider, or
agreed upon later. amendment.
----------------------------------------------------------------------------------------------------
CHANGES
Policy changes must be in writing and signed agent or any other person may alter or change
by our President or Secretary, or one of our the terms and conditions of this policy.
Vice Presidents or Assistant Secretaries. NO
- -----------------------------------------------------------------------------------------------------------------------------------
- ------------ -----------
86-026 3
- ------------ -----------
14
- -----------------------------------------------------------------------------------------------------------------------------------
DEFINITIONS ACCUMULATION UNIT A unit of measure used to determine the Var-
iable Accumulation Value.
-----------------------------------------------------------------------------------------------------
ACCUMULATION VALUE The total amount that this policy provides for
investment at any time. The Accumulation
Value is the total of the Fixed Accumulation
Value and the Variable Accumulation Value.
-----------------------------------------------------------------------------------------------------
AGE 65, 85, AND 100 The policy anniversary nearest the 65th,
85th, and 100th birthdays of the Insured, re-
spectively.
-----------------------------------------------------------------------------------------------------
CASH VALUE The Accumulation Value minus any Surrender
Charge.
-----------------------------------------------------------------------------------------------------
CASH SURRENDER VALUE The amount payable to you if you surrender
this policy. It is the Cash Value minus any
Loan Amount and unpaid Monthly De-
ductions.
-----------------------------------------------------------------------------------------------------
THE CODE The Internal Revenue Code of 1986, as
amended.
-----------------------------------------------------------------------------------------------------
FACE AMOUNT The Initial Face Amount is shown on the Pol-
icy Data Page. You may change the Face
Amount as described in this policy.
-----------------------------------------------------------------------------------------------------
FIXED ACCOUNT All our assets other than those allocated to
the Variable Account or any other separate
account. We have complete ownership and
control of the assets in the Fixed Account.
-----------------------------------------------------------------------------------------------------
IN FORCE This policy is in effect.
-----------------------------------------------------------------------------------------------------
THE INSURED The person upon whose life this policy is is-
sued. The Policy Data Page lists the Insured.
-----------------------------------------------------------------------------------------------------
LOAN AMOUNT The sum of all unpaid policy loans, including
Preferred Loans.
-----------------------------------------------------------------------------------------------------
MONTHLY ANNIVERSARY The first Monthly Anniversary is on the Policy
Date. Every month, the Monthly Anniversary
will be on the first Valuation Date on or after
the same day of the month as the Policy Date.
-----------------------------------------------------------------------------------------------------
POLICY DATE The Policy Date is shown on the Policy Data
Page. We use the Policy Date to determine
policy years, policy months, Monthly Anni-
versaries, and policy anniversaries.
-----------------------------------------------------------------------------------------------------
PROCEEDS The amount we pay when the Death Benefit
becomes payable or when you surrender this
policy.
- -----------------------------------------------------------------------------------------------------------------------------------
- --------------- ---------------
5771 4
- --------------- ---------------
15
- -----------------------------------------------------------------------------------------------------------------------------------
DEFINITIONS SUB-ACCOUNT A subdivision of the Variable Account. Each
(continued) Sub-account invests exclusively in the shares
of one of the mutual funds shown on the Pol-
icy Data Page, or added later.
-----------------------------------------------------------------------------------------------------
VALUATION DATE The close of business each day that the New
York Stock Exchange is open for trading and
valuations have not been suspended by the
Securities and Exchange Commission. We
may also declare a Valuation Date on any
other day on which there is sufficient trading
in the mutual funds' portfolio to materially
affect the Accumulation Unit Value in the
corresponding Sub-account.
-----------------------------------------------------------------------------------------------------
VALUATION PERIOD The period of time between a Valuation Date
and the next Valuation Date.
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WE, US, OUR ReliaStar Life Insurance Company of New
York at our Home Office in Woodbury, New
York.
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WRITTEN, IN WRITING A written request or notice, signed and dated,
and received at our Home Office. The form
and content of the request or notice must be
acceptable to us.
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YOU, YOUR The owner of this policy, as shown on the
Policy Data Page, unless changed as allowed
in this policy. The Insured owns this policy
unless another owner is named.
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VARIABLE ACCOUNT ReliaStar Life Insurance Company of New exceed the liabilities of the Variable Account
York Variable Life Separate Account I, a sep- to our Fixed Account.
arate investment account of ours. The Vari-
able Account is used only to receive and The Variable Account is treated as a unit in-
invest Net Premiums paid under our variable vestment trust under federal securities laws.
life insurance policies. The assets of the It is registered with the Securities and Ex-
Variable Account will be valued on each Val- change Commission according to the Invest-
uation Date. We have complete ownership ment Company Act of 1940. It was
and control of the assets in the Variable Ac- established under the insurance laws of the
count. State of New York. Any change in the in-
vestment policy of the Variable Account must
Assets of the Variable Account equal to its li- be approved by the Department of Insurance
abilities will not be charged with liabilities of the State of New York according to the
arising out of any other business we conduct. approval process on file with the State.
However, we may transfer any assets which
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86-027 5
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16
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DEATH BENEFIT DEATH BENEFIT BEFORE AGE 100
This policy has two Death Benefit Options. Page, according to the attained Age of the
The Death Benefit Option in effect on the Insured.
Policy Date is shown on the Policy Data Page.
All values are determined as of the Valuation Option B (Variable Amount Option) -- The
Date on or next following the date of the Death Benefit is the greater of:
death of the Insured. The two Death Benefit
Options are: 1.
Option A (Level Amount Option) -- The Death The Face Amount plus the Accumulation
Benefit before Age 100 is the greater of: Value; or
1. 2.
The Face Amount; or The Accumulation Value multiplied by the
Corridor Percentage shown on the Policy Data
2. Page, according to the attained Age of the
The Accumulation Value multiplied by the Insured.
Corridor Percentage shown on the Policy Data
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DEATH BENEFIT ON OR AFTER AGE 100
The Death Benefit on or after Age 100 is the Page, according to the attained Age of the
Accumulation Value multiplied by the Corri- Insured.
dor Percentage shown on the Policy Data
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REQUESTED CHANGES IN After the first policy year, you may request Changes go into effect on the Monthly Anni-
FACE AMOUNT an increase or decrease in your Face Amount versary on or next following the date we re-
by notifying us in writing. ceive your request.
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INCREASES
Increases in Face Amount must be at least We may require written proof that the In-
$5,000. You cannot increase the Face sured is still insurable before making an In-
Amount after Age 85. crease. An approved Increase goes into effect
on the Monthly Anniversary on or next fol-
lowing the date of the approval.
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DECREASES
You cannot decrease the Face Amount below Amount will be reduced in the following or
the Minimum Face Amount shown on the der:
Policy Data Page. You cannot decrease the
Face Amount below the amount needed to 1.
qualify as life insurance under federal tax The Face Amount provided by the most re-
law. cent Increase;
For the purpose of determining the Cost Of 2.
Insurance when more than one Rate Class The next most recent Increases successively;
applies to the current Face Amount, the Face and
3.
The Initial Face Amount.
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5772 6
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17
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CHANGES IN DEATH You may request in writing to change the If you change from Option B (Variable
BENEFIT OPTION Death Benefit Option. When you change the Amount Option) to Option A (Level Amount
Death Benefit Option, we will change the Option), the Face Amount is increased by an
Face Amount so the change in Death Benefit amount equal to the Accumulation Value on
Option will not cause an immediate change in the effective date of the change. The change
the amount of the Death Benefit. is effective on the Monthly Anniversary on or
next following the date we receive your re-
If you change from Option A (Level Amount quest. We do not require proof of insurability
Option) to Option B (Variable Amount Option), for this Increase.
the Face Amount is decreased by an amount
equal to the Accumulation Value on the ef- A change in Face Amount due to a change in
fective date of the change. The change is ef- Death Benefit Option will affect the Monthly
fective on the Monthly Anniversary on or next Deduction because the Cost Of Insurance and
following the date we receive your request. the Monthly Expense Charge depend on the
You cannot change the Death Benefit Option Face Amount. The cost of certain rider bene
if the resulting Face Amount would fall below fits may also be affected.
the Minimum Face Amount shown on the
Policy Data Page. The Surrender Charges will not be affected
by a change in the Death Benefit Option.
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PREMIUMS There is no insurance under this policy until
the initial premium is paid. The initial pre-
mium is shown on the Policy Data Page.
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NET PREMIUM
When you pay a premium, we deduct the The amount remaining after we have de-
Premium Expense Charge. The Premium Ex- ducted the Premium Expense Charge from a
pense Charge is the premium multiplied by premium is the Net Premium.
the Percent of Premium Rate shown on the
Policy Data Page.
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CREDITING NET PREMIUMS
We will credit Net Premiums on the next 2.
Valuation Date on or after the latest of: The date of underwriting approval to issue
this policy; and
1.
The date we receive the premium; 3.
The date we receive all delivery requirements,
including the minimum initial premium pay-
ment.
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ALLOCATION OF NET PREMIUMS
Net Premiums are allocated among the Fixed Net Premiums allocated to the Fixed Account
Account and the Sub-accounts of the Variable will be credited to the Fixed Account.
Account. You choose how the Net Premiums
are to be allocated, within the limits de- Net Premiums allocated to the Variable Ac-
scribed. count and received on or after the Initial Pre-
mium Transfer Date will be credited to the
The initial allocation you chose is shown on Sub-accounts according to the allocation in
the Policy Data Page. You may change the effect. Net Premiums allocated to the Vari-
allocation at any time by notifying us in able Account and received before the Initial
writing. Changes to the allocation will not be Premium Transfer Date will be allocated to
effective until the date we receive your no- the Initial Premium Sub-account. On the Ini-
tification. Changes to the allocation will only tial Premium Transfer Date, the dollar value
affect Net Premiums we receive on or after of the Accumulation Units in the Initial Pre-
the date we receive your notification. mium Sub-account will be transferred to the
Sub-accounts according to the allocation in
You may allocate 100% to any account or effect.
divide your allocation among several ac-
counts. Your allocation must be in whole The Initial Premium Transfer Date and Initial
percentage points totaling 100%. We may Premium Sub-account are shown on the Pol-
adjust your allocation to eliminate fractional icy Data Page.
percentage points.
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86-028 7
- ------------- -------------
18
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PREMIUMS AMOUNT AND TIMING OF PREMIUM PAYMENTS
(continued)
The amount and timing of premium payments 4.
will affect the Accumulation Value, the Cash We may refuse any premium payment after
Surrender Value, how long the life insurance Age 100 of the Insured; and
provided by this policy will remain in force,
and the Death Benefit Guarantees. 5.
We may treat any payment as a loan repay-
After the initial premium you may determine ment if doing so will:
the amount and timing of premium payments,
within the following restrictions: a.
Prevent this policy from lapsing; or
1.
We may require proof which satisfies us that b.
the Insured is still insurable if any premium Prevent borrowing from this policy to pay
payment, whether planned or unscheduled, premiums.
would increase the difference between the
Death Benefit and the Accumulation Value; You may pay premiums by sending them to
the address shown below. Please include
2. your policy number. The current address for
If you pay premiums which would disqualify payment is:
your policy for favorable tax treatment under
the Code, we will return the excess premiums ReliaStar Life Insurance Company of New York
with interest to you within 60 days after the P.O. Box 802511
end of the policy year. Premiums required to Chicago, Illinois 60680-2511
keep this policy in force to the end of the
policy year will not disqualify your policy; Upon request, we will send you a receipt
signed by one of our officers.
3.
We may refuse to accept any premium less
than $25;
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PLANNED PERIODIC PREMIUMS
You may pay planned periodic premiums an- planned periodic premiums that are larger
nually, semi-annually, or quarterly. If you than either of 1 or 2, where:
choose, we can also deduct planned periodic
premiums from your bank account monthly. 1.
We will notify you of your planned periodic Is the maximum premium we would accept
premium at least once a year. under the terms of the Amount and Timing
of Premium Payments provision; and
The amount and frequency of the initial
planned periodic premiums are shown on the 2.
Policy Data Page. You may change the fre- Is a planned periodic premium which would
quency and amount of planned periodic pre- total more than $50,000 per year.
miums by notifying us in writing of the
change. We may reserve the right to limit the We may send you periodic premium notices
amount of any increase in planned periodic depending on the frequency and method of
premiums if such increase would result in premium payment you have chosen.
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UNSCHEDULED ADDITIONAL PREMIUMS
Premiums, other than planned periodic pre- limit the number and amount of these addi-
miums, may be paid at any time up to Age tional payments according to the Amount and
100 of the Insured, except while this policy Timing of Premium Payments provision
is in force as paid-up life insurance. We may above.
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- --------------- ---------------
5773 8
- --------------- ---------------
19
- -----------------------------------------------------------------------------------------------------------------------------------
DEATH BENEFIT This policy has a Basic Death Benefit Guarantee and 1.
GUARANTEES and Extended Death Benefit Guarantee. If either the Request a change in Face Amount;
Basic Death Benefit Guarantee or the Extended Death
Benefit Guarantee is in effect, we guarantee that 2.
we will not lapse your policy even if the Cash Request a change in Death Benefit Option; or
Surrender Value is not sufficient to pay the Monthly
Deduction that is due. The Basic Death Benefit 3.
Guarantee Period and the Benefit Guarantee Period Add or terminate a rider.
are shown on the Policy Data Page and begin on the
Policy Date
The new Minimum Monthly Premiums will apply from the
During each Death Benefit Guarantee Period, if you date of the change. We will send you a new Policy
have not made sufficient premium payments to keep a Data Page showing the new Minimum Monthly Premiums.
Death Benefit Guarantee in effect, we will send you When a Minimum Monthly Premium increases, you may
notice of the premium payment which will keep that need to increase your premium payments to keep that
Death Benefit Guarantee in effect. If we do not Death Benefit Guarantee in effect.
receive the required premium payment within 61 days
following the date we mail you written notice, that You cannot lengthen either Death Benefit Guarantee
Death Benefit Guarantee will no longer be in effect. Period. After a Death Benefit Guarantee is not in
effect, it cannot be put back into effect. Neither
The Minimum Monthly Premium for both Death Benefit Death Benefit Guarantee will be reinstated after the
Guarantees will change when you do any of the policy lapses.
following:
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BASIC DEATH BENEFIT GUARANTEE
The Basic Death Benefit Guarantee is in effect 2.
during the Basic Death Benefit Guarantee Period Is the sum of Basic Minimum Monthly Premiums since
only if, on each Monthly Anniversary since the the Policy Date, including the Basic Minimum Monthly
Policy Date, 1 is equal to or greater than 2, where: Premium for the current Monthly Anniversary.
1. The Basic Minimum Monthly Premium is shown on the
Policy Data Page.
Is the sum of all premiums paid minus any partial
withdrawals and any Loan Amount; and
------------------------------------------------------------------------------------------------------------
EXTENDED DEATH BENEFIT GUARANTEE
The Extended Death Benefit Guarantee is in effect 2.
during the Extended Death Benefit Guarantee Period Is the sum of Extended Minimum Monthly Premiums for
only if, on each Monthly Anniversary since the each Monthly Anniversary since the Policy Date,
Policy Date, 1 is equal to or greater than 2, where: including the Extended Minimum Monthly Premium for
the current Monthly Anniversary.
1.
Is the sum of all premiums paid minus any partial The Extended Minimum Monthly Premium is shown on the
withdrawals and any Loan Amount; and Policy Data Page.
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- --------- ---------
86-029 9
- --------- ---------
20
- -----------------------------------------------------------------------------------------------------------------------------------
GRACE PERIOD AND If no Death Benefit Guarantee is in effect, when than the sum of 1 plus 2, (1 + 2), where:
POLICY LAPSE the Cash Surrender Value is less than the Monthly
Deduction due, this policy will lapse, unless you 1.
make a large enough premium payment before the end Is the amount by which the Accumulation Value is
of the Grace Period. The Grace Period is 61 days less than the Surrender Charge as of the beginning
long and begins when we send you notice of the of the Grace Period; and
premium payment required to keep this policy in
force. We will send this notice within 30 days 2.
of the Monthly Anniversary when the Cash Surrender Is the sum of past due Monthly Deductions.
Value is less than the Monthly Deduction due.
If we do not receive enough premium payment from
The premium payment required to keep this policy in you within the Grace Period, this policy will lapse
force is enough so that the Net Premium is larger at the end of the Grace Period. When this policy
lapses, it is no longer in force.
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REINSTATEMENT Reinstatement means putting a lapsed policy back in The Surrender Charges after reinstatement will be
force. You may reinstate this policy by written those in effect on the date of termination, reduced
request any time within five years after it has in the same proportion as the Accumulation Value on
lapsed. You may not reinstate this policy if you the date of termination to the Surrender Charge on
surrendered this policy for its Cash Surrender Value. that date. The Surrender Charge will not be less
than zero.
This policy will be reinstated only as of a Monthly
Anniversary. To reinstate this policy and any The Accumulation Value on the date of reinstatement
riders you must: will be the amount provided by the Net Premium paid
to reinstate this policy. Subsequent Accumulation
1. Values will be calculated as shown in the Accumula-
Submit proof which satisfies us that all Insureds tion Value provision of this policy.
are still insurable; and
2. If you have met the above conditions and the Insu-
Pay a premium large enough such that the Net red dies before the Monthly Anniversary on which the
Premium is as large as the sum of the Surrender policy would be reinstated, we will pay the Death
Charge after reinstatement, plus the Monthly Benefit as of that Monthly Anniversary.
Deductions for the date of reinstatement and the
following Monthly Anniversary.
- -----------------------------------------------------------------------------------------------------------------------------------
- ---------------------- ----------
5774 10
- ---------------------- ----------
21
- -----------------------------------------------------------------------------------------------------------------------------------
ACCUMULATION VALUE The Accumulation Value of this policy is equal to
the sum of the Fixed Accumulation Value plus the
Variable Accumulation Value.
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FIXED ACCUMULATION VALUE 4.
Is the total of your Loan Amount transferred from
The Fixed Accumulation Value on the Policy Date is the Variable Account since the preceding Monthly
your Net Premium credited to the Fixed Account on Anniversary;
that date minus the Monthly Deduction applicable to
the Fixed Accumulation Value for the first policy 5.
month. Is the total of your transfers to the Variable
Account from the Fixed Account since the preceding
After the Policy Date, the Fixed Accumulation Value Monthly Anniversary, plus interest from the date of
is calculated as 1+2+3+4-5-6, where: transfer to the date of the calculation; and
1. 6.
Is the Fixed Accumulation Value on the preceding Is the total of your partial withdrawals from the
Monthly Anniversary, plus interest from the Monthly Fixed Account since the preceding Monthly Anniver-
Anniversary to the date of the calculation; sary, plus interest from the date of withdrawal to
the date of the calculation.
2.
Is the total of your Net Premiums credited to the If the date of the calculation is a Monthly Anni-
Fixed Account since the preceding Monthly Anniver- versary, we also reduce the Fixed Accumulation Value
sary, plus interest from the date premiums are by the applicable portion of the Monthly Deduction
credited to the date of the calculation; for the policy month following the Monthly Anniver-
sary.
3.
Is the total of your transfers from the Variable
Account to the Fixed Account since the preceding
Monthly Anniversary, plus interest from the date of
transfer to the date of the calculation;
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INTEREST ON THE FIXED ACCUMULATION VALUE
The interest rate applied in the calculation of the The interest rate applied to any portion of the
Fixed Accumulation Value will not be less than the Fixed Accumulation Value which is held as security
Minimum Annual Interest Rate shown on the Policy for a policy loan may be less than the interest
Data Page. This rate is an effective annual interest rate applied to the rest of the Fixed Accumulation
rate compounded yearly. Value, but not less than the Minimum Annual
Interest Rate.
Interest in excess of the Minimum Annual Interest
Rate may be applied in the calculation of your Any interest is nonforfeitable, except as it is
Fixed Accumulation Value in a manner which our subject to the deductions and charges, including
Board of Directors determines. We will credit Surrender Charges, stated elsewhere in this policy.
interest no less frequently than annually. Interest credited on the loaned Accumulation Value
is credited annually on the Policy Anniversary
to the Fixed Account and the Variable Account
according to your premium allocation.
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VARIABLE ACCUMULATION VALUE
The Variable Accumulation Value is the total of 2.
your values in each Sub-account. The value for each Is the current Unit Value.
Sub-account is equal to 1 multiplied by 2, (1 x 2),
where: The Variable Accumulation Value will vary from
Valuation Date to Valuation Date reflecting changes
1. in 1 and 2 above.
Is your current number of Accumulation Units; and
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86-030 11
- --------- ---------
22
- -----------------------------------------------------------------------------------------------------------------------------------
ACCUMULATION VALUE ACCUMULATION UNITS
(continued)
When transactions are made which affect the Variable The number of Accumulation Units for a Sub-account
Accumulation Value, dollar amounts are converted to decreases when:
Accumulation Units. The number of Accumulation Units
for a transaction is found by dividing the dollar 1.
amount of the transaction by the current Unit Value. You take out a Policy Loan which causes a transfer
from that Sub-account;
The number of Accumulation Units for a Sub-account
increases when: 2.
You take a partial withdrawal from that Sub-account;
1.
Net Premiums are credited to that Sub-account; or 3.
We take a portion of the Monthly Deduction from that
2. sub-account; or
Transfers from the Fixed Account or other Sub-
accounts are credited to that Sub-account. 4.
Transfers are made from that Sub-account to the
Fixed Account or other Sub-accounts.
------------------------------------------------------------------------------------------------------------
UNIT VALUE
The Unit Value for a Sub-account on any Valuation for the Valuation Period ending on that Valuation
Date is equal to the previous Unit Value multiplied Date.
by the Net Investment Factor for that Sub-account
------------------------------------------------------------------------------------------------------------
NET INVESTMENT FACTOR
The Net Investment Factor is a number that reflects c
charges to this policy and the investment performance Plus or minus a per share charge or credit for any
during a Valuation Period of the mutual fund in taxes reserved for which we determine to have
which a Sub-account is invested. If the Net Invest- resulted from the investment operations of the Sub-
ment Factor is greater than one, the Unit Value is account and to be applicable to this policy.
increased. If the Net Investment Factor is less
than one, the Unit Value is decreased. The Net 2.
Investment Factor for a Sub-account is determined Is the result of:
by dividing 1 by 2, ( 1 / 2 ), where:
a
1. The net asset value per share of the mutual fund
Is the result of: shares held in the Sub-account, determined at the
end of the last prior Valuation Period; and
a
The net asset value per share of the mutual fund b
shares in which the Sub-account invests, determined Plus or minus a per share charge or credit for any
at the end of the current Valuation Period; taxes reserved for the last prior Valuation Period
which we determine to have resulted from the
b investment operations of the Sub-account and to be
Plus the per share amount of any dividend or capital applicable to this policy.
gain distributions made on the mutual fund shares
in which the Sub-account invests during the current
Valuation Period; and
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5775 12
- --------- ---------
23
- -----------------------------------------------------------------------------------------------------------------------------------
MONTHLY DEDUCTIONS The Monthly Deduction is a charge made monthly lation Value is 1 multiplied by 2 divided by 3,
against the Accumulation Value. The Monthly (1 x 2 / 3), where:
Deduction for a policy month will be calculated as
1 plus 2 plus 3 plus 4 plus 5, (1 + 2 + 3 + 4 + 5), 1.
where: Is the cost of any rider benefits plus the Cost Of
Insurance for this policy plus the Monthly Expense
1. Charge, for the policy month;
Is the cost of any rider benefits, other than any
Waiver of Monthly Deduction rider, for the policy 2.
month; Is the Fixed Accumulation Value minus the Loan
Amount; and
2.
Is the Cost Of Insurance for this policy for the 3.
policy month; Is the Accumulation Value minus the Loan Amount.
3.
Is the Monthly Expense Charge; The remainder of the Monthly Deduction is deducted
from the Variable Accumulation Value.
4.
Is the Monthly Variable Accumulation Value Charge The portion of the Monthly Deduction we deduct from
for the policy month; and each Sub-account is 1 times 2 divided by 3,
(1 x 2 / 3), where:
5.
Is the cost of any Waiver of Monthly Deduction 1.
rider for the policy month. Is the amount of Monthly Deduction deducted from
the Variable Accumulation Value;
The Monthly Deduction is deducted from the Fixed Accumu-
lation Value and the Variable Accumulation Value as 2.
of the Monthly Anniversary. The amount of the Is the value of each Sub-account, and
Monthly Deduction we deduct from the Fixed Accumu-
3.
Is the Variable Accumulation Value.
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COST OF INSURANCE
We determine the Cost Of Insurance on a monthly 3.
basis. The Cost Of Insurance for a policy month is Is the Accumulation Value immediately before the
calculated as 1 multiplied by the result of 2 minus Monthly Deduction, minus the cost for any rider
3 (1 x (2- 3)), where: benefits other than any Waiver of Monthly
Deduction rider, for the month.
1.
Is the Cost Of Insurance Rate as described in the The Cost Of Insurance is determined separately for
Cost of Insurance Rates provision of this policy; the Initial Face Amount and any Increases made
later. The Accumulation Value used in 3 above will
2. first be subtracted from the Initial Face Amount.
Is the Death Benefit at the beginning of the policy If the Accumulation Value on the Monthly
month, divided by 1.000000 plus the Minimum Monthly Anniversary exceeds the Initial Face Amount, it
Interest Rate shown on the Policy Data Page; and will be subtracted from any increase in the Face
Amount in the order the Increases were made.
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- ---------- ----------
86-031 13
- ---------- ----------
24
- -----------------------------------------------------------------------------------------------------------------------------------
MONTHLY DEDUCTIONS COST OF INSURANCE RATES
(continued)
The monthly Cost Of Insurance Rate for the Monthly Guaranteed Cost Of Insurance Rates,
Initial Face Amount and any Increases in Face multiplied by the Rate Class Rating Factor,
Amount is based on the policy year, and the plus any Extra Cost Of Insurance Rates.
Sex, Age, and Rate Class of the Insured on the
effective date of coverage. If the Death
Benefit equals the Accumulation Value multi- The Table of Monthly Guaranteed Cost Of In-
plied by the Corridor Percentage, the Rate surance Rates is based on the Commissioners
Class with the most recent effective date will Standard Ordinary (CSO) Table shown on the
apply. Policy Data Page. The Rate Class Rating Fac-
tor and any Extra Cost Of Insurance Rates are
The Cost Of Insurance Rates can never be shown on the Policy Data Page.
greater than the rates shown in the Table of
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MONTHLY EXPENSE CHARGE
The Monthly Expense Charge for a policy
month is the Monthly Administrative Charge
plus the Monthly Amount Charge.
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MONTHLY ADMINISTRATIVE CHARGE
The Monthly Administrative Charge is subject 1.
to change, but will not exceed the Maximum Is the Consumer Price Index (for all urban
Monthly Administrative Charge shown on the households) for the preceding September; and
Policy Data Page. The Monthly Administra-
tive Charge will not exceed the product of 2.
$5.00 and the ratio (not to exceed 2.00) of a Is the Consumer Price Index for September
to b, where: 1985.
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MONTHLY AMOUNT CHARGE
The Monthly Amount Charge for the Initial the Policy Date Page. The Monthly Amount
Face Amount and any Increases in Face Charge for the Initial Face Amount and for
Amount is equal to the Monthly Amount any Increase in Face Amount is charged dur-
Charge Rate times the Face Amount. ing the Term shown on the Policy Data Page,
beginning on the effective date of the cover-
The Monthly Amount Charge Rate for the Ini- age. Decreases to the Face Amount do not
tial Face Amount and any Increases in Face decrease the Monthly Amount Charge.
Amount is based on the Sex, Age, and Rate
Class of the Insured on the effective date of Any change in Face Amount due solely to a
the coverage. The Monthly Amount Charge change of Death Benefit Option does not af-
Rate for the Initial Face Amount is shown on fect the Monthly Amount Charge.
- -----------------------------------------------------------------------------------------------------------------------------------
- --------------- ---------------
5776 14
- --------------- ---------------
25
- -----------------------------------------------------------------------------------------------------------------------------------
MONTHLY DEDUCTIONS MONTHLY VARIABLE ACCUMULATION VALUE
(continued) CHARGE
The Monthly Variable Accumulation Value a.
Charge for a policy month will be calculated Is the cost of any rider benefits other than
as 1 multiplied by the result of 2 minus 3, (1 any Waiver of Monthly Deduction rider;
x (2 - 3)), where:
b.
1. Is the Cost Of Insurance; and
Is the Variable Accumulation Value Charge
Rate, divided by 12; c.
Is the Monthly Expense Charge.
2.
Is the Variable Accumulation Value before the The Variable Accumulation Value Charge Rate
Monthly Deduction; will not exceed the Maximum Variable Accu-
mulation Value Charge Rate shown on the
3. Policy Data Page.
Is the sum of the portion of the following
charges which is taken from the Variable Ac-
cumulation Value:
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ADJUSTMENTS TO POLICY COST FACTORS
Adjustments to the monthly Cost Of Insur- ture expectations, in accordance with proce-
ance Rate and Monthly Administrative Charge dures and standards on file with the New
will be by Rate Class and based upon York Insurance Department. Changes will not
changes in future expectations for mortality, be used to recoup past losses or distribute
persistency, interest, taxes, and expenses. past gains. The experience underlying the
Any changes to the monthly Cost Of Insur- monthly Cost Of Insurance Rate will be re-
ance Rate or Monthly Administrative Charge viewed at regular intervals, no less often than
will be made only prospectively, based on fu- every five years.
- -----------------------------------------------------------------------------------------------------------------------------------
TRANSFERS You may request in writing the transfer of all ever, we may make a charge for each transfer
or part of your Accumulation Value between you request in excess of the first 12 transfers
the Fixed Account and the Sub-accounts of in a policy year. The charge may not exceed
the Variable Account. The transfer will be the maximum charge shown on the Policy
initiated on the date we receive your request. Data Page. We may limit the number of
Your current premium allocation will remain transfers you request in a policy year to 12.
in effect unless you have requested the Port- We consider all transfers requested at the
folio Rebalancing Service, or you are trans- same time and made on the same Valuation
ferring all of the Variable Accumulation Value Date as one transfer. All transfers are also
from the Variable Account to the Fixed Ac- subject to any charges and conditions im-
count in exercise of conversion rights. posed by the mutual fund whose shares are
involved.
We do not make a charge for the first 12
transfers you request in a policy year. How-
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TRANSFERS TO AND FROM THE FIXED ACCOUNT
You may transfer up to 100% of the value of 2.
the Sub-accounts into the Fixed Account at You may transfer up to 50% of the portion
any time. of the Fixed Accumulation Value which is not
held as security for a policy loan. However,
You may only transfer value out of the Fixed if the portion of the Fixed Accumulation
Account under the following conditions: Value which is not held as security for a pol-
icy loan is $2,000 or less, you may transfer
1. up to 100%.
Your request to transfer must be postmarked
no more than 30 days before the policy anni- 3.
versary, and no later than 30 days after the The amount of the transfer must be at least
policy anniversary. Only one transfer is al- $500 or, if smaller, the entire portion of the
lowed during this period; Fixed Accumulation Value which is not held
as security for a policy loan.
- -----------------------------------------------------------------------------------------------------------------------------------
- --------------- ---------------
86-032 15
- --------------- ---------------
26
- ------------------------------------------------------------------------------------------------------------------------------------
TRANSFERS TRANSFERS TO AND FROM SUB-ACCOUNTS
(continued)
You may transfer up to 100% of the value All transfers to and from Sub-accounts hap-
out of any or all Sub-accounts. Any value you pen on the next Valuation Date on or after the
transfer from the Fixed Account or from Sub- date the transfer is initiated.
accounts may be transferred into any one or
more Sub-accounts.
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DOLLAR COST AVERAGING SERVICE
You may request this service if your Face 2.
Amount is at least $100,000 and either your On receipt of any request to begin a Portfolio
Accumulation Value, less any Loan Amount, Rebalancing service;
is at least $5,000 or your initial premium is
at least $5,000. If you request this service 3.
in writing, we will make specific periodic If the policy is in the grace period on any
transfers of a fixed dollar amount from any date when Dollar Cost Averaging transfers are
of the Sub-accounts to one or more of the scheduled;
Sub-accounts or to the Fixed Account. No
transfers from the Fixed Account are permit- 4.
ted under this service. Transfers of this type If the specified transfer amount from any
may be made on a monthly, quarterly, semi- Sub-account is more than the Accumulation
annual, or annual basis. We make no guar- Value in that Sub-account; or
antees that Dollar Cost Averaging will result
in a profit or protect against loss. 5.
The Dollar Cost Averaging service will be Thirty-six months after the Dollar Cost Aver-
discontinued immediately: aging start date.
1. We may discontinue, modify, or suspend this
If you make a written request to discontinue service. Any such modification or discontin-
this service; uation would not affect any Dollar Cost Aver-
aging service requests already commenced.
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PORTFOLIO REBALANCING SERVICE
You may request this service if your Face under this service may be made on a quar-
Amount is at least $100,000 and your Accu- terly, semi-annual, or annual basis.
mulation Value, less any Loan Amount, is at
least $10,000. If you request this service in The Portfolio Rebalancing service will be dis-
writing, we will make periodic transfers to continued immediately:
maintain your specified percentage allocation
of Accumulation Value, less any Loan 1.
Amount, among the Sub-accounts of the Var- If you make a written requst to discontinue
iable Account and the Fixed Account. Your this service;
allocation of future Net Premium payments
will also be changed to be equal to this spec- 2.
ified percentage allocation. Transfers made On receipt of any request to change the allo-
cation of premiums to the Fixed Account and
Sub-account of the Variable Account;
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5777 16
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27
__________________________________________________________________________________________________________________________________
TRANSFERS PORTFOLIO REBALANCING SERVICE (cont.)
(continued)
3. 6.
On receipt of any request to begin a Dollar The Accumulation Value, less any Loan
Cost Averaging service; Amount, is less than $7,500 on any Valuation
Date when Portfolio Rebalancing transfers are
4. scheduled.
On receipt of any request to transfer Accu-
mulation Value among the Fixed Account or We may discontinue, modify, or suspend this
Sub-accounts; service. Any such modification or discontin-
uation could affect Portfolio Rebalancing ser-
5. vices currently in effect, but only after 30
If the policy is in the grace period; or days notice to you.
___________________________________________________________________________________________________________________________________
NONFORFEITURE CONTINUATION OF INSURANCE
PROVISIONS
Even if you do not make additional premium Monthly Deduction. If the Cash Surrender
payments your insurance coverage under this Value is less than the Monthly Deduction due,
policy, and any benefits provided by rider, we will use the Cash Surrender Value to con-
will stay in force as long as the Cash Surren- tinue the insurance during the grace period.
der Value is large enough to cover the
_____________________________________________________________________________________________________
PAID-UP LIFE INSURANCE
Any time before Age 100 of the Insured, you is also calculated based on this CSO Table
may use the Cash Surrender Value to pur- and Interest Rate.
chase single premium paid-up life insurance.
To purchase paid-up life insurance, we trans-
Any paid-up life insurance purchased under fer the Cash Surrender Value of this policy to
the terms of this policy will not be larger than the Fixed Account.
the sum of the Cash Value of the paid-up life
insurance, plus the Death Benefit of this pol- If this policy is in force as paid-up life
icy, minus the Accumulation Value of this insurance:
policy. Any Cash Surrender Value not used
to purchase paid-up life insurance will be 1.
paid to you in cash. The Accumulation Value provision of this
policy no longer applies;
We base the single premium for paid-up in-
surance on the Sex, Age, and Rate Class or 2.
Classes of the Insured at the time this option You cannot pay additional premiums;
is exercised, and the single premium life in-
surance rates based on the Commissioner's 3.
Standard Ordinary Mortality (CSO) Table and You cannot make partial withdrawals; and
Interest Rate shown on the Policy Data Page.
The Cash Value of the paid-up life insurance 4.
We do not make any further Monthly De-
ductions.
___________________________________________________________________________________________________________________________________
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86-033 17
- -------------- --------------
28
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CASH VALUE, CASH BASIS OF COMPUTATIONS
SURRENDER VALUE,
TOTAL SURRENDER, AND Cash values under this policy are not less
PARTIAL WITHDRAWAL than the minimums required by the state of
BENEFITS New York.
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CASH VALUE
The Cash Value of this policy is the Accumu- The Cash Value is never less than zero.
lation Value minus any Surrender Charge.
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CASH SURRENDER VALUE
The Cash Surrender Value of this policy is the unpaid Monthly Deductions.
Cash Value minus the Loan Amount and any
----------------------------------------------------------------------------------------------------
SURRENDER CHARGE
We make a Surrender Charge if you surrender
this policy or it lapses. The Surrender Charge
is not less than zero.
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SURRENDER CHARGE ON INITIAL FACE AMOUNT
The amount and duration of the Surrender amount of the Surrender Charge depends on
Charge applicable to the Initial Fact Amount the Initial Face Amount and the Sex, Age, and
is described on the Policy Data Page. The Rate Class of the Insured.
----------------------------------------------------------------------------------------------------
SURRENDER CHARGE AFTER REQUESTED
CHANGES IN FACE AMOUNT
Additional Surrender Charges will apply to written notice of the amount and duration of
any approved Increase in Face Amount. Addi- the additional Surrender Charge.
tional Surrender Charges will apply to any
Increase in Face Amount resulting from any Any Increases or decreases in Face Amount
Rider attached to this policy. The additional resulting from changes in the Death Benefit
Surrender Charge depends on the amount of Option do not affect the Surrender Charges.
the Increase in Face Amount and the Sex,
Age, and Rate Class of the Insured on the ef- Any requested decreases in Face Amount do
fective date of the increase. We will send you not affect the Surrender Charges.
- ----------------------------------------------------------------------------------------------------------------------------------
- ---------- ----------
5778 18
- ---------- ----------
29
- ------------------------------------------------------------------------------------------------------------------------------------
CASH VALUE, CASH TOTAL SURRENDER
SURRENDER VALUE,
TOTAL SURRENDER, AND You may surrender this policy for its Cash
PARTIAL WITHDRAWAL Surrender Value by sending us a written request.
BENEFITS
(continued) ------------------------------------------------------------------------------------------------------
PARTIAL WITHDRAWAL
After the first policy year, you may withdraw part imum Partial Withdrawal Percent shown on the
of your Cash Surrender Value by sending us a Policy Data Page.
written request. We may make a charge for each
partial withdrawal, but the charge will not exceed 3.
the maximum shown on the Policy Data Page. Partial Only one partial withdrawal is allowed in any
withdrawals are subject to the following limits: policy year.
1. Unless you specify otherwise, we make partial
The amount of any partial withdrawal must be at withdrawals from the Fixed and Variable
least equal to $500.00. Accumulation Values in proportion to the
amount of the Fixed and Variable Accumulation
2. Values, net of Loan Amount.
The maximum partial withdrawal equals the Cash
Surrender Value multiplied by the Max- If you request a partial withdrawal of the en-
tire Cash Surrender Value, we will consider it
a request for Total Surrender
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THE EFFECT OF PARTIAL WITHDRAWALS
The Accumulation Value is reduced by the Data Page. If more than one Rate Class
amount of any partial withdrawal. Partial applies to the current Face Amount, for the
withdrawals from the Fixed Account reduce the purpose of determining the Cost Of Insurance,
amount of the Fixed Accumulation Value. the Face Amount will be reduced in the
Partial withdrawals from a Sub-account reduce following order:
the Variable Accumulation Value through the
surrender of Accumulation Units for the 1.
amount withdrawn. The Face Amount provided by the most recent
Increase;
The Death Benefit is reduced by the amount of
the withdrawal, or, if the Death Benefit 2.
equals the Accumulation Value multiplied by The next most recent Increases successively;
the Corridor Percentage, by an amount equal and
to the Corridor Percentage times the amount
of the withdrawal. 3.
The Initial Face Amount.
If Option A (Level Amount Option) is in
effect, the Face Amount will be reduced by If Death Benefit Option B (Variable Amount
the amount of the partial withdrawal. We do Option) is in effect, a partial withdrawal
not allow a withdrawal if the Face Amount does not affect the Face Amount.
after a partial withdrawal would be less than
the Minimum Face Amount shown on the Policy A partial withdrawal may cause the Death
Benefit Guarantee to terminate.
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86-034 19
- -------------- --------------
30
- -----------------------------------------------------------------------------------------------------------------------------------
POLICY LOANS
After the first policy year, if this policy 1.
has a Loan Value, you may take out a loan Is the Cash Value;
from us by written request. We will not lend
you more than the Loan Value. 2.
Is the existing Loan Amount.
The Loan Value is 1 minus 2, (1 - 2), where:
Each loan must be at least $500.
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EFFECT OF POLICY LOANS
We deduct any policy loans from any proceeds. you specify otherwise, amounts held as
A policy loan may reduce the Cash Surrender security for the loan will come from the
Value to the point where the grace period Fixed Accumulation Value and the Variable
goes into effect and we may lapse this Accumulation Value in proportion to the
policy. A policy loan may cause the Death amount of the Fixed and Variable Accumulation
Benefit Guarantee to terminate. Values, net of Loan Amount.
We use this policy as security for the loan. Amounts coming from the Sub-accounts of the
When we make a policy loan, an amount equal Variable Account are transferred to the Fixed
to the policy loan will be held within a Account, reducing the Variable Accumulation
segregated portion of your Fixed Accumulation Value.
Value as security for the loan. Unless
-----------------------------------------------------------------------------------------------------
LOAN INTEREST
We charge interest on the Loan Amount at the The Preferred Loan Amount is calculated on
Loan Interest Rate shown on the Policy Data the date of any loan and on each policy
Page. After the tenth policy year, we charge anniversary thereafter. Policy loan
interest on the Preferred Loan Amount at the repayments received will be applied first to
Preferred Loan Interest Rate shown on the reduce the portion of your policy loan that
Policy Data Page. The Preferred Loan Amount is not the Preferred Loan Amount, and then to
is the smaller of the Loan Amount or the reduce the Preferred Loan Amount.
result of 1 minus 2 plus 3, ( 1 - 2 + 3 ),
where: On the date of any policy loan, interest is
due in advance for the remainder of the
1. policy year. On each policy anniversary
Is the Accumulation Value; thereafter, interest is due in advance for
the next full policy year. Any unpaid
2. interest is added to the Loan Amount, and we
Is the sum of all premiums paid; and charge interest on it.
3.
Is the sum of all partial withdrawals.
- -----------------------------------------------------------------------------------------------------------------------------------
- ---------- ----------
5579 20
- ---------- ----------
31
- -----------------------------------------------------------------------------------------------------------------------------------
POLICY LOANS LOAN REPAYMENT
(continued)
You may repay all or part of any policy loan transfer an amount from the Fixed Account to
during the lifetime of the Insured. each Sub-account of the Variable Account. The
amount we transfer to each Sub-account is 1
When you make a loan repayment, you must tell multiplied by 2, ( 1 x 2 ), where:
us that you are making a loan repayment.
Otherwise, we may consider any payment we 1.
receive to be a premium payment, which will Is the amount of the loan repayment; and
be subject to a Premium Expense Charge, and
will not reduce the Loan Amount. 2.
Is the current proportion used to allocate
Loan repayments reduce the Loan Amount. When premiums to that Sub-account.
you make a loan repayment, we will
- ------------------------------------------------------------------------------------------------------------------------------------
DELAY OF PAYMENT ON
SURRENDER, PARTIAL
WITHDRAWALS AND
LOANS
The amount surrendered, withdrawn, or loaned 2.
will normally be paid to you within seven The Securities and Exchange Commission
days of: determines that a state of emergency exists.
1. We may delay paying a surrender, partial
Receipt of your written request; and withdrawal, or loan from the Fixed Account
for up to six months from the date we receive
2. your request. If we delay payment for 10
Receipt of your policy, if required. working days or more, we pay interest from
the date of the surrender, partial
We may delay making the payment when we are withdrawal, or loan request to the date of
not able to determine the Variable payment. We pay interest at the same rate we
Accumulation Value because: are currently paying on proceeds at death.
1.
The New York Stock Exchange is closed for
trading; or
- ------------------------------------------------------------------------------------------------------------------------------------
BENEFICIARY The beneficiary is named to receive the described below. You may also choose to name
proceeds to be paid at the death of the an irrevocable beneficiary. You cannot change
Insured. You may name one or more an irrevocable beneficiary without his or her
beneficiaries on the application. Later, you consent.
may name, add, or change beneficiaries by
written request as
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NAMING, ADDING, OR CHANGING BENEFICIARIES
You can name, add, or change beneficiaries by 3.
written request if all of these are true. We have the written consent of all
irrevocable beneficiaries.
1.
This policy is in force; A change will take effect as of the date it
is signed but will not affect any payment we
2. make or action we take before receiving your
The Insured is alive; and request.
- ------------------------------------------------------------------------------------------------------------------------------------
- --------------- ---------------
86-035 21
- --------------- ---------------
32
- -----------------------------------------------------------------------------------------------------------------------------------
PAYMENT OF PROCEEDS We pay proceeds to a payee. We pay proceeds 2.
in one sum, unless a Settlement Option is The beneficiary, if any, if any proceeds
requested and we agree to it. We will also remain after paying collateral assignees. If
use any other method of payment that is there is more than one beneficiary, each
acceptable to the payee and to us. receives an equal share, unless you have
requested another method in writing. To
We pay proceeds from a Total Surrender to you. receive proceeds, a beneficiary must be
living on the 10th day after the death of the
We pay death proceeds to: Insured; or
1. 3.
Collateral assignees, up to the amount of the You, if there are no beneficiaries and if any
debt; proceeds remain after paying collateral
assignees.
------------------------------------------------------------------------------------------------------
SETTLEMENT OPTIONS
Settlement Options are ways of paying the Settlement Option Interest Rate shown on the
proceeds of this policy. We issue a Policy Data Page.
supplemental contract for proceeds applied
under any option. If the payee dies after we have paid or
credited proceeds, we will pay the proceeds
Settlement Options are chosen or withdrawn by and any unpaid interest in one sum to the
making a written agreement with us or by payee's estate.
sending us written notice. Our approval is
needed for any option to be chosen or OPTION 2
withdrawn. Before the death of the Insured,
only you can choose or withdraw an option. We pay the proceeds with interest in equal
After the death of the Insured, a beneficiary installments for the amount you choose at
may choose an option depending on prior equal intervals until the proceeds and
restrictions made by you or a collateral interest are all paid. The interval you
assignee. A change of beneficiary or owner choose may be one month, three months, six
withdraws all chosen options; you must choose months, or a year. The amount chosen for each
again any options you want. installment must be such that the total
installments payable in the first 12 months
We may refuse to accept an option where less is at least one year of interest plus 4% of
than $2,500 will be applied for each payee. the total amount of the proceeds. The last
In this case, we would pay a payee's proceeds installment will be for the remaining
in one sum. Under an installment option, each proceeds and interest, and might not be equal
payment must be at least $25. If needed, we to the other installments.
may increase the time between payments to
three months, six months, or a year to make We base the interest rate for proceeds
each payment at least $25. applied under Option 2 on the interest rate
we declare on funds that we consider to be in
OPTION 1 the same classification based on the option,
restriction on withdrawal, and other factors.
The proceeds are left with us to earn The interest rate will never be less than the
interest. The withdrawal rights, the length Settlement Option Interest Rate shown on the
of time we will hold the proceeds, and any Policy Data Page.
future change of option are subject to our
approval. We pay the first installment as of the date
we issue a supplemental contract to pay the
We base the interest rate for proceeds proceeds.
applied under Option 1 on the interest rate
we declare on funds that we consider to be in If a payee dies after we have paid or
the same classification based on the option, credited proceeds, we will pay the remaining
restrictions on withdrawal, and other payments to any contingent payees. If there
factors. The interest rate will never be less are no contingent payees, we pay to the
than the payee's estate any unpaid sum left with us
plus any unpaid interest on that sum.
- ------------------------------------------------------------------------------------------------------------------------------------
- --------------- ---------------
5780 22
- --------------- ---------------
33
- ------------------------------------------------------------------------------------------------------------------------------------
PAYMENT OF PROCEEDS OPTION 3 This means that we continue paying the
(continued) primary payee, the first person to whom
We pay the proceeds in equal installments at benefits are payable, in equal monthly
equal intervals for the number of years you installments for as long as the primary payee
choose. The interval may be one month, three lives with a number of months certain.
months, six months, or a year. Use the Option Certain means that we make payments for at
3 Table to determine the amount of each least as long as the period you choose
installment. The Option 3 table is shown on (either 60, 120, 180, or 240 months), no
the Policy Data Page. If you ask, we will matter when the primary payee dies. If the
tell you the payment amounts for numbers of primary payee dies before the certain period
years or intervals not shown. ends, the remaining payments are payable to
the contingent payee. If there are no
We pay the first installment as of the date contingent payees, we pay to the primary
we issue a supplemental contract to pay the payee's estate the commuted value of any
proceeds. unpaid installments remaining in the certain
period. The commuted value will be calculated
If a payee dies after we have paid or based on interest at the effective annual
credited proceeds, we will pay the remaining rate which we are then using to credit excess
payments to any contingent payees. If there interest on new Option 4 settlements.
are no contingent payees, we pay the commuted
value of any unpaid installments. The We compute the installments using the
commuted value will be calculated based on calendar year in which the proceeds are
interest at the effective annual rate which applied and the sex and age of the payee at
we are then using to credit excess interest that time. We require written proof of the
on new Option 3 settlements. payee's sex and age. If you ask, we will tell
you payment amounts for this option. The
For Option 3 we may credit excess interest. amounts of the installments are computed
Any excess interest we may declare will be using the Settlement Option Mortality Table
based on the interest rate on funds that we and Settlement Option Interest Rate shown on
consider to be in the same classification the Policy Data Page.
based on the option, restrictions on
withdrawal, and other factors. For Option 4 we may credit excess interest.
Any excess interest we may declare will be
OPTION 4 based on the interest rate on funds that we
consider to be in the same classification
The proceeds are used to provide an annuity based on the option, restrictions on
with 60, 120, 180, or 240 months certain. withdrawal, and other factors.
- -----------------------------------------------------------------------------------------------------------------------------------
- --------------- ---------------
86-036 23
- --------------- ---------------
34
...................................................................................................................................
SETTLEMENT OPTIONS OPTION 5 Option Mortality Table and Settlement Option
(continued) Interest Rate shown on the Policy Data Page.
The proceeds are used to provide a "joint and
two-thirds to survivor" life income for two We pay the first installment as of the date
payees. We make monthly payments jointly we issue a supplemental contract to pay the
to the two payees as long as they both live. proceeds.
When one payee dies, the other receives
two-thirds of the amount of the joint monthly OPTION 6 (ANNUITY OPTION)
payment for life. Payments stop when both
payees have died. We compute the payment The proceeds are used to provide an annuity.
amounts using the calendar year in which the Each annuity installment is 103% of the
proceeds are applied and the ages and sexes payment that we would make if the payee
of the payees when the proceeds are applied. had used the proceeds to buy a similar, non-
We require written proof of the ages of the participating, single premium immediate an-
payees. If you ask, we will tell you any of nuity at our rates on the date the proceeds
these amounts. The amounts of the monthly are applied. We will not apply this option if
payments are computed using the Settlement a similar option would be more favorable to
the payee when proceeds are applied.
...................................................................................................................................
PROTECTION OF PROCEEDS
Unless we agree to it, a payee may not do 4.
any of the following: Change the amount of payment;
1. 5.
Withdraw any part of the proceeds or inter- Surrender the supplemental contract for cash;
est;
6.
2. Borrow against the supplemental contract; or
Change the fixed payment intervals or the
length of the payment period; 7.
Assign the supplemental contract.
3.
Change the settlement option, except if the A creditor of the payee may not claim any of
payee chooses Option 1, 2, or 3, the payee the proceeds or interest. This provision ap-
may change the option and transfer the funds plies unless altered by federal or state law.
that remain to a new option;
..................................................................................................................................
INTEREST ON PROCEEDS
For proceeds payable at the death of the In- The interest rate will be the current interest
sured, if payment of proceeds, or application rate being credited on the interest only
of proceeds to a settlement option is delayed settlement option (Option 1), but it will never
more than 30 days, we will pay interest on be less than the Settlement Option Interest
the proceeds for the time between the death Rate shown on the Policy Data Page.
of the Insured and the earlier of the following:
As of the date of death of the Insured, or date
1. of Total Surrender, the proceeds no longer
The date we pay proceeds; or earn interest at the rate applied to the Fixed
Account nor do the proceeds participate in
2. the investment experience of the Variable
The date we issue a supplemental contract Account. As of the date a supplemental con-
under one of the Settlement Options. tract is issued, interest is determined by the
provisions of the supplemental contract.
...................................................................................................................................
- --------------- ---------------
5781 24
- --------------- ---------------
35
- -----------------------------------------------------------------------------------------------------------------------------------
CONTROL OF POLICY OWNERSHIP
As owner, you have the rights and duties 8.
outlined in this policy. However, we need the Add a Term Insurance Rider;
written consent of all irrevocable beneficiaries
and collateral assignees, if you wish to: 9.
Change the Face Amount; or
1.
Surrender this policy or make a partial with- 10.
drawal; Change the Death Benefit Option.
2. We need the written consent of all irrevocable
Take out a policy loan; beneficiaries, if you wish to:
3. 1.
Change the policy to paid-up life insurance; Change a beneficiary;
4. 2.
Change the owner; Choose or change a Settlement Option; or
5. 3.
Name or change a contingent owner; Assign this policy or any of its benefits as
collateral.
6.
Add a Children's Insurance Rider; Your rights, as outlined in this policy, end at
the death of the Insured.
7.
Add an Additional Insured Rider;
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COLLATERAL ASSIGNMENT
You may assign the benefits of this policy as An assignment is not binding on us until we
collateral for a debt. This limits your rights receive written notice of it. We assume no
to the Cash Surrender Value and the benefi- responsibility as to the validity of any as-
ciary's rights to the proceeds. A collateral as- signment. When we pay proceeds, we may
signment does not change the owner. A rely on what the collateral assignee states as
collateral assignee does not have ownership the debt due.
rights.
-----------------------------------------------------------------------------------------------------
CHANGING OWNERSHIP
You can change the owner of this policy by 1.
sending us a written request. This is called Does not change the coverage or the benefi-
an absolute assignment. You transfer all your ciary;
rights and duties as owner to a new owner.
The new owner can then make any change 2.
the policy allows. Applies only if we receive your request;
You can also name a contingent owner who 3.
will own this policy at your death. You may Takes effect from the date signed;
name, change, or withdraw a contingent
owner by sending us a written request. 4.
Does not affect any payment we make or
An absolute assignment or contingent owner action we take before receiving your request;
request: and
5.
Is not a collateral assignment.
- -----------------------------------------------------------------------------------------------------------------------------------
- --------- --------
86-037 25
- --------- --------
36
- ------------------------------------------------------------------------------------------------------------------------------------
GENERAL PROVISIONS VOTING OF MUTUAL FUND SHARES
While this policy is in force, you have the termine that, because of applicable law or
right to instruct us how to vote the mutual regulation, we do not have to vote the mutual
fund shares attributable to this policy. All fund shares according to the voting in-
fund proxy material and forms used to give structions received.
voting instructions will be sent to persons
having voting interests. If we do not receive timely voting instructions
from you, we will vote the applicable mutual
We will vote the mutual fund shares held in fund shares in proportion to the instructions
Sub-accounts according to the instructions which are received with respect to the other
received, as long as: policies providing benefits related to the ap-
plicable Sub-account.
1.
The Variable Account is registered as a unit The persons entitled to give voting in-
investment trust under the Investment Com- structions and the number of votes affected
pany Act of 1940; and by their instructions will be determined as of
a record date selected by us, not more than
2. 90 days before the meeting of the applicable
The assets of the Variable Account are allo- mutual fund.
cated to Sub-accounts that are invested in
mutual funds shares. This policy does not give you the right to vote
at meetings of our stockholders and/or
We may vote the mutual fund shares held in policyholders.
the Sub-accounts at our discretion if we de-
------------------------------------------------------------------------------------------------------
SUBSTITUTION OF MUTUAL FUND SHARES
We may reserve the right, if permitted by law account. (If this type of transfer is made, the
and subject to the approval of the Super- term "ReliaStar Life Insurance Company of
intendent, to: New York Variable Life Separate Account I"
as used in this policy will then mean the var-
1. iable account to which the assets were trans-
Create new variable accounts; ferred.);
2. 6.
Combine variable accounts, including the Deregister the ReliaStar Life Insurance Com-
ReliaStar Life Insurance Company of New pany of New York Variable Life Separate Ac-
York Variable Life Separate Account I; count I under the Investment Company Act
of 1940 if registration is no longer required;
3.
Remove, add, or combine Sub-accounts and 7.
make the new Sub-accounts available to you Make any changes required by the Invest-
at our discretion; ment Company Act of 1940;
4. 8.
Substitute shares of other investment funds Operate the ReliaStar Life Insurance Com-
or series thereof for those of the investment pany of New York Variable Life Separate Ac-
funds and series made available under the count I as a managed company under the
policy; Investment Company Act of 1940 or any
other form permitted by law; and
5.
Transfer assets of the ReliaStar Life Insur- 9.
ance Company of New York Variable Life Restrict or eliminate any voting privileges you
Separate Account I, which we determine to or other persons may have as to the ReliaStar
be associated with the class of contracts to Life Insurance Company of New York Vari-
which this policy belongs, to another variable able Life Separate Account I.
- ------------------------------------------------------------------------------------------------------------------------------------
- ---------- ----------
5782 26
- ---------- ----------
37
- ------------------------------------------------------------------------------------------------------------------------------------
GENERAL PROVISIONS INCONTESTABILITY
(continued)
This policy has a two-year contestable period If you make a Face Amount Increase or pre-
running from the Issue Date shown on the mium payment which requires proof of
Policy Data Page. During this period we insurability, the corresponding Death Benefit
ould ask for information that could lead us Increase has its own two-year contestable
to contesting this policy or refusing to pay its period measured from the date of the Increase
benefits. After this policy has been in force in Death Benefit.
during the lifetime of the Insured for two
years from the Issue Date, we cannot claim If this policy is reinstated, this provision
your policy is void or refuse to pay any pro- will be measured from the date of reinstate-
ceeds unless the policy terminated before the ment.
death of the Insured.
------------------------------------------------------------------------------------------------------
AGE AND SEX
If the Age or Sex of the Insured is misstated, chase using the current Cost Of Insurance
the Death Benefit will be the amount that the Rate for the correct Age and Sex.
most recent Cost Of Insurance would pur-
------------------------------------------------------------------------------------------------------
SUICIDE
If the Insured commits suicide within two insurability, the corresponding Death Benefit
years of the Issue Date, we do not pay the increase has its own two-year suicide limita-
Death Benefit. Instead, we pay to you the tion for the proceeds associated with that In-
Accumulation Value, plus a refund of all crease. If the Insured commits suicide within
charges made on this policy and any attached two years of the effective date of the In-
riders, minus the Loan Amount. crease, we pay the Death Benefit without the
Increase and refund the Cost Of Insurance
If you make a Face Amount Increase or pre- charges made for that Increase.
mium payment which requires proof of
------------------------------------------------------------------------------------------------------
TERMINATION
This policy terminates when any of the fol- 3.
lowing occur: You surrender this policy for its full Cash
Surrender Value; or
1.
No Death Benefit Guarantee is in effect, and 4.
the Cash Surrender Value is less than the This policy is amended according to the
Monthly Deduction due and you do not make Amendment provision of this policy and you
the required payment by the end of the grace do not accept the amendment.
period.
If we make a Monthly Deduction from the
2. Accumulation Value after this policy termi-
The Insured dies; nates, the deduction is not considered a rein-
statement of the policy or a waiver of the
termination.
- ------------------------------------------------------------------------------------------------------------------------------------
- --------------- ---------------
86-038 27
- --------------- ---------------
38
- ------------------------------------------------------------------------------------------------------------------------------------
GENERAL PROVISIONS CONVERSION RIGHT
(continued)
You may, by written request, convert this transfer is not counted against the limit on
policy, without evidence of insurability, to a the number of transfers in a policy year.
policy in which the benefits do not vary with
the investment performance of the Variable If you exercise this conversion right, we will
Account. This conversion is done by trans- automatically credit all future premium pay-
ferring all of your Variable Accumulation ments to the Fixed Account, until you specify
Value to your Fixed Accumulation Value. You a change in allocation. At the time of the
must tell use you are exercising your conver- transfer, there is no effect on the Death Ben-
sion rights when requesting the transfer. We efit, Accumulation Value, Face Amount, net
will then waive the transfer charge and that amount at risk, Rate Class, or Issue Age.
------------------------------------------------------------------------------------------------------
ANNUAL STATEMENT
Each year we will send you an annual state- 7.
ment, free of charge, showing the following: Death Benefit;
1. 8.
Face Amount; Loan Amounts;
2. 9.
Cash Surrender Values; Partial withdrawals;
3. 10.
Accumulation Values; Transfers; and
4. 11.
Premiums paid; Charges since the last statement.
5. We will make a charge not to exceed $50 for
Planned periodic premiums; any additional statements you request.
6.
Interest credits;
------------------------------------------------------------------------------------------------------
PROJECTION REPORT
If you ask, we will provide a report projecting 3.
future results. The report will be based on The Accumulation Value at the end of the
the following: prior policy year; and
1. 4.
The Death Benefit Option you specify; Any other assumptions specified by you or
us, subject to any limitations imposed by the
2. Securities and Exchange Commission.
Planned periodic premiums you specify;
We will make a charge not to exceed $50 for
each Projection Report you request.
------------------------------------------------------------------------------------------------------
NONPARTICIPATING
This contract does not entitle you to partic-
ipate in our surplus.
- ------------------------------------------------------------------------------------------------------------------------------------
- --------- ---------
5783 28
- --------- ---------
39
- ----------------------------------------------------------------------------------------------------------------------------------
GENERAL PROVISIONS AMENDMENT
We may reserve the right to amend this pol- o The Code;
icy, subject to the approval of the Insurance
Department, to include any future changes o Internal Revenue Service rulings and
relating to the following: regulations; and
1. o Any requirements imposed by the
Any Securities and Exchange Commission Internal Revenue Service.
rulings and regulations;
We will send you a copy of any amendments
2. promptly.
This policy's qualification for treatment as a
Life Insurance policy under the following:
----------------------------------------------------------------------------------------------------
DISCLAIMER
We are not liable for any tax or tax penalty the requirements of the Code, regulations and
you owe resulting from failure to comply with rulings imposed on this policy.
----------------------------------------------------------------------------------------------------
LIMITATION ON AMOUNT OF INSURANCE FOR
JUVENILE INSURED
The total amount of life insurance proceeds The limitation does not apply to any Acci-
payable under this and any other policy be- dental Death Benefit or any refund of premi-
cause of an Insured child's death which oc- ums. Any amount payable on more than one
curs before that child is 14 years and 6 policy will be paid in order of Issue Date.
months old will be limited to the amount as
determined in 1 or 2 below: Any amount of life insurance which exceeds
this limitation under this and any other policy
1. will not be payable. We will terminate any
If death occurs before the child is 4 years and amount of insurance under this policy which
and 6 months old, the total amount payable may exceeds the limitation upon receipt of this
not be more than the greater of: policy and satisfactory proof that the amount
is in excess of the limitation. The termination
a. will be made upon written request by the
$5,000; or owner, or upon the death of the Insured.
b. If we terminate the entire amount of life in-
25% of the amount of life insurance in force surance provided by this policy, we will pay
on the date of issue on the life of the appli- to you the Accumulation Value, plus a refund
cant for this policy. of all charges made on this policy and any
attached riders, minus the Loan Amount.
2.
If death occurs when that child is at least 4 If we terminate a portion of the life insurance
years and 6 months old, but before the child provided by this policy, we will refund the
is 14 years and 6 months old, the total Cost Of Insurance charged for the amount
amount payable may not be more than the terminated.
greater of:
We shall not be liable for any refund if pay-
a. ment of any life insurance proceeds is made
$10,000; or without having proof that the amount of
those proceeds was in excess of the limita-
b. 50% of the amount of life insurance in force tion.
on the date of issue on the life of the appli-
cant for this policy. In no event will the amount of insurance pay-
able under this policy be a greater amount than
if this rider was not a part of the policy.
- ----------------------------------------------------------------------------------------------------------------------------------
- --------- ---------
86-039 29
- --------- ---------
40
TERM RIDER (TR)
This rider is a part of the base policy whose
number is shown below. The Rider Data is
shown on the Policy Data Page. All base
policy provisions apply to this rider, unless
changed by this rider.
- ----------------------------------------------------------------------------------------------------------------------------------
BENEFITS If we have written proof that the Insured died The proceeds of this rider are additional
while this rider was in force, we will pay the amounts provided by rider, as referred to in
TR Face Amount. The TR Face Amount is the base policy.
shown on the Policy Data Page.
- ----------------------------------------------------------------------------------------------------------------------------------
MONTHLY DEDUCTION FOR The cost of this rider is part of the Monthly The total monthly cost of this rider equals the
THIS RIDER Deduction from Accumulation Value of the sum of 1 plus 2, (1 + 2), where:
base policy. Consequently, the cost of this
rider reduces the Cash Value and Loan Value 1.
of the base policy. Is the TR Cost Of Insurance;
2.
Is the TR Monthly Amount Charge.
----------------------------------------------------------------------------------------------------
TR COST OF INSURANCE
We determine the TR Cost Of Insurance on a 1.
monthly basis. The TR Cost Of Insurance for Is the TR Cost Of Insurance Rate as described
a policy month is calculated as 1 multiplied in the TR Cost Of Insurance Rates provision
by 2, (1 x 2), where: of this rider;
2.
Is the TR Face Amount at the beginning of
the policy month.
----------------------------------------------------------------------------------------------------
TR COST OF INSURANCE RATES
The monthly Cost Of Insurance Rate for the tor, plus any Extra TR Cost Of Insurance
TR Face Amount is based on the policy year, Rates.
and the Sex, Age, and Rate Class of the In-
sured on the effective date of this rider. The Table of Monthly Guaranteed Cost Of In-
surance Rates is based on the Commissioners
The TR Cost Of Insurance Rates can never be Standard Ordinary (CSO) Table shown on the
greater than the rates shown in the Table of Policy Data Page. The TR Rate Class Rating
Monthly Guaranteed Cost Of Insurance Rates, Factor and any Extra TR Cost Of Insurance
multiplied by the TR Rate Class Rating Fac- Rates are shown on the Policy Data Page.
- ----------------------------------------------------------------------------------------------------------------------------------
RELIASTAR RELIASTAR LIFE INSURANCE COMPANY Executed at our Home Office
OF NEW YORK ---------------------------------------------
James R. Gelder President
1000 Woodbury Road, Suite 102 ---------------------------------------------
P.O. Box 9004 /s/ James R. Gelder
Woodbury, New York 11797 ---------------------------------------------
Susan M. Bergen Secretary
---------------------------------------------
/s/ Susan M. Bergen
---------------------------------------------
- ---------- ----------
86-040 1
- ---------- ----------
41
- ----------------------------------------------------------------------------------------------------------------------------------
MONTHLY DEDUCTION FOR TR MONTHLY AMOUNT CHARGE
THIS RIDER
(continued) The TR Monthly Amount Charge is the TR The TR Monthly Amount Charge Rate is
Monthly Amount Charge Rate times the initial shown on the Policy Data Page.
TR Face Amount.
The TR Monthly Amount Charge is charged
The TR Monthly Amount Charge Rate is during the Term shown on the Policy Data
based on the Sex, Age, and Rate Class of the Page, beginning on the effective date of this
Insured on the effective date of the coverage. rider. Decreases to the TR Face Amount do
not decrease the TR Monthly Amount Charge.
- ----------------------------------------------------------------------------------------------------------------------------------
CONVERSION This rider may be converted to a new life in- 4.
surance policy, without proof of insurability, We would normally issue a policy with the
if all of the following conditions are met: characteristics required.
To convert this rider, you must apply in writ-
1. ing. Only you may apply to convert this rider.
The Insured is alive; If you wish to convert this rider, we may re-
quire that you send us the base policy and
2. this rider so that we can endorse them.
This rider is in force;
3.
The Insured has not reached Age 75; and
----------------------------------------------------------------------------------------------------
THE NEW POLICY
If this Rider is converted to a new life insur- the new policy and this rider both be in ef-
ance policy, the new policy must have the fect;
following characteristics:
6.
The Rate Class of the new policy will be the
1. most favorable Rate Class which does not
The Insured on the new policy must be the have any requirements which are more re-
same as the Insured of the Base Policy; strictive that the requirements to qualify for
the Rate Class of the Insured on the effective
2. date of this rider.
The new policy must be a life insurance pol-
icy that does not expire before Age 95; 7.
3. The new policy must be a policy we would
The new policy must have level required pre- normally issue at the time of conversion;
miums or flexible premiums;
8.
4. The new policy must not contain any benefits
The Face Amount of the new policy cannot or rights involving a greater aggregate risk,
be greater than the TR Face Amount; relative to premium, than is insured under
this rider.
5.
The effective date of the new policy will be
the date of the conversion, and at no time will
- ----------------------------------------------------------------------------------------------------------------------------------
- --------- ---------
5784 2
- --------- ---------
42
- ----------------------------------------------------------------------------------------------------------------------------------
EXCHANGE In exchange for terminating this rider, you 1.
may make an Increase in Face Amount on the The last Monthly Anniversary Date on or be-
base policy, without evidence of insurability. fore the Rider Expiry Date; or
You may make this exchange only if the In- 2.
sured is alive and this rider is in force on: A Monthly Anniversary Date when the Death
Benefit equals the Accumulation Value multi-
plied by the Corridor Percentage.
----------------------------------------------------------------------------------------------------
THE INCREASE
If you terminate this rider to make an Increase 4.
in Face Amount on the base policy without No additional Surrender Charge will apply to
evidence of insurability, then; the Increase.
1. 5.
The effective date of the Increase will be the The Monthly Amount Charge Rate for the In-
date this rider terminates, and at no time will crease will be based on the Sex, Age and
the Increase and this rider both be in effect. Rate Class of the Insured as of the Rider Ef-
fective Date. The term of the Monthly
2. Amount Charge applied to the Increase will
The amount of the Increase cannot be more be measured from the Rider Effective Date.
than the TR Face Amount.
6.
3. The Cost Of Insurance Rates for the Increase
The Rate Class for the Increase will be the will be based on the Sex, Age and Rate Class
same as the Rate Class of the Insured on the of the Insured as of the Rider Effective Date,
Rider Effective Date. and the policy years since the Rider Effective
Date.
- ----------------------------------------------------------------------------------------------------------------------------------
TERMINATION This rider ends when the first of the following 6.
occurs: You ask us in writing to end this rider.
1. If you ask us in writing to terminate this
On the Rider Expiry Date shown on the Policy rider, we may ask that you return the policy
Data Page; and this rider so that we can endorse them.
This rider will end on the first Monthly Anni-
2. versary Date after we receive your written
This rider is converted; request to end this rider.
3. After this rider ends, we are not liable for it
This rider is exchanged; benefits, even if we have included the Cost
Of Insurance and Monthly Amount Charges
4. for this rider in the total monthly deduction
The base policy terminates; for the base policy. We will refund any such
amounts that we deduct after this rider ends.
5.
The Insured dies; or
- ----------------------------------------------------------------------------------------------------------------------------------
- --------- ---------
86-041 3
- --------- ---------
43
- ----------------------------------------------------------------------------------------------------------------------------------
REINSTATEMENT If this rider terminates solely because the rider when you reinstate the base policy
base policy lapses, you can reinstate this before the Rider Expiry Date.
- ----------------------------------------------------------------------------------------------------------------------------------
AGE AND SEX If the Age or Sex of the Insured is misstated, purchase using the current TR Cost Of Insur-
the TR Face Amount will be the amount that ance Rate for the correct Age and Sex.
the most recent TR Cost Of Insurance would
- ----------------------------------------------------------------------------------------------------------------------------------
SUICIDE The Suicide provision of the base policy ap- base policy from the Issue Date of the base
plies to this rider from the Rider Effective policy.
Date in the same way that it applies to the
- ----------------------------------------------------------------------------------------------------------------------------------
INCONTESTABILITY The Incontestability provision of the base base policy. If this rider is reinstated, this
policy applies to this rider from the Rider Ef- provision will be measured from the rein-
fective Date, in the same way that it applies statement date with respect to statements
to the base policy from the Issue Date of the made in the application for reinstatement.
- ----------------------------------------------------------------------------------------------------------------------------------
CASH VALUES This rider has no Cash Value or Loan Value.
This rider does not increase any cash or loan
values of the base policy.
- ----------------------------------------------------------------------------------------------------------------------------------
- --------- ---------
5785 4
- --------- ---------
44
ACCIDENTAL DEATH BENEFIT RIDER (ADB)
This rider is a part of the base policy whose number is shown below. If not shown below, the Base
Policy Number is shown on the Policy Data Page.
- ------------------------------------------------------------------------------------------------------------------------------------
BASE POLICY NUMBER
- ------------------------------------------------------------------------------------------------------------------------------------
DEFINITIONS THE INSURED The person upon whose life the base policy is
issued.
------------------------------------------------------------------------------------------------------
YOU, YOUR The current owner of the base policy.
------------------------------------------------------------------------------------------------------
WE, US, OUR ReliaStar Bankers Security Life Insurance
Company at our Home Office in Woodbury, New
York.
------------------------------------------------------------------------------------------------------
WRITTEN, IN WRITING A written request or notice, signed and
dated, and received at our Home Office. The
form and content of the request or notice
must be acceptable to us.
------------------------------------------------------------------------------------------------------
ACCIDENTAL DEATH Death that is directly caused by accidental
bodily injury. Death must occur within 365
days after the date of this injury.
- ------------------------------------------------------------------------------------------------------------------------------------
BENEFITS We pay the ADB Amount shown on the Policy 2.
Data Page to the beneficiary, subject to the Occurred while the base policy and this rider
terms of this rider, when we receive written were in force.
proof that the insured's death:
Any benefit we pay under this rider is in
1. addition to the amount payable under the base
Was an Accidental Death as defined above; and policy.
- ------------------------------------------------------------------------------------------------------------------------------------
REQUESTED CHANGES IN After the second policy year, you may request
ADB AMOUNT an increase or decrease in your ADB Amount by
notifying us in writing.
------------------------------------------------------------------------------------------------------
INCREASES
Increases in the ADB Amount must be at least We may require written proof that the insured
$5,000. You cannot increase the Face Amount is still insurable before making an increase.
after Age 60. An approved increase goes into effect on the
Monthly Anniversary on or next following the
date of the approval.
------------------------------------------------------------------------------------------------------
DECREASES
You cannot decrease the ADB Amount below Changes go into effect on the Monthly
$5,000. Anniversary on or next following the date we
receive you request. At least six months must
elapse between decreases.
- ------------------------------------------------------------------------------------------------------------------------------------
[RELIASTAR LOGO] RELIASTAR LIFE INSURANCE COMPANY Executed at our Home Office
OF NEW YORK ----------------------------------------------
James R. Gelder President
----------------------------------------------
1000 Woodbury Road, Suite 102 /s/ James R. Gelder
P.O. Box 9004 ----------------------------------------------
Woodbury, New York 11797 Susan M. Bergen Secretary
----------------------------------------------
/s/ Susan M. Bergen
----------------------------------------------
- --------- ---------
86-052 1
- --------- ---------
45
- ------------------------------------------------------------------------------------------------------------------------------------
BENEFITS NOT PROVIDED We will not pay benefits under this rider 4.
when one or more of the following caused or Suicide;
contributed to death:
5.
1. A felony that the insured committed or tried
Disease, illness, mental illness, or medical to commit;
or surgical treatment of them;
6.
2. Travel in or descent from any type of
Any poison (except for food poisoning), aircraft where the insured:
including carbon monoxide, was voluntarily
taken by the insured; a.
Was a pilot or a crew member;
3.
Any drug, medication, or sedative not b.
prescribed by a physician was voluntarily Was giving or receiving aviation training; or
taken by the insured;
c.
Had any duties on the aircraft whether or not
they were related to operating it.
- ------------------------------------------------------------------------------------------------------------------------------------
COST OF RIDER BENEFITS The cost of this rider's benefits is in 1.
addition to the cost of the base policy and Is the ADB Rate as described below; and
is included in the Monthly Deduction. The
cost of this rider's benefits is 1 multiplied 2.
by 2, divided by 1,000 (1 x 2) where: Is the ADB Amount at the beginning of the
policy month.
- ------------------------------------------------------------------------------------------------------------------------------------
ADB RATES The ADB Rates are based on the insured's sex, prior policy anniversary. The ADB Rates are
attained age, and Rate Class for this rider shown on the Policy Data Page. For insureds
shown on the Policy Data Page. Attained age in a Rated Rate Class for this rider, the ADB
means the insured's age on the Rates will be increased appropriately.
- ------------------------------------------------------------------------------------------------------------------------------------
TERMINATION This rider terminates: 4.
When the base policy is in force as paid-up
1. life insurance.
On the Rider Expiry Date;
After this rider terminates, we are not
2. liable for its benefits. If we deduct the
On the first Monthly Anniversary Date after cost of this rider's benefits after it
we receive your written request to terminate terminates, it is not considered a
this rider. We may ask that you return the reinstatement of the rider. The deduction
policy and this rider so that we can endorse will be added back to the Accumulation Value
them; of the policy as of the date of the
deduction.
3.
When the base policy is surrendered or
terminates; or
- ------------------------------------------------------------------------------------------------------------------------------------
GENERAL PROVISIONS This rider does not increase the Accumulation rider. The Incontestability provision of the
Value, Cash Surrender Value, or Loan Value of base policy applies to this rider from the
the base policy. All base policy provisions Rider Issue Date, and any increases in ADB
apply to this rider, unless changed by the Amount from the date of the increase.
- ------------------------------------------------------------------------------------------------------------------------------------
- --------- ---------
5790 2
- --------- ---------
46
Additional Insured Rider (AIR)
This rider is a part of the base policy whose
number is shown below. If not shown below,
the Base Policy Number is shown on the Policy
Data Page.
- ------------------------------------------------------------------------------------------------------------------------------------
RIDER DATA BASE POLICY NUMBER
- ------------------------------------------------------------------------------------------------------------------------------------
DEFINITIONS THE ADDITIONAL INSURED The person insured under this rider. The
Additional Insured is shown on the Policy
Data Page.
------------------------------------------------------------------------------------------------------
THE INSURED The person insured under the base policy.
------------------------------------------------------------------------------------------------------
YOU, YOUR The current owner of the base policy.
------------------------------------------------------------------------------------------------------
WE, US, OUR ReliaStar Life Insurance Company of New York
at our Home Office in Woodbury, New York.
------------------------------------------------------------------------------------------------------
WRITTEN, IN WRITING A written request or notice, signed and
dated, and received at our Home Office, in a
form we accept. You may get forms for this
purpose from us.
- ------------------------------------------------------------------------------------------------------------------------------------
BENEFITS When we have written proof that the der any base policy settlement option. After
Additional Insured died while this rider was the Additional Insured's death, a beneficiary
in force, we will pay the AIR Face Amount may choose to have the proceeds applied under
then in force. any base policy settlement option, depending
on any prior restrictions made by you and
While the Additional Insured is living, you agreed to by us.
may choose to have the proceeds applied un-
- ------------------------------------------------------------------------------------------------------------------------------------
BENEFICIARY The beneficiary is named to receive the 4.
proceeds to be paid at the Additional We have the written consent of all
Insured's death. You may name one or more irrevocable beneficiaries of this rider.
beneficiaries on the application. Later, you
may name, add or change beneficiaries by A change of beneficiary will take effect as
written request if all of these are true: of the date it is signed but will not affect
any payment we make or action we take before
1. receiving your notice.
The base policy is in force;
When you name, add, or change a beneficiary,
2. we will assume that this applies to the base
This rider is in force; policy unless you tell us that it applies to
the Additional Insured Rider. If you assign
3. the benefits of this rider as collateral for
The Additional Insured is alive; and a debt, this limits the beneficiary's rights
to the proceeds.
- ------------------------------------------------------------------------------------------------------------------------------------
[RELIASTAR LOGO] RELIASTAR LIFE INSURANCE COMPANY Executed at our Home Office
OF NEW YORK ----------------------------------------------
James R. Gelder President
----------------------------------------------
1000 Woodbury Road, Suite 102 /s/ James R. Gelder
P.O. Box 9004 ----------------------------------------------
Woodbury, New York 11797 Susan M. Bergen Secretary
----------------------------------------------
/s/ Susan M. Bergen
----------------------------------------------
- --------- ----------
86-053 1
- --------- ----------
47
- ------------------------------------------------------------------------------------------------------------------------------------
COST OF INSURANCE AND The total monthly deduction for this rider Amount during the Term shown on the Policy
MONTHLY AMOUNT includes the sum of 1 plus 2, where: Data Page. The Term applies to the Initial
CHARGES Face Amount from the Policy Date of the
1. policy and to any increases in Face Amount
Is the Monthly Amount Charge per $1,000 from the Effective Date of that increase.
(shown on the Policy Data Page) multiplied by
the AIR Face Amount divided by $1,000. 2.
Is the AIR Face Amount times the monthly cost
This charge applies to the Initial AIR Face of insurance rate described below.
Amount and to any increases in AIR Face
- ------------------------------------------------------------------------------------------------------------------------------------
COST OF INSURANCE The monthly cost of insurance rate is based tribute past gains. The experience underlying
RATES on the Additional Insured's sex, issue age, the monthly cost of insurance rate will be
and Rate Class as shown on the Policy Data reviewed at regular intervals, no less often
Page, and the policy year of the rider. Issue than every five years.
age means age on the Rider Effective Date.
Policy years of the rider are measured from Except for Face Amounts in a rated Rate Class
the Rider Effective Date. the cost of insurance rates can never be
greater than the rates shown in the Table of
Adjustments to the monthly cost of insurance Monthly Guaranteed Cost of Insurance Rates
rate will be by Rate Class and based upon shown on the Policy Data Page. For those in a
changes in future expectations for mortality, rated Rate Class, the cost of insurance rates
persistency, interest, taxes, and expenses. are calculated by multiplying the rates shown
Any changes to the monthly cost of insurance in the Table of Monthly Guaranteed Cost of
rate will be made only prospectively, based Insurance Rates by the Rate Class Rating
on future expectations, in accordance with Factor shown on the Policy Data Page. The
procedures and standards on file with the New rates may also be increased by any extra cost
York Insurance Department. Changes will not of insurance rates shown on the Policy Data
be used to recoup past losses or dis- Page.
- ------------------------------------------------------------------------------------------------------------------------------------
PAYING PROCEEDS We pay proceeds in the following order: method in writing. Unless otherwise
provided, to receive proceeds, a beneficiary
1. must be living on the 10th day after the
Collateral assignees, if any, have first Additional Insured's death; then
2. 3.
The beneficiary, if any, receives any If there are no beneficiaries, you receive
proceeds that remain. If there is more than any proceeds that remain.
one beneficiary, each receives an equal
share, unless you have requested another
- ------------------------------------------------------------------------------------------------------------------------------------
- --------- ---------
5788 2
- --------- ---------
48
- ------------------------------------------------------------------------------------------------------------------------------------
CONVERSION The insurance on the life of the Additional 3.
Insured may be converted to a new individual Before the Additional Insured reaches age 75;
life insurance policy without proof of and
insurability. This rider may be converted
only: 4.
While the base policy is in force or within
1. 31 days of the insured's death.
While the Additional Insured is alive;
Application for conversion must be in
2. writing. Only you may apply. But if the
While this rider is in force; insured has died, only the Additional Insured
may apply. We may require that you send us
the base policy and this rider so that we can
endorse them.
- ------------------------------------------------------------------------------------------------------------------------------------
THE NEW POLICY
The amount of the new policy may be for an 3.
amount up to the AIR Face Amount in force at Have level premiums that are at least equal
the time of the conversion. The date of the to those of the whole life plan we offer that
new policy will be the date of the has the lowest level premiums;
conversion. The new policy, which will be in
the same Rate Class as this rider, can be on 4.
any of our plans in use at the time of the Do not participate in our surplus; and
conversion that:
5.
1. Do not contain any benefits or rights
We would normally issue; involving a greater aggregate risk, relative
to premium, than is insured under this
2. policy. However, the new policy may contain a
Provide for a level amount of insurance with disability waiver benefit provision on the
level premiums; Additional Insured if you give us written
proof of the Additional Insured's
insurability.
- ------------------------------------------------------------------------------------------------------------------------------------
TERMINATION This rider ends:
1. 5.
On the Rider Expiry Date shown on the Policy If you ask us in writing to end this rider.
Data Page; In this case, we may ask that you return the
policy and this rider so that we can endorse
2. them. This rider will end on the first
If this rider is converted; Monthly Anniversary Date after we receive
your written request to end this rider; or
3.
If the base policy is surrendered or ends, 6.
other than at the insured's death; If the Cash Surrender Value of the base
policy is used to purchase paid-up insurance.
4.
31 days after the insured's death. During After this rider ends, we are not liable for
this 31 days we do not charge you for the its benefits, even if we have included the
continued coverage; cost of insurance and monthly amount charges
for this rider in the total monthly deduction
for the base policy. We will refund any such
amounts that we deduct after this rider ends.
- ------------------------------------------------------------------------------------------------------------------------------------
- --------- ---------
85-270 3
- --------- ---------
49
- ------------------------------------------------------------------------------------------------------------------------------------
REINSTATEMENT If this rider and the base policy lapse, you 1.
can reinstate this rider if: Give us proof of insurability for the
Additional Insured; and
1.
This rider was in effect when the base policy 2.
lapsed; Pay a premium large enough such that the Net
Premium is as large as the sum of the
2. Surrender Charge after reinstatement, plus
This rider would otherwise not have expired the Monthly Deductions for the date of
during the time it was lapsed; and reinstatement and the following Monthly
Anniversary.
3.
You reinstate the base policy. The base policy may be reinstated without
this rider, in which case proof and payment
To reinstate this rider, you must do both of for this rider are not needed.
the following:
- ------------------------------------------------------------------------------------------------------------------------------------
AGE AND SEX If the Additional Insured's age or sex is purchase using the current cost of insurance
misstated, the Death Benefit will be the rates for the correct age and sex.
amount that the most recent cost of insurance
would
- ------------------------------------------------------------------------------------------------------------------------------------
SUICIDE The Suicide provision of the base policy is the base policy also applies in this way to
changed to also apply to the Additional any increases in the AIR Face Amount for
Insured from the Rider Issue Date in the same which we require evidence of insurability
way that it applies to the insured from the from the effective date of each increase.
policy's Issue Date. The Suicide provision of
- ------------------------------------------------------------------------------------------------------------------------------------
INCONTESTABILITY This rider has a 2-year contestable period If you make an increase in the AIR Face
running from the Rider Issue Date. During Amount that requires proof of insurability,
this period, we may ask for information that that increase has its own 2 year contestable
could lead to our contesting this rider or period running from the effective date of the
refusing to pay its benefits. After this increase.
rider has been in force during the Additional
Insured's lifetime for 2 years from the Rider If this rider lapses and is then reinstated,
Issue Date, we cannot claim this rider is this provision will be measured from the date
void or refuse to pay any benefits with of reinstatement.
respect to the initial AIR Face Amount unless
this rider has lapsed.
- ------------------------------------------------------------------------------------------------------------------------------------
GENERAL PROVISIONS This rider does not increase any cash or loan All base policy provisions apply to this
values of the base policy. The monthly rider, unless changed by this rider.
deductions for this rider decrease the cash
value of the base policy.
- ------------------------------------------------------------------------------------------------------------------------------------
- --------- ---------
5264 4
- --------- ---------
50
INSURED'S COST OF LIVING RIDER
This rider is a part of the base policy whose number is shown below. If not shown below,
the Base Policy Number is shown on the Policy Data Page.
- ------------------------------------------------------------------------------------------------------------------------------------
RIDER DATA BASE POLICY NUMBER
- ------------------------------------------------------------------------------------------------------------------------------------
DEFINITIONS THE INSURED The person upon whose life the base policy is
issued. The insured is shown on the Policy
Data Page.
------------------------------------------------------------------------------------------------------
YOU, YOUR The current owner of the base policy.
------------------------------------------------------------------------------------------------------
WE, US, OUR ReliaStar Life Insurance Company of New York
at our Home Office in Woodbury, New York.
------------------------------------------------------------------------------------------------------
WRITTEN, IN WRITING A written request or notice, signed and
dated, and received at our Home Office in a
form we accept. You may get forms for this
purpose from us.
------------------------------------------------------------------------------------------------------
INCREASE DATE A date on which we make a cost of living
increase according to the terms of this
rider.
------------------------------------------------------------------------------------------------------
CPI The U.S. Consumer Price Index for All Urban
Consumers as published by the U.S. Department
of Labor. We will substitute what we believe
is an appropriate index for the CPI if:
1.
The composition of, base of, or method of
calculating the CPI changes so that, in our
opinion, it is not appropriate for use with
this rider; or
2.
The publication of the CPI is delayed or
ceases.
If required, we will file a detailed
description of any alternate price index with
the Insurance Department of the state where
this rider is delivered.
- ------------------------------------------------------------------------------------------------------------------------------------
BENEFITS AND MONTHLY We will increase the Face Amount of the base the terms of the base policy and will
DEDUCTIONS policy on the Increase Dates under the terms increase the Surrender Charge. We will make
of this rider. Cost of living increases are these cost of living increases without
Requested Changes in Face Amount under requiring proof of insurability.
- ------------------------------------------------------------------------------------------------------------------------------------
[RELIASTAR LOGO] RELIASTAR LIFE INSURANCE COMPANY Executed at our Home Office
OF NEW YORK ----------------------------------------------
James R. Gelder President
----------------------------------------------
1000 Woodbury Road, Suite 102 /s/ James R. Gelder
P.O. Box 9004 ----------------------------------------------
Woodbury, New York 11797 Susan M. Bergen Secretary
----------------------------------------------
/s/ Susan M. Bergen
----------------------------------------------
- --------- ---------
86-054 1
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51
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BENEFITS AND MONTHLY On each Increase Date, the Monthly Deduction 3.
DEDUCTIONS will be increased to account for the The Death Benefit Guarantee Charge, if the
(continued) following: Death Benefit Guarantee is in effect; and
1. 4.
The larger cost of insurance; The Cost of Waiver Benefits, if a Waiver of
Monthly Deduction Rider is part of the base
2. policy.
The Monthly Expense Charge;
- ------------------------------------------------------------------------------------------------------------------------------------
DETERMINING INCREASE Increase Dates normally occur every two two years after the increase. If this rider
DATES years, beginning with the first Monthly terminates and is then reinstated, the next
Anniversary two years after the Rider Issue Increase Date after reinstatement is the
Date. But, if you increase the Face Amount of first Monthly Anniversary two years after the
the base policy 10% or more, then the next reinstatement date.
Increase Date is the first Monthly
Anniversary
- ------------------------------------------------------------------------------------------------------------------------------------
CALCULATING A COST OF The Increase Factor is [A divided by B] - 1, If the Increase Factor is zero or less, we
LIVING INCREASE where: make no change. If the Increase Factor is
greater than zero, we multiply it by the
A insured's CPI Increase Base shown on the
Is the CPI five months before an Increase Policy Data Page. We round the result to the
Date; and next higher $500. We will not permit an
increase higher than the Maximum Increase
B Amount for the Insured, which is shown on the
Is the CPI 29 months before an Increase Date. Policy Data Page. The Maximum Increase Amount
for the insured is 20% of the insured's CPI
Increase Base, or $50,000, whichever is less.
- ------------------------------------------------------------------------------------------------------------------------------------
ACCEPTING OR We will notify you of the amount of each cost Age 21, we will not offer you any further
REJECTING AN INCREASE of living increase at least 30 days before increases until Age 21. If you do not accept
its effective date. If you wish to accept the the full amount of an increase at that time,
increase, you must notify us in writing. this rider terminates. However, you can
reinstate this rider with proof of
If you do not accept the full amount of any insurability for the insured.
cost of living increase before the insured's
- ------------------------------------------------------------------------------------------------------------------------------------
BENEFITS WHEN If the insured becomes eligible for benefits Date is the next Monthly Anniversary two
MONTHLY DEDUCTIONS under a waiver of monthly deduction rider, years after we receive the notice, unless the
ARE WAIVED cost of living increases are not available. rider has otherwise terminated. Future
If the insured recovers from the disability Increase Dates then follow as shown above in
and we are notified in writing, the next "Determining Increase Dates."
Increase
- ------------------------------------------------------------------------------------------------------------------------------------
TERMINATION This rider terminates: rider. We may ask you to return the policy
and this rider so that we can endorse them;
1.
At Age 55; 4.
When the policy terminates; or
2.
On the first Increase Date for which you do 5.
not accept the full amount of any cost of When the base policy is in force as paid-up
living increase after Age 21; life insurance.
3. After this rider terminates, we will make no
On the Monthly Anniversary on or after we further cost of living increases.
receive your written request to terminate
this
- ------------------------------------------------------------------------------------------------------------------------------------
GENERAL PROVISIONS All base policy provisions apply to this
rider, unless changed by this rider.
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5789 2
- ---------- ---------
52
TOTAL DISABILITY SPECIFIED PREMIUM RIDER (TDSP)
This rider is a part of the base policy whose
number is shown below. If not shown below,
the Rider Data is shown on the Policy Data
Page.
- ------------------------------------------------------------------------------------------------------------------------------------
RIDER DATA BASE POLICY NUMBER
RIDER ISSUE DATE
RIDER EXPIRY DATE
- ------------------------------------------------------------------------------------------------------------------------------------
DEFINITIONS THE INSURED The person insured under the base policy.
------------------------------------------------------------------------------------------------------
YOU, YOUR The current owner of the base policy.
------------------------------------------------------------------------------------------------------
WE, US, OUR ReliaStar Life Insurance Company of New York
at our Home Office in Woodbury, New York.
------------------------------------------------------------------------------------------------------
WRITTEN, IN WRITING A written request or notice, signed and
dated, and received at our Home Office. The
form and content of the request or notice
must be acceptable to us.
------------------------------------------------------------------------------------------------------
MAXIMUM TDSP AGE Maximum Total Disability Specified Premium
Age as shown on the Policy Data Page.
------------------------------------------------------------------------------------------------------
WAR An armed conflict, whether declared or not,
that any country resists.
------------------------------------------------------------------------------------------------------
COUNTRY Any government or group of governments.
- ------------------------------------------------------------------------------------------------------------------------------------
TOTAL DISABILITY During the first 24 months of the insured's Loss means the total and permanent loss of
disability, we consider the insured totally any of the following resulting from injury or
disabled if, due to the disability resulting disease:
from injury or disease, the insured is unable
to work at his or her regular occupation for 1.
remuneration or profit. The sight in both eyes;
After the first 24 months of the insured's 2.
disability, we consider the insured totally The use of both hands;
disabled if, due to the disability resulting
from injury or disease, the insured is unable 3.
to work at any job suited to his or her The use of both feet; or
education, training, and experience for
remuneration or profit. 4.
The use of one hand and one foot.
We also consider the insured totally disabled
if the insured has a Specific Loss. Specific In any case, the insured must be totally
disabled due to sickness or injury.
- ------------------------------------------------------------------------------------------------------------------------------------
[RELIASTAR LOGO] RELIASTAR LIFE INSURANCE COMPANY Executed at our Home Office
OF NEW YORK ----------------------------------------------
James R. Gelder President
----------------------------------------------
1000 Woodbury Road, Suite 102 /s/ James R. Gelder
P.O. Box 9004 ----------------------------------------------
Woodbury, New York 11797 Susan M. Bergen Secretary
----------------------------------------------
/s/ Susan M. Bergen
----------------------------------------------
- --------- ---------
86-055 1
- --------- ---------
53
- ------------------------------------------------------------------------------------------------------------------------------------
BENEFITS If the insured is totally disabled, this the Internal Revenue Code will be paid to the
rider provides a monthly benefit. The monthly Owner.
benefit is that we credit your base policy
with the following premium amount: Before we will provide the benefits of this
rider, the following must be true:
1.
If the insured's age is less than the Maximum 1.
TDSP Age, as shown on the Policy Data Page, The base policy must be in force;
we credit the greater of a or b, where:
2.
a. This rider must be in force;
Is the Monthly Specified Premium, as shown on
the Policy Data Page; and 3.
The insured must be totally disabled; and
b.
Is the sum of i, plus ii, (i + ii), where: 4.
1, 2, and 3 must be continuously true for 6
i. months.
Is the Monthly Deduction of the base policy;
and If the base policy enters the grace period
during this 6-month period, you must pay the
ii. required premium to keep the policy in force.
Is any premium expense charges associated If we approve your claim, we will provide
with i. monthly benefits beginning on the first
monthly anniversary after the date we approve
2. your claim. Upon approval of your claim, we
If the insured's age is equal to or greater will also provide monthly benefits for the
than the Maximum TDSP Age, as shown on the period after the date your disability began
Policy Data Page, we credit the sum of a plus and up to the date we approved your claim.
b, (a + b), where:
If this rider and the base policy lapse
a. during the first 6 months of total disability
Is the Monthly Deduction of the base policy; because a premium large enough to cover a
and Monthly Deduction was not paid within the
grace period, you may still be eligible for
b. this rider's benefits if:
Is any premium expense charges associated
with a. 1.
We are given timely written notice of claim
If the insured is totally disabled at or as defined in the Notice of Claim provision;
after Age 5 and before Age 60, the monthly
benefit is payable until the base policy ends 2.
or is changed to paid-up insurance. If the The total disability for which claim is made
insured becomes totally disabled at or after began before the date of lapse; and
Age 60 but before Age 65, the monthly benefit
is payable to Age 65 or for 2 years, 3.
whichever is longer. No benefits will be paid All other terms of this rider are met.
if the insured is not totally disabled.
When the insured is no longer totally
We will not provide benefits for total disabled, we stop providing the benefits. If
disability that starts before Age 5, after the insured becomes totally disabled again,
Age 65, or while this rider is not in force. we consider it a new period of total
disability. The terms of this rider apply to
Any benefit payment which would cause this the new period separately from any earlier
policy to fail to qualify as life insurance period.
under
- ------------------------------------------------------------------------------------------------------------------------------------
- ---------- -----------
5271 2
- ---------- -----------
54
- ------------------------------------------------------------------------------------------------------------------------------------
COST OF INSURANCE The cost of insurance for this rider, and the 1.
cost of insurance for the base policy, are Is the Total Disability Specified Premium
determined separately, on a monthly basis. Rate as described below; and
The cost of insurance for this rider is 1
multiplied by 2; that is, 1 x 2, where: 2.
Is the Monthly Specified Premium shown on the
Policy Data Page.
- ------------------------------------------------------------------------------------------------------------------------------------
TOTAL DISABILITY The Total Disability Specified Premium Rate a rated total disability rate class, the
SPECIFIED PREMIUM is based on the insured's sex, attained age, Total Disability Specified Premium Rates are
RATES and rate class for this rider as shown on the calculated by multiplying the Total
Policy Data Page. Attained age means age on Disability Specified Premium Rates shown on
the prior policy anniversary. The Total the Policy Data Page by the Total Disability
Disability Specified Premium Rates are shown Rate Class Rating Factor shown on the Policy
on the Policy Data Page. For those in Data Page.
- ------------------------------------------------------------------------------------------------------------------------------------
NOTICE OF CLAIM We require timely written notice of claim 2.
before we will provide any future benefits. While the insured is totally disabled.
You must give us timely written notice of However, your claim may not be invalidated
claim: nor your benefits reduced if you can show
that you provided the written notice as soon
1. as was reasonably possible.
While the insured is living; and
- ------------------------------------------------------------------------------------------------------------------------------------
PHYSICAL EXAMS We may require written proof of the insured's We cannot require any exam after the
total disability before we will provide any insured's Age 65. We will stop providing the
benefits. This proof may include physical benefits if you do not give us the proof we
exams by doctors we choose. However, for each ask for. However, your claim may not be
period of total disability, we can only invalidated nor your benefits reduced if you
require one exam a year after we have can show that you provided the required proof
provided the benefits for 2 consecutive as soon as was reasonably possible.
years.
- ------------------------------------------------------------------------------------------------------------------------------------
FACE AMOUNT CHANGES The Monthly Specified Premium after any Face Revenue Code. You may not make any other
Amount increase must be increased, if Monthly Specified Premium changes.
necessary, to be greater than or equal to the
Minimum Monthly Premium for the policy as While we are providing benefits under this
shown on the Policy Data Page. rider, you are limited to making increases in
the Face Amount of the base policy under the
The Monthly Specified Premium after any Face terms of a future purchase option rider if
Amount decrease must be reduced, if one is attached to the base policy. You may
necessary, to be less than or equal to 1/12th not make any other Face Amount increases
of the Guideline Level Premium for the policy while we are providing the benefits.
as defined in Section 7702 of the Internal
- ------------------------------------------------------------------------------------------------------------------------------------
BENEFITS NOT PROVIDED This rider will not provide any benefit for 2.
either of the following: Total disability which commences within two
years of the Rider Issue Date which was the
1. result of bodily injury or sickness first
Total disability which was the result of manifesting itself before this rider is in
intentional, self-inflicted injury; or force, unless such bodily injury or sickness
is disclosed on the application.
- ------------------------------------------------------------------------------------------------------------------------------------
- --------- ---------
86-056 3
- --------- ---------
55
- ------------------------------------------------------------------------------------------------------------------------------------
TERMINATION This rider ends at the earliest of the 5.
following: When the insured reaches Age 65 if we are not
providing benefits due to the disability of
1. the insured.
When the base policy becomes in force as
paid-up life insurance. 6.
When the monthly benefit for this rider ends
2. if we are providing monthly benefits under
When the base policy is surrendered or ends. this rider after Age 65.
3. After this rider ends, we are not liable for
At the death of the insured. its benefits, even if we deduct the cost of
insurance for this rider after it ends. We
4. will add to the accumulation value any cost
If you ask us in writing to end this rider. of insurance we have deducted for this rider
In this case, we may ask that you return the after it ends.
policy and this rider so that we can endorse
them. This rider will end on the first Termination will not invalidate or diminish
Monthly Anniversary Date after we receive any benefit for which the insured has
your written request to end this rider. qualified.
- ------------------------------------------------------------------------------------------------------------------------------------
REINSTATEMENT If this rider and the base policy lapse, you 1.
can reinstate this rider if: Give us proof of insurability for the
insured; and
1.
This rider was in effect when the base policy 2.
lapsed; Pay a premium large enough such that the Net
Premium is as large as the sum of the
2. Surrender Charge after reinstatement, plus
This rider would otherwise not have expired the Monthly Deductions for the date of
during the time it was lapsed; and reinstatement and the following Monthly
Anniversary.
3.
You reinstate the base policy. The base policy may be reinstated without
this rider, in which case proof and payment
To reinstate this rider you must do both of for this rider are not needed.
the following:
- ------------------------------------------------------------------------------------------------------------------------------------
GENERAL PROVISIONS All base policy provisions apply to this bility Provision of the base policy applies
rider, unless changed by this rider. The to this rider from the Rider Issue Date.
Incontesta-
- ------------------------------------------------------------------------------------------------------------------------------------
- --------- ---------
5272 4
- --------- ---------
56
WAIVER OF MONTHLY DEDUCTION RIDER
This rider is a part of the base policy whose number
is shown below. If not shown below,
the Base Policy Number is shown
on the Policy Data Page.
- ------------------------------------------------------------------------------------------------------------------------------------
BASE POLICY NUMBER
- ------------------------------------------------------------------------------------------------------------------------------------
DEFINITIONS THE INSURED The person insured under the base policy.
-------------------------------------------------------------------------------------------------------------
YOU, YOUR The current owner of the base policy.
-------------------------------------------------------------------------------------------------------------
WE, US, OUR ReliaStar Life Insurance Company of New York at our
Home Office in Woodbury, New York.
-------------------------------------------------------------------------------------------------------------
WRITTEN, IN WRITING A written request or notice, signed and dated, and
received at our Home Office in a form we accept. The
form and content of the request or notice must be
acceptable to us.
-------------------------------------------------------------------------------------------------------------
AGE The insured's age as of the prior policy anniver-
sary; however, if the insured's birthday is a policy
anniversary, the insured's age on that birthday.
- ------------------------------------------------------------------------------------------------------------------------------------
TOTAL DISABILITY For the first 24 months of the insured's disability, 2.
we consider the insured totally disabled if: The insured has a Specific Loss.
1. Specific Loss means the total and permanent loss of
Due to the disability resulting from injury or any of the following resulting from injury or
disease, the insured is unable to work at his or her disease:
regular occupation for remuneration or profit; or
1.
2. The sight in both eyes;
The insured has a Specific Loss.
2.
After the first 24 months of the insured's disabi- The use of both hands;
lity, we consider the insured totally disabled if:
3.
1. The use of both feet; or
Due to the disability resulting from injury or
disease, the insured is unable to work at any job 4.
suited to his or her education, training, and The use of one hand and one foot.
experience for remuneration or profit; or
We consider the insured totally disabled for as long
as the Specific Loss lasts.
- ------------------------------------------------------------------------------------------------------------------------------------
[RELIASTAR LOGO] RELIASTAR LIFE INSURANCE COMPANY Executed at our Home Office
OF NEW YORK ----------------------------------------------------
James R. Gelder President
1000 Woodbury Road, Suite 102 ----------------------------------------------------
P.O. Box 9004 /s/ James R. Gelder
Woodbury, New York 11797 ----------------------------------------------------
Susan M. Bergen Secretary
----------------------------------------------------
/s/ Susan M. Bergen
----------------------------------------------------
- --------- ---------
86-057 1
- --------- ---------
57
- ------------------------------------------------------------------------------------------------------------------------------------
WAIVER BENEFITS We will pay the Monthly Deduction for you if the 2.
insured becomes totally disabled and meets the Two years from the date of disability.
Conditions for Waiver Benefits. We do not apply the
Minimum Premium Requirement for the Death Benefit When the insured is no longer totally disabled, we
Guarantee during the period of total disability. will stop paying the Monthly Deduction for you. If
the Death Benefit Guarantee was in effect when total
The length of time we continue the Waiver Benefits disability began, we apply the Minimum Premium
depends on when total disability begins. If the Requirement for the Death Benefit Guarantee as of
insured becomes totally disabled before Age 60, we the Monthly Anniversary on or next following the
will pay the Monthly Deduction for as long as the date the insured is no longer totally disabled.
insured remains totally disabled. If the insured
becomes totally disabled after Age 60, we will If the insured becomes totally disabled again, we
continue to pay the Monthly Deduction if the insured consider it a new period of total disability. The
remains totally disabled until the later of: terms of this rider apply to the new period separa-
tely from any earlier period.
1.
The insured's Age 65; or
- ------------------------------------------------------------------------------------------------------------------------------------
CONDITIONS FOR WAIVER To pay Waiver Benefits, we need timely written If we approve your claim, the Waiver Benefit begins
BENEFITS Notice of Claim and Proof of Total Disability. with the Monthly Deduction due on or after the date
All of the following conditions must also be met: the total disability began. Any Monthly Deductions
that were deducted from the Accumulation Value of
1. the base policy after the disability began will be
The policy and this rider must be in force when the added back to the Accumulation Value as of the date
sickness or injury causing the total disability occurs; we approve your claim. We credit those Monthly
Deductions as Net Premiums without Premium Expense
2. Charges.
The policy and this rider must be in force when
total disability begins; If this rider and the base policy lapse, you may
still qualify for Waiver Benefits if:
3.
Total disability must begin on or after the 1.
insured's Age five and before the insured's Age 65; We receive timely written Notice of Claim as defined
below in the Notice of Claim provision;
4.
The insured must be continuously totally disabled 2.
for at least six months; and The total disability for which claim is made began
before the date of lapse; and
5.
You must pay all the required premiums until the end 3.
of this six month period. All other terms of this rider are met.
-------------------------------------------------------------------------------------------------------------
Notice of Claim
We require timely written Notice of Claim before we 2.
will pay any future Monthly Deductions. You must During the period of total disability.
give us timely written Notice:
However, your claim may not be invalidated nor your
1. benefits reduced if you can show that you provided
While the insured is living; and the written Notice as soon as was reasonably
possible.
- ------------------------------------------------------------------------------------------------------------------------------------
--------- ---------
5269 2
--------- ---------
58
- ------------------------------------------------------------------------------------------------------------------------------------
CONDITIONS FOR WAIVER PROOF OF TOTAL DISABILITY
BENEFITS
(continued) We may require written proof of the insured's total the insured's Age 65. We will stop paying the
disability before we provide Waiver Benefits. This Monthly Deductions if you do not give us the
proof may include physical exams at our expense by required proof. However, your claim may not be inva-
doctors we choose. However, for each period of total lidated nor your benefits reduced if you can show
disability, we can only require one exam a year that you provided the required proof as soon as was
after we have paid the Monthly Deductions for two reasonably possible.
consecutive years. We cannot require any exam after
- ------------------------------------------------------------------------------------------------------------------------------------
COST OF RIDER BENEFITS The cost of this rider's benefits is in addition to of the Monthly Deduction which is shown on the
the cost for the base policy and is included in the Policy Data Page.
Monthly Deduction. This cost is based on a Percent
- ------------------------------------------------------------------------------------------------------------------------------------
FACE AMOUNT CHANGES While the insured is totally disabled and we are option rider, if any, attached to the base policy.
DURING TOTAL paying the Monthly Deduction for you, you are You may not make any adjustments in Face Amount
DISABILITY limited to making increases in the Face Amount of while we are paying the Monthly Deduction.
the base policy under the terms of a future purchase
- ------------------------------------------------------------------------------------------------------------------------------------
Death Benefit Option If the Death Benefit Option in effect at the end of Benefit under Option A minus the Accumulation Value
the first six months of total disability is Option on the Monthly Anniversary on or next following the
A (Level Amount Option), it will be changed to date we approve your claim. If the Death Benefit
Option B (Variable Amount Option) on the first Option in effect at the end of the first six months
Monthly Anniversary Date after we approve your claim. of the total disability is Option B, we make no
In this case, the Face Amount of the base policy is change. You cannot make changes in Death Benefit
decreased on that date so that it equals the Death Option while the insured is totally disabled.
- ------------------------------------------------------------------------------------------------------------------------------------
TERMINATION This rider terminates: this rider. We may ask that you return the policy
and this rider so that we can endorse them;
1.
If we are not paying Waiver Benefits, at the insu- 4.
red's Age 65; If the base policy is surrendered or terminates; or
2. 5.
If we are paying Waiver Benefits due to total When the base policy is in force as paid-up life
disability which began after the insured's Age 60, insurance.
the later of:
After this rider terminates, we are not liable for
a its benefits. If we deduct the cost of this rider's
The insured's Age 65, or benefits after it terminates, it is not considered
a reinstatement of this rider. The deduction will be
b added back to the Accumulation Value of the base
Two years after the date of disability; policy as of the date of the deduction.
3. Termination will not invalidate or diminish any
On the Monthly Anniversary on or next following the benefit for which the insured has qualified.
date we receive your written request to terminate
- ------------------------------------------------------------------------------------------------------------------------------------
- --------- ---------
86-058 3
- --------- ---------
59
- ------------------------------------------------------------------------------------------------------------------------------------
REINSTATEMENT If this rider and the base policy lapse, you can 1.
reinstate this rider if: Give us proof of insurability for the insured; and
1. 2.
You reinstate the base policy; Pay a premium large enough such that the Net Premium
is as large as the sum of the Surrender Charge after
2. reinstatement, plus the Monthly Deductions for the
This rider was in effect when the base policy date of reinstatement and the following Monthly
lapsed; and Anniversary.
3. The base policy may be reinstated without this
This rider would otherwise not have terminated rider, in which case proof and payment for this
during the time it was lapsed. rider are not needed.
To reinstate the base policy and this rider you must
do all of the following:
- ------------------------------------------------------------------------------------------------------------------------------------
GENERAL PROVISIONS All base policy provisions apply to this rider, Provision of the base policy applies to this rider
unless changed by this rider. The Incontestability from the Rider Issue Date.
- ------------------------------------------------------------------------------------------------------------------------------------
--------- ---------
5270 4
--------- ---------
60
FLEXIBLE PREMIUM
VARIABLE LIFE
INSURANCE POLICY
------------------------------ -----------------------------
Variable and/or Fixed Death Benefit Guarantee
Accumulation Values -----------------------------
------------------------------ Death Benefit Options
Flexible Premiums Payable to -----------------------------
Age 100 of the Insured Nonparticipating
------------------------------ -----------------------------
Adjustable Face Amount
------------------------------
- --------------------------------------------------------------------------------
To make a claim or exercise Writing directly to us will
your rights under this policy, save time and expense. You
please write to us at the do not need to hire any
address below and include your person firm, or corporation
policy number. unless, because of a
dispute, you wish to.
[RELIASTAR LOGO] ReliaStar Life Insurance Company
of New York
ReliaStar Service Center
P.O. Box 5011
Minot, North Dakota 58702-5011
---------
86-025
---------