EX-4.C 3 ex4c.htm EX 4C CONTRACT SCHEDULE PAGE S40875

 
Contract Schedule

Owner:
[John Doe]
Contract Number:
[??687456]
[Joint Owner:
[Jane Doe]]
Issue Date:
[04/15/10]
Annuitant:
[John Doe]
Scheduled Annuity Date:
[04/01/65]
Determining Life (Lives):
[John Doe]
Maximum Issue Age:
[80]
 
[Jane Doe]
    

Purchase Payments
  
Initial Purchase Payment:
$[10,000.00]
Minimum Additional Purchase Payment:
$[50.00]
Maximum Total Purchase Payments:
$[1 million; higher amounts may be accepted with our approval]
   
Transfers
  
Number of Free Transfers Permitted:
[12] each Contract Year
Transfer Fee:
$[25.00] for each transfer in excess of the free transfers permitted
Transfer Index Anniversary:
Every [Sixth] Index Anniversary
   
Contract Charges
  
Product Fee:
[0.25]%
Contract Maintenance Charge:
$[50.00] each Contract Year
Designated Amount:
Contract Value must be $[100,000.00] to waive the Contract Maintenance Charge
   
Withdrawals
  
Minimum Partial Withdrawal:
$[100.00]
Minimum Required Value:
$[2,000.00]
Free Withdrawal Amount:
[10]% of total Purchase Payments
Only Withdrawals from the Index Options are counted towards the Free Withdrawal Amount.
  

Withdrawal Charge Percentages Table

 
Number of Complete Years Since Receipt of Purchase Payment
Charge
  
 
 
   [0   6.50%   
 
   1    6.00%  
 
   2    5.00%  
 
   3    4.00%  
 
   4    3.00%  
 
   5    2.00%  
 
6 years or more
0%]
 
  
The Withdrawal Charge applies only to the Index Options. The Variable Options are not subject to a Withdrawal Charge.

Annuity Payments
  
Minimum Annuity Payment:
$[100.00]
Annuity Mortality Table:
[Annuity 2000 Mortality Table]
Minimum Annual Annuity Payment Rate:
[1.00]%
   
Riders:
[The applicable riders based on the information from the application will populate this area.]



S40875-01-ADV 3


Guaranteed Purchase Rate Table
Upon request, we will furnish rates for ages and guaranteed periods not shown.

Annuity Options - Guaranteed monthly annuity payments per $1,000
 
 
Option 1
Option 2
Option 3
Option 4
Option 5
   
10-year guaranteed period
20-year guaranteed period
100% joint and survivor
10-year guaranteed period
  
Age on
Annuity Date
Male
Female
Male
Female
Male
Female
Male & Female
Same Age
Male & Female
Same Age
Male
Female
30
[2.08
1.97
2.08
1.97
2.07
1.97
1.84
1.84
2.00
1.92
40
2.45
2.29
2.45
2.29
2.42
2.28
2.10
2.10
2.29
2.19
50
3.02
2.78
3.00
2.77
2.92
2.73
2.49
2.49
2.70
2.57
60
3.95
3.57
3.87
3.53
3.59
3.37
3.12
3.11
3.29
3.14
70
5.66
5.03
5.28
4.83
4.24
4.13
4.22
4.20
4.18
4.00
80
8.93
8.09
7.07
6.79
4.55
4.53
6.37
6.04
5.54
5.38
90
15.24
14.64
8.36
8.30
4.59
4.59
10.68
7.98
7.66
7.50]

S40875-01-ADV [3A]