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Exhibit 4(a)(ii)
JOHN HANCOCK LIFE INSURANCE COMPANY OF [JOHN HANCOCK LOGO]
NEW YORK
A STOCK LIFE INSURANCE COMPANY
- --------------------------------------------------------------------------------
OVERNIGHT MAILING ADDRESS: ANNUITY SERVICE OFFICE: HOME OFFICE:
[164 Corporate Drive [P.O. Box 9506 [100 Summit Lake Drive]
Portsmouth, NH 03801-6815] Portsmouth, NH 03802-9506 Valhalla, NY 10595]
For Inquiries or Assistance in
Resolving Complaints:
1-800-344-1029]
THIS IS A LEGAL CERTIFICATE - READ IT CAREFULLY.
WE AGREE to pay the benefits of this Certificate in accordance with its terms.
THIS CERTIFICATE is issued in consideration of the Payment.
John Hancock Life Insurance Company of New York ("the Company") will pay an
annuity benefit commencing on the Maturity Date to the Payee as directed by the
Owner, in accordance with the Annuity Payments provision of this Certificate.
Unless another available option under this Certificate is elected, annuity
benefit payments will be payable for a guaranteed period of 10 years and as long
thereafter as the Annuitant lives. If the Owner dies while this Certificate is
in effect prior to the Maturity Date, we will pay a Death Benefit to the
Beneficiary upon receipt of all required claim forms and proof of death of the
Owner at the Annuity Service Office.
FIFTEEN DAY RIGHT TO REVIEW
THE OWNER MAY CANCEL THE CERTIFICATE BY RETURNING IT TO OUR ANNUITY SERVICE
OFFICE OR AGENT AT ANY TIME WITHIN 15 DAYS AFTER RECEIPT OF THE CERTIFICATE.
WITHIN 7 DAYS OF RECEIPT OF THE CERTIFICATE BY US, WE WILL PAY THE ACCOUNT
VALUE, ADJUSTED BY ANY MARKET VALUE ADJUSTMENT COMPUTED ON THE DATE THE
CERTIFICATE IS RECEIVED BY US, TO THE OWNER.
WHEN THE CERTIFICATE IS ISSUED AS AN INDIVIDUAL RETIREMENT ANNUITY, DURING THE
FIRST 7 DAYS OF THIS 15 DAY PERIOD, WE WILL RETURN THE GREATER OF (I) ACCOUNT
VALUE, ADJUSTED BY ANY MARKET VALUE ADJUSTMENT OR (II) AN AMOUNT EQUAL TO THE
PAYMENT.
We hold reserves for our guarantees under this Contract in a non-unitized MVA
Separate Account established within the General Account. The assets of the MVA
Separate Account are subject to the liabilities that arise out of the other
business that we conduct. General Account assets are also available to meet the
guarantees under this Contract as well as our other general obligations.
SIGNED FOR US at Boston, Massachusetts, on the Certificate Date.
/s/ John DesPrez III /s/ Emanuel Alves
- ------------------------------------ ---------------------------------------
President Secretary
Modified Single Premium Deferred Annuity with Market Value Adjustment
Non-Participating
AMOUNTS PAYABLE UNDER THIS CERTIFICATE MAY BE SUBJECT TO AN UPWARD OR DOWNWARD
MARKET VALUE ADJUSTMENT. AMOUNTS WITHDRAWN UNDER THIS CERTIFICATE MAY BE SUBJECT
TO AN EARLY WITHDRAWAL CHARGE.
09MVAGRP
INTRODUCTION
This is a Modified Single Premium Annuity Certificate. It is effective when we
receive your Payment and apply the Net Payment to the Account Value. We
determine Account Value during the Initial Guarantee Period shown on the
Specifications Page based on the Net Payment and the Initial Guaranteed Interest
Rate. After that, and prior to the Maturity Date while you are still living, the
Account Value will accumulate based on the interest rate we guarantee for each
Subsequent Guarantee Period selected. Amounts withdrawn prior to the end of any
Guarantee Period are subject to a Market Value Adjustment and possible
Withdrawal Charges, which could reduce the withdrawal amount and any remaining
Account Value below the Payment.
You must allocate the Payment to one Guarantee Period.
On the Maturity Date, if the Annuitant and Owner are still living, the
Certificate will provide for Annuity Payments to the Payee based upon the
Annuity Option selected. Fixed annuity dollar amounts are guaranteed by the
Company.
TABLE OF CONTENTS PAGE
- ------------------------------------------------------------ ----
PART 1 - DEFINITIONS 3
PART 2 - GENERAL PROVISIONS 4
PART 3 - OWNER, BENEFICIARY 6
PART 4 - PAYMENT 6
PART 5 - GUARANTEE PERIOD, SUBSEQUENT GUARANTEE PERIODS 6
PART 6 - MARKET VALUE ADJUSTMENT (MVA) FORMULA 7
PART 7 - INTEREST ON ACCOUNT VALUE 7
PART 8 - WITHDRAWAL(S) 8
PART 9 - FEES AND DEDUCTIONS 9
PART 10 - DEATH BENEFITS 9
PART 11 - ANNUITY PAYMENTS 10
PART 1: DEFINITIONS
WE AND YOU "We", "us" and "our" means the Company. "You"
or "your" means the Owner of this Certificate.
ACCOUNT VALUE The amount we hold under this Certificate for
you at any given time. On the Certificate
Date, the Account Value is equal to the Net
Payment. Thereafter, we determine the Account
Value as specified in the Certificate, "Part
7: Interest on Account Value."
ANNUITANT Any individual person or persons whose life is
used to determine the duration of Annuity
Payments involving life contingencies. The
Annuitant is as designated on the
Specifications Page, unless changed prior to
the Maturity Date.
ANNUITY OPTION The method selected by you for Annuity
Payments made by us.
ANNUITY PAYMENT(S) Payment(s) by us to you or your designated
Payee, which commence on or after the Maturity
Date and are in accordance with the Annuity
Option elected under the terms of this
Certificate.
ANNUITY SERVICE OFFICE Any office designated by us for the receipt of
Payment and processing of Owner requests. The
Annuity Service Office is shown on the
Certificate Cover Page.
BENEFICIARY The person, persons or entity to whom certain
benefits are payable following the death of an
Owner, or if the Owner is a non natural
person, an Annuitant.
CERTIFICATE ANNIVERSARY The anniversary of the Certificate beginning
twelve consecutive months from the Certificate
Date and each year thereafter.
CERTIFICATE DATE The date of issue of this Certificate as
designated on the Specifications Page.
CERTIFICATE YEAR The period of time measured twelve consecutive
months from the Certificate Date or any
Certificate Anniversary thereafter.
CONTINGENT BENEFICIARY The person, persons or entity, who becomes the
Beneficiary if the Beneficiary is not alive
when a benefit is due and payable.
ENDORSEMENT An Endorsement modifies the Certificate to
which it is attached. Endorsements must be
signed by an officer of the Company in order
to be effective.
GENERAL ACCOUNT All of the Company's assets other than the
assets in segregated asset accounts which are
maintained as "insulated" separate accounts
under applicable law.
GROSS WITHDRAWAL AMOUNT The amount deducted from the Account Value for
a full or partial withdrawal. For a full
withdrawal such amount is the Account Value.
For a partial withdrawal, it is the amount you
request plus any applicable Withdrawal Charge,
adjusted by any applicable Market Value
Adjustment.
IN WRITING Unless otherwise stated, means a notice
provided in a format acceptable to us based on
the type of request, which is received at our
Annuity Servicing Office.
INTERNAL REVENUE CODE (IRC) The Internal Revenue Code of 1986, as amended
from time to time, and any successor statute
of similar purposes.
INITIAL GUARANTEE PERIOD The period of time beginning on the
Certificate Date that the Initial Guaranteed
Interest Rate is in effect. The Initial
Guarantee Period continues for the period
shown on the Specifications Page.
INITIAL GUARANTEED INTEREST RATE The compound annual rate, shown on the
Specifications Page of the Certificate,
credited to the Account Value during the
Initial Guarantee Period under the terms of
the Certificate.
Page 3
MATURITY DATE The date on which Annuity Payments are
scheduled to commence. It is the date
specified on the Specifications Page, unless
changed.
MEASURING PERSON The person on whose life annuity payments will
be based.
NET PAYMENT The Payment less the amount of premium tax, if
any, deducted from the Payment.
OWNER(S) The person, persons or entity entitled to the
ownership rights under this Certificate. The
Owner is as designated on the Specifications
Page, unless changed.
PAYEE Any of the person(s) or entity to whom Annuity
Payments are to be made.
PAYMENT An amount paid to us by you that we accept as
consideration for the benefits provided by
this Certificate.
QUALIFIED CERTIFICATE A Certificate issued under a Qualified Plan.
QUALIFIED PLANS Retirement plans, which receive favorable tax
treatment under sections 401, 403, 408, 408A,
414 or 457, of the Internal Revenue Code of
1986, as amended.
MVA SEPARATE ACCOUNT A non-registered separate account that we
established within the General Account and in
which we hold reserves for our guarantees
under the Contract. Our other General Account
assets are also available to meet the
guarantees under the Contract and our other
general obligations. The assets of the MVA
Separate Account are subject to the
liabilities that arise out of the other
business that we conduct.
SUBSEQUENT GUARANTEE PERIOD A period of time beginning on the day
following expiry of the immediately preceding
Guarantee Period.
PART 2: GENERAL PROVISIONS
ENTIRE CERTIFICATE
This Certificate is an agreement between the Owner(s) and the Company. The
entire Certificate consists of this Certificate, any Riders, Endorsements and
application, if one is attached.
The benefits and values available under this Certificate are not less than the
minimum required by any statute of the state in which this Certificate is
delivered. We have filed a detailed statement of the method used to calculate
the benefits and values with the Department of Insurance in the state in which
this Certificate is delivered, if required by law.
You may also have access to (i) information for you or a member of your family,
regarding elder care needs and questions, either directly or through a third
party arrangement, and (ii) assistance that may help you identify various elder
care service agencies available in your community.
MODIFICATION
Only the President, a Vice President, or the Secretary of the Company has
authority to agree on our behalf to any alteration of the Certificate or to any
waiver of our rights or requirements. The alteration or waiver must be in
writing. We will not change or modify this Certificate without your consent
except as may be required to make it conform to any applicable law or regulation
or any ruling issued by a government agency; or unless we have reserved the
right to change the terms herein.
CHANGE IN MATURITY DATE
Prior to the Maturity Date, an Owner may request in writing a change of the
Maturity Date. Any extension of the Maturity Date will be subject to our
approval.
ASSIGNMENT
You may assign this Certificate, except as otherwise provided, at any time prior
to the Maturity Date. Your interest, any interest of the Annuitant and of any
revocable Beneficiary shall be subject to the terms of the assignment. We will
not be on notice of any assignment unless it is in writing. We will not be
liable for any payments made or actions we take
Page 4
before the assignment is accepted by us. An absolute assignment will revoke the
interest of any revocable Beneficiary. We assume no responsibility for the
validity or sufficiency of any assignment.
If this Certificate is issued in a tax qualified plan, this Certificate is
subject to assignment restrictions for Federal Income Tax purposes. In such
event, this Certificate shall not be sold, assigned, discounted, or pledged as
collateral for a loan or as security for the performance of an obligation or for
any other purpose, to any person other than us.
CLAIMS OF CREDITORS
All benefits and payments under this Certificate shall be exempt from the claims
of creditors of the Certificate Owner to the extent permitted by law.
MISSTATEMENT AND PROOF OF AGE, SEX OR SURVIVAL
We may require proof of age, sex or survival of any person upon whose age, sex
or survival an Annuity Payment depends. If the age or sex of the Annuitant has
been misstated, the benefits will be those which the Annuity Payment would have
provided for the correct age and sex. If we have made incorrect Annuity
Payments, the amount of any underpayment will be paid immediately. The amount of
any overpayment will be deducted from future Annuity Payments. We will uniformly
charge or credit interest in accordance with state law, as applicable.
NON-PARTICIPATING
Your Certificate is non-participating and will not share in our profits or
surplus earnings. We will pay no dividends on your Certificate.
CANCELLATION FOR MINIMUM ACCOUNT VALUE
If, as a result of any partial withdrawal, the Account Value would be reduced to
less than the Minimum Account Value, indicated on the Specifications Page, we
may cancel this Certificate and pay you the amount equal to that which would be
paid as a result of a Total Withdrawal, as described in Part 8, "Withdrawals".
REPORTS
We will send you any reports required by law.
CURRENCY AND PLACE OF PAYMENTS
All payments made to or by us shall be made in the lawful currency of the United
States of America at the Annuity Service Office or elsewhere if we consent.
NOTICES AND ELECTIONS
To be effective, all notices and elections you make under this Certificate must
be in writing, signed by you and received by us at the Annuity Service Office.
Unless otherwise provided in this Certificate, all notices, requests and
elections will be effective when received by us at our Annuity Service Office,
complete with all necessary information and your signature.
ISSUE STATE
This Certificate will be governed by the laws of the jurisdiction indicated on
the Specifications Page.
SECTION 72(s)
The provisions of this Certificate shall be interpreted so as to comply with the
requirements of Section 72(s) of the Internal Revenue Code.
Page 5
PART 3: OWNER, BENEFICIARY
OWNER
The Owner of this Certificate shall be the person, persons or entity designated
on the Specifications Page unless otherwise changed by you in writing. If
amounts become payable to the Beneficiary under this Certificate, the
Beneficiary becomes the Owner of this Certificate.
BENEFICIARY
Upon the death of the Owner, any surviving Owner will become the Beneficiary. If
there is no surviving Owner, the Beneficiary will be as designated on the
Specifications Page, unless otherwise changed during the Owner's lifetime. If no
such Beneficiary is living, the Beneficiary is the "Contingent Beneficiary". If
no Beneficiary or Contingent Beneficiary is living, the Beneficiary is the
estate of the deceased Owner.
CHANGE OF OWNER, ANNUITANT, BENEFICIARY
Subject to the rights of an irrevocable Beneficiary, you may request to change
the Owner, Annuitant, or Beneficiary by sending us notice in writing. Any such
request must be received at our Annuity Service Office and approved by us. If we
approved a change of Beneficiary, it will take effect on the date the request is
signed. If we approve a change of Owner or Annuitant, it will take effect on the
date we received the request at the Annuity Service Office. The Annuitant may
not be changed after the Maturity Date. You need not send us the Certificate
unless we request it. We will not be liable for any payments or actions we take
before we approve the change.
If any Annuitant is changed and any Owner is not an individual, the entire
interest in the Certificate must be distributed to the Owner within five years
of the change.
PART 4: PAYMENT
The Certificate is not effective until Payment is received by us at our Annuity
Service Office or such other place as we may designate. The Payment deposited
into the Certificate can not exceed the Maximum Payment Limit shown on the
Specifications Page. Upon request we will consider, applying nondiscriminatory
financial factors, waiving any of the above conditions.
ALLOCATION OF NET PAYMENT
When we receive the Payment, the Net Payment will be allocated to the Initial
Guarantee Period as shown on the Specifications Page.
PART 5: GUARANTEE PERIOD, SUBSEQUENT GUARANTEE PERIODS
GUARANTEE PERIOD
The Guarantee Period may be either the Initial Guarantee Period or a Subsequent
Guarantee Period. We allocate the Payment to the Initial Guarantee Period
elected and shown on the Specifications Page. Thereafter, any allocation of your
Account Value will be in a Subsequent Guarantee Period then available under this
Certificate. The Initial Guarantee Period is measured from the date your Payment
is allocated to the Guarantee Period. All Subsequent Guarantee Periods are
measured from the first day following the last day of the immediately preceding
Guarantee Period.
Page 6
SUBSEQUENT GUARANTEE PERIODS
At least 15 days, but not more than 45 days prior to the expiration of the
initial Guarantee Period and any Subsequent Guarantee Period, we will provide
you with a written notice of the expiry of the Guarantee Period and notice of
the Subsequent Guarantee Periods available. Unless we receive written
instructions from You selecting a Subsequent Guarantee Period from those then
available, upon expiration of any Guarantee Period, a Subsequent Guarantee
Period of one year will commence. If a one year Guarantee Period is not
available, you will be placed in the next shortest available Guarantee Period.
Any Subsequent Guarantee Period will begin the day after the expiration of the
immediately proceeding Guarantee Period. We do not subject an amount to a Market
Value Adjustment when it is applied to a Subsequent Guarantee Period.
If you elect a Subsequent Guarantee Period that extends beyond the Maturity Date
shown on the Specifications Page, your Maturity Date will be extended to the
last day of that Subsequent Guarantee Period. In no event will you be permitted
to elect a Subsequent Guarantee Period longer than the shortest Guarantee Period
ending on or after the Maximum Maturity Date shown on the Specifications Page.
PART 6: MARKET VALUE ADJUSTMENT (MVA) FORMULA
Any amounts withdrawn or converted to Annuity Payments on any date other than
the period 30 days after the expiration of the Guarantee Period may be adjusted
upward or downward by the application of a Market Value Adjustment Factor
described below.
The Market Value Adjustment Factor is determined by the following formula:
n
--
12
l + i
[---------]
l + j + k
Where k, i, j and n are defined as follows:
I = guaranteed rate in effect for the current Guarantee Period for this
Certificate
J = rate offered on a Guarantee Period equal to number of months remaining in
the current Guarantee Period, as of the date your request is processed. For
purposes of this calculation, months remaining will be rounded up to the next
nearest whole number. If a rate for this duration is not available, the Company
will declare a rate solely for this purpose that is consistent with rates for
durations that are currently available
K = Adjustment Factor, as indicated on the Specifications Page
N = number of months from date that any amounts withdrawn or converted to
Annuity Payments are processed to the end of your current Guarantee Period. In
the case of partial months, n is rounded up to the next month.
The amount of Market Value Adjustment, if any, upon withdrawal is specified in
Part 8, "Withdrawals."
The Market Value Adjustment is equal to A x (B-1) where A is the amount subject
to adjustment, and B is the Market Value Adjustment factor above. The Market
Value Adjustment may be positive or negative.
PART 7: INTEREST ON ACCOUNT VALUE
The Account Value is the value of the amount allocated to the Guarantee Period,
reduced by any Gross Withdrawal Amounts and reduced by any other applicable
charges described in the Certificate and accumulated with interest. The Account
Value will accumulate at a rate of interest determined by us and in effect on
the date the amount is allocated to the Guarantee Period. The Initial Guaranteed
Interest Rate is shown on the Specification Page. The Initial Guaranteed
Interest Rate may vary based on the amount of the Payment allocated to the
Guarantee Period and will apply throughout the Initial Guarantee Period. At the
commencement of any Subsequent Guarantee Period, the interest rate credited will
be at least equal to our declared interest rate then in effect for new policies
of the same size with Guarantee Periods of the same duration commencing at the
beginning of the Subsequent Guarantee Period. All
Page 7
such declared interest rates will be expressed on an annual effective basis and
will never be less than the guaranteed minimum interest rate required by law, if
any. The interest credited on any given day will be a rate which, if compounded
daily for one year, would equal the applicable declared interest rate.
PART 8: WITHDRAWALS
You may withdraw part or all of the Account Value at any time before the earlier
of the death of an Owner or Annuitant if the Owner is a non natural person or
the Maturity Date by sending us a notice in writing.
We will not defer payment more than six months beyond the date we receive such
notice. If we defer payment for more than 30 days, the amount deferred will earn
interest at a rate not less than the minimum required by law.
FREE WITHDRAWAL AMOUNT
The Free Withdrawal Amount will equal the greater of a) the annual Required
Minimum Distribution amount for Owners of Qualified Certificates aged 70 1/2 or
more or b) the amount of any interest credited to the Account Value during the
12 months prior to the date of your request, less any Gross Withdrawal Amount(s)
taken during this 12 month period.
TOTAL WITHDRAWAL
Upon receipt of your request to withdraw all of your Account Value, we will
terminate the Certificate and we will pay you the following amount:
F + [(A-F) x M] -W, WHERE:
F = the Free Withdrawal Amount;
A = the Account Value, reduced by any applicable Annual Fee;
M = the Market Value Adjustment Factor;
W = the Withdrawal Charge.
PARTIAL WITHDRAWAL(S)
You may withdraw less than your entire Account Value. However, requests for
amounts in excess of the Free Withdrawal Value are subject to a Withdrawal
Charge, a Market Value Adjustment and will be determined using the following
calculation:
F + [(G -F) x M] -W, WHERE:
F = the Free Withdrawal Amount;
G = the Gross Withdrawal Amount;
M = the Market Value Adjustment Factor;
W = the Withdrawal Charge.
We do not restrict the frequency of withdrawals. However, amounts withdrawn must
be no less than the Minimum Partial Withdrawal Amount shown on the Certificate's
Specifications Pages. Any withdrawal which would reduce the Account Value to
less than the Minimum Account Value, indicated on the Specifications Page, may
be treated as a request for a Total Withdrawal of your Account Value.
WITHDRAWAL CHARGE
If a withdrawal is made from the Certificate prior to the Maturity Date, a
Withdrawal Charge may be assessed against the portion of the Account Value being
withdrawn. The amount of the Withdrawal Charge and when it is assessed is
discussed below
1) The Free Withdrawal Amount is defined above and may be withdrawn
free of a Withdrawal Charge and is not subject to a Market Value
Adjustment.
Page 8
2) Any amounts withdrawn in excess of the Free Withdrawal Amount will
be subject to a Withdrawal Charge, if any. The Withdrawal Charge is
determined by multiplying the Gross Withdrawal Amount less any
annual administration fee and Free Withdrawal Amount by the
applicable Withdrawal Charge percentage shown on the Specifications
Page.
3) No Withdrawal Charge will apply to withdrawals made at the end of a
Guarantee Period as described in "Part 5: Guarantee Period,
Subsequent Guarantee Period". A request for withdrawal at the end of
a Guarantee Period must be received in writing during the 30 day
period immediately following the end of that Guarantee Period.
PART 9: FEES AND DEDUCTIONS
ANNUAL FEE
To compensate us for assuming certain administrative expenses, we may charge an
Annual Fee as set forth on the Specifications Page. Prior to the Maturity Date,
the Annual Fee is deducted from the Account Value on each Certificate
Anniversary. If the Account Value is totally withdrawn on any date other than
the Certificate Anniversary, we will deduct the total amount of the Annual Fee
from the amount paid. After the Maturity Date, the Annual Fee is deducted on a
pro rata basis from each Annuity Payment.
TAXES
We may charge certain taxes against your Payment, Account Value, payment of
Death Benefit, or Annuity Payments (either at the time of Payment, full
withdrawal, or when Annuity Payments commence), as appropriate. Such taxes may
include premium taxes or other taxes levied by any government entity which we
determine have resulted from the establishment or maintenance of the MVA
Separate Account, or from the receipt by us of Payments, or from the issuance of
this Certificate, or from the commencement or continuance of Annuity Payments
under this Certificate.
PART 10: DEATH BENEFITS
DEATH BEFORE MATURITY DATE
If any Owner dies prior to the Maturity Date (or date Annuity Payments begin, if
earlier) the Death Benefit will be equal to the Account Value, as of the date on
which written notice and proof of death and all required claim forms are
received in good order at the Company's Annuity Service Office.
On the death of the last surviving Annuitant, the Owner becomes the new
Annuitant, if the Owner is an individual. If any Owner is a non natural person,
the death of an Annuitant is treated as the death of an Owner.
If the co-Owner predeceases the Owner, the Owner will be treated as the
Beneficiary.
The Beneficiary may continue the Certificate as the Owner, subject to the
requirements of Section 72(s) of the Internal Revenue Code. If the Certificate
cannot continue under Section 72(s), or if the Beneficiary elects not to
continue the Certificate, the Death Benefit will be distributed under one of the
following provisions:
(i) as an Annuity Option as described within Part 11: "Annuity
Payments"; or
(ii) over the life of the Beneficiary, or over a period not to extend
beyond the life expectancy of the Beneficiary, with all such
distributions beginning within one year from the date of the Owner's
Death; or
(iii) the entire interest in the Certificate must be distributed within
five (5) years of the Owner's Death; or
(iv) in one lump sum.
Withdrawal Charges will be waived on any withdrawals under (ii), (iii) or (iv).
If the Beneficiary dies before distributions under (ii) or (iii) are complete,
the remaining Death Benefit must be distributed in a lump sum immediately. If
there is more than one Beneficiary, the foregoing provisions will independently
apply to each Beneficiary.
The Certificate will terminate if the Death Benefit is taken in one sum.
Page 9
If the Beneficiary decides to continue the Certificate as the Owner, subject to
Section 72(s), the new Owner must carry out the current Guarantee Period and
thereafter, applicable Market Value Adjustments will apply to amounts withdrawn
as described under the Certificate. Such amounts may be adjusted upward or
downward by the application of a Market Value Adjustment Factor. Subject to the
rights of an irrevocable Beneficiary, the new Owner in such instance may name a
new Beneficiary and, if no Beneficiary is so named, the decedent Beneficiary's
estate will be the Beneficiary.
If the Certificate is held as part of a Qualified Plan, the terms of your
Qualified Plan Endorsement form will control.
We will permit the Owner to limit the Death Benefit option(s) to be offered to
any named Beneficiary, if the Owner provides notice in writing to the Company
prior to death and the desired option(s) is one provided for in this
Certificate.
DEATH BENEFIT ON OR AFTER MATURITY DATE
On or after the date Annuity Payments begin, if the Annuitant dies, the Death
Benefit will depend on the Annuity Option selected in accordance with Part 11:
"Annuity Payments".
PROOF OF DEATH
Proof of death is required upon the death of the Annuitant or the Owner. Proof
of death is one of the following received at the Annuity Service Office:
a) A certified copy of a death certificate.
b) A certified copy of a decree of a court of competent jurisdiction as
to the finding of death.
c) Any other proof satisfactory to us.
PART 11: ANNUITY PAYMENTS
GENERAL
Any amounts payable under this Certificate may be converted to Annuity Payments
in accordance with one or more of the Annuity Options described below, subject
to any restrictions of Internal Revenue Code section 72(s). Once Annuity
Payments commence, the Annuity Option and the Annuitant may not be changed.
We will pay annuity benefits in the form of Annuity Payment(s) on the life of
the Annuitant, to the Payee, if living, on the Maturity Date. Annuity Payments
will commence on or after the Maturity Date and continue for the period of time
provided for under the Annuity Option You elect.
MATURITY DATE
On the Maturity Date or other date elected to commence Annuity Payments, we will
convert the Account Value adjusted by any Market Value Adjustment as described
in Part 6 of this Certificate, into Annuity Payments. The amount used to
determine the first Annuity Payment will be measured as of a date not more than
10 business days prior to the Maturity Date.
Only a Certificate Value of $5,000 or more may be applied to one of the annuity
payment options offered. If the amount of the first annuity payment would be
less than our minimum requirements then in effect, we may make a single payment,
adjusted by any Market Value Adjustment as described in Part 6 of this
Certificate, on the date the first payment is payable. This single payment is in
place of all other benefits provided by this Certificate.
CALCULATION USED TO DETERMINE ANNUITY PAYMENT(S)
The amount of each Annuity Payment is determined by applying the amounts which
will be converted to Annuity Payment(s) to the appropriate table(s) identified
by this Certificate. We guarantee the dollar amount of each Annuity Payment.
Annuity Payments will never be less than that available by applying the Account
Value adjusted by any Market Value Adjustment as described in Part 6 of this
Certificate, to buy a single premium immediate annuity then offered by us, or by
one of our affiliated companies if we do not offer a single premium immediate
annuity.
Page 10
DESCRIPTION OF ANNUITY OPTIONS
The following annuity payment options are available under this Certificate for a
single life:
a. Life Annuity with a Guaranteed Period of 5, 10, or 20 Years. Under
this option we will make payments for the guaranteed period elected,
and as long thereafter as the Measuring Person lives.
b. Life Annuity. Under this option, we will make payments throughout
the lifetime of the Measuring Person. No further payments will be
made after the death of the Measuring Person.
c. A single sum or any other option which we may make available
including joint lives.
ALTERNATIVE ANNUITY OPTIONS
Instead of settlement in accordance with the Annuity Options described above,
you may choose an alternate form of settlement acceptable to us. Once Annuity
Payments commence, the form of settlement may not be changed.
Page 11
TABLE OF PAYMENT RATES
The rates shown below are guaranteed minimum rates. The actual rates that we
will apply will be the greater of these guaranteed minimum rates and the current
rates in effect at the time Annuity Payments begin. Information regarding our
current rates will be available to any Owner upon request.
MONTHLY ANNUITY PAYMENT RATE TABLE
AGE OF MEASURING LIFE ANNUITY WITH GUARANTEED
- ------------------- -----------------------------------------
PERSON ON BIRTHDAY PERIOD
NEAREST DATE
OF FIRST PAYMENT 5 YEARS 10 YEARS 20 YEARS LIFE ANNUITY
- ------------------- ------- -------- -------- ------------
55 3.07 3.05 3.00 3.07
56 3.14 3.13 3.07 3.14
57 3.21 3.20 3.13 3.22
58 3.29 3.28 3.20 3.30
59 3.38 3.36 3.27 3.39
60 3.47 3.45 3.34 3.48
61 3.57 3.54 3.42 3.58
62 3.67 3.64 3.50 3.68
63 3.78 3.74 3.58 3.79
64 3.89 3.85 3.66 3.91
65 4.02 3.97 3.74 4.03
66 4.15 4.09 3.83 4.17
67 4.29 4.22 3.91 4.31
68 4.44 4.36 4.00 4.46
69 4.60 4.50 4.08 4.63
70 4.78 4.66 4.17 4.81
71 4.96 4.82 4.25 5.00
72 5.16 4.99 4.32 5.21
73 5.38 5.17 4.40 5.44
74 5.61 5.36 4.47 5.69
75 5.83 5.56 4.53 5.95
76 6.13 5.76 4.59 6.24
77 6.41 5.97 4.64 6.55
78 6.71 6.18 4.69 6.89
79 7.03 6.40 4.73 7.25
80 7.38 6.62 4.77 7.65
81 7.74 6.83 4.80 8.08
82 8.13 7.04 4.82 8.55
83 8.54 7.25 4.84 9.06
84 8.97 7.45 4.86 9.61
85 9.41 7.63 4.87 10.21
86 9.87 7.80 4.88 10.86
87 10.33 7.96 4.89 11.57
88 10.80 8.10 4.90 12.32
89 11.26 8.23 4.90 13.12
90 11.71 8.35 4.91 13.96
91 12.15 8.45 4.91 14.84
92 12.57 8.54 4.91 15.75
93 12.97 8.62 4.91 16.69
94 13.35 8.69 4.91 17.66
95 and over 13.73 8.75 4.91 18.67
These rates are based on the Annuity 2000 mortality table for Females projected
for improvement using projection scale G. Interest is at an annual effective
rate of 1.5%.
Page 12
- --------------------------------------------------------------------------------
JOHN HANCOCK LIFE INSURANCE COMPANY OF [JOHN HANCOCK LOGO]
NEW YORK
A STOCK LIFE INSURANCE COMPANY
- --------------------------------------------------------------------------------
SPECIFICATIONS PAGE
TYPE OF CONTRACT/CERTIFICATE: [QUALIFIED] MATURITY DATE [8/1/2032]
CONTRACT/CERTIFICATE DATE: [8/1/2009] MAXIMUM MATURITY DATE [8/1/2052]
PAYMENT: [$250,000] CONTRACT/CERTIFICATE NUMBER [000111]
OWNER: [DOROTHY HANCOCK] ISSUE STATE: [MA]
CO-OWNER: [JAMES DOE] OWNER'S AGE [52]
ANNUITANT [JOHN HANCOCK] ANNUITANT'S AGE [52]
CO-ANNUITANT [NON APPLICABLE]
INITIAL GUARANTEE PERIOD
INITIAL GUARANTEE PERIOD INITIAL GUARANTEED INTEREST RATE EXPIRATION DATE
- ------------------------ -------------------------------- ------------------------
[3 Years] [3.95%] [8/1/2012]
ADJUSTMENT FACTOR [0.25%]
ANNUAL FEE [$0]
PARTIAL WITHDRAWAL LIMITATIONS:
MINIMUM PARTIAL WITHDRAWAL AMOUNT [$1000]
MINIMUM ACCOUNT VALUE AFTER PARTIAL WITHDRAWAL [$5000]
MAXIMUM PAYMENT [$1,000,000]
[THIS CONTRACT/CERTIFICATE IS INTENDED FOR ISSUES AS TO A TAX-QUALIFIED
RETIREMENT PLAN UNDER THE INTERNAL REVENUE CODE FOR TAX-FAVORED STATUS. UNLESS
OTHERWISE REQUIRED TO QUALIFY FOR SUCH STATUS, LANGUAGE IN THIS
CONTRACT/CERTIFICATE REFERRING TO FEDERAL TAX STATUS OR RULES IS INFORMATIONAL
AND INSTRUCTIONAL. SUCH LANGUAGE IS NOT SUBJECT TO APPROVAL OR DISAPPROVAL BY
THE STATE IN WHICH THE CONTRACT/CERTIFICATE IS ISSUED FOR DELIVERY. PLEASE SEEK
THE ADVICE OF YOUR OWN TAX ADVISOR REGARDING YOUR INDIVIDUAL TAX TREATMENT.]
S.1
[TABLES OF WITHDRAWAL CHARGES:
APPLICABLE TO ACCOUNT VALUE DURING THE INITIAL GUARANTEE PERIOD:
CONTRACT/CERTIFICATE YEAR AT TIME OF WITHDRAWAL
GUARANTEE PERIOD 1 2 3 4 5 6 7 8 9 10
- ---------------- - - - - - - - - - --
1 YEAR 0%
2 YEAR 0% 0%
3 YEAR 7% 6% 5%
4 YEAR 7% 6% 5% 4%
5 YEAR 7% 6% 5% 4% 3%
6 YEAR 7% 6% 5% 4% 3% 2%
7 YEAR 7% 6% 5% 4% 3% 2% 1%
8 YEAR 7% 6% 5% 4% 3% 2% 1% 0%
9 YEAR 7% 6% 5% 4% 3% 2% 1% 0% 0%
10 YEAR 7% 6% 5% 4% 3% 2% 1% 0% 0% 0%
APPLICABLE TO ACCOUNT VALUE DURING ANY SUBSEQUENT GUARANTEE PERIOD:
YEARS SINCE THE COMMENCEMENT OF ANY SUBSEQUENT GUARANTEE PERIOD AT
THE TIME OF WITHDRAWAL
GUARANTEE PERIOD 1 2 3 4 5 6 7 8 9 10
- ---------------- - - - - - - - - - --
1 YEAR 0%
2 YEAR 0% 0%
3 YEAR 5% 4% 3%
4 YEAR 5% 4% 3% 2%
5 YEAR 5% 4% 3% 2% 1%
6 YEAR 5% 4% 3% 2% 1% 0%
7 YEAR 5% 4% 3% 2% 1% 0% 0%
8 YEAR 5% 4% 3% 2% 1% 0% 0% 0%
9 YEAR 5% 4% 3% 2% 1% 0% 0% 0% 0%
10 YEAR 5% 4% 3% 2% 1% 0% 0% 0% 0% 0%
]
S.2
BENEFICIARY INFORMATION
Beneficiary(s) [John Doe]
Contingent Beneficiary(s) [Jane Doe.]
S.3