EX-99.B4.C. 3 exb4c.htm EX-99.B4.C.-S40875-ADV BASE SCHEDULE PAGE

EX-99.B4.c. Contract Schedule Page (Base)-S40875-ADV

Contract Schedule

Owner:
[John Doe]
Contract Number:
[??687456]
[Joint Owner:
[Jane Doe]]
Issue Date:
[04/15/10]
Annuitant:
[John Doe]
Scheduled Annuity Date:
[04/01/65]
Determining Life (Lives):
[John Doe]
Maximum Issue Age:
[80]
 
[Jane Doe]
    

Purchase Payments
    
Initial Purchase Payment:
  
$
[10,000.00]
Minimum Additional Purchase Payment:
  
$
[50.00]
Maximum Total Purchase Payments:
  
$[1 million; higher amounts may be accepted with our approval]
       
Transfers
      
Number of Free Transfers Permitted:
  
[12] each Contract Year
Transfer Fee:
  
$[25.00] for each transfer in excess of the free transfers permitted
Transfer Index Anniversary:
  
Every [Sixth] Index Anniversary
       
Contract Charges
      
Product Fee:
    
[0.25]%
Contract Maintenance Charge:
  
$[50.00] each Contract Year
Designated Amount:
  
Contract Value must be $[100,000.00] to waive the Contract Maintenance Charge
       
Withdrawals
      
Minimum Partial Withdrawal:
  
$
[100.00]
Minimum Required Value:
  
$
[2,000.00]
Free Withdrawal Amount:
  
[10]% of total Purchase Payments

Withdrawal Charge Percentages Table

Number of Complete Years Since Receipt of Purchase Payment
Charge
[0
6.50%
1
6.00%
2
5.00%
3
4.00%
4
3.00%
5
2.00%
6 years or more
0%]

Annuity Payments
Minimum Annuity Payment:
  
$
[100.00
]
Annuity Mortality Table:
  
[Annuity 2000 Mortality Table]
  
Minimum Annual Annuity Payment Rate:
    
[1.00
]%

Riders:
[The applicable riders based on the information from the application will populate this area.]



S40875-ADV                                                                                                        3


Guaranteed Purchase Rate Table
Upon request, we will furnish rates for ages and guaranteed periods not shown.

Annuity Options - Guaranteed monthly annuity payments per $1,000
 
 
Option 1
Option 2
Option 3
Option 4
Option 5
   
10-year guaranteed period
20-year guaranteed period
100% joint and survivor
10-year guaranteed period
  
Age on
Annuity Date
Male
Female
Male
Female
Male
Female
Male & Female
Same Age
Male & Female
Same Age
Male
Female
30
[2.08
1.97
2.08
1.97
2.07
1.97
1.84
1.84
2.00
1.92
40
2.45
2.29
2.45
2.29
2.42
2.28
2.10
2.10
2.29
2.19
50
3.02
2.78
3.00
2.77
2.92
2.73
2.49
2.49
2.70
2.57
60
3.95
3.57
3.87
3.53
3.59
3.37
3.12
3.11
3.29
3.14
70
5.66
5.03
5.28
4.83
4.24
4.13
4.22
4.20
4.18
4.00
80
8.93
8.09
7.07
6.79
4.55
4.53
6.37
6.04
5.54
5.38
90
15.24
14.64
8.36
8.30
4.59
4.59
10.68
7.98
7.66
7.50]

S40875-ADV                                                                                                    [3A]