EX-99.4(B) 3 a20-22208_1ex99d4b.htm EX-99.4(B)

Exhibit 99.4(b)

 

[ SCHWAB GENESIS VARIABLE ANNUITY NY ] SCHEDULE

 

CONTRACT NUMBER

 

ISSUE DATE

[ VA00000001 ]

 

[ June 1, 2020 ]

 

 

 

OWNER 1

 

BIRTH DATE OF OWNER 1

[ John Doe ]

 

[ January 1, 1950 ]

 

 

 

OWNER 2

 

BIRTH DATE OF OWNER 2

[ None ]

 

[ Not Applicable ]

 

 

 

ANNUITANT

 

BIRTH DATE OF ANNUITANT

[ John Doe ]

 

[ January 1, 1950 ]

 

 

 

BENEFICIARY

 

ANNUITY DATE

As contained in our records

 

[ January 1, 2045 ]

 

 

 

PROTECTED LIFETIME INCOME OPTION

 

DEATH BENEFIT

[ Marketing Name ]

 

[ Contract Value ]

 

 

 

AGENT

 

INSURANCE REGULATORY AUTHORITY

[ Allen Agent ]

 

[ New York State Department of Financial Services ]

[ Brisk Financial Services ]

 

[ 800-342-3736 ]

[ 5678 High Street ]

 

[ www.dfs.ny.gov ]

[ Anycity, NY 12345 ]

 

 

 

 

 

INITIAL PURCHASE PAYMENT

 

TAX-QUALIFIED STATUS

[ $100,000.00 ]

 

[ Non-Qualified ]

 

INTEREST RATES FOR THE GUARANTEED ACCOUNT

 

Annual Effective Interest Rates for the

 

FIXED ACCOUNT — [ 1.00% ]

Guaranteed Account on the Issue Date:

 

DCA ACCOUNT 1 — [ 2.00% ]

 

 

DCA ACCOUNT 2 — [ 3.00% ]

 

 

 

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-2006SF-1

[ Schwab Genesis VA NY 7/20 ]

 

A


 

[ SCHWAB GENESIS VARIABLE ANNUITY NY ] SCHEDULE

 

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 or within 3 years of the Annuity Date.

 

 

 

Minimum Additional Purchase Payment:

 

$100.00

 

 

 

Maximum Aggregate Purchase Payments:

 

$1,000,000.00

 

 

 

Mortality & Expense Risk Charge:

 

[ 0.15% ] 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.

 

 

 

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.

 

B


 

[ SCHWAB GENESIS VARIABLE ANNUITY NY ] SCHEDULE

 

INVESTMENT OPTIONS AVAILABLE ON THE ISSUE DATE

 

Protective Life Guaranteed Account

 

Fixed Account

 

DCA Account 1

 

DCA Account 2

 

Sub-Accounts of the Protective Variable Annuity Separate Account

 

[ American Funds IS

 

Invesco

Asset Allocation Class 4

 

Balanced-Risk Allocation Series II

Blue Chip Income & Growth Class 4

 

Comstock Series II

Bond Class 4

 

Equity and Income Series II

Capital Income Builder Class 4

 

Global Real Estate Series II

Global Growth Class 4

 

Government Securities Series II

Global Growth & Income Class 4

 

Growth and Income Series II

Global Small Cap Class 4

 

International Growth Series II

Growth Class 4

 

Oppenheimer Global Series II

Growth-Income Class 4

 

Oppenheimer Government Money Series I

International Class 4

 

Oppenheimer Main Street Series II

New World Class 4

 

 

U.S. Government/AAA-Rated Securities Class 4

 

Legg Mason

 

 

ClearBridge Variable Mid Cap Class II

Clayton Street (Managed by Janus Capital Management, LLC)

 

ClearBridge Variable Small Cap Class II

Protective Life Dynamic Allocation Series Conservative

 

 

Protective Life Dynamic Allocation Series Moderate

 

Lord Abbett

Protective Life Dynamic Allocation Series Growth

 

Bond Debenture Value Class

 

 

Dividend Growth Value Class

Fidelity Investments

 

Fundamental Equity Value Class

Investment-Grade Bond Portfolio SC2

 

Growth Opportunities Value Class

Mid Cap Portfolio SC2

 

 

 

 

PIMCO

Franklin Templeton Investments

 

All Asset Advisor Class

Franklin Flex Cap Growth Class 2

 

Global Diversified Allocation Advisor Class

Franklin Income Class 2

 

Long-Term U.S. Government Advisor Class

Franklin Mutual Global Discovery Class

 

Low Duration Advisor Class

Franklin Mutual Shares Class 2

 

Real Return Advisor Class

Franklin Rising Dividends Class 2

 

Short Term Advisor Class

Franklin Small Cap Value Class 2

 

Total Return Advisor Class

Franklin Small Mid Cap Growth Class 2

 

 

Franklin Strategic Income Class 2

 

Royce

Templeton Developing Markets Class 2

 

Small-Cap Service Class

Templeton Foreign Class 2

 

 

Templeton Global Bond Class 2

 

Schwab

 

 

Balanced

Goldman Sachs

 

Balanced with Growth

Core Fixed Income Service Class

 

Government Money Market Portfolio™

Global Trends Allocation Service Class

 

Growth

Growth Opportunities Service Class

 

S&P 500 Index ]

Mid Cap Value Service Class

 

 

Strategic Growth Service Class

 

 

 

 

 

Great-West

 

 

Bond Index Fund

 

 

 

C