EX-99.4(B)(I) 5 a11-31224_1ex99d4bi.htm EX-99.4(D)(I)

Exhibit 99.4(b)(i)

 

[ PRODUCT B ] SCHEDULE

 

CONTRACT NUMBER

 

ISSUE DATE

[ VA00000001 ]

 

[ June 1, 2012 ]

 

 

 

OWNER 1

 

BIRTH DATE OF OWNER 1

[ John Doe ]

 

[ May 15, 1947 ]

 

 

 

OWNER 2

 

BIRTH DATE OF OWNER 2

[ None ]

 

[ Not Applicable ]

 

 

 

ANNUITANT

 

BIRTH DATE OF ANNUITANT

[ John Doe ]

 

[ May 15, 1947 ]

 

 

 

BENEFICIARY

 

ANNUITY DATE

As contained in our records

 

[ May 15, 2042 ]

 

 

 

PROTECTED LIFETIME INCOME OPTION

 

DEATH BENEFIT

[ SecurePaySM R72 ]

 

[ Maximum Anniversary Value ]

 

 

 

AGENT

 

INSURANCE REGULATORY AUTHORITY

[ Allen Agent ]

 

[ New York State Department of Financial Services ]

[ Brisk Financial Services ]

 

[ 800-342-3736 ]

[ 456 High Street ]

 

[ www.dfs.ny.gov ]

[ New York, New York 10111 ]

 

 

[ 212-987-6543 ]

 

 

 

 

 

 

 

 

INITIAL PURCHASE PAYMENT

 

TAX-QUALIFIED STATUS

[ $100,000.00 ]

 

[ Non-Qualified ]

 

 

 

INTEREST RATES FOR THE GUARANTEED ACCOUNT

 

 

 

Annual Effective Interest Rates for the Guaranteed Account on the Issue Date:

 

FIXED ACCOUNT — [ 1.25% ]
DCA ACCOUNT 1 — [ 3.00% ]
DCA ACCOUNT 2 — [ 6.00% ]

 

 

 

Non-Forfeiture Interest Rate (NFIR) for the Guaranteed Account:

 

[ 1.00% ]

 

The Contract’s NFIR for the Guaranteed Account was established on the Issue Date and will not change.  It was determined by taking the 5-Year Constant Maturity Treasury Rate as of the January 31 prior to the May 1 — April 30 annual period during which the Contract was issued, subtracting 1.25%, and rounding the result to the nearest 0.05%.  The NFIR cannot be less than 1.00% and will not be more than 3.00%.  Interest rates declared by the Company for the Guaranteed Account will be at least equal to the Contract’s NFIR.

 

NY-VDA-A-2006SB-1

[ B 5/12 ]

 

A


 

[ PRODUCT B ] SCHEDULE, continued

 

CONTRACT LIMITATIONS, FEES, AND CHARGES

 

Maximum Issue Date:

 

We will not issue a Contract on or after the oldest Owner’s or Annuitant’s [ 86th ] birthday.

 

 

 

Maximum Annuity Date:

 

The oldest Owner’s or Annuitant’s [ 95th ] birthday.

 

 

 

Additional Purchase Payments:

 

Not permitted on or after the oldest Owner’s or Annuitant’s [ 86th ] birthday.

 

 

 

Minimum Additional Purchase Payment:

 

$100.00

 

 

 

Maximum Aggregate Purchase Payments:

 

$1,000,000.00

 

 

 

Mortality & Expense Risk Charge:

 

[ 1.20% ] per year

 

 

 

The Mortality & Expense Risk Charge was established on the Issue Date and will not change.

 

 

 

Administration Charge:

 

[ 0.10% ] per year

 

 

 

The Administration Charge was established on the Issue Date and will not change.

 

 

 

Transfer Fee for Transfers in Excess of Limit:

 

$25 for each transfer in excess of 12 per Contract Year.

 

 

 

The Transfer Fee was established on the Issue Date and will not change.

 

 

 

Contract Maintenance Fee:

 

[ $30 ]

 

 

 

The Contract Maintenance Fee was established on the Issue Date and will not change.  It is deducted prior to the Annuity Date on each Contract Anniversary, and on any day that the Contract is surrendered other than a Contract Anniversary. The Contract Maintenance Fee will be deducted from the Investment Options in the same proportion as their values are to the Contract Value. The Contract Maintenance Fee will be waived by the Company in the event either the Contract Value, or the aggregate Purchase Payments reduced by aggregate withdrawals, equals or exceeds [ $100,000 ] on the date the Fee is to be deducted.

 

 

 

Assumed Investment Return:

 

5.00% per year

 

 

 

The Assumed Investment Return was established on the Issue Date and will not change.  It is used in the calculation of variable annuity income payments as described in the ANNUITY INCOME PAYMENTS section of the Contract.

 

NY-VDA-A-2006SB-1

[ B 5/12 ]

 

B


 

[ PRODUCT B ] SCHEDULE, continued

 

CONTRACT LIMITATIONS, FEES, AND CHARGES, continued

 

Surrender Charge:

 

The Surrender Charge Percentages Table was established on the Issue Date and will not change.  The Surrender Charge is assessed for both surrenders and withdrawals in excess of any free withdrawal amount, but does not apply to amounts paid as a death benefit, applied to an Annuity Option, or taken as a lump sum as of the Annuity Date.  It will be deducted from the amount withdrawn from the Contract Value to satisfy the surrender or withdrawal request.

 

In order to assess the Surrender Charge, we must first associate the entire amount withdrawn (in excess of any free withdrawal amount) with one or more Purchase Payments as follows:  We allocate the amount withdrawn (in excess of any free withdrawal amount) to Purchase Payments not previously assessed with a Surrender Charge using a “first-in, first-out” (FIFO) basis.  We then allocate any remaining amount withdrawn pro rata to these Purchase Payments.  If no amount withdrawn was allocated to Purchase Payments as described above, we will deem the entire amount withdrawn (in excess of any free withdrawal amount) to be allocated to the most recent Purchase Payment we accepted.

 

The Surrender Charge percentage applicable to each allocated amount withdrawn is then determined, as shown in the table below, based on how many complete years have elapsed between the date the allocated amount’s associated Purchase Payment was applied to the Contract and the withdrawal or surrender date.  Each allocated amount is multiplied by its applicable Surrender Charge percentage to determine its Surrender Charge.  The total Surrender Charge is the sum of the Surrender Charges determined for each allocated amount.

 

Surrender Charge Percentages Table

 

Number of Complete Years Elapsed Between the Date
the Purchase Payment was Applied to the Contract
and the Withdrawal or Surrender Date

 

Surrender Charge Percentage

 

0

 

7.0

%

1

 

6.0

%

2

 

6.0

%

3

 

5.0

%

4

 

4.0

%

5

 

3.0

%

6

 

2.0

%

7+

 

0.0

%

 

Free Withdrawal Amount:

 

The Free Withdrawal Amount was established on the Issue Date and will not change.  It is the Contract Value that may be withdrawn each Contract Year without incurring any Surrender Charge.  During the first Contract Year, the Free Withdrawal Amount is equal to [ 10% ] of the Initial Purchase Payment.  In subsequent Contract Years, it is equal to the greatest of the following:

 

1)              the earnings, if any, in the Contract as of the prior Contract Anniversary; or,

2)              [ 10% ] of cumulative Purchase Payments as of the prior Contract Anniversary; or,

3)              [ 10% ] of the Contract Value as of the prior Contract Anniversary.

 

For the purpose of determining the Free Withdrawal Amount, ‘earnings’ (in Item 1 above) equal the Contract Value on the prior Contract Anniversary minus Purchase Payments not previously assessed with a Surrender Charge.  Withdrawals in excess of the Free Withdrawal Amount in any Contract Year are subject to the Surrender Charge described above.

 

NY-VDA-A-2006SB-1

[ B 5/12 ]

 

C


 

[ PRODUCT B ] SCHEDULE, continued

 

INVESTMENT OPTIONS AVAILABLE ON THE ISSUE DATE

 

Protective Life Guaranteed Account

 

 

 

 

 

Fixed Account

 

 

DCA Account 1

 

 

DCA Account 2

 

 

 

 

 

Sub-Accounts of Variable Annuity Account A

 

 

 

 

 

[ Fidelity

 

Lord Abbett

Contrafund®  Service Class 2

 

Bond Debenture

Index 500  Service Class 2

 

Capital Structure

Investment Grade Bond  Service Class 2

 

Classic Stock

Mid Cap  Service Class 2

 

Fundamental Equity

 

 

Growth Opportunities

Franklin Templeton

 

Mid Cap Stock

Franklin Flex Cap Growth  Class 2

 

 

Franklin Income  Class 2

 

MFS Investment Management

Franklin Rising Dividends  Class 2

 

Emerging Markets Equity  Service Class

Franklin Small Cap Value  Class 2

 

Growth  Service Class

Franklin Small-Mid Cap Growth  Class 2

 

International Value  Service Class

Franklin U. S. Government  Class 2

 

Investors Growth Stock  Service Class

Mutual Shares  Class 2

 

Investors Trust  Service Class

Templeton Developing Markets  Class 2

 

New Discovery  Service Class

Templeton Foreign  Class 2

 

Research  Service Class

Templeton Global Bond  Class 2

 

Research Bond  Service Class

Templeton Growth  Class 2

 

Total Return  Service Class

 

 

Utilities  Service Class

Goldman Sachs

 

Value  Service Class

Growth Opportunities  Service Class Shares

 

 

Mid Cap Value  Service Class Shares

 

OppenheimerFunds

Strategic Growth  Service Class Shares

 

Capital Appreciation  Service Class

Strategic International Equity  Service Class Shares

 

Global Securities  Service Class

 

 

Global Strategic Income  Service Class

Invesco

 

Main Street®  Service Class

Balanced Risk Allocation  Class II

 

Money  Service Class

Global Real Estate  Class II

 

 

Government Securities  Class II

 

PIMCO

International Growth  Class II

 

All Asset  Advisor

Small Cap Equity  Class II

 

Long-Term U. S. Government  Advisor

 

 

Low Duration  Advisor

Invesco Van Kampen

 

Real Return  Advisor

Comstock  Class II

 

Short-Term  Advisor

Equity and Income  Class II

 

Total Return  Advisor

Growth and Income  Class II

 

 

Mid Cap Growth  Class II

 

Royce

Mid Cap Value  Class II

 

Micro-Cap  Service Class

 

 

Small-Cap  Service Class ]

Legg Mason

 

 

ClearBridge Mid Cap Core  Class II

 

 

ClearBridge Small Cap Growth  Class II

 

 

Dynamic Multi-Strategy  Class II

 

 

 

NY-VDA-A-2006SB-1

[ B 5/12 ]

 

D