EX-99.13 OTH CONTRCT 4 contract8134.txt SPECIMEN CONTRACT FORM Founded in 1867...A Mutual Company...P.O. Box 40888, Cincinnati, Ohio 45240 ANNUITANT: John Doe OWNER: John Doe CONTRACT NUMBER: 01234567 CONTRACT DATE: April 05, 2001 WE PROMISE to pay the benefits of this contract in accordance with its terms. LOOK AT THE APPLICATION FORMS. This contract is issued based on payment of the initial premium and the answers in the application (see copy attached). If all answers are not true and complete, this contract may be affected. PLEASE READ THIS CONTRACT CAREFULLY. This is a legal contract between you and Union Central. 10 DAY RIGHT TO EXAMINE THE CONTRACT. IT IS IMPORTANT TO UNION CENTRAL THAT YOU ARE SATISFIED WITH THIS CONTRACT. YOU HAVE 10 DAYS AFTER YOU RECEIVE IT TO REVIEW THE CONTRACT. IF YOU ARE NOT SATISFIED, YOU MAY SEND IT BACK TO US OR GIVE IT TO OUR AGENT. IN SUCH CASE, THIS CONTRACT WILL BE VOID FROM THE BEGINNING. WE WILL REFUND, WITHIN 7 DAYS AFTER THIS CONTRACT IS RETURNED, ANY PREMIUMS PAID. ALL ACCUMULATION VALUES AND ANNUITY PAYMENTS PROVIDED BY THIS CONTRACT, WHEN BASED ON THE INVESTMENT EXPERIENCE OF A SEPARATE ACCOUNT, ARE VARIABLE AND ARE NOT GUARANTEED AS TO FIXED DOLLAR AMOUNTS. Signed for the Company at Cincinnati, Ohio /s/ David F. Westerbeck /s/ John H. Jacobs Secretary President Flexible Premium Deferred Variable Annuity Participating ----------------------- Licensed Resident Agent UC 8134 01/02 INTRODUCTION ------------------------------------------------------------- This is a flexible premium deferred variable annuity. This annuity contract provides that both the accumulation value and annuity payments may be either fixed or variable, or a combination of fixed and variable. You determine the investment allocation for this annuity. You may allocate your premiums to either the guaranteed account or the variable account, or a combination of these accounts. If you select the guaranteed account, then your accumulation value and annuity payments will be fixed and guaranteed. If you select the variable account, your accumulation value and annuity payments will vary with the investment performance of the separate account's subaccounts. If you select both the guaranteed and variable accounts, then your values and payments will be fixed in part, and variable in part. If you select the variable account, then you must allocate premiums among one or more subdivisions of the variable account. These subdivisions are identified in the contract application and on the schedule page. CONTRACT INDEX -------------------------------------------------------------- Page Definitions . . . . . . . . . . . . . . . . . . . . . . . . . 4 Ownership . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Premiums. . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Variable Account Provisions . . . . . . . . . . . . . . . . . 8 Guaranteed Account Provisions. . . . . . . . . . . . . . . . 11 Transfers. . . . . . . . . . . . . . . . . . . . . . . . . . 11 Surrender Provisions. . . . . . . . . . . . . . . . . . . . .12 Charges and Deductions. . . . . . . . . . . . . . . . . . . .13 General Provisions. . . . . . . . . . . . . . . . . . . . . .14 Payment of Contract Benefits. . . . . . . . . . . . . . . . .16 Schedule Page -------------------------------------------------------------- Initial Allocation of Net Premiums: Money Source Separate Account: Carillon Account SUBDIVISIONS OF THE VARIABLE ACCOUNT: [AIM VI CAP APPRECIATION 0]% [AIM VI GROWTH 0] [ALGER AMERICAN LEVERAGED ALLCAP 0] [ALGER AMERICAN MIDCAP GROWTH 0] [AM CENTURY VP GROWTH & IN 0] [AM CENTURY VP VALUE 0] [MFS VIT EMERGING GROWTH 0] [MFS VIT INVESTORS TRUST 0] [MFS VIT HIGH INCOME 0] [MFS VIT NEW DISCOVERY 0] [MFS VIT TOTAL RETURN 0] [NEUBERGER BERMAN AMT GUARD 0] [OPPENHEIMER GLOBAL SEC/VA 0] [OPPENHEIMER MAIN ST/VA 0] [SCUDDER VSI CAP GROWTH 0] [SCUDDER VSI INTL 0] [SCUDDER VSI MONEY MARKET 0] [SELIGMAN SMALLCAP VALUE CLASS 2 0] [SELIGMAN COMM & INFO CLASS 2 0] [SUMMIT BALANCED INDEX 0] [SUMMIT BOND 25] [SUMMIT NASDAQ 100 INDEX 0] [SUMMIT RUSSELL 2000 0] [SUMMIT S&P MID CAP 400 0] [SUMMIT S&P 500 INDEX 0] [SUMMIT ZENITH 25] [FTVIP TEMPLETON INTL CLASS 2 0] GUARANTEED ACCOUNT: [50] ------- TOTAL: 100% Transfer Charge: Current: [$10] Maximum: $100 Mortality and Expense Charge: Current: [1.00%] Maximum: 2.00% Administration Fee: Current: [0.25%] Maximum: 0.25% Contract Fee for any full or partial year: $30.00 Guaranteed Account Guaranteed Minimum Interest Rate: 3.00% ------------------------------------------------------------- Annuitant: John Doe Contract Number: 01234567 Owner: John Doe Maturity Date: February 01, 2058 Joint Owner: N/A Contract Date: April 05, 2001 UC 8134 - 3 - Schedule Page -------------------------------------------------------------- Surrender Charge: We impose a surrender charge on certain early surrenders. The amount of the surrender charge is a percentage of the amount withdrawn and is set forth below. Contract Surrender Charge Year Percentage [ 1 7% ] [ 2 7% ] [ 3 6% ] [ 4 5% ] [ 5 4% ] [ 6 3% ] [ 7 2% ] [ 8 1% ] [ 9 AND ABOVE 0% ] Partial surrenders totaling not more than 10% of the accumulation value may be made each contract year without a surrender charge being imposed. In no event will the cumulative total of all surrender charges exceed 9% of premiums. Annuitant: John Doe Contract Number: 01234567 Owner: John Doe Maturity Date: February 01, 2058 Joint Owner: N/A Contract Date: April 05, 2001 UC 8134 -3A-
DEFINITIONS ------------------------------------------------------------ ACCUMULATION Means the period before the maturity date and PERIOD during the lifetime of the annuitant. ACCUMULATION Means a unit of measure that is used to UNIT calculate the value of your interest in the separate account (SA) before the maturity date. ACCUMULATION Means the sum of the values of the guaranteed VALUE account and the variable account credited to this contract. ANNUITANT Means the person(s) whose life is used to determine the duration of any annuity payments involving life contingencies. The annuitant is named in the application and on the schedule page. ANNUITY UNIT Means a unit of measure that is used to calculate variable annuity payments. BENEFICIARY Means the person(s) designated by you to receive the death benefits from this contract upon your death. CALCULATION DATE Means a date not more than 10 business days prior to the maturity date. CONTRACT YEAR Means a period of 12 consecutive months beginning on the contract date or any anniversary thereafter. The contract date is shown on the schedule page. DUE PROOF Means one of the following: OF DEATH 1. A certified copy of a death certificate; 2. A certified copy of a decree of a court of competent jurisdiction as to the finding of death; 3. A written statement by a medical doctor who attended the deceased; and 4. Any other proof satisfactory to us. FIXED ANNUITY Means an annuity with payments fixed through- out the annuity payment period. GUARANTEED Means this contract's value which is held by ACCOUNT The Union Central Life Insurance Company other than those in its separate accounts (SA). HOME OFFICE Means the home office of The Union Central Life Insurance Company which is: 1876 Waycross Road (P.O. Box 40888), Cincinnati, Ohio 45240. MATURITY DATE Means the date on which annuity payments will begin. This date shall be the annuitant's 95th birthday unless an earlier date is chosen by you. NOTICE Means information we have received at our home office which is written, is signed by you, and is acceptable to us. PORTFOLIO OR Means a separate portfolio of one of the FUND PORTFOLIO mutual funds in which separate account (SA) invests through its subaccounts, or its successors and assigns. SCHEDULE PAGE Means the contract schedule page, or the supplemental contract schedule page most recently sent to you by us. SEPARATE ACCOUNT Means the Carillon Account of The Union ("SA") Central Life Insurance Company. The separate account is divided into several subaccounts.
John Doe 012345678 UC 8134 -4- 01/02
SUBACCOUNT(S) Means one or more of the subaccounts of the SA. Each subaccount is invested in a different fund portfolio. SUBDIVISION Means the portion of your variable account which is invested in a specific subaccount. VARIABLE ACCOUNT Means this contract's value which is invested in one or more subaccounts of the SA. VARIABLE ANNUITY Means an annuity with payments which: (1) are not predetermined or guaranteed as to dollar amount; and (2) vary in amount in relation to the investment experience of one or more specified subaccounts. WE AND YOU "We," "us," or "our" means The Union Central Life Insurance Company. "You" or "your" means the owner of this contract.
John Doe 012345678 UC 8134 -5- 01/02
OWNERSHIP --------------------------------------------------------------- GENERAL The owner of this contract shall be the person so named in the application or the latest change filed with us. CHANGE OF Prior to the maturity date, you may assign the OWNERSHIP ownership of this contract by providing notice. CHANGE OF Prior to the maturity date, you may name a ANNUITANT new annuitant. Such change must be made by written notice in a form acceptable to us and received at our home office. BENEFITS --------------------------------------------------------------- ANNUITY BENEFITS We will pay an annuity benefit to the annuitant, if living, on the maturity date. Annuity benefits will begin on the maturity date and continue while the annuitant is living, with monthly payments guaranteed for 10 years, unless you elect a different annuity option at least 30 days before the maturity date. If you die after the annuity benefits have begun, the entire remaining interest will continue to be distributed to the annuitant, if you are not also the annuitant, at least as rapidly as under the annuity option being used as of the date of your death. If you are the annuitant, we will continue to pay the beneficiary, if a benefit is payable to a beneficiary. We may pay the accumulation value on the maturity date in one lump sum if it is less than $5,000. We may change the payment frequency to quarterly, semiannually or annually if the first monthly annuity payment would be less than $50. At least 30 days before the maturity date you must select how the accumulation value will be used to provide the annuity benefit. Any election must be written in a form satisfactory to us and received at our home office. If you do not so select how you wish settlement to be effected, we will provide a fixed annuity. If a variable annuity is used, subsequent annuity benefit payments will vary based on the investment experience of the subaccount(s) used to effect the annuity. The method used to calculate the amount of subsequent payments is described in the Variable Annuity Payments provision. DEATH BENEFITS Notwithstanding any provision to the contrary, death benefits shall always be made in accordance with the distribution requirements of the Internal Revenue Code for annuity contracts. If the death benefit is paid before the maturity date, the death benefit will be the greater of : (a) the accumulation value on the date that due proof of death is received; or (b) the sum of all premiums paid, less any amounts deducted in connection with partial surrenders.
John Doe 012345678 UC 8134 -6- 01/02 Death of Owner. If you are an owner and if you die before the maturity date, the following will apply: 1. If your spouse is not the beneficiary, the death benefit will be paid to the named beneficiary: a. upon written request it may be paid under any option listed in the Payment of Contract Benefits section of this contract over a period not exceeding the beneficiary's life expectancy. If the death benefit is paid in installments, the first installment payment must be made no later than one year after the date of your death; or b. in a single sum. The beneficiary has the option to elect to receive the single sum any time within five years after the date of your death. 2. If your spouse is the beneficiary, your spouse may elect, by a written request to us, one of the following options: a. to continue this contract as the owner; or b. to receive the death benefit under any option listed in the Payment of Contract Benefits section of this contract over a period not exceeding the beneficiary's life expectancy. If the death benefit is paid in installments, the first installment payment must be made no later than one year after the date of your death; or c. to receive the death benefit in a single sum. Your spouse may elect to receive the single sum any time within five years after the date of your death. If none of these options is elected by your spouse within 45 days after we receive due proof of death, option a. above shall apply. 3. If no beneficiary is living or if no beneficiary has been named, at the date of your death, the death benefit will be paid in a single sum to the executor or administrator of your estate within five years after the date of your death. Joint Owners. If this contract is owned jointly, the death of the first joint owner shall be treated as the death of the owner. Death of Annuitant before the Maturity Date. If you, the owner, are a different person from the annuitant, and the annuitant dies during your lifetime and before the maturity date, you will be treated as the annuitant. If you are not a natural person, and the annuitant dies before the maturity date, we will pay the death benefit to you in a single sum. You have the option to elect to receive the single sum any time within five years of the death of the annuitant. Death of Annuitant on or after the Maturity Date. If the annuitant dies on or after the maturity date, the death benefit, if any, will depend on the annuity option in effect on the date of the annuitant's death. Death of Beneficiary. Unless otherwise provided, if any beneficiary dies before, at the same time as, or within 30 days after your death, that beneficiary will be treated as if their death occurred before yours.
John Doe 012345678 UC 8134 -7- 01/02
PREMIUMS --------------------------------------------------------------- GENERAL All premiums under this contract are payable at our home office or such other place as we may designate. No premium may be paid under this contract unless it is at least $50. Premiums may be paid at any time. The amount of the premium may be increased or decreased any time subject to the $50 minimum and a maximum of $10,000 per contract year. We may waive the $10,000 per year maximum, but waiver in one instance does not constitute waiver for additional premiums. NET PREMIUM The net premium is the premium less any premium tax. ALLOCATION OF You determine the allocation of the net NET PREMIUM premiums between the guaranteed account and the variable account. You may allocate the net premiums totally to the guaranteed account, totally to the variable account or partially to both accounts. The minimum amount of any net premium that you can allocate to the guaranteed account or any subdivision of the variable account is $10. If you allocate a part or all of your premiums to the variable account, then you will further allocate that portion of your premiums among one or more subdivisions of the variable account. To the extent that you allocate premiums to the variable account, your accumulation value will be subject to the investment experience of the SA. Premiums that you allocate to the guaranteed account will be guaranteed a minimum value. We will credit interest to amounts allocated to the guaranteed account at a rate of at least the guaranteed interest rate as shown on the schedule page, compounded annually. We may credit a higher rate of interest to such amounts, but we are not required to do so. When we receive the premiums, the net premiums will be allocated in accordance with the net premium allocation percentages shown in the application or as of the most recent change of allocation received from you. No allocation will be made prior to the contract date. You may change the allocation of subsequent premiums at any time, without charge, by giving us written notice. VARIABLE ACCOUNT PROVISIONS --------------------------------------------------------------- SEPARATE ACCOUNT The separate account is shown on the schedule page. It is a unit investment trust registered with the Securities and Exchange Commission under the Investment Company Act of 1940. It is established under the laws of Ohio. The assets in the separate account are kept separate from our general assets and assets of other separate accounts. SUBACCOUNTS The separate account is divided into subaccounts, each of which invests in a different portfolio.
John Doe 012345678 UC 8134 -8- 01/02 CREDITING OF We will credit net premiums allocated to the ACCUMULATION variable account in the form of variable UNITS accumulation units. The number of variable accumulation units to be credited to this contract for each subdivision of the variable account will be determined by dividing the net premium allocated to each subdivision of the variable account by the accumulation unit value for the corresponding subaccount as of the end of the valuation period during which the premium is received. In the case of the initial premium, accumulation units will be credited on the later of these dates: 1. the contract date; or 2. the date we receive the premium. Accumulation units are credited when amounts are transferred into a subaccount. Accumulation units are deducted when the charges and deductions are assessed or when amounts are partially surrendered or transferred, including transfer charges, out of a subaccount. VARIABLE ACCOUNT At any time prior to the maturity date, the variable account of this contract equals the sum for all subdivisions of the variable account of (1) times (2) where: 1. equals the number of accumulation units credited to a subdivision of the variable account; and 2. equals the value of the appropriate accumulation unit. VALUATION DATE A valuation date is any date on which the New AND VALUATION York Stock Exchange is open for trading and we PERIOD are open for business. The assets of each subaccount will be valued on each valuation date. A valuation period is a period beginning with the close of the New York Stock Exchange on a valuation date and ending at the close of the New York Stock Exchange for the next valuation date. ACCUMULATION The value of a variable accumulation unit for UNIT each subaccount was arbitrarily set at $10 when funds were first credited to the respective subaccount. The variable accumulation unit value for any subsequent valuation period is determined by multiplying the variable accumulation unit value for the immediately preceding valuation period by the "net investment factor" for the valuation period for which the value is being determined. The value of a variable accumulation unit may increase or decrease from one valuation period to the next. NET INVESTMENT The net investment factor is an index that FACTOR measures the investment performance of a subaccount from one valuation period to the next. The net investment factor for each subaccount for any valuation period is determined by dividing (1) by (2) and subtracting (3) from the result, where: 1. is the net result of: a. the net asset value per share of a portfolio share held in the subaccount determined as of the end of the current valuation period, plus b. the per share amount of any dividend or capital gain distributions made by the portfolio on shares held in the subaccount if the "exdividend" date occurs during the current valuation period, plus or minus
John Doe 012345678 UC 8134 -9- 01/02 c. a per share charge or credit for any taxes incurred by or reserved for in the subaccount, which is determined by us to have resulted from the maintenance of the subaccount; and 2. is the net result of: a. the net asset value per share of a portfolio share held in the subaccount determined as of the end of the immediately preceding valuation period (adjusted for an "exdividend"), plus or minus b. the per share charge or credit for any taxes reserved for the immediately preceding valuation period; and 3. is a factor representing the charges deducted from the subaccounts on a daily basis for administrative expenses and mortality and expense risks. Such factor is equal on an annual basis to the amount shown on the schedule page. VARIABLE ANNUITY The amount of the first variable annuity PAYMENT payment is determined by applying the variable account accumulation value of your contract, measured as of the calculation date (minus any applicable premium taxes), to the appropriate Option Table contained in this contract. This is done separately for each subdivision of the variable account. We will determine subsequent payments by dividing the first payment derived from each subdivision of the variable account by the annuity unit value determined as of the calculation date. This number of annuity units is then multiplied by the annuity unit value for each subsequent determination date which is a uniformly applied date not more than 10 business days before payment is due. ANNUITY UNIT The value of an annuity unit for each VALUE subaccount was arbitrarily set at $10 when funds were first credited to the respective subaccount. Subsequently, the value of an annuity unit in each subaccount for any valuation period is determined as follows: (a) the net investment factor for each subaccount for the valuation period for which the annuity unit value is being calculated is multiplied by the value of the annuity unit on the preceding valuation date; and (b) the result is adjusted to compensate for the interest rate assumed in the Option Tables used to determine the first variable annuity payment. The dollar value of annuity units may change from one valuation period to the next. ADDITION, We reserve the right, subject to compliance DELETION, OR with applicable law, to make additions to, SUBSTITUTION OF deletions from, or substitution for the INVESTMENTS portfolio shares that are held by the separate account or that the separate account may purchase. We reserve the right to eliminate the shares of any of the eligible portfolios and to substitute shares of another portfolio, or of another open-end, registered investment company, if the shares of an eligible portfolio are no longer available for investment, or if in our judgment further investment in any eligible portfolio should become inappropriate in view of the purposes of the separate account. We will not substitute any shares attributable to your interest in a subaccount without notice to you and prior approval of the Securities and Exchange Commission, to the extent required by the Investment Company Act of 1940. Nothing contained herein shall prevent the separate account from purchasing other securities for other series or classes of policies, or from effecting a conversion between series or classes of policies on the basis of requests made by owners.
John Doe 012345678 UC 8134 -10- 01/02 We reserve the right to establish additional subaccounts, each of which would invest in a new portfolio, or in shares of another open- end investment company. We also reserve the right to eliminate existing subaccounts. In the event of any such substitution or change, we may, by appropriate endorsement, make such changes in this and other policies as may be necessary or appropriate to reflect such substitution or change. If deemed by us to be in the best interest of persons having voting rights under the policies, the separate account may be operated as a management company under the Investment Company Act of 1940 or it may be deregistered under such Act in the event such registration is no longer required. The investment contract of the separate account will not be changed without the approval of the Insurance Commissioner of the State of Ohio. If required, the approval process is on file with the Commissioner of the state in which this contract is issued.
GUARANTEED ACCOUNT PROVISIONS ---------------------------------------------------------------- GUARANTEED The guaranteed account of your contract at ACCOUNT any time equals: 1. the total of all net premiums allocated to the guaranteed account; plus 2. the total of all amounts transferred to the guaranteed account from the variable account; minus 3. the total of all amounts transferred from the guaranteed account to the variable account (including the transfer fee); minus 4. the total of all partial surrenders from the guaranteed account (including any surrender charges); plus 5. interest. GUARANTEED The guaranteed interest rate used in the ACCOUNT INTEREST calculation of the guaranteed account is found RATE on the schedule page. Interest in excess of the guaranteed rate may be used in the calculation of the guaranteed account at such increased rates and in such a manner as we may determine. FIXED ANNUITY We guarantee the amount of fixed annuity PAYMENTS payments. The payment amount depends only on the annuity option elected, the age (and possibly sex) of the annuitant, and the amount applied to purchase the fixed annuity, in accordance with the Option Tables contained in the contract. TRANSFERS ---------------------------------------------------------------- TRANSFERS BEFORE Before the maturity date you may transfer MATURITY DATE amounts between the guaranteed account and subdivisions of the variable account or among subdivisions. Transfers from subdivisions of the variable account will be made based on the accumulation unit values at the end of the valuation period during which we receive the request for transfer. You must transfer at least $300 or, if less, the entire amount in the guaranteed account or a subdivision each time you make a transfer. If after the transfer the amount remaining in the guaranteed account or any subdivision of the
John Doe 012345678 UC 8134 -11- 01/02 variable account from which the transfer is made is less than $25, then we will transfer the entire amount instead of the requested amount. A transfer charge as shown on the schedule page will be imposed for each transfer. The charge will be deducted from the account from which the transfer is made. TRANSFERS AFTER After annuity payments have been made for MATURITY DATE at least 12 months, you may, no more than once each 12 months, change all or part of the investment upon which your annuity payments are based from one subaccount to another. After your death, the annuitant assumes this right. To do this, we will convert the number of annuity units being changed to the number of annuity units of the subaccount to which you are changing so as to result in the next annuity payment being of the same amount that it would have been without the change. After that, annuity payments will reflect changes in the values of your new annuity units. You must give us notice at least 30 days before the due date of the first annuity payment to which the change will apply. No transfers may be made with respect to fixed annuity payments.
SURRENDER PROVISIONS ---------------------------------------------------------------- PAYMENT OF You may totally or partially surrender the SURRENDERS contract and receive all of the accumulation value at any time before the earlier of the death of the annuitant or the maturity date, by sending us a written request. We will pay all surrenders from the variable account within seven days of receipt of the written request, subject to postponement for any period during which the New York Stock Exchange is closed for trading (except for normal holiday closing) or when the Securities and Exchange Commission has determined that a state of emergency exists. We reserve the right to postpone surrenders from the guaranteed account for up to six months after we receive the request. TOTAL SURRENDERS If you are totally surrendering the contract, we will deduct the surrender charge, if applicable, and the administration fee from the amount paid. PARTIAL SURRENDER If you are partially surrendering the contract, you should specify the amounts that should be withdrawn from the guaranteed account or each subdivision of the variable account. If you do not so specify, the requested amount will be withdrawn from the guaranteed account and each subdivision of the variable account in which you have an interest, in the same proportion that your interest therein bears to the accumulation value. You may pre-authorize periodic surrenders by entering into a separate agreement with us. Under this agreement, you may withdraw part of your accumulation value at a regular interval chosen by you. You may choose to withdraw a level dollar amount or a percentage of your accumulation value. If you choose the latter, the accumulation value for the first year you choose to make these withdrawals is set on the date we approve your request. In later years, the accumulation value is set on the first day of the contract year. These surrenders may be subject to the 10% federal tax on early withdrawals. We will deduct the surrender charge, if applicable, from the accumulation value remaining after the payment of the requested amount.
John Doe 012345678 UC 8134 -12- 01/02 FREQUENCY AND You may make as many partial surrenders as you AMOUNT OF wish. Any surrender from the guaranteed SURRENDERS account or a subdivision of the variable account must be at least $100 or the entire balance of the guaranteed account or subdivision of the variable account. If, after the surrender (and deduction of any surrender charge), the amount remaining in the guaranteed account or a subdivision is less than $25, then we may consider the surrender request to be a request for surrender of the entire amount held in the guaranteed account or subdivision. If a partial surrender would reduce the accumulation value to less than $100, then we may treat the partial surrender request as a total surrender of the contract.
CHARGES AND DEDUCTIONS ---------------------------------------------------------------- MORTALITY AND To compensate us for assuming the mortality EXPENSE RISK and expense risks, we deduct from the variable CHARGE account a charge each valuation period. The current charge is shown on the schedule page as is the maximum effective annual rate that can be charged. We will deduct the charge from each subdivision of the variable account in the same proportion that the value of each subdivision bears to the variable account. SURRENDER CHARGE A surrender charge is imposed on total and partial surrenders other than those made pursuant to the death of the annuitant or upon annuitization under the contract. The amount of the charge and the period for which it will be assessed are shown on the schedule page. ADMINISTRATION During the accumulation period we deduct an FEE annual administration fee of $30 as partial compensation for the cost of providing and/or purchasing certain administrative services. The fee is not imposed during the annuity period. The administrative fee is deducted on the anniversary date. It is withdrawn from the guaranteed account or any subdivision of the variable account in which you have an interest, in proportion to their value. If the contract is totally surrendered on any date other than the last day of any contract year, we will deduct the full amount of the administrative fee from the amount paid. We also deduct from the variable account a charge each valuation period at an effective annual rate of .25% to partially defray the expenses of maintaining the contract. TAXES We will charge certain taxes against your premiums, accumulation value, or annuity payments, when incurred. These taxes include any premium taxes or other taxes levied by any government entity which we, in our sole discretion, determine have resulted from: 1. the establishment or maintenance of the variable account; or 2. from the investment experience of the variable account; or 3. from the receipt by us of the premium; or 4. from the issuance of this contract, or 5. from the commencement or continuance of annuity payments under this contract.
John Doe 012345678 UC 8134 -13- 01/02
GENERAL PROVISIONS --------------------------------------------------------------- ENTIRE CONTRACT This contract is a legal contract that you have entered into with us. The entire contract consists of this contract, any endorsements, schedule pages, amendments, and the attached copy of the application and supplemental applications. Any change in the contract must be written and signed by our President, one of our Vice Presidents, our Secretary or Assistant Secretary. No agent or person other than the above-named has the authority to change or modify this contract or waive any of its provisions. Words that can be interpreted as singular or plural shall mean both singular and plural. BENEFICIARY The primary and any contingent beneficiaries of this contract are named in the application. If changed, the beneficiary is as shown in the latest change. Unless the beneficiary designation provides otherwise, any death benefits will be divided equally among beneficiaries of the same class. The contingent beneficiary will receive the death benefits if no primary beneficiary is living at the time of the event giving rise to the benefit payment. Prior to the maturity date, if no beneficiary survives you, your estate will be the beneficiary. The interest of any beneficiary is subject to that of any assignee. CHANGE OF You may change the beneficiary, unless an BENEFICIARY irrevocable designation has been made. Any such change must be made by written notice in a form acceptable to us and received at our home office. If you die after the maturity date, the annuitant may change the beneficiary unless an irrevocable designation has been made. CHANGE IN Prior to the maturity date, you may change MATURITY DATE the maturity date by written request at least 30 days before the previously specified maturity date. After the election, the new maturity date will become the maturity date. ASSIGNMENT You may assign this contract. No assignment will be binding on us unless it is written in a form acceptable to us and received at our home office. We will not be responsible for the validity of any assignment. We will not be liable for any payments we make or actions we take before we receive notice of an assignment. CLAIMS OF Any accumulation value, before paid, under CREDITORS this contract, will not be subject to the claims of a beneficiary's creditors, except as required by law. MISSTATEMENT AND We may require proof of age, sex, or PROOF OF AGE, survival of any person upon whose age, sex, SEX OR SURVIVAL or survival any payments depend. If the age or sex of the annuitant has been misstated, the benefits will be those which the premiums would have provided for the correct age and sex. If we have made incorrect annuity payments, we will adjust future payments. The adjustments will reflect any overpayment or underpayment.
John Doe 012345678 UC 8134 -14- 01/02 DIVIDEND As long as this contract is in force, you will receive any dividends declared by us. It is anticipated that no dividends will be declared. You have these options: 1. take the dividends in cash; or 2. use the dividends to be credited as additional accumulation units with respect to the variable account or added to the guaranteed account. You may choose either option or change options by notice to us. If none is chosen, the second option will be used. REPORTS At least once a year we will send you a report showing: 1. the accumulation unit value as of the beginning date of the report; 2. the accumulation unit value as of the ending date of the report; 3. the total number of accumulation units as of the ending date of the report; 4. the value of the guaranteed account and/or each subdivision of the variable account on the beginning date of the report; 5. the value of the guaranteed account and/or each subdivision of the variable account on the ending date of the report; and 6. the gain or loss for each subdivision of the variable account and/or the guaranteed account. For the column headings within the report, the accumulation unit is referred to as "unit." INSULATION The assets of SA are not chargeable with liabilities arising out of any other business we may conduct. OWNERSHIP OF We shall have exclusive and absolute ownership ASSETS and control of our assets, including the assets of SA. MODIFICATION We may not modify this contract without OF CONTRACT your consent except: 1. to make the contract meet the requirements of the Investment Company Act of 1940; 2. to make the contract comply with any changes in the Internal Revenue Code; or 3. as required by any other applicable law in order to continue treatment of the contract as an annuity. INCONTESTABILITY We cannot contest this contract after it has been in force during the lifetime of the annuitant for a period of two years from the date of issue.
John Doe 012345678 UC 8134 -15- 01/02 WAIVER OF Notwithstanding the surrender charge described SURRENDER on the contract schedule page, the surrender CHARGES charge will be waived in the event (a) or (b) below: (1) You become confined in a qualified institution for a period of at least 30 consecutive days after the contract date, subject to the following: (a) You must be a natural person (not a Trust, Corporation, or other legal entity). (b) You must have been an owner of this contract continuously since the contract date. (c) You were not confined in a qualified institution at any time during the 60 day period just prior to the contract date. (d) We receive a written request for a full or partial surrender along with due proof of confinement within 12 months following such confinement. (e) A "qualified institution" means any licensed hospital or licensed skilled or intermediate care nursing facility at which: (i) medical treatment is available on a daily basis; and (ii) daily medical records are kept for each patient. (2) You acquire a terminal illness after the contract date, subject to the following: (f) You must be a natural person (not a Trust, Corporation, or other legal entity). (g) You must have been an owner of this contract continuously since the contract date. (h) You Must have less than 12 months to live. (i) We must receive a written statement for full or partial surrender together with a certificate from your attending physician stating your life expectancy and any other proof we may require. (j) "Physician" means a medical doctor licensed in the United States who: (i) is operating within the scope of that license; and (ii) is not the owner and is not related to the owner.
PAYMENT OF CONTRACT BENEFITS --------------------------------------------------------------- GENERAL Annuity benefits under this contract are payable in accordance with the Option Tables given below or under such other annuity options as we may agree to. ALTERNATE Instead of an annuity in accordance with the ANNUITY OPTIONS Option Tables given below, you may choose an alternate type of fixed annuity payment. Such alternate annuity option shall be based on rates at least as favorable as those for fixed dollar single premium immediate annuities being issued by us on the maturity date. They may only be elected within 30 days before that date.
John Doe 012345678 UC 8134 -16- 01/02 DESCRIPTION OF Option 1: Life Annuity ANNUITY OPTIONS (a) Nonrefund. We will make payments during the lifetime of the annuitant. No payments are due after the death of the annuitant. (b) 5-Years Certain. We will make payments for 5 years and after that during the lifetime of the annuitant. No payments are due after the death of the annuitant or, if later, the end of the 5-year period certain. (c) 10-Years Certain. We will make payments for 10 years and after that during the lifetime of the annuitant. No payments are due after the death of the annuitant or, if later, the end of the 10-year period certain. (d) Installment Refund. We will make payments for a period certain and after that during the lifetime of the annuitant. No payments are due after the death of the annuitant or, if later, the end of the period certain. The number of period certain payments is equal to the amount applied under this Installment Refund Option divided by the amount of the first annuity payment; provided, however, that the amount of the final period certain payment shall be multiplied by that part of the preceding quotient which is not an integer. Option 2: Joint and Survivor Life Annuity (a) Joint and Survivor Nonrefund. We will make payments during the joint lifetime of the annuitant and contingent annuitant. Payments will then continue during the remaining lifetime of the survivor of them. No payments are due after the death of the last survivor of the annuitant and contingent annuitant. (b) Joint and Survivor with 10-Years Certain. We will make payments for 10 years and after that during the joint lifetime of the annuitant and contingent annuitant. Payments will then continue during the remaining lifetime of the survivor of them. No payments are due after the death of the survivor of the annuitant and contingent annuitant or, if later, the end of the 10-year period certain.
John Doe 012345678 UC 8134 -17- 01/02 Flexible Premium Deferred Variable Annuity Participating UC 8134