INSURED PERSON	RICHARD ROE
		VARIABLE LIFE
POLICY OWNER	RICHARD ROE	INSURANCE
		POLICY
POLICY NUMBER	XX XXX XXX

AXA EQUITABLE LIFE INSURANCE COMPANY

HOME OFFICE: 1290 AVENUE OF THE AMERICAS, NEW YORK, NEW YORK 10104

(800) 777-6510

We agree to pay the Insurance Benefit of this policy and to provide its other benefits and rights in accordance with its provisions. This is a flexible premium variable life insurance policy. You can, within limits:

• make premium payments at any time and in any amount;

• change the face amount of insurance or the death benefit option;

• change the allocation of net premiums and deductions among your investment options; and

• transfer amounts among your investment options.

This policy is guaranteed not to lapse during the No Lapse Guarantee period shown on Page 3 provided that premiums are paid in accordance with the No Lapse Guarantee provision and any outstanding policy loan and accrued loan interest does not exceed the Policy Account Value.

All of these rights and benefits are subject to the terms and conditions of this policy. All requests for policy changes are subject to our approval and may require evidence of insurability.

We put your net premiums into your Policy Account. You may allocate them to one or more investment funds of our Separate Account(s) (SA) or to our Guaranteed Interest Account (GIA).

The portion of your Policy Account that is in an investment fund of our SA will vary up or down depending on the unit value of such investment fund, which in turn depends on the investment performance of the securities held by that fund. There are no minimum guarantees as to such portion of your Policy Account.

The portion of your Policy Account that is in our GIA will accumulate, after deductions, at rates of interest we determine. Such rates will not be less than the minimum guaranteed interest rate shown on Page 3 of this policy.

The amount and duration of the death benefit may be variable or fixed under specified conditions, and may increase or decrease. See the “Base Policy Death Benefit” provision for a description of the variable death benefit.

Right to Examine Policy. You may examine this policy and if for any reason you are not satisfied with it, you may cancel it by returning this policy with a written request for cancellation to our Administrative Office or to the agent who sold it to you or to an agent of the Company by the 10th day after you receive it. If you do this, we will refund the Policy Account Value calculated as of the business day we receive your request for cancellation at our Administrative Office (or, as of the business day the agent receives your request), plus any charges deducted from premiums that were paid and from the Policy Account Value, minus any outstanding loan and accrued loan interest. The policy shall be void from the beginning and the parties shall be in the same position as if no policy had been issued.

Read Your Policy Carefully. It is a legal contract between you and AXA Equitable Life Insurance Company.

This is a flexible premium variable life insurance policy. The Insurance Benefit is payable upon the death of the insured person while this policy is in force. You may pay premiums while the insured person is living and not yet attained age 121. The values provided by this policy are based on declared interest rates and on the unit values of the investment funds of a Separate Account, which in turn depend on the investment performance of the securities held by such investment funds. They are not guaranteed as to dollar amount. This is a non-participating policy.

Countersignature                                                                                                                                                                                     

Mark Pearson, Chairman of the Board	Dave S. Hattem, Senior Executive Director,
and Chief Executive Officer	Secretary and Associate General Counsel

ICC09-100

Contents

Policy Information 3

Table of Maximum Monthly Cost of Insurance Rates per $1,000 of Base Policy Net Amount at Risk 4

Those Who Benefit from this Policy 5

The Insurance Benefit We Pay 5

Changing the Face Amount of the Base Policy or Changing the Death Benefit Option 7

The Premiums You Pay 8

Your Policy Account and How it Works 10

Your Investment Options 10

The Value of Your Policy Account 12

The Cash Surrender Value of this Policy 13

How a Loan Can Be Made 14

Our Separate Account(s) (SA) 16

Our Annual Report to You 16

How Benefits are Paid 17

Other Important Information 17

In this policy:

“We,” “our” and “us” mean AXA Equitable Life Insurance Company.

“You” and “your” mean the owner of this policy at the time an owner’s right is exercised.

Unless otherwise stated, all references to interest in this policy are effective annual rates of interest.

Attained age means age on the birthday nearest to the beginning of the current policy year.

Administrative Office:

The address of our Administrative Office is shown on Page 3. You should send correspondence to that office. Premium payments should be sent to the address listed on your billing notice.

Copies of the application for this policy and any additional benefit riders are attached to the policy.

INTRODUCTION

The premiums you pay, after deductions are made in accordance with the Table of Maximum Deductions from Premium Payments in the “Policy Information” section of this policy, are put into your Policy Account. Amounts in your Policy Account are allocated at your direction to one or more investment funds of our SA or to our GIA.

The investment funds of our SA invest in securities and other investments whose value is subject to market fluctuations and investment risk. There is no guarantee of principal or investment experience.

Our GIA earns interest at rates we declare. The principal, after deductions, is guaranteed.

If death benefit Option A is in effect, the death benefit is the base policy face amount and the amount of the death benefit is fixed except when it is a percentage of your Policy Account. If death benefit Option B is in effect, the death benefit is the base policy face amount plus the amount in your Policy Account. The amount of the death benefit is variable. Under either option, the death benefit will never be less than a percentage of your Policy Account as stated in the “Base Policy Death Benefit” provision.

This policy is guaranteed not to lapse during the No Lapse Guarantee period shown on Page 3 provided that premiums are paid in accordance with the No Lapse Guarantee provision, and any outstanding policy loan and accrued loan interest does not exceed the Policy Account Value.

The Insurance Benefit of this policy is payable upon the death of the insured person while the policy is in force.

We make monthly deductions from your Policy Account to cover the cost of the benefits provided by this policy and the cost of any benefits provided by riders to this policy. If you give up this policy for its Net Cash Surrender Value or reduce the base policy face amount, we may deduct a surrender charge from your Policy Account.

This is only a summary of what this policy provides. You should read all of it carefully. Its terms govern your rights and our obligations.

ICC09-100

LIST OF STATE INSURANCE DEPARTMENTS

Alabama Department of Insurance	Alaska Division of Insurance	Arkansas Department of Insurance
201 Monroe Street, Suite 502	550 West 7th Avenue, Suite 1560	1200 West Third Street
P. O. Box 303351	Anchorage, Alaska 99501-3567	Little Rock, Arkansas 72201-1904
Montgomery, Alabama 36130-3351	Tel: 907-269-7900	Tel. 501-371-2600
Tel. 334-269-3550	Fax: 907-269-7910	Fax. 501-371-2618
Fax: 334-241-4192
Arizona Department of Insurance	Colorado Division of Insurance	Connecticut Insurance Department
2910 North 44th Street, Suite 210	1560 Broadway, Suite 850	153 Market Street, 7th Floor
Phoenix, Arizona 85018-7269	Denver, Colorado 80202	Hartford, Connecticut 06103
Tel. 602-364-3100	Tel. 303-894-7499	Tel. 860-297-3800
Fax 602-364-2400	Fax 303-894-7455	Fax 860-297-3872
District of Columbia Department of	Georgia Office of Insurance and	Hawaii Insurance Division
Insurance Securities and Banking	Safety Fire Commissioner	Dept. of Commerce & Consumer
1050 First Street, NE, 801	2 Martin Luther King, Jr. Drive	Affairs
Washington, DC 20002	West Tower, Suite 704	335 Merchant Street, Room 213
(202) 727-8000	Atlanta, Georgia 30334	P.O. Box 3614
	Tel. 404-656-2070	Honolulu, Hawaii 96811-3614
	Fax 404-656-8542	Tel. 808-586-2790
		Fax 808-586-2806
Idaho Department of Insurance	Illinois Department of Insurance	Indiana Department of Insurance
700 West State Street, 3rd Floor	320 West Washington Street	311 W. Washington Street,
P.O. Box 83720	Springfield, Illinois 67267-0001	Suite 300
Boise, Idaho 83720-0043	Tel. 217-782-4515	Indianapolis, Indiana 46204-2787
Tel: 208-334-4250	Fax. 217-782-5020	Tel. 317-232-2385
Fax: 208-334-4398		Fax 317-232-5251
Iowa Insurance Division	Kansas Department of Insurance	Kentucky Department of Insurance
Two Ruan Center	420 S.W. 9th Street	215 West Main Street
601 Locust, 4th Floor	Topeka, Kansas 66612-1678	P.O. Box 517
Des Moines, Iowa 50309-3738	Tel. 785-296-3071	Frankfort, Kentucky 40602-0517
Tel. 515-281-5705	Fax 785-296-7805	Tel. 502-564-3630
Fax 515-281-3059		Fax 502-564-1453
Louisiana Department of Insurance	Maine Bureau of Insurance	Maryland Insurance Administration
1702 North 3rd Street	34 State House Station	200 St. Paul Place, Suite 2700
P.O. Box 94214	Augusta, Maine 04333-0034	Baltimore, Maryland 21202-2272
Baton Rouge, Louisiana 70802	Tel. 207-624-8475	Tel. 410-468-2000
Tel. 225-342-5900	Fax 207-624-8599	Fax 410-468-2020
Fax. 225-342-8622
Massachusetts Divisions of Insurance	Michigan Dept. of Insurance and	Minnesota Department of Commerce
1000 Washington Street, Suite 810	Financial Services	85 7th Place East, Suite 280
Boston, Massachusetts 02118-6200	530 West Allegan Street, 7th Floor	St. Paul, Minnesota 55101-2198
Tel. 617-521-7794	P.O. Box 30220	Tel. 651-539-1600
Fax 617-753-6830	Lansing, Michigan 48909-7720	Fax 651-539-1547
	Tel. 877-999-6442
	Fax 517-284-8837
Mississippi Department of Insurance	State of Missouri Department of	Office of the Montana State Auditor,
1001 Woolfolk State Office Bldg.	Insurance Financial Institutes and	Commissioner of Securities and
501 North West Street	Professional Registration	Insurance
Jackson, Mississippi 39201	301 West High Street, Room 530	840 Helena Avenue
Tel. 800-562-2957	P. O. Box 690	Helena, Montana 59601
Fax 601-359-2474	Jefferson City, Missouri 65102-0690	Tel. 406-444-2040
	Tel. 573-751-4126	Fax 406-444-3497
	Fax 573-526-4898

ICC09-100 Page 2.2 VUL LEGACY

Nebraska Department of Insurance	Nevada Division of Insurance	New Hampshire Insurance Department
Terminal Building	1818 E. College Parkway, Suite 103	21 South Fruit Street, Suite 14
941 O Street, Suite 400	Carson City, Nevada 89706	Concord, New Hampshire 03301
P.O. Box 82089	Tel. 775-687-0700	Tel. 603-271-2261
Lincoln, Nebraska 68501-2089	Fax 775-687-0787	Fax 603-271-1406
Tel. 402-471-2201
Fax 402-471-4610
New Jersey Department of Banking	New Mexico Office of	North Carolina Dept. of Insurance
and Insurance	Superintendent of Insurance	Dobbs Building
20 West State Street	P.O. Box 1689	430 N. Salisbury Street
P. O. Box 325	1120 Paseo de Peralta	1201 Mail Service Center
Trenton, New Jersey 08625-0325	Santa Fe, New Mexico 87504-1689	Raleigh, North Carolina 27699-1201
Tel. 609-292-7272	Tel. 505-827-4601	Tel. 919-807-6750
Fax 609-777-0508	Fax 505-827-4734	Fax 919-715-1156
Ohio Department of Insurance	Oklahoma Insurance Department	Department of Consumer and Business
50 W. Town Street	Five Corporate Plaza	Services
Third Floor – Suite 300	3625 N.W. 56th Street, Suite 100	350 Winter Street NE, Room 410
Columbus, Ohio 43215-1067	Oklahoma City, Oklahoma 73112	P. O. Box 14480
Tel. 614-644-2658	Tel. 405-521-2828	Salem, Oregon 97309-0405
Fax 614-644-3743	Fax 405-521-6635	Tel. 503-947-7984
		Fax 503-378-4351
Pennsylvania Insurance Department	Puerto Rico Office of the	Rhode Island Department of Business
1326 Strawberry Square,	Commissioner of Insurance	Regulation
13th Floor	B5 Calle Tabonuco Street, Suite 216	Insurance Regulation Division
Harrisburg, Pennsylvania 17120	PMB 356	1511 Pontiac Avenue,
Tel. 717-787-2317	Guaynabo, Puerto Rico 00968-3029	Building 69-2
Fax 717-787-8585	Tel. 787-304-8686	Cranston, Rhode Island 02920
	Fax 787-723-6082	Tel. 401-462-9520
		Fax 401-462-9602
South Carolina Department of	Tennessee Dept. of Commerce & Ins.	Texas Department of Insurance
Insurance	Davy Crockett Tower, Fifth Floor	333 Guadalupe Street
1201 Main Street, Suite 1000	500 James Robertson Parkway	P.O. Box 149104
P.O. Box 100105	Nashville, Tennessee 37243-0565	Austin, Texas 78714-9104
Columbia, South Carolina 29202-3105	Tel. 615-741-6007	Tel. 800-252-3439
Tel. 803-737-6180	Fax 615-532-2788	Fax 512-490-1003
Fax 803-737-6231
Utah Department of Insurance	Vermont Department. of Financial	Virginia State Corporation
State Office Building, Room 3110	Regulation	Commission
450 North State Street	89 Main Street	Bureau of Insurance
Salt Lake City, Utah 84114-6901	Montpelier, Vermont 05620-3101	Tyler Building, 6th Floor
Tel. 801-538-3800	Tel. 802-828-3301	1300 East Main Street
Fax 801-538-3829	Fax 802-828-3306	Richmond, Virginia 23219
		Tel. 804-371-9741
		Fax 804-371-9873
Washington State Office of the	West Virginia offices of the	Wisconsin Office of the Commissioner
Insurance Commissioner	Insurance Commissioner	of Insurance
5000 Capitol Boulevard SE	West Virginia Lottery Building	125 South Webster Street
P.O. Box 40255	900 Pennsylvania Avenue	P.O. Box 7873
Olympia, Washington 98504-0257	P.O. Box 50540	Madison, Wisconsin 53707-7873
Tel. 360-725-700	Charleston, West Virginia 25305-0540	Tel. 608-266-3585
Fax 360-586-2574	Tel. 304-558-3386	Fax 608-266-9935
	Fax 304-558-0412

ICC09-100 Page 2.2 VUL LEGACY

Wyoming Department of Insurance

106 East 6th Avenue

Cheyenne, Wyoming 82002-0440

Tel. 307-777-7401

Fax 307-777-2446

ICC09-100 Page 2.2 VUL LEGACY

POLICY INFORMATION

INSURED PERSON	[RICHARD ROE]
POLICY OWNER	[RICHARD ROE]
FACE AMOUNT
OF BASE POLICY	[$100,000]
DEATH BENEFIT	[OPTION A]		SEPARATE ACCOUNT [FP]
POLICY NUMBER	[XX XXX XXX]		ISSUE AGE [35]
BENEFICIARY	[MARGARET ROE]		SEX [MALE]
REGISTER DATE	[MAY 1, 2019]	RATING CLASS:	[STANDARD
			NON-TOBACCO USER]
DATE OF ISSUE	[MAY 1, 2019]

The life insurance qualification test is the [Guideline Premium Test].

The minimum base policy face amount is [$100,000].

A minimum initial premium payment of [$110.97] is due on or before delivery of the policy. Each premium payment thereafter must be at least [$50.00].

The planned periodic premium of [$500.00] is payable [quarterly].

The minimum guaranteed interest rate we credit to the portion of your Policy Account that is in our GIA is 1.5% per year.

The No Lapse Guarantee Period is [15] years from the Register Date. See the No Lapse Guarantee provision.

The No Lapse Guarantee Accumulation Rate: [None].

See Page 4 for the Table of Guarantee Premiums.

The maximum age for a base policy face amount increase or a change to death benefit Option B is attained age [85] of the insured person. The maximum age may vary based on the rating class of the insured person at the time of such increase or change to Option B.

[The planned periodic premiums shown above may not be sufficient to continue the policy and life insurance coverage in force. 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) changes in the interest rates credited to our GIA and the investment performance of the investment funds of our SA including the VIO Holding Account; (4) the rate of return applied to any Segment Account at Segment Maturity, and any Market Value Adjustment associated with a loan, monthly deduction, or other distribution prior to Segment Maturity; (5) changes in the monthly deductions from your Policy Account for this policy and any benefits provided by riders to this policy; (6) changes in deductions from premium payments; (7) changes in the VIO Growth Cap Rates and Segment Loss Absorption Threshold Rates; and (8) loan and partial Net Cash Surrender Value withdrawal activity.]

However, this policy is guaranteed not to lapse during the No Lapse Guarantee Period, subject to the No Lapse Guarantee provision that is part of this policy. See the No Lapse Guarantee provision for further details.

ICC19-09-100-3 PAGE 3 VUL LEGACY

POLICY INFORMATION CONTINUED — POLICY NUMBER [XX XXX XXX]

INVESTMENT EXPENSE REDUCTION

[INVESTMENT EXPENSE REDUCTION

We will apply an Expense Reduction to the Investment Funds in the calculation of the daily unit values of each Investment Fund of our SA. The Expense Reduction for each Investment Fund will be determined based upon the net total annual portfolio operating expense of each Investment Fund’s corresponding portfolio, in the manner summarized in the table below. For purposes of determining the Expense Reduction for each Investment Fund, we will use the net total annual portfolio operating expense of each Investment Fund’s corresponding portfolio (1) as shown in the portfolio prospectuses dated on or about [May 1st ] of each calendar year for existing portfolios which are already effective as of that date; or (2) as shown in the initial effective portfolio prospectuses for new portfolios that become effective after that date; whichever is applicable. The minimum annual Expense Reduction for each Investment Fund is [0.15%]; however, in no event will the annual Expense Reduction for each Investment Fund exceed the net total annual portfolio operating expenses of each Investment Fund’s corresponding portfolio as of the date each unit value is calculated.

Net Total Annual Portfolio Operating Expense (before Investment Expense Reduction)	Annual Investment Expense Reduction
[[Less than [0.80%]	[Annual Investment Expense Reduction will be the amount equal to the greater of [0.15%] and any excess of the net total annual portfolio operating expense over [0.40%]. However, in no event will the annual Investment Expense Reduction exceed the net total annual portfolio operating expenses.]]
0.80%] through [1.15%]	[Annual Investment Expense Reduction will be the amount equal to the greater of [0.15%] and any excess of the net total annual portfolio operating expense over [0.80%]].
Greater than [1.15%]	Annual Investment Expense Reduction will equal [0.15%]].
]

ICC19-09-100-3 PAGE 3.1 VUL LEGACY

POLICY INFORMATION CONTINUED — POLICY NUMBER [XX XXX XXX]

ADDITIONAL BENEFIT RIDERS

The Additional Benefit Riders listed below are included in this policy:

Paid Up No Lapse Guarantee

If the Paid Up No Lapse Guarantee is elected, and while it remains in effect, the percentage referred to in the “Fund Allocations” provision of the endorsement shall be 25%.

ICC19-09-100-3 PAGE 3.2 VUL LEGACY

POLICY INFORMATION CONTINUED — POLICY NUMBER [XX XXX XXX]

ADDITIONAL BENEFIT RIDERS

The Additional Benefit Riders listed below are included in this policy:

Variable Indexed Option Rider (with a -25%	[Separate Account [67]
Segment Loss Absorption Threshold Rate)
Variable Index Benefit Charge	[.75% of the amount to be transferred from the VIO Holding Account into a new Segment on a Segment Start Date]
Segment Start Date:	[the 3rd Friday of each calendar month]
Segment Maturity Date:	[the 3rd Friday of the same calendar month as the calendar month of the Segment Start Date, in the calendar year next following the calendar year of the Segment Start Date]
Guaranteed Participation Rate:	[100%]
Guaranteed Minimum Growth Cap Rate:	[6%]
Segment Loss Absorption Threshold Rate:	[-25%]
Maximum difference between the annual interest rate we credit and the annual loan interest rate we charge on the amount of any loan deducted from a VIO Segment:	[5%]
VIO Holding Account:	[EQ/Money Market Variable
	Investment Option – Separate Account FP]
Investment Fund if we restrict future allocations to the VIO:	[EQ/Money Market Variable
	Investment Option – Separate Account FP]

ICC19-09-100-3 PAGE 3.3 VUL LEGACY

POLICY INFORMATION CONTINUED — POLICY NUMBER [XX XXX XXX]

ADDITIONAL BENEFIT RIDERS

HOW THE VARIABLE INDEXED OPTION RIDER

RELATES TO OTHER RIDERS OR ENDORSEMENTS ON YOUR POLICY

[PAID UP NO LAPSE GUARANTEE ENDORSEMENT

If you elect the Paid Up No Lapse Guarantee, and any Segment is in effect, the Segment Value will be used in place of the Segment Account in the calculation of your Policy Account value for purposes of determining the Paid Up No Lapse Guarantee face amount. All Segments will be terminated on the effective date of the Paid Up No Lapse Guarantee with corresponding Market Value Adjustments, and the Segment Values will be reallocated to certain available investment funds of our SA under the base policy and to the unloaned portion of our GIA as described in the Paid Up No Lapse Guarantee Endorsement.]

[LOAN EXTENSION ENDORSEMENT

If the Loan Extension Endorsement is in effect, and any Segments are in effect, the Segment Values will be used in place of the Segment Accounts in the calculation of your Net Policy Account Value in determining whether the policy will go onto loan extension. If loan extension goes into effect, any remaining Segments will be terminated on the effective date of loan extension with corresponding Market Value Adjustments, and the Segment Values will be transferred to the unloaned portion of our GIA, as described in the Loan Extension Endorsement].

[ACCELERATED DEATH BENEFIT RIDER (for terminal illness)

The third paragraph of the “Effect of Accelerated Death Benefit Payment on the Policy” provision of the Accelerated Death Benefit Rider is replaced by the following:

Additionally, if your policy is a variable life policy, the portion of the Cash Surrender Value that is equal to the specified percentage of the lien and is allocated to your values in the investment funds of the Separate Account (SA) under the base policy and the Variable Indexed Option will be transferred to and maintained as part of the unloaned portion of the Guaranteed Interest Account (GIA). You may tell us how much of the accelerated payment is to be transferred from your value in each investment fund of our SA under the base policy and your value in the Variable Indexed Option. Units will be redeemed from each investment fund of our SA under the base policy sufficient to cover the amount of the accelerated payment that is allocated to it and transferred to the unloaned portion of the GIA. Any portion of the payment allocated to the Variable Indexed Option based on your instructions will be deducted from any value in the VIO Holding Account and the individual Segments on a pro-rata basis, based on any value in the VIO Holding Account and the current Segment Value of each Segment, and transferred to the unloaned portion of the GIA. Any portion of the payment allocated to an individual Segment will cause a corresponding Segment Market Value Adjustment of the Segment Account. If you do not tell us how to allocate the payment, or if we cannot allocate it based on your directions, we will allocate it based on our rules then in effect].

ICC19-09-100-3 PAGE 3.4 VUL LEGACY

POLICY INFORMATION CONTINUED — POLICY NUMBER [XX XXX XXX]

TABLE OF GUARANTEE PREMIUMS

Benefits	Monthly Premium	Premium Period
No Lapse Guarantee	[$36.99]	[15] Years

You can, within limits, make premium payments at any time and in any amount. However, the monthly premiums shown above are used to determine whether the No Lapse Guarantee benefit is in effect as described in the “Grace Period” provision.

If the Net Policy Account Value at the termination of the No Lapse Guarantee Period shown above is not sufficient to cover total monthly deductions due at that time, this policy will terminate without value unless an additional payment is made.

ICC19-09-100-4 PAGE 4 VUL LEGACY

POLICY INFORMATION CONTINUED — POLICY NUMBER [XX XXX XXX]

TABLE OF MAXIMUM DEDUCTIONS FROM PREMIUM PAYMENTS

Premium Charge:

We deduct an amount not to exceed [8%] from each premium payment.

FOR INFORMATION OR TO MAKE A COMPLAINT

ADMINISTRATIVE OFFICE:

AXA EQUITABLE LIFE INSURANCE COMPANY

[LIFE OPERATIONS

8501 IBM DRIVE, SUITE 150

CHARLOTTE, NC 28262

(800) 777-6510

www.axa.com]

We will notify you of any change in our address. We will not consider any correspondence you send to us as having been received until it is recorded at our Administrative Office.

Contact for Contract State. Please use the contact information on the attached listing if you need to contact the state insurance department where your policy was purchased.

ICC19-09-100-4 PAGE 4.1 VUL LEGACY

POLICY INFORMATION CONTINUED — POLICY NUMBER [XX XXX XXX]

TABLE OF MAXIMUM MONTHLY DEDUCTIONS FROM YOUR POLICY ACCOUNT

BENEFITS		PERIOD
Base Policy Cost of Insurance Charge	Maximum monthly cost of insurance rate for the base policy (see page 4.3) times thousands of base policy net amount at risk.	[86] Years
Variable Index Segment Account Charge	An amount not to exceed [0.1375%] each policy month of each Segment Account while any Segment is in effect.	All Years
Mortality and Expense Risk Charge	An amount not to exceed [0.07083%] each policy month of the amount of your Policy Account that is then allocated to the investment funds of our Separate Account, including the VIO Holding Account and VIO Segment Accounts.	All Years
Administrative Charge	Each policy month during the first policy year: an amount not to exceed [$0.14] for each $1,000 of Initial Base Policy Face Amount plus an amount not to exceed [$15.00].	1 Year
	Each policy month during the second and subsequent policy years: an amount not to exceed [$0.14] for each $1,000 of initial base policy face amount plus an amount not to exceed [$10.00].	[85] Years
	Each policy year following an approved requested face amount increase, we deduct at the beginning of each policy month a fixed amount for each $1,000 of face amount increase that exceeds the previous highest face amount. This amount is determined based on the attained age, sex, and tobacco or non-tobacco user status of the insured person on the effective date of the increase. Changes in the base policy face amount resulting from a change in death benefit option will not be considered in computing the previous highest face amount.	To attained age 121 as measured from the effective date of increase, if applicable

ICC19-09-100-4 PAGE 4.2 VUL LEGACY

POLICY INFORMATION CONTINUED — POLICY NUMBER [XX XXX XXX]

TABLE OF MAXIMUM MONTHLY COST OF INSURANCE RATES

PER $1,000 OF BASE POLICY NET AMOUNT AT RISK

INSURED PERSON’S ATTAINED AGE	RATE	INSURED PERSON’S ATTAINED AGE	RATE	INSURED PERSON’S ATTAINED AGE	RATE
[35	0.07500	65	0.66500	95	22.97500
36	0.08750	66	0.73667	96	25.04667
37	0.09833	67	0.81333	97	27.30667
38	0.10833	68	0.89833	98	29.83083
39	0.11417	69	0.99417	99	32.58167
40	0.11917	70	1.10750	100	35.52000
41	0.12583	71	1.24167	101	38.34167
42	0.13417	72	1.40167	102	41.25000
43	0.14167	73	1.58917	103	44.19500
44	0.14917	74	1.80333	104	47.11917
45	0.15250	75	2.04250	105	49.95833
46	0.15917	76	2.30500	106	52.64583
47	0.16417	77	2.59583	107	56.64917
48	0.17083	78	2.91750	108	61.08083
49	0.17833	79	3.28667	109	66.01917
50	0.18750	80	3.71417	110	71.55333
51	0.20167	81	4.21750	111	77.81083
52	0.21917	82	4.78417	112	83.33250
53	0.24000	83	5.44833	113	83.33250
54	0.26167	84	6.22417	114	83.33250
55	0.28333	85	7.13500	115	83.33250
56	0.30333	86	8.20000	116	83.33250
57	0.32250	87	9.44250	117	83.33250
58	0.34250	88	10.86833	118	83.33250
59	0.36583	89	12.44083	119	83.33250
60	0.39583	90	14.14833	120	83.33250
61	0.43500	91	15.93750	121 AND ABOVE	00.00000]
62	0.48333	92	17.76333
63	0.53750	93	19.60583
64	0.59917	94	21.37083

ICC19-09-100-4 PAGE 4.3 VUL LEGACY

POLICY INFORMATION CONTINUED — POLICY NUMBER [XX XXX XXX]

TABLE OF SURRENDER CHARGES

FOR THE INITIAL BASE POLICY FACE AMOUNT

BEGINNING OF POLICY YEAR	CHARGE	BEGINNING OF POLICY YEAR	CHARGE
[1	$1,770.01	9	$1,291.82
2	1,758.07	10	1,205.59
3	1,742.42	11	1,116.24
4	1,675.06	12	1,022.93
5	1,603.92	13	925.60
6	1,530.66	14	824.24
7	1,454.35	15	667.35
8	1,374.17	16 AND LATER]	0.00]

A surrender charge will be deducted from your Policy Account if this policy is given up for its Net Cash Surrender Value within the first [fifteen] policy years. The surrender charge in the first policy month of each policy year is shown in the table above. The surrender charge declines uniformly in equal monthly amounts within each policy year until it reaches zero in the twelfth month of policy year [fifteen].

This table assumes no face amount increases. Additional surrender charges may apply for certain face amount increases. See the “surrender charges” provision of this policy for a description of changes to surrender charges for face amount increases.

If the base policy face amount is reduced within the first [fifteen] policy years or within [fifteen] years following a face amount increase, a surrender charge will be deducted from your Policy Account. See the “Surrender Charges” provision of this policy for a description of the surrender charge deducted for a face amount reduction.

ICC19-09-100-4 PAGE 4.4 VUL LEGACY

POLICY INFORMATION CONTINUED — POLICY NUMBER [XX XXX XXX]

TABLE OF PERCENTAGES

INSURED PERSON’S ATTAINED AGE	PERCENTAGE	INSURED PERSON’S ATTAINED AGE	PERCENTAGE
40 and under	250%	61	128%
41	243	62	126
42	236	63	124
43	229	64	122
44	222	65	120
45	215	66	119
46	209	67	118
47	203	68	117
48	197	69	116
49	191	70	115
50	185	71	113
51	178	72	111
52	171	73	109
53	164	74	107
54	157	75-90	105
55	150	91	104
56	146	92	103
57	142	93	102
58	138	94 and above	101
59	134
60	130

Section 7702 of the Internal Revenue Code of 1986, as amended (i.e., the “Code”), gives a definition of life insurance which limits the amounts that may be paid into a life insurance policy relative to the benefits it provides. Even if this policy states otherwise, at no time will the “future benefits” under this policy be less than an amount such that the “premiums paid” do not exceed the Code’s “guideline premium limitations.” We may adjust the amount of premium paid to meet these limitations. Also, at no time will the “death benefit” under the policy be less than the “applicable percentage” of the “cash surrender value” of the policy. The above terms are as defined in the Code. In addition, we may take certain actions, described here and elsewhere in the policy, to meet the definitions and limitations in the Code, based on our interpretation of the Code. Please see “Policy Changes —Applicable Tax Law” for more information.

ICC19-09-100-4-GPT PAGE 4.5 VUL LEGACY

POLICY INFORMATION CONTINUED — POLICY NUMBER [XX XXX XXX]

TABLE OF PERCENTAGES

INSURED PERSON’S ATTAINED AGE	PERCENTAGE	INSURED PERSON’S ATTAINED AGE	PERCENTAGE	INSURED PERSON’S ATTAINED AGE	PERCENTAGE
[35	570.9%	55	290.2%	75	157.6%
36	551.2	56	280.8	76	153.7
37	532.5	57	271.7	77	149.9
38	514.6	58	263.0	78	146.3
39	497.4	59	254.5	79	142.9
40	480.9	60	246.3	80	139.7
41	464.9	61	238.5	81	136.6
42	449.4	62	230.9	82	133.7
43	434.5	63	223.7	83	131.0
44	420.1	64	216.8	84	128.4
45	406.2	65	210.2	85	126.0
46	392.8	66	203.8	86	123.8
47	379.7	67	197.7	87	121.8
48	367.1	68	191.9	88	119.9
49	354.9	69	186.3	89	118.2
50	343.1	70	180.9	90	116.7
51	331.7	71	175.8	91	115.3
52	320.7	72	170.9	92	114.0
53	310.1	73	166.3	93	112.8
54	299.9	74	161.8	94	111.6
				95	110.4
				96	109.0
				97	107.5
				98	105.7
				99	103.3
				100 AND ABOVE	101.0]

This policy is designed to satisfy the definition of life insurance for Federal income tax purposes under Section 7702 of the Internal Revenue Code of 1986, as amended (i.e., the “Code”). Accordingly, even if this policy states otherwise, at no time will the death benefits under the policy be less than the cash surrender value of the policy, divided by the net single premium per dollar of insurance which would have to be paid at such time to fund such benefits consistent with the definition of such terms in the Code. At no time will the “death benefit” under the policy be less than the applicable percentage of the “cash surrender value” of the policy. In addition, we may take certain actions, described here and elsewhere in the policy, to meet the definitions and limitations in the Code, based on our interpretation of the Code. Please see “Policy Changes – Applicable Tax Law” for more information.

(NOTE: THIS IS THE POLICY INFORMATION PAGE THAT WILL BE GENERATED IF THE CASH VALUE ACCUMULATION TEST IS SELECTED AT ISSUE)

ICC19-09-100-4-CVAT PAGE 4.5 VUL LEGACY

POLICY INFORMATION CONTINUED — POLICY NUMBER [XX XXX XXX]

TABLE OF FACTORS FOR PAID UP NO LAPSE GUARANTEE

INSURED PERSON’S ATTAINED AGE	FACTOR	INSURED PERSON’S ATTAINED AGE	FACTOR	INSURED PERSON’S ATTAINED AGE	FACTOR
[35	0.19307	64	0.48185	93	0.88673
36	0.19957	65	0.49616	94	0.89350
37	0.20620	66	0.51072	95	0.89987
38	0.21298	67	0.52552	96	0.90621
39	0.21993	68	0.54057	97	0.91223
40	0.22709	69	0.55586	98	0.91790
41	0.23448	70	0.57139	99	0.92315
42	0.24210	71	0.58710	100	0.92791
43	0.24994	72	0.60295	101	0.93213
44	0.25802	73	0.61887	102	0.93598
45	0.26634	74	0.63480	103	0.93947
46	0.27497	75	0.65070	104	0.94266
47	0.28388	76	0.66655	105	0.94562
48	0.29309	77	0.68233	106	0.94855
49	0.30261	78	0.69805	107	0.95180
50	0.31245	79	0.71369	108	0.95493
51	0.32260	80	0.72922	109	0.95791
52	0.33303	81	0.74456	110	0.96068
53	0.34374	82	0.75965	111	0.96308
54	0.35472	83	0.77444	112	0.96455
55	0.36597	84	0.78887	113	0.96456
56	0.37752	85	0.80284	114	0.96458
57	0.38938	86	0.81624	115	0.96463
58	0.40159	87	0.82897	116	0.96479
59	0.41417	88	0.84090	117	0.96520
60	0.42710	89	0.85191	118	0.96632
61	0.44037	90	0.86198	119	0.96937
62	0.45394	91	0.87109	120	0.97762]
63	0.46777	92	0.87930

ICC19-09-100-4 Page 4.6 VUL LEGACY

Those Who Benefit from this Policy

Owner. The owner of this policy is the insured person unless otherwise stated in the application, or later changed. Changes in the Owner, unless otherwise specified by you, shall take effect on the date the notice of change is signed by you, subject to any payments made or other actions taken by us prior to receipt of this notice.

As the owner, you are entitled to exercise all the rights of this policy while the insured person is living. To exercise a right, you do not need the consent of anyone who has only a conditional or future ownership interest in this policy. If there are multiple owners, consent of all owners is required to exercise the rights in this policy.

Consent to Jurisdiction. By accepting this policy, the owner of this policy at the time the policy is issued, regardless of current residence, agrees that the owner shall be subject to jurisdiction over its person in any court in the United States in any litigation involving this policy. Furthermore, any subsequent transfer of ownership to an owner(s) who is not a resident of the United States shall subject the owner to jurisdiction over its person in any court in the United States regarding any litigation involving this policy. By accepting transfer of ownership of this policy, a subsequent owner agrees to be subject to jurisdiction over its person in the United States. The parties to this contract agree that any action involving this contract shall be brought in any court in the United States of America in which venue is proper. The parties to this contract also agree that the law of the state in which the application for this policy is signed shall be the law applied in any dispute over the contract. This acceptance of jurisdiction of the United States by an owner shall also be binding upon any beneficiary or beneficiaries now or hereafter designated by such owner. For purposes of this provision, United States shall mean the fifty states, the District of Columbia, Puerto Rico, and the United States Virgin Islands.

Beneficiary. The beneficiary is as stated in the application, unless later changed. The beneficiary is entitled to the Insurance Benefit of this policy. One or more beneficiaries for the Insurance Benefit can be named in the application. If more than one beneficiary is named, they can be classed as primary or contingent. If two or more persons are named in a class, their shares in the benefit can be stated. The stated shares in the Insurance Benefit will be paid to any primary beneficiaries who survive the insured person. If no primary beneficiaries survive, payment will be made to any surviving contingent beneficiaries. Beneficiaries who survive in the same class will share the Insurance Benefit equally, unless you have made another arrangement with us.

If there is no designated beneficiary living at the death of the insured person, we will pay the Insurance Benefit to the insured person’s surviving children in equal shares. If none survive, we will pay the insured person’s estate.

Changing the Owner or Beneficiary. While the insured person is living, you may change the owner or beneficiary by written notice in a form satisfactory to us. You can get such a form from your agent or by writing to us at our Administrative Office. The change will take effect on the date you sign the notice, unless otherwise specified by you, except that it will not apply to any payment we make or other action we take before we receive the notice in our Administrative Office.

Assignment. You may assign this policy; however, we will not be bound by an assignment unless we have received it in writing at our Administrative Office. Your rights and those of any other person referred to in this policy will be subject to the assignment. We assume no responsibility for the validity of an assignment. An absolute assignment will be considered as a change of ownership to the assignee. The assignment, unless otherwise specified by you, will take effect on the date you sign the assignment notice, except that it will not apply to any payment we make or other action we take before we receive the notice in our Administrative Office.

ICC09-100-5 Page 5

The Insurance Benefit We Pay

We will pay the Insurance Benefit of this policy to the beneficiary upon the death of the insured person when we receive at our Administrative Office (1) proof that the insured person died while this policy was in force; (2) proof of interest of the claimant; and (3) all other requirements we deem necessary. The Insurance Benefit includes the following amounts, which we will determine as of the date of death of the insured person:

• the death benefit described in the “Base Policy Death Benefit” provision;

• plus any other benefits then due from riders to this policy, which are payable to the base policy beneficiary;

• minus any outstanding policy loan and accrued interest, or liens;

• minus any overdue deductions from your Policy Account if the insured person dies during a grace period (if the insured person dies during a grace period within the No Lapse Guarantee Period, this amount will be the lesser of the overdue deductions or the amount that would have been necessary to pass the No Lapse Guarantee Premium Fund test. See the “Grace Period” provision of this policy for more information).

Interest on the Insurance Benefit We Pay. Interest on the resulting amount stated above shall accrue and be payable from the date of death. Interest shall accrue at a rate not less than the Two Year Treasury Constant Maturity Rate as published by the Federal Reserve. In determining the effective annual rate or rates, we will use the rate in effect on the date of death.

Interest shall accrue at the effective annual rate determined above, plus additional interest at a rate of 10% annually beginning with the date that is 31 calendar days from the latest of Items 1, 2, and 3.

1. The date that due proof of death is received by us;

2. The date the company receives sufficient information to determine its liability, the extent of the liability, and the appropriate payee legally entitled to the proceeds; and

3. The date that legal impediments to payment of proceeds that depend on the action of parties other than the company are resolved and sufficient evidence of the same is provided to the company. Legal impediments to payment include, but are not limited to (a) the establishment of guardianships and conservatorships; (b) the appointment and qualification of trustees, executors and administrators; and (c) the submission of information required to satisfy State and Federal reporting requirements.

Payment of the Insurance Benefit may also be affected by other provisions of this policy. See the “Other Important Information” section of this policy, where we specify our right to contest the policy, the suicide exclusion, and what happens if age or sex has been misstated. Additional exclusions or limitations (if any) are listed in the “Policy Information” section of this policy.

Base Policy Death Benefit. The death benefit of this policy will be determined under either Option A or Option B, whichever you have chosen and is in effect on the date of death of the insured person.

Under Option A, the death benefit is the greater of (a) the base policy face amount; or (b) a percentage of the amount in your Policy Account on the date of death of the insured person. Under this option, the amount of the death benefit is fixed, except when it is determined by such percentage.

Under Option B, the death benefit is the greater of (a) the base policy face amount plus the amount in your Policy Account on the date of death of the insured person; or (b) a percentage of the amount in your Policy Account on the date of death of the insured person. Under this option the amount of the death benefit is variable.

The percentages referred to above are the percentages from the “Table of Percentages” shown on Page 4-Continued of this policy for the insured person’s age (nearest birthday) at the beginning of the policy year of determination.

No Lapse Guarantee. This policy is guaranteed not to lapse during the No Lapse Guarantee period shown on Page 3 provided that at the beginning of each policy month the sum of premium payments, accumulated at the No Lapse Guarantee Accumulation Rate, if any, shown on Page 3, less any partial withdrawals accumulated at the No Lapse Guarantee Accumulation Rate, if any, is at least equal to the sum of the monthly No Lapse Guarantee Premium(s) and guarantee premiums for any additional benefit riders shown on Page 3 – Continued, accumulated at the No Lapse Guarantee Accumulation Rate, if any, and any outstanding policy loan and accrued loan interest does not exceed the Policy Account Value. Certain policy changes after issue will change the No Lapse Guarantee Premium(s); however, they will not start a new guarantee period. As long as the Net Policy Account Value is sufficient to cover monthly deductions, the policy will not go into default even if you do not pay premiums sufficient to maintain this guarantee. This guarantee will terminate on the date that a new insured person is substituted for the original insured person under the terms of any Substitution of Insured rider.

ICC09-100-5 Page 6

Coverage Upon Reaching Attained Age 121. If this policy is in force on the policy anniversary when the insured person reaches attained age 121, it will remain in force subject to the policy loan provision. The death benefit will continue to be determined as described in the “Base Policy Death Benefit” provision. No premium payments (except as needed to keep the policy from terminating), partial withdrawals, changes in face amount or changes in death benefit option will be permitted upon reaching attained age 121 of the insured person; policy loans, loan repayments, and transfers among your investment options may continue to be made, subject to our normal rules as stated in other provisions of the policy pertaining to these items. No deductions for cost of insurance or administrative charges (except for the mortality and expense risk charge) will be made upon reaching attained age 121 of the insured person.

This policy may not qualify as life insurance if it is continued beyond age 100 of the insured person and may be subject to adverse tax consequences. You should consult a tax advisor prior to continuing coverage beyond that time.

Changing the Face Amount of the Base Policy or Changing the Death Benefit Option.

You may, starting in the second policy year, change the face amount of the base policy or change the death benefit option by written request to us at our Administrative Office, subject to the following conditions:

1. You may ask us to increase the base policy face amount while the insured person is not more than the maximum age shown on Page 3 of this policy. Any requested increase must be for at least $10,000. You must provide evidence satisfactory to us of the insurability of the insured person. We will decline your request if the insured person does not qualify for the increase subject to our underwriting rules then in effect. If you increase the base policy face amount, an additional fifteen year surrender charge may apply to that increase; see the “Surrender Charges” provision for more information.

2. You may ask us to reduce the base policy face amount while the insured person is less than attained age 121, but not to less than the minimum base policy face amount shown on Page 3 of this policy. Any such reduction in the base policy face amount may not be less than $10,000. If you reduce the base policy face amount before the end of the fifteenth policy year, or within fifteen years following a base policy face amount increase, we will deduct a proportionate amount of any applicable surrender charge from your Policy Account; see the “Surrender Charges” provision for more information.

3. You may request a change in your death benefit option. Any requested change to death benefit Option B must be made while the insured person is not more than the maximum age shown on Page 3 of this policy; we reserve the right to require satisfactory evidence of insurability of the insured person for such change. Any requested change to death benefit Option A must be made while the insured person is less than attained age 121. If you ask us to change from Option A to Option B, we will decrease the base policy face amount by the amount in your Policy Account on the date the change takes effect. However, we will decline to make such change if it would reduce the base policy face amount to less than the minimum base policy face amount shown on Page 3 of this policy. If you ask us to change from Option B to Option A, we will increase the base policy face by the amount in your Policy Account on the date the change takes effect. Such decreases and increases in the base policy face amount are made so that the death benefit remains the same on the date the change takes effect.

4. The change will take effect at the beginning of the policy month that coincides with or next follows the date we approve your request.

5. We reserve the right to decline to make any change that we determine would cause this policy to fail to qualify as life insurance under applicable tax law as interpreted by us. We also reserve the right to decline any change that may cause this policy to lose its ability to be tested for Federal income tax purposes under the 2001 Commissioners Standard Ordinary mortality tables. See “Policy Changes –Applicable Tax Law” provision for more information.

ICC09-100-7 PAGE 7

6. You may ask for a change by completing an application for change, which you can get from your agent or by writing to us at our Administrative Office. A copy of your application for change will be attached to the new “Policy Information” section that we will issue when the change is made. The new section and the application for change will become a part of this policy. We may require you to return this policy to our Administrative Office to make a policy change.

The Premiums You Pay

The minimum initial premium payment shown in the “Policy Information” section is due on or before delivery of this policy. No insurance will take effect before a premium at least equal to the minimum initial premium is paid. Other premiums may be paid at our Administrative Office at any time while this policy is in force and the age of the insured person is less than attained age 121. We will furnish you with a premium receipt, signed by one of our officers, upon request.

We will send premium notices to you for the planned periodic premium (this is the amount for which you asked us to bill you) shown in the “Policy Information” section. You may skip planned periodic premium payments. However, this may adversely affect the duration of the death benefit and your policy’s values. We will assume that any payment you make to us is a premium payment, unless you tell us in writing that it is a loan repayment, and except as described in the “Grace Period” provision of this policy.

If you stop paying premiums, insurance coverage will continue for as long as the Net Policy Account Value is sufficient to cover the monthly deductions described in the “Monthly Deductions” provision, with a further extension of coverage as described in the “Grace Period” provision.

Limits. Each premium payment after the initial one must be at least the amount shown on Page 3 of the policy. We may increase this minimum limit 90 days after we send you written notice of such increase. We reserve the right to limit the amount of any premium payments you may make if they would immediately result in more than a dollar for dollar increase in the death benefit (which would happen if the death benefit is determined as a percentage of the Policy Account, as described in the “Base Policy Death Benefit” provision), unless you provide satisfactory evidence of insurability of the insured person and it would not cause this policy to lose its ability to be tested for Federal income tax purposes under the 2001 Commissioners Standard Ordinary mortality tables.

We also reserve the right not to accept premium payments or to return excess amounts that we determine would cause this policy to fail to qualify as life insurance under applicable tax law as interpreted by us, unless they are necessary to continue coverage.

Grace Period. At the beginning of each policy month, we compare the Net Policy Account Value (this is equal to the amount in your Policy Account minus any outstanding policy loan and accrued loan interest) to the total monthly deductions described in the “Monthly Deductions” provision. If the Net Policy Account Value is sufficient to cover the total monthly deductions, this policy is not in default.

If the Net Policy Account Value at the beginning of any policy month is not sufficient to cover the total monthly deductions, during the No Lapse Guarantee period, we will perform the following calculations to determine whether the policy is in default:

1. Determine the No Lapse Guarantee Premium fund. The No Lapse Guarantee Premium fund for any policy month is the accumulation of all the monthly no lapse guarantee premiums and guarantee premiums for any additional benefit riders, shown on Page 3–Continued, accumulated at the No Lapse Guarantee Accumulation Rate, if any, shown on Page 3, from the Register Date of the policy up to that month.

2. Determine the actual premium fund. The actual premium fund for any policy month is the accumulation of all the premiums received, accumulated at the No Lapse Guarantee Accumulation Rate, if any, minus all withdrawals, accumulated at the No Lapse Guarantee Accumulation Rate, if any, from the Register Date of the policy up to that month.

3. If the result in Step 2 is greater than or equal to the result in Step 1, and any outstanding loan and accrued loan interest does not exceed the Policy Account Value, the policy is not in default. The guarantee will be in effect and monthly deductions will be taken up to the amount in the Policy Account.

ICC09-100-7 PAGE 8

4. If the result in Step 2 is less than the result in Step 1, or if the result in Step 2 is greater than or equal to the result in Step 1 and any outstanding policy loan and accrued loan interest exceeds the Policy Account Value, the policy is in default as of the first day of that policy month. This is the date of default.

If the No Lapse Guarantee is no longer in effect, the calculations described above are not performed. In that case, if the Net Policy Account Value at the beginning of any policy month is less than the monthly deductions for that month, the policy is in default as of the first day of such policy month.

If the policy is in default, we will send you and any assignee on our records at the last known addresses written notice stating that a grace period of 61 days has begun starting with the date the notice is mailed. The notice will also state the amount of payment that is due.

The payment required will be an amount sufficient to increase the Net Policy Account Value to cover all monthly deductions for 3 months, calculated assuming no interest or investment performance was credited to or charged against the Policy Account and no policy changes were made. However, if default occurs during the No Lapse Guarantee period, the payment required will not be greater than the sum of (1) the premium amount, if any, necessary to pass the No Lapse Guarantee Premium Fund Test as described above, and (2) the loan repayment amount necessary to repay any outstanding policy loan and accrued loan interest.

If we do not receive such amount at our Administrative Office before the end of the grace period, we will then (1) withdraw and retain any amount in your Policy Account; and (2) send a written notice to you and any assignee on our records at the last known addresses stating that this policy has ended without value.

If we receive the requested amount before the end of the grace period, it will be treated as a loan repayment to the extent that it is less than or equal to any outstanding policy loan and accrued loan interest. The remainder of the payment, if any, will be treated as a premium payment. If your Net Policy Account Value is still insufficient to cover total monthly deductions, we will send a written notice that a new 61 day grace period has begun and request an additional payment.

If the insured person dies during a grace period, we will pay the Insurance Benefit as described on Page 5.

Restoring Your Policy Benefits. If this policy has ended without value and was not given up for its Net Cash Surrender Value, you may restore policy benefits while the insured person is alive. In order to restore benefits, you must:

1. Ask for restoration of policy benefits within 3 years from the end of the grace period; and

2. Provide evidence of insurability satisfactory to us; and

3. Make the required payment. The required payment will be an amount sufficient to cover (i) total monthly deductions for 3 months, calculated from the effective date of restoration; and (ii) the premium charge. We will determine the amount of the required payment as if no interest or investment performance was credited to or charged against your Policy Account.

We will not restore the policy unless the insured person is alive on the effective date of policy restoration. The effective date of the restoration of policy benefits will be the beginning of the policy month which coincides with or next follows the date we approve your request. We will deduct the premium charge from the required payment. Your Policy Account on the date of restoration will be equal to the balance of the required payment.

We will start to make monthly deductions again as of the effective date of restoration. The schedule of surrender charges that was applicable on the date of default will also be applicable to the restored policy. Any remaining No Lapse Guarantee period as measured from the policy Register Date will not be restored if this policy is restored.

We reserve the right to decline to restore this policy if it would cause this policy to fail to qualify as life insurance under applicable tax law as interpreted by us. We also reserve the right to decline a restoration that may cause this policy to lose its ability to be tested for Federal income tax purposes under the 2001 Commissioners Standard Ordinary mortality tables. See “Policy Changes –Applicable Tax Law” provision for more information.

ICC09-100-9 PAGE 9

Your Policy Account and How it Works

Premium Payments. When we receive your premium payments, we deduct the premium charge(s) shown in the Table of Maximum Deductions from Premium Payments in the “Policy Information” section of this policy and any overdue monthly deductions. We put the balance (the net premium) into your Policy Account as of the date we receive the premium payment at our Administrative Office and before any deductions from your Policy Account due on that date are made. However, we will put the initial net premium payment into your Policy Account as of the Register Date if it is later than the date of receipt. No premiums will be applied to your Policy Account until the minimum initial premium payment, as shown in the “Policy Information” section, is received at our Administrative Office.

Monthly Deductions. At the beginning of each policy month we make a deduction from your Policy Account to cover the monthly administrative charge and to provide insurance coverage. If you do not submit the full minimum initial premium with your application, and the minimum initial premium is paid upon delivery, your monthly deductions commence as of the Register Date. Such deduction for any policy month is the sum of the following amounts determined as of the beginning of that month:

• the monthly administrative charge;

• the monthly mortality and expense risk charge;

• the monthly cost of insurance for the insured person; and

• the monthly cost of any benefits provided by riders to this policy.

The monthly cost of insurance is the sum of (a) our current monthly cost of insurance rate times the net amount at risk at the beginning of the policy month divided by $1,000; plus (b) any flat extra charge shown in the “Policy Information” section. The net amount at risk at any time is the base policy death benefit (calculated as of that time) minus the amount in your Policy Account at that time.

We will determine cost of insurance rates from time to time. Any change in the cost of insurance rates we use will be as described in the “Changes in Policy Cost Factors” provision. They will never be more than those shown in the Table of Maximum Monthly Cost of Insurance Rates Per $1000 of Base Policy Net Amount at Risk on Page 4 of this policy.

No deduction is made (except for the mortality and expense risk charge) upon reaching attained age 121 of the insured person.

Other Deductions. We also make the following other deductions from your Policy Account as they occur:

• We deduct a surrender charge if, before the end of the fifteenth policy year, or within fifteen years following a face amount increase, you give up this policy for its Net Cash Surrender Value or you reduce the base policy face amount.

• We deduct a charge for certain transfers (see “Transfers” provision).

Your Investment Options

Allocations. This policy provides investment options for the amount in your Policy Account. Amounts put into your Policy Account and deductions from it are allocated to the investment funds of our SA and to the unloaned portion of our GIA at your direction. You specified your initial premium allocation and deduction allocation percentages in your application for this policy, a copy of which is attached to this policy. Unless you change them, such percentages shall also apply to subsequent premium and deduction allocations.

Allocation percentages must be zero or a whole number not greater than 100. The sum of the premium allocation percentages and of the deduction allocation percentages must each equal 100.

You may change future allocation percentages by written notice to our Administrative Office. A change will take effect on the date we receive it at our Administrative Office.

If we cannot make a monthly deduction on the basis of the deduction allocation percentages then in effect, we will make that deduction based on the proportion that your unloaned value in our GIA and your values in the investment funds of our SA bear to the total unloaned value in your Policy Account.

ICC09-100-9 PAGE 10

Transfers. Transfer requests must be in writing and delivered by U.S. mail to our Administrative Office unless we accept an alternative form of communication (such as internet or facsimile). The use of alternative forms of communication is subject to our rules then in effect for each such service. We may provide information about our rules and the use of communications services in the policy prospectus, prospectus supplements or other notifications, as mailed to your last known address in our records from time to time. Any alternative form of communication that we make available may be changed or discontinued at any time. Communications services may be restricted or denied if we determine that you are using such services for market timing or other trading strategies that may disrupt operation of an investment fund of our SA or have a detrimental effect on the unit value of any investment fund of our SA.

We reserve the right to:

1. limit transfers among or to the investment funds of our SA to no more than once every 30 days;

2. require a minimum time period between each transfer into or out of one or more specified investment funds of our SA;

3. establish a maximum dollar amount that may be transferred by an owner on any transaction date among investment funds of our SA;

4. reject transfer requests from a person acting on behalf of multiple policy owners unless pursuant to a trading authorization agreement that we have accepted;

5. restrict or prohibit transfers in connection with the execution of instructions from an investment fund of our SA to restrict or prohibit purchases or redemptions of fund shares or to collect a redemption fee on transfers involving fund shares;

6. impose conditions or limitations on transfer rights, restrict transfers or refuse any particular transfer if we are concerned that market timing, excessive trading or other trading strategies may disrupt operation of an investment fund of our SA or may have a detrimental effect on the unit value of any investment fund of our SA or determine that you have engaged in any such strategy.

At your written request to our Administrative Office, we will transfer amounts from your value in any investment fund of our SA to one or more other funds of our SA or to our GIA. Any such transfer will take effect on the business day we receive your written request at our Administrative Office.

Once during each policy year you may ask us, by written request to our Administrative Office, to transfer an amount you specify from your unloaned value in our GIA to one or more investment funds of our SA. We must receive your request within a period beginning 30 days prior to the policy anniversary and ending 60 days after the policy anniversary. A transfer request received up to 30 days prior to the policy anniversary will be effective on the anniversary. A transfer request received on or within 60 days after the policy anniversary will be effective on the date the request is received at our Administrative Office. The maximum amount that you may transfer in any policy year is the greater of (a) $500, (b) 25% of the unloaned value in the GIA on the transfer effective date or (c) the amount transferred from the GIA in the immediately preceding policy year, if any. In no event will we transfer more than your unloaned value in our GIA

The minimum amount that we will transfer from your value in an investment fund of our SA on any date is the lesser of $500.00 or your value in that investment fund on that date, except as stated in the next paragraph. The minimum amount that we will transfer from your value in our GIA is the lesser of $500.00 or your unloaned value in our GIA as of the date the transfer takes effect, except as stated in the next paragraph.

We will waive the minimum amount limitations set forth in the immediately preceding paragraph if the total amount being transferred on that date is at least $500.00.

We reserve the right to make a transfer charge up to $25.00 for each transfer of amounts among your investment options. The transfer charge, if any, is deducted from the amounts transferred from the investment funds of our SA and our GIA based on the proportion that the amount transferred from each investment fund of our SA and our GIA bears to the total amount being transferred.

If you ask us to transfer the entire amount of your value in the investment funds of our SA to our GIA, we will not make a charge for that transfer.

ICC09-100-11 Page 11

The Value of Your Policy Account

The amount in your Policy Account at any time is equal to the sum of the amounts you then have in our GIA and in the investment funds of our SA under this policy. Your Net Policy Account Value is equal to the amount in your Policy Account minus any outstanding policy loan and accrued loan interest.

Your Value in our GIA. The amount you have in our GIA at any time is equal to the amounts allocated and transferred to it, plus the interest credited to it, minus amounts deducted, transferred and withdrawn from it. We will credit the amount in our GIA with interest at rates we determine. We will determine such interest rates periodically in advance for unloaned and loaned amounts in our GIA. The rates may be different for unloaned and loaned amounts. Any change in the interest rates we determine will be as described in the “Changes in Policy Cost Factors” provision. Such interest rates will not be less than the minimum guaranteed interest rate shown on Page 3 of this policy. Once interest above the minimum guaranteed interest rate is credited, it is non-forfeitable except indirectly due to any surrender charges incurred. Interest accrues and is credited on unloaned amounts in the GIA daily. However, we will credit interest on any portion of the initial net premium allocated to our GIA from the Register Date if it is later than the date of receipt provided the initial premium is at least equal to the minimum initial premium shown on Page 3 of the policy.

We credit interest on the loaned portion of our GIA daily. The interest rate we credit to the loaned portion of our GIA will be at an annual rate up to 1% less than the loan interest rate we charge. In no event will we credit less than the minimum guaranteed interest rate shown on Page 3 of this policy.

On each policy anniversary, and at any time you repay all of a policy loan, we allocate the interest that has been credited to the loaned portion of our GIA to the investment funds of our SA and the unloaned portion of our GIA in accordance with your premium allocation percentages.

Your Value in the Investment Funds of our SA. The amount you have in an investment fund of our SA under this policy at any time is equal to the number of units this policy then has in that fund multiplied by the fund’s unit value at that time.

Amounts allocated, transferred or added to an investment fund of our SA are used to purchase units of that fund; units are redeemed when amounts are deducted, loaned, transferred or withdrawn. These transactions are called policy transactions. The number of units a policy has in an investment fund at any time is equal to the number of units purchased minus the number of units redeemed in that fund to that time. The number of units purchased or redeemed in a policy transaction is equal to the dollar amount of the policy transaction divided by the fund’s unit value on the date of the policy transaction. Policy transactions may be made on any day. The unit value that applies to a transaction made on a business day will be the unit value for that day. The unit value that applies to a transaction made on a non-business day will be the unit value for the next business day.

We determine unit values for the investment funds of our SA at the end of each business day. Generally, a business day is any day the New York Stock Exchange is open for trading. A business day immediately preceded by one or more non-business days will include those non-business days as part of that business day. For example, a business day which falls on a Monday will consist of that Monday and the immediately preceding Saturday and Sunday.

The unit value of an investment fund of our SA on any business day is equal to the unit value for that fund on the immediately preceding business day multiplied by the net investment factor for that fund on that business day.

The net investment factor for an investment fund of our SA on any business day is (a) divided by (b), minus (c), where:

(a) is the net asset value of the shares in designated investment companies that belong to the investment fund at the close of business on such business day before any policy transactions are made on that day, plus the amount of any dividend or capital gain distribution paid by the investment companies on that day;

(b) is the value of the assets in that investment fund at the close of business on the immediately preceding business day after all policy transactions were made for that day; and

(c) is any charge for that day for taxes, amounts set aside as a reserve for taxes, or any operating expenses of our SA (including, without limitation, SEC registration fees and auditing fees).

The net asset value of an investment company’s shares held in each investment fund shall be the value reported to us by that investment company.

ICC09-100-11 Page 12

The Cash Surrender Value of this Policy

Cash Surrender Value. The Cash Surrender Value on any date is equal to the amount in your Policy Account on that date minus any applicable surrender charge.

Net Cash Surrender Value. The Net Cash Surrender Value is equal to the Cash Surrender Value minus any outstanding policy loan and accrued loan interest. You may give up this policy for its Net Cash Surrender Value at any time while the insured person is living. You may do this by sending us a written request for it and this policy to our Administrative Office. Your written request for cancellation or surrender must include the following:

1. A statement that makes it clear that you intend to surrender the policy;

2. The policy number of the policy to be surrendered;

3. The name of the insured person and your name (if other than the insured person) and address where proceeds should be mailed;

4. Your signature and, if required by a legally binding document of which we have an actual notice, the signature of a collateral assignee or other person having an interest in the policy through the legally binding document.

If this policy has a Cash Surrender Value and is being given up for its Net Cash Surrender Value, a completed withholding authorization must also be included with your written request. If this form is not provided to us with your written request for surrender, we will withhold income tax on the taxable portion of your distribution at the mandated federal and state tax rates. Withholding rules may also apply to other distributions under this policy.

We will compute the Net Cash Surrender Value as of the date we receive your request for it and this policy at our Administrative Office. If the policy has been lost, stolen or destroyed, you must include a statement in the written request that the policy was lost, stolen or destroyed with an approximate date of when the policy was lost, stolen or destroyed. All insurance coverage under this policy ends on the date we receive your written request.

Surrender Charges. If you give up this policy for its Net Cash Surrender Value before the end of the fifteenth policy year, we will subtract a surrender charge from your Policy Account. A table of surrender charges for the initial base policy face amount is in the “Policy Information” section.

We will establish additional surrender charges for any increase in the base policy face amount that represents an increase over the previous highest base policy face amount. These charges will apply for fifteen years from the effective date of such increase. Changes in the base policy face amount resulting from a change in death benefit option will not be considered in computing the previous highest face amount.

If you reduce the base policy face amount before the end of the fifteenth policy year, we will deduct a proportionate amount of any applicable surrender charge from your Policy Account. If you reduce the base policy face amount within fifteen years following a face amount increase, we will also deduct a proportionate amount of any applicable surrender charge from your Policy Account. Reductions will first be applied against the most recent increase in the base policy face amount. They will then be applied to prior increases in the base policy face amount in the reverse order in which such increases took place, and then to the original base policy face amount.

Assuming you have not previously changed the base policy face amount, a proportionate surrender charge will be determined by dividing the amount of the reduction in base policy face amount by the initial base policy face amount of insurance, and then multiplying that fraction by the surrender charge immediately before the reduction. The proportionate surrender charge will not exceed the unloaned Policy Account at the time of the reduction. If a proportionate surrender charge is made, the surrender charges shown in the table in the “Policy Information” section will be reduced proportionately. We will not deduct a proportionate surrender charge if the reduction resulted from a change in death benefit option.

ICC09-100-13 PAGE 13

Any deductions for surrender charges will be made in accordance with the “Allocations” provision. We will send you a new “Policy Information” section in the event of an increase or a reduction in the base policy face amount, which will include any new surrender charges. It will become a part of this policy. We may require you to return this policy to our Administrative Office to make a change.

Partial Net Cash Surrender Value Withdrawal. Starting in the second policy year while this policy is in force and the age of the insured person is less than attained age 121, you may ask for a partial Net Cash Surrender Value withdrawal by written request to our Administrative Office. Your request will be subject to our approval based on our rules in effect when we receive your request, and to the minimum withdrawal amount of $500.00. We have the right to decline a request for a partial Net Cash Surrender Value withdrawal if this would cause the policy to fail to qualify as life insurance under applicable tax law, as interpreted by us. We will decline a request for a partial Net Cash Surrender Value withdrawal if this would cause a decrease in the base policy face amount to less than the minimum base policy face amount shown on Page 3 of this policy.

A partial withdrawal will result in a reduction in the Cash Surrender Value and in your Policy Account equal to the amount withdrawn as well as a reduction in your death benefit. If the death benefit is Option A, and the death benefit minus the amount to be withdrawn is less than the base policy face amount, the base policy face amount will be reduced to the death benefit minus the amount to be withdrawn. If the death benefit is Option B, the base policy face amount will not be reduced. Under either death benefit option, the partial withdrawal will result in a reduction in your death benefit. The death benefit after the withdrawal will be determined as described in the “Base Policy Death Benefit” provision based on the Policy Account and the base policy face amount after the withdrawal. There will be no proportionate surrender charge due to a decrease in base policy face amount resulting from a partial withdrawal.

You may tell us how much of each partial withdrawal is to come from your unloaned value in our GIA and from your values in each of the investment funds of our SA. If you do not tell us, we will make the withdrawal on the basis of your monthly deduction allocation percentages then in effect. If we cannot make the withdrawal as indicated above, we will make the withdrawal based on the proportion that your unloaned value in our GIA and your values in the investment funds of our SA bear to the total unloaned value in your Policy Account.

Such withdrawal and resulting reduction in the death benefit, in the Cash Surrender Value and in your Policy Account will take effect on the date we receive your written request at our Administrative Office. We will send you a new “Policy Information” section if a withdrawal results in a reduction in the face amount. It will become a part of this policy. We may require you to return this policy to our Administrative Office to make a change.

How A Loan Can Be Made

Policy Loans. You can take a loan on this policy while it has a loan value. This policy will be the only security for the loan. The initial loan and each additional loan must be for at least $500. Any amount on loan is part of your Policy Account. We refer to this as the loaned portion of your Policy Account.

Carry Over Loans. If this policy was issued based, in whole or in part, upon an exchange of another life insurance policy, any existing loan transferred from the exchanged policy as approved by us subject to our rules then in effect will be put into the loaned portion of your Policy Account. For purposes of determining any premium charge as shown in the Table of Maximum Deductions from Premium Payments in the “Policy Information” section, we will consider the transferred loan amount as premium received by us in consideration of issuing this policy. If a refund is made under the “Right to Examine Policy” provision, we will deduct any outstanding policy loan and accrued loan interest from that refund.

Loan Value. The loan value on any date before attained age 75 of the insured person is 90% of the Cash Surrender Value on that date, and 100% thereafter. The amount of any new loan you take may not be more than the loan value, less any existing loan and accrued loan interest. If you request an increase to an existing loan, the additional amount requested will be added to the amount of the existing loan and accrued loan interest.

ICC09-100-13 PAGE 14

Your request for a policy loan must be in writing to our Administrative Office. You may tell us how much of the requested loan is to be allocated to your unloaned value in our GIA and your value in each investment fund of our SA. Such values will be determined as of the date we receive your request. If you do not tell us, we will allocate the loan on the basis of your monthly deduction allocation percentages then in effect. If we cannot allocate the loan on the basis of your direction or those percentages, we will allocate it based on the proportion that your unloaned value in our GIA and your values in the investment funds of our SA bear to the total unloaned value in your Policy Account.

The loaned portion of your Policy Account will be maintained as a part of our GIA. Thus, when a loaned amount is allocated to an investment fund of our SA, we will redeem units of that investment fund sufficient in value to cover the amount of the loan so allocated and transfer that amount to our GIA.

Loan Interest. Interest on a loan accrues daily at an adjustable loan interest rate. We will determine the rate at the beginning of each policy year, subject to the following paragraphs. It will apply to any new or outstanding loan under the policy during the policy year next following the date of determination.

The maximum loan interest rate for a policy year shall be the greater of (1) the “Published Monthly Average,” as defined below, for the calendar month that ends two months before the date of determination or (2) the minimum guaranteed interest rate shown on Page 3 of this policy plus 1% per year. “Published Monthly Average” means the Moody’s Corporate Bond Yield Average – Monthly Average Corporates as published by Moody’s Investors Service, Inc., or any successor thereto. If such averages are no longer published, we will use such other averages as may be permitted by the Interstate Insurance Product Regulation Commission.

We will determine the rate for each policy at regular intervals at least once every twelve (12) months but not more frequently than once in every three (3) month period. No change in the rate shall be less than ¹/₂ of 1% a year. We may increase the rate if the maximum rate as determined by clause (1) of the preceding paragraph exceeds the rate being charged by ¹/₂ of 1% or more. We will reduce the rate to or below the maximum rate as determined by clause (1) of the preceding paragraph if such maximum is lower than the rate being charged by ¹/₂ of 1% or more. We reserve the right to establish a rate lower than the maximum.

We will notify you of the initial loan interest rate when you make a loan. We will also give you advance written notice of any increase in the interest rate of any outstanding loan.

Loan interest is due on each policy anniversary. If the interest is not paid when due, it will be added to your outstanding loan and allocated on the basis of the deduction allocation percentages then in effect. If we cannot make the allocation on the basis of these percentages, we will make it based on the proportion that your unloaned values in our GIA and your values in the investment funds of our SA bear to the total unloaned value in your Policy Account. The unpaid interest will then be treated as part of the loaned amount and will bear interest at the loan rate then in effect.

When unpaid loan interest is allocated to an investment fund of our SA, we will redeem units of that investment fund sufficient in value to cover the amount of the interest so allocated and transfer that amount to the loaned portion of your Policy Account.

Loan Repayment. You may repay all or part of a policy loan at any time while the insured person is alive and this policy is in force.

Repayments will first be allocated to our GIA until you have repaid any loaned amounts that were allocated to our GIA. You may tell us how to allocate repayments above that amount among our GIA and the investment funds of our SA. If you do not tell us, we will make the allocation on the basis of the premium allocation percentages then in effect.

Failure to repay a policy loan or to pay loan interest will not terminate this policy unless at the beginning of a policy month the Net Policy Account Value is less than the total monthly deduction then due, if any. In that case, the “Grace Period” provision will apply.

A policy loan may have a permanent effect on your benefits under this policy even if it is repaid. During any period in which there is an outstanding loan, the interest rate we credit to the loaned portion of the Policy Account may be different than the rate we credit to the unloaned portion of the Policy Account. See the “Your Value in our GIA” provision.

ICC09-100-15 PAGE 15

Our Separate Account(s) (SA)

We established and we maintain our SA under the laws of the State of New York. Realized and unrealized gains and losses from the assets of our SA are credited to or charged against it without regard to our other income, gains, or losses. Assets are put in our SA to support this policy and other variable life insurance policies. Assets may be put in our SA for other purposes, but not to support contracts or policies other than variable contracts. The assets of our SA are our property. The portion of its assets equal to the reserves and other policy liabilities with respect to our SA will not be chargeable with liabilities arising out of any other business we conduct. We may transfer assets of an investment fund in excess of the reserves and other liabilities with respect to that fund to another investment fund or to our General Account.

Investment Funds. Our SA consists of investment funds. Each fund may invest its assets in a separate class of shares of a designated investment company, or companies, or make direct investments in securities. The investment funds of our SA that you chose for your initial allocations are shown on the application for this policy, a copy of which is attached to this policy. We may from time to time make other investment funds available to you, or we may create a new SA. We will provide you with written notice of all material details including investment objectives and all charges.

We have the right to change or add designated investment companies. We have the right to add or remove investment funds. We have the right to withdraw assets of a class of policies to which this policy belongs from an investment fund and put them in another investment fund. We also have the right to combine any two or more investment funds. The term investment fund in this policy shall then refer to any other investment fund in which the assets of a class of policies to which this policy belongs were placed.

We have the right to:

1. register or deregister any SA available under this policy under the Investment Company Act of 1940;

2. run any SA available under this policy under the direction of a committee, and discharge such committee at any time;

3. restrict or eliminate any voting rights of policy owners, or other persons who have voting rights as to any SA available under this policy; and

4. operate any SA available under this policy, or one or more of its investment funds, by making direct investments or in any other form. If we do so, we may invest the assets of such SA, or one or more of the investment funds, in any legal investments. We will rely upon our own or outside counsel for advice in this regard. Also, unless otherwise required by law or regulation, an investment adviser or any investment policy may not be changed without our consent. If required by law or regulation, the investment policy of an investment fund of any SA available under this policy will not be changed by us unless approved by the Superintendent of Insurance of the State of New York or deemed approved in accordance with such law or regulation. If so required, the process for getting such approval is on file with the insurance supervisory official of the jurisdiction in which this policy is delivered.

If any of these changes result in a material change in the underlying investments of an investment fund of our SA, we will notify you of such change, as required by law. If you have value in that investment fund we will, if you wish, transfer it at your written direction from that fund to another fund(s) of our SA or to our GIA, and you may then change your premium and deduction allocation percentages. There will be no charge for such a transfer.

Our Annual Report to You

For each policy year we will send you without charge a report for this policy that shows the current death benefit, the value you have in our GIA and in each investment fund of any SA available under this policy, the Cash Surrender Value and any policy loan with the current loan interest rate. It will also show the premiums paid and any other information as may be required by state or Federal law, in addition to the information required by the Interstate Insurance Product Regulation Commission.

05-200-15 PAGE 16

How Benefits Are Paid

The Insurance Benefit or your Net Cash Surrender Value withdrawals are paid immediately in one sum. Amounts paid will not be subject to the claims of creditors or to legal process, to the extent permitted by law.

Other Important Information

Your Contract with Us. This policy is issued in consideration of payment of a premium at least equal to the minimum initial premium payment shown in the “Policy Information” section. This policy, any riders or endorsements, and the attached copy of the initial application and all subsequent applications to change this policy, and all additional “Policy Information” sections added to this policy, make up the entire contract. The rights conferred by this policy are in addition to those provided by applicable Federal and State laws and regulations.

Only our Chairman of the Board, our President or one of our Vice Presidents can modify this policy or waive any of our rights or requirements under it. The person making these changes must put them in writing and sign them.

Policy Changes — Applicable Tax Law. For you and the beneficiary to receive the tax treatment accorded to life insurance under Federal law, this policy must qualify initially and continue to qualify as life insurance under the Code or successor law. Therefore, we have reserved earlier in this policy the right to decline to accept premium payments, to decline to change death benefit options, to decline to change the face amount, or to decline to make partial withdrawals that, in our opinion, would cause this policy to fail to qualify as life insurance under applicable tax law. Further, we reserve the right to make changes in this policy or its riders (for example, in the percentages referred to in the “Base Policy Death Benefit” provision) or to require additional premium payments, or to make distributions from this policy or to change the face amount to the extent we deem it necessary to continue to qualify this policy as life insurance. We also reserve the right to decline any change that may cause this policy to lose its ability to be tested for Federal income tax purposes under the 2001 Commissioners Standard Ordinary mortality tables. Any such changes will apply uniformly to all policies that are affected. You will be given advance written notice of such changes.

Changes in Policy Cost Factors. Changes in policy cost factors (interest rates we credit to our GIA, cost of insurance rates, the premium charge, the administrative charge, and the mortality and expense risk charge) will be on a basis that is equitable to all policyholders of a given class, and will be determined based on reasonable assumptions as to expenses, mortality, policy and contract claims, taxes, investment income, and lapses. Any change in policy cost factors will never result in an interest crediting rate that is lower than that guaranteed in the policy, or policy charges that exceed the maximum policy charges guaranteed in the policy. Any change in policy cost factors will be on a prospective basis; that is, any change will be determined based on future anticipated or emerging experience.

When the Policy is Incontestable. We have the right to contest the validity of this policy based on material misstatements made in the initial application for this policy. However, in the absence of fraud, we will not contest the validity of this policy after it has been in effect during the lifetime of the insured person for two years from the date of issue shown in the “Policy Information” section.

We also have the right to contest the validity of any policy change or restoration based on material misstatements made in any application for that change or restoration. In the absence of fraud, we will not contest any policy change that requires evidence of insurability, or any restoration of this policy, after the change or restoration has been in effect for two years during the lifetime of the insured person.

No statement shall be used to contest a claim unless contained in an application.

All statements made in an application are, in the absence of fraud, representations and not warranties.

See any additional benefit riders for modifications of this provision that apply to them.

ICC09-100-17 PAGE 17

Fraud Exception. As used in this policy, fraud shall mean false statements, representations or warranties knowingly and intentionally provided, or caused to be provided, by any person involved in the procurement of any coverage or any change to existing coverage provided under the policy, for the purpose of inducing the company to accept a risk or assume a hazard it would otherwise not have so accepted or assumed. This provision applies where permitted by applicable State law.

What if Age or Sex has Been Misstated? If the insured person’s age or sex has been misstated on any application, and we become aware of this fact while the insured person is alive, we will not make any retrospective recalculation of the Policy Account. However, future monthly deductions from the Policy Account will be based upon the rates for the correct age and sex. If the insured person’s age or sex has been misstated on any application, and we become aware of this fact on or after the date of death of the insured person, the death benefit and any benefits provided by riders to this policy will be those which would be purchased by the most recent deduction for the cost of insurance, and the cost of any benefits provided by riders, at the rates for the correct age and sex.

How the Suicide Exclusion Affects Benefits. If the insured person commits suicide (while sane or insane) within two years after the date of issue shown in the “Policy Information” section, our liability will be limited to the payment of a single sum. This sum will be equal to the premiums paid, minus any loan and accrued loan interest and minus any partial withdrawal of the Net Cash Surrender Value. If the insured person commits suicide (while sane or insane) within two years after the effective date of a change that you asked for that increases the death benefit, then our liability as to the increase in amount will be limited to the payment of a single sum equal to the monthly cost of insurance deductions and any monthly administrative charge deductions made for such increase.

If the insured person commits suicide (while sane or insane) within two years after the effective date of any policy restoration, our liability will be limited to the payment of a single sum. This sum will be equal to the premiums paid on and after the effective date of restoration, minus any outstanding policy loan and accrued loan interest and minus any partial withdrawal of the Net Cash Surrender Value.

How We Measure Policy Periods and Anniversaries. We measure policy years, policy months, and policy anniversaries from the Register Date shown in the “Policy Information” section. Each policy month begins on the same day in each calendar month as the day of the month in the Register Date.

How, When and What We May Defer. We may not be able to obtain the value of the assets of the investment funds of our SA if (1) the New York Stock Exchange is closed for trading; or (2) when the Securities and Exchange Commission has determined that a state of emergency exists that may make determination and payment impractical. During such times, as to amounts allocated to the investment funds of our SA, we may defer:

1. Determination and payment of Net Cash Surrender Value withdrawals (except when used to pay premiums to us);

2. Determination and payment of any death benefit in excess of the face amount;

3. Payment of loans (except when used to pay premiums to us);

4. Determination of the unit values of the investment funds of our SA; and

5. Any requested transfer.

As to amounts allocated to our GIA, we may defer payment of any Net Cash Surrender Value withdrawal or loan amount (except when used to pay premiums to us) for up to six months after we receive a request for it. We will allow interest at a rate that is not less than the minimum guaranteed interest rate shown on Page 3 of this policy on any Net Cash Surrender Value payment derived from our GIA that we defer for 30 days or more.

ICC09-100-17 PAGE 18

The Basis We Use for Computation. We provide Cash Surrender Values that are at least equal to those required by the NAIC Variable Life Insurance Regulation, model #270 using Actuarial Guideline XXIV. We have filed with the Interstate Insurance Product Regulation Commission a detailed statement of the basis of the charges for this policy and of our method of computing the charges, values and benefits of this policy.

We use the 2001 Commissioners Standard Ordinary Male or Female, Composite Ultimate Age Nearest Birthday Mortality Tables at attained ages 0-17, and the 2001 Commissioners Standard Ordinary Male or Female, Smoker or Non-Smoker Ultimate Age Nearest Birthday Mortality Tables at attained ages 18 and over, as the basis for determining maximum cost of insurance rates, net single premiums and minimum cash surrender values. We take account of the sex, attained age, and class of risk of the insured person. However, the maximum cost of insurance rates, net single premiums, and minimum cash surrender values for the base policy do not vary by class of risk of insured persons for risk classifications of Standard or better.

The minimum guaranteed interest rate we credit to the portion of your Policy Account in our GIA is shown on Page 3 of this policy.

For policies issued at attained ages 0-17, an insured person’s cost of insurance rate is not based on that person’s status as a tobacco user or non-tobacco user. Effective with the policy anniversary when that insured person reaches attained age 18, non-tobacco user cost of insurance rates will be charged for that person. That insured person may also be eligible for a more favorable risk classification, subject to our underwriting rules; see “Change in Risk Classification” provision. For policies issued at attained age 18 or over, an insured person’s cost of insurance rate takes account of that person’s status as a tobacco user or non-tobacco user.

Change from Tobacco User Rates to Non-Tobacco User Rates. If you are being charged tobacco user rates for an insured person attained age 18 or over, you may apply for non-tobacco user rates for that insured person. The change, if approved, may result in lower future cost of insurance rates beginning on the effective date of change to non-tobacco user rates. Upon request made to our Administrative Office, we will provide forms and instructions as to how you may apply for non-tobacco user rates.

The change will be based upon our general underwriting rules in effect at the time of application, and may include criteria other than tobacco use status as well as a definition of tobacco use different from that applicable at the time this policy was issued.

The change to non-tobacco user rates, if approved, will take effect at the beginning of the policy month that coincides with or next follows the date we approve your request. A copy of your application for the change will be attached to the new “Policy Information” section that we will issue when the change is made. The new section and the application for change will become part of this policy. We may require you to return this policy to our Administrative Office to make the change. This change may have adverse tax consequences.

The change to non-tobacco user rates will be contestable; however, in the absence of fraud, we will not contest the change after it has been in effect for two years during the lifetime of the insured person. In the event of a successful contest, the death benefit and any benefits provided by riders to this policy will be those which would be purchased by the most recent deduction for the cost of insurance, and the cost of any benefits provided by riders, at tobacco user rates.

Change in Risk Classification. Any insured person attained age 18 or over may be eligible for a more favorable risk classification, if available. Upon request made to our Administrative Office, we will provide forms and instructions as to how you may apply for such a change. The change will be based upon our general underwriting rules in effect at the time of application, which may be different from those applicable at the time this policy was issued. This change, if approved, may result in lower future cost of insurance rates beginning on the effective date of the change.

The change in risk classification, if approved, will take effect at the beginning of the policy month that coincides with or next follows the date we approve your request. A copy of your application for the change will be attached to the new “Policy Information” section that we will issue when the change is made. The new section and the application for change will become part of this policy. We may require you to return this policy to our Administrative Office to make the change. This change may have adverse tax consequences.

ICC09-100-19 PAGE 19

The change in risk classification will be contestable; however, in the absence of fraud, we will not contest the change after it has been in effect for two years during the lifetime of the insured person. In the event of a successful contest, the death benefit and any benefits provided by riders to this policy will be those which would be purchased by the most recent deduction for the cost of insurance, and the cost of any benefits provided by riders, at the rates for the prior risk classification.

Policy Illustrations. Upon request we will give you an illustration of the potential future benefits under this policy, based upon both guaranteed and current non-guaranteed cost factor assumptions. We will provide the first illustration requested in a policy year free of charge. We reserve the right to charge up to $25 for each additional illustration requested in a policy year.

Conformity With Interstate Insurance Product Regulation Commission Standards. This policy was approved under the authority of the Interstate Insurance Product Regulation Commission and issued under the Commission standards. Any provision of this policy that on the provision’s effective date is in conflict with the Interstate Insurance Product Regulation Commission standards for this product type is hereby amended to conform to the Interstate Insurance Product Regulation Commission standards for this product type as of the provision’s effective date.

ICC09-100-19 PAGE 20

AXA EQUITABLE LIFE

INSURANCE COMPANY

Home Office: 1290 Avenue of the Americas, New York, New York 10104

This is a Flexible Premium Variable Life Insurance Policy. The Insurance Benefit is payable upon the death of the insured person while this policy is in force. You may pay premiums while the insured person is living and is not yet attained age 121. The values provided by this policy are based on declared interest rates and on the unit values of the investment funds of a Separate Account, which in turn depend on the investment performance of the securities held by such investment funds. They are not guaranteed as to dollar amount. This is a non-participating policy.

ICC09-100