EX-99.4(A)(1) 3 a21-5483_1ex99d4a1.htm EX-99.4(A)(1)

Exhibit 99.4(a)(1)

 

CONTRACT SPECIFICATIONS

 

CONTRACT DATA

 

Contract Number:

[VR99999999]

Contract Date:

[09-01-2021]

 

 

 

 

Contract Type:

[Non-Qualified]

Maximum Issue Age:

[85]

 

 

 

 

Owner(s):

[John Doe]

[Jane Doe]

Owner’s Age:

[35]

[35]

 

 

 

 

Annuitant(s):

[John Doe]

[Jane Doe]

Annuitant’s Age:

[35]

[35]

 

 

 

 

Annuity Date:

[01-01-2080]

Annuitant’s Sex:

[Male]

[Female]

 

PURCHASE PAYMENTS

 

Initial Purchase Payment Amount:

[$100,000]

 

 

Minimum Purchase Payment Amount for Non-Qualified Contracts:

[$10,000]

 

 

Minimum Subsequent Purchase Payment Amount for Non-Qualified Contracts:

[$250]

 

 

Minimum Purchase Payment Amount for Qualified Contracts:

[$2,000]

 

 

Minimum Subsequent Purchase Payment Amount for Qualified Contracts:

[$50]

 

 

Maximum Aggregate Purchase Payment Amount Without Pacific Life Home Office Approval:

[$1,000,000]

 

 

Minimum Transfer Amount:

[$250]

 

 

Minimum Investment Option Value:

[$500]

 

 

Interest Rate Used for Misstatement of Age and/or Sex:

[1.50%]

 

 

Minimum Contract Value to Avoid Contract Termination:

[$1,000]

 

 

Free Withdrawal Percentage:

[10.00%]

 

Minimum Withdrawal Amounts:

·                  [$500] for each unscheduled Withdrawal

 

·                  [$250] for each systematic Withdrawal

 

·                  [$100] for each systematic Withdrawal paid by electronic funds transfer (EFT)

 

Maximum Annuitization Age:

[95]

 

 

Minimum Annuitization Amount:

[$10,000]

 

 

Minimum Annuity Payment Amount:

[$240]

 

10-2025-CS

 

3A

 

CONTRACT SPECIFICATIONS (continued)

 

FEES AND CHARGES

 

 

 

Mortality and Expense Risk Charge:

[0.70%]

Administrative Fee:

[0.25%]

Annual Fee:

[$50.00]*

 

*Waived if the Contract Value is equal to or greater than [$50,000] on the day the fee is assessed.

 

WITHDRAWAL CHARGE PERIOD / TABLE OF WITHDRAWAL CHARGE PERCENTAGES

 

[10-year]:

 

[

 

From Issue Date

 

Withdrawal Charge
Percentages

 

Contract Year 1

 

9

%

Contract Year 2

 

8

%

Contract Year 3

 

7

%

Contract Year 4

 

6

%

Contract Year 5

 

5

%

Contract Year 6

 

4

%

Contract Year 7

 

3

%

Contract Year 8 and later

 

0

%

 

]

 

Free Withdrawal Contract Year Age: [8]

 

Eligibility Dates for The Withdrawal Charge Waivers

[Nursing Home Confinement Waiver:

[12/01/2020]]

[Terminal Illness Waiver:

[09/01/2021]]

 

RIDER(S)

 

Name

 

Current
Annual
Charge %

 

Maximum Annual
Charge %

 

[Return of Premium Death Benefit Rider

 

[0.25

%]

0.25

%]

[Guaranteed Withdrawal Benefit XXIV Rider — Single Life]

 

[

%]

[

%]

[Guaranteed Withdrawal Benefit XXIV Rider — Joint Life]

 

[

%]

[

%]

[Stepped-Up Death Benefit Rider]

 

[

%]

[

%]

 

For a complete description of the charges, fees and deductions shown above and other applicable fees and charges, refer to the Charges, Fees and Deductions Provisions of the Contract or the Annual Charge provision of the Rider(s) shown above, if applicable.

 

[DOLLAR COST AVERAGING (DCA) PLUS FIXED OPTION RIDER GUARANTEE TERMS AND RATES

 

[6 Mos.    3.00%*]

[12 Mos.  2.00%*]

 

*Minimum Guaranteed Interest Rate is [1.00%] per year.]

 

3B

 

CONTRACT SPECIFICATIONS (continued)

 

INVESTMENT OPTIONS

 

[Fund 1

Fund 2

Fund 3

Fund 4

Fund 5]

[Fund 6

Fund 7

Fund 8

Fund 9

Fund 10

DCA Plus 6-Month

DCA Plus 12-Month

VIP Government Money Market*

 

* not available for direct investment]

 

 

3C

 

CONTRACT SPECIFICATIONS (continued)

 

SERVICE CENTER

 

Send Forms and written requests to:

Send Payments to:

Pacific Life & Annuity Company

Pacific Life & Annuity Company

[P.O. Box 2829

[P.O. Box 2736

Omaha, Nebraska  68103-2829]

Omaha, Nebraska  68103-2736]

 

Hours: [Between 6:00 am and 5:00 pm, Pacific Standard Time.]

Toll-Free Number for Contract Owners:  [1-800-748-6907]

Toll-Free Number for Financial Professionals:  [1-800-748-6907]

Website: [www.PacificLife.com]

 

Please use our toll-free telephone number to present inquiries or obtain information about your coverage and for us to provide assistance in resolving complaints.

 

3D