EX-99.4(F) 7 dex994f.htm FORM OF SEP IRA/SIMPLE IRA/TSA CONTRACT DATA PAGE Form of SEP IRA/Simple IRA/TSA Contract Data Page

Exhibit 99.4(f)

CONTRACT DATA PAGE

PRODUCT:         [Spinnaker® Variable Annuity – TAX SHELTERED ANNUITY]

 

OWNER/ANNUITANT:    [John Doe]
    Address:    [1234 Main St.]
   [Any City, ST 99999-9999]
    Date of Birth:    [1/01/1970]
    Age:    [35]
    Sex:    [Male]

 

CONTRACT NUMBER:

   [LP12345678]

CONTRACT DATE:

   [5/01/2005]

ANNUITY DATE:

   Before [1/01/2061]

INITIAL PURCHASE PAYMENT:

   [$50,000]

AMOUNT ALLOCATED TO PORTFOLIOS:

   [$35,000]

AMOUNT ALLOCATED TO FIXED ACCOUNT:

  

INITIAL GUARANTEED INTEREST PERIOD - [1 Year]

   [$5,000]

INITIAL GUARANTEED INTEREST PERIOD - [3 Years]

   [$5,000]

INITIAL GUARANTEED INTEREST PERIOD - [5 Years]

   [$5,000]

DELIVERED IN THE STATE OF         [Any State]                                AND GOVERNED BY ITS LAWS.

MAXIMUM ISSUE AGE:         [85].    The contract date must be prior to the Owner’s (and any second Annuitant’s) [86th] birthday.

MAXIMUM ANNUITIZATION AGE:    [90].  Annuity payments must begin prior to the Annuitant’s (including any second Annuitant’s) [91st] birthday.

MINIMUM INITIAL AND SUBSEQUENT PURCHASE PAYMENTS:    [$30]

MINIMUM GUARANTEED INTEREST RATE:    [2.00%] during the first eight Contract Years, thereafter [1.50%].

ADDITIONAL INTEREST ON FIXED ACCOUNT IN FIRST CONTRACT YEAR:

Once the total Purchase Payments made during the first Contract Year exceed [$100,000], additional interest of an annual effective interest rate of [1.00%] will be credited on amounts allocated to the Fixed Account. The additional interest will be credited from the date we receive the Purchase Payment that causes the total to exceed [$100,000] until the end of the first Contract Year.

MINIMUM GUARANTEED VALUE FOR THE FIXED ACCOUNT:    Upon annuitization, death of the Owner, or a total withdrawal from the Fixed Account, the minimum value that will be applied toward annuity payments or paid to the Beneficiary or Owner will not be less than 90% of your Purchase Payments and transfers allocated to the Fixed Account accumulated at an annual effective interest rate of 3% each year, less prior withdrawals and transfers from the Fixed Account accumulated at an annual effective interest rate of 3% each year. If necessary to meet this minimum, charges will be waived.

Symetra is a service mark of Symetra Life Insurance Company.

[Spinnaker® ] is a registered trademark of Symetra Life Insurance Company.

 

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CONTRACT DATA PAGE

INSURANCE CHARGES:

MORTALITY AND EXPENSE RISK CHARGE:    Equal on an annual basis to [1.25%] of the average daily net assets of each Portfolio.

ASSET-RELATED ADMINISTRATION CHARGE:    Equal on an annual basis to [0.15%] of the average daily net assets of each Portfolio.

ANNUAL ADMINISTRATION MAINTENANCE CHARGE:    [$30] each Contract Year. The charge may be changed prior to the Annuity Date but will never exceed $50 per Contract Year. The charge will not be deducted if the contract value is [$50,000] or more when the charge is to be deducted.

MINIMUM WITHDRAWAL:    [$250] ([$100] if withdrawals made by electronic funds transfer), or the contract value if less. You must withdraw the entire amount out of an investment option if, after a withdrawal, the remaining balance in the investment option would be less than [$500]. You must withdraw the entire contract value and your Contract will terminate if, after a withdrawal, the remaining contract value would be less than [$1,000].

CONTINGENT DEFERRED SALES CHARGE:    May be assessed on a withdrawal. The contingent deferred sales charge is stated as a percentage of the amount withdrawn that exceeds the 10% free withdrawal amount. Total contingent deferred sales charges will not exceed 9% of the Purchase Payments made under this Contract.

 

Contract Year

  

Contingent Deferred Sales Charge

[1    8% of amount withdrawn]
[2    7% of amount withdrawn]
[3    6% of amount withdrawn]
[4    5% of amount withdrawn]
[5    4% of amount withdrawn]
[6    3% of amount withdrawn]
[7    2% of amount withdrawn]
[8    1% of amount withdrawn]
[After 8    0% of amount withdrawn]

WITHDRAWAL CHARGE:    [$25] or 2% of the amount withdrawn, whichever is less, for each withdrawal after the first withdrawal in a Contract Year.

TRANSFERS:    The minimum amount you can transfer out of any investment option at one time is [$500], or the entire value of the investment option if less. In addition to this [$500] minimum, transfers out of the Fixed Account are limited to a maximum of [10%] of the Fixed Account value per Contract Year. We may waive this [10%] limitation upon written notice to you. If we waive it, we reserve the right to reinstate the [10%] limitation upon written notice. You must transfer the entire amount of the investment option if, after a transfer, the remaining balance would be less than [$500]. The minimum amount you can transfer into any investment option is [$50].

TRANSFER CHARGE:    Each Contract Year, [12] transfers are free of charge. For each transfer after the [12th] transfer in a Contract Year, the transfer charge is [$10] or 2% of the amount transferred, whichever is less.

 

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CONTRACT DATA PAGE

PREMIUM TAXES: As of the contract date, premium taxes are not charged in your state. However, if we ever incur such taxes, we reserve the right to make a deduction from your Contract for the payment of the premium taxes assessed in connection with your Contract.

SEPARATE ACCOUNT: Symetra Separate Account C

 

ELIGIBLE INVESTMENTS:     
[1.    Fidelity VIP Money Market Portfolio-Service Class 2]    [21.   Fidelity VIP Mid Cap Portfolio-Service Class 2]
[2.    Franklin U.S. Government Fund-Class 2]    [22.   Mutual Shares Securities Fund-Class 2]
[3.    Federated High Income Bond Fund II]    [23.   Dreyfus IP-MidCap Stock Portfolio-Initial Shares]
[4.    Pioneer Strategic Income VCT Portfolio-Class II]    [24.   JPMorgan Mid Cap Value Portfolio]
[5.    Templeton Global Income Securities Fund-Class 2]    [25.   AIM V.I. Capital Development Fund (Series II Shares)]
[6.    American Century Investments VP Inflation Protection    [26.   Dreyfus IP-Technology Growth Portfolio-Initial Shares]
   Bond Class II Fund]    [27.   The Dreyfus Socially Responsible Growth Fund, Inc.-
[7.    Pioneer High Yield VCT Portfolio-Class II]      Initial Shares]
[8.    Franklin Income Securities Fund-Class 2]    [28.   Franklin Small-Mid Cap Growth Securities Fund-Class 2]
[9.    American Century Investments VP Balanced Fund]    [29.   Franklin Small Cap Value Securities Fund-Class 2]
[10.    PIMCO All Asset Portfolio-Advisor Class]    [30.   AIM V.I. Capital Appreciation Fund (Series II Shares)]
[11.    Dreyfus Stock Index Fund, Inc.-Service Shares]    [31.   Franklin Flex Cap Growth Securities Fund-Class 2]
[12.    PIMCO CommodityRealReturn Strategy Portfolio- Administrative Class]    [32.   AIM V.I. Real Estate Fund (Series I Shares)]
[13.    Fidelity VIP Contrafund Portfolio-Initial Class]    [33.   American Century Investments VP International Fund]
[14.    Fidelity VIP Growth & Income Portfolio-Initial Class]    [34.   Templeton Growth Securities Fund-Class 2]
[15.    Fidelity VIP Growth Portfolio-Initial Class]    [35.   Templeton Developing Markets Securities Fund-Class 2]
[16.    American Century Investments VP Value Fund]    [36.   JPMorgan International Equity Portfolio]
[17.    Dreyfus VIF-Appreciation Portfolio-Initial Shares]    [37.   AIM V.I. International Growth Fund (Series II Shares)]
[18.    Fidelity VIP Equity-Income Portfolio-Initial Class]    [38.   Pioneer Equity Income VCT Portfolio-Class II]
[19.    American Century Investments VP Large Company Value Class II Fund]    [39.   Pioneer Small Cap Value VCT Portfolio-Class II]
[20.    American Century Investments VP Ultra Class II Fund]    [40.   Pioneer Emerging Markets VCT Portfolio-Class II]
      [41.]   Symetra Life Fixed Account

 

ANNUITY SERVICE OFFICE:      
Home Office:    Mailing Address:    Telephone:    [877-SYMETRA]
Symetra Life Insurance Company    Symetra Life Insurance Company       [877-796-3872]
[Retirement Services]    [Retirement Services]    Fax:    [425-376-5599]
[5069 154th Place NE]    [P.O. Box 3882]      
[Redmond, WA 98052-9669]    [Seattle, WA 98124-3882]      

 

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