EX-99.A9.A 5 g73877ex99-a9_a.txt SPECIMEN FLEXIBLE PAYMENT VARIABLE CONTRACT Exhibit 99.A9.A Exhibit 24(b)(4)(a) Specimen Flexible Payment Variable Accumulation Deferred Annuity Contract AUSA LIFE INSURANCE COMPANY, INC. (A STOCK COMPANY) Home Office: Purchase, New York Administrative Office: Clearwater, Florida -------------------------------------------------------------------------------- IN THIS CONTRACT AUSA Life Insurance Company, Inc. will be referred to as WE, OUR or US. OFFICE refers to Our Administrative Office located in Clearwater, Florida. -------------------------------------------------------------------------------- WE agree to pay the benefits of this Contract in accordance with its provisions. CONTRACT VALUES AND BENEFITS DURING THE ACCUMULATION PERIOD WILL INCREASE OR DECREASE IN ACCORDANCE WITH THE CONTRACT VALUE PROVISIONS AND THE INVESTMENT EXPERIENCE OF THE APPLICABLE SUBACCOUNTS IN THE SEPARATE ACCOUNT. CONTRACT VALUES, WHEN BASED ON THE INVESTMENT EXPERIENCE OF A SUBACCOUNT OF THE SEPARATE ACCOUNT, ARE VARIABLE AND ARE NOT GUARANTEED AS TO FIXED DOLLAR AMOUNT. THE SMALLEST annual rate of investment return which would have to be earned on Separate Account assets so that the dollar amount of variable annuity payments will not decrease is 5.65%. THE CONSIDERATION for this Contract is the application and the payment of the Initial Payment. THE ANNUITANT, OWNER, AND BENEFICIARY are as shown in the application unless changed in accordance with the provisions of this Contract. THE PROVISIONS on the following pages are part of this Contract. IN WITNESS WHEREOF, We have signed this Contract at Our Office in Clearwater, Florida as of the Contract Date. /s/ Craig D. Vermie /s/ Tom A. Schlossberg _____________________________________ _______________________________ Secretary President -------------------------------------------------------------------------------- RIGHT TO EXAMINE CONTRACT - The Owner may cancel this Contract at any time within thirty days after receipt by returning it to Us at P.O. Box 9054, Clearwater, Florida 33758-9054. If the Contract is returned within this period, We will pay to the Owner the sum of all purchase payments received for this Contract. -------------------------------------------------------------------------------- FLEXIBLE PAYMENT VARIABLE ACCUMULATION DEFERRED ANNUITY Death Benefit Prior to Maturity Monthly Annuity Commencing on Maturity Date Non-Participating - No Dividends CONTRACT GUIDE ENDORSEMENTS.............................................................. 2 CONTRACT SCHEDULE......................................................... 3 DEFINITIONS............................................................... 5 SEPARATE ACCOUNT PROVISIONS............................................... 7 GENERAL PROVISIONS........................................................ 9 PURCHASE PAYMENT PROVISIONS............................................... 11 CONTRACT VALUE PROVISIONS................................................. 11 DEATH BENEFIT PROVISIONS.................................................. 13 ANNUITY PROVISIONS........................................................ 14 FIXED ACCOUNT ANNUITY PAYMENTS............................................ 16 VARIABLE ACCOUNT ANNUITY PAYMENTS......................................... 18 -------------------------------------------------------------------------------- ENDORSEMENTS Page 2 AUSA LIFE INSURANCE COMPANY, INC. CLEARWATER, FLORIDA CONTRACT SCHEDULE OWNER: JOHN DOE CONTRACT NUMBER: 01-12345678 ANNUITANT: JOHN DOE CONTRACT DATE: September 01, 2000 ANNUITY OPTION: D-10 YEAR CERTAIN MATURITY DATE: September 01, 2026 INITIAL PAYMENT: $29,000.00 REALLOCATION DATE: September 01, 2000 REALLOCATION ACCOUNT: Money Market ANTICIPATED PURCHASE PAYMENT PATTERN * NO PLANNED PAYMENT - ISSUED WITH THE INITIAL PAYMENT AS A SINGLE PAYMENT PLAN. * THE ANTICIPATED PURCHASE PAYMENT PATTERN IS BASED UPON SELECTION MADE IN THE APPLICATION. THE AMOUNT AND MODE MAY BE CHANGED IN ACCORDANCE WITH THE PURCHASE PAYMENT PROVISIONS ON PAGE 10. SEPARATE ACCOUNT PROVISIONS SEPARATE ACCOUNT: AUSA SERIES ANNUITY ACCOUNT B SEPARATE ACCOUNT CHARGE: 0.65% ANNUALLY PURCHASE PAYMENT PROVISIONS MAXIMUM ADDITIONAL PAYMENT: $1,000,000 MINIMUM ADDITIONAL PAYMENT: $100 CONTRACT VALUE PROVISIONS MINIMUM ALLOCATION PERCENTAGE: 1% ANNUAL CONTRACT CHARGE: $30** MINIMUM BALANCE: $2,500 FIXED ACCOUNT MINIMUM GUARANTEED EFFECTIVE ANNUAL INTEREST RATE: 3% CURRENT INTEREST RATE: 4%
**CURRENTLY WAIVED IF THE ANNUITY VALUE IS GREATER THAN OR EQUAL TO $25,000 ON THE CONTRACT ANNIVERSARY. Page 3 THIS PAGE INTENTIONALLY LEFT BLANK Page 4 DEFINITIONS ================================================================================ ACCOUNTS Allocation options including the Fixed Account and the Subaccounts of the Separate Account. ACCUMULATION The period between the Contract Date and the Maturity Date PERIOD while the Contract is in force. ACCUMULATION An accounting unit of measure used to calculate Subaccount UNIT VALUE values for the Contract during the Accumulation Period. ANNUITANT The person named on the application, or as subsequently changed, to receive annuity payments. The Annuitant may be changed as provided in the Death Benefit Provisions and Annuity Provisions. ANNUITY PROCEEDS The amount applied to purchase periodic annuity payments. Such amount is the Annuity Value on the Maturity Date, less any applicable Premium Tax. ANNUITY UNIT An accounting unit of measure used to calculate annuity VALUE payments from a Subaccount after the Maturity Date. ANNUITY VALUE The value as described in the Annuity Value section of the Contract Value Provisions. CASH VALUE The value as described in the Cash Value section of the Contract Value Provisions. CONTINGENT The new Beneficiary upon the current Beneficiary's death. BENEFICIARY CONTRACT DATE The later of the date on which payments are first received and the date the properly completed application is received by Us at Our Office. DEATH BENEFIT The value as described in the Death Benefit Proceeds section PROCEEDS of the Death Benefit Provisions. DEATH REPORT DAY The Valuation Date coincident with or next following the day on which We have received both: 1) due proof of death; and 2) a Written Notice for an election of a) a single sum payment or b) an alternative election as described under the Death Benefit Provisions. Page 5 FIXED ACCOUNT An allocation option other than the Separate Account. MATURITY DATE The date on which the Accumulation Period ends and annuity payments are to commence. The date may be changed as provided in the Annuity Provisions PREMIUM TAX Premium Tax levied by a state or other government entity. The Premium Tax will be paid when due and charged either against the purchase payment or the contract value. REALLOCATION DATE The date on which any purchase payments are reallocated from the Reallocation Account to the Accounts elected by the Owner. The Reallocation Date is shown on the Contract Schedule page. SEC The United States Securities and Exchange Commission. SEPARATE ACCOUNT A unit investment trust, consisting of Subaccounts. Each Subaccount of the Separate Account buys shares of a corresponding portfolio of a Series Fund. SERIES FUND A designated mutual fund from which a Subaccount of the Separate Account will buy shares. SUBACCOUNT A Separate Account allocation option that is made available under this Contract. SURRENDER The termination of the Contract at the option of the Owner. VALUATION DATE Each Monday through Friday except customary national business holidays on which the New York Stock Exchange is not open for business. VALUATION PERIOD The period commencing at the end of one Valuation Date and continuing to the end of the next succeeding Valuation Date. WRITTEN NOTICE Written Notice means a notice by the Owner to Us requesting or exercising a right of the Owner as provided in the Contract provisions. In order for a notice to be considered a Written Notice, it must: be in writing, signed by the Owner; be in a form acceptable to Us; and contain the information and documentation, as determined in Our sole discretion, necessary for Us to take the action requested or for the Owner to exercise the right specified. A Written Notice will not be considered complete until all necessary supporting documentation required or requested by Us has been received by Us at Our Administrative Office. Page 6 SEPARATE ACCOUNT PROVISIONS ================================================================================ The variable benefits under this Contract are provided through the Separate Account referenced on Page 3. This Separate Account is established under the Laws and Regulations of New York. The assets of the Separate Account are Our property. Assets equal to the liabilities of the Separate Account will not be charged with liabilities arising out of any other business We may conduct. If the assets of the Separate Account exceed the liabilities arising under the contracts supported by the Separate Account, then the excess may be used to cover the liabilities of Our general account. The assets of the Separate Account shall be valued as often as any contract benefits vary, but at least monthly. SUBACCOUNTS The Separate Account has various Subaccounts. Each Subaccount invests exclusively in shares of one of the portfolios of an underlying Series Fund. Assets invested after the Maturity Date may be invested in different Subaccounts than assets invested during the Accumulation Period. We reserve the right to add or remove any Subaccount of the Separate Account. Income and realized and unrealized gains and losses from assets in each Subaccount are credited to, or charged against, that Subaccount without regard to income, gains, or losses in other Subaccounts. Any amount charged against the contract value for federal or state income taxes will be deducted from that Subaccount. TRANSFERS AMONG During the Accumulation Period, the Owner may transfer SUBACCOUNTS all or a portion of this Contract's value in its Subaccounts to other Subaccounts or the Fixed Account. We reserve the right to charge a $10 fee for each transfer after the first twelve transfers during any one contract year. This charge will be deducted from the funds transferred. We must be notified in a manner satisfactory to Us. The transfer ordinarily will take effect on the first Valuation Date on or following the date notice is received at Our Office. After the Maturity Date, the Owner may transfer the value of the variable annuity units from one Subaccount to another. The minimum amount which may be transferred is the lesser of $10 monthly income or the entire monthly income of the variable annuity units in the Subaccount from which the transfer is being made. If the monthly income of the remaining units in a Subaccount is less than $10, We reserve the right to include the value of those variable annuity units as part of the transfer. After the Maturity Date, no transfers may be made to or from the Fixed Account. We reserve the right to limit transfers to once per contract year. ADDITION, DELETION We reserve the right to transfer assets of the OR SUBSTITUTION Separate Account, which We determine to be associated with OF INVESTMENTS the class of contracts to which this Contract belongs, to another Separate Account, subject to prior approval by the Superintendent of Insurance of New York State. If this type of transfer is made, the term "Separate Account", as used in this Contract, shall then mean the Separate Account to which the assets were transferred. We also reserve the right to add, delete, or substitute investments held by any Subaccount, subject to prior approval by the Superintendent of Insurance of New York State. Page 7 We reserve the right, when permitted by law, to: 1. Deregister the Separate Account under the Investment Company Act of 1940; 2. Manage the Separate Account under the direction of a committee at any time; 3. Restrict or eliminate any voting privileges of contractowners or other persons who have voting privileges as to the Separate Account; and 4. Combine the Separate Account or any Subaccount(s) with one or more other separate accounts or subaccounts. CHANGE OF We reserve the right to change the investment objective INVESTMENT of any Subaccount. If required by law or regulation, OBJECTIVES an investment objective of the Separate Account, or of a Series Fund portfolio designated for a Subaccount, will not be materially changed unless a statement of the change is filed with and approved by the appropriate insurance official of the state of Our domicile or deemed approved in accordance with such law or regulation. If required, approval of or change of any investment objective will be filed with the Insurance Department of the state where this Contract is delivered. ACCUMULATION Some of the contract values fluctuate with the investment UNIT VALUE results of the Subaccounts. In order to determine how investment results affect the contract values, an Accumulation Unit Value is determined for each Subaccount. The Accumulation Unit Value may increase or decrease from one Valuation Period to the next. Accumulation Unit Values also will vary between Subaccounts. The Accumulation Unit Value of any Subaccount at the end of a Valuation Period is the result of: 1. The total value of the assets held in the Subaccount, including the value of any dividends or capital gains distribution declared and reinvested by the portfolio during the Valuation Period. This value is determined by multiplying the number of shares of the designated Series Fund portfolio owned by the Subaccount times the net asset value per share; minus 2. The accrued charge for administration and mortality and expense. The annual Separate Account Charge is shown on Page 3. The daily amount of this charge is equal to the net assets of the Subaccount multiplied by the Separate Account Charge; minus 3. The accrued amount of reserve for any taxes that are determined by Us, subject to prior approval by the Superintendent of Insurance of New York State, to have resulted from the investment operations of the Subaccount; and the result divided by 4. The number of outstanding units in the Subaccount prior to the purchase or redemption of any units on that date. The use of the Accumulation Unit Value in determining contract values is described in the Contract Value Provisions. Page 8 GENERAL PROVISIONS ================================================================================ THE CONTRACT This Contract and the attached application constitute the entire Contract. All statements in the application will be deemed representations and not warranties. No statement can be used to void this Contract or be used in defense of a claim unless it is contained in the written application. No Contract provision can be waived or changed except by endorsement. Such endorsement must be signed by Our President or Secretary. We reserve the right to amend the Contract to meet the requirements of any applicable Federal or state laws or regulations, subject to prior approval by the Superintendent of Insurance of New York State. OWNERSHIP This Contract belongs to the Owner. The Owner as shown on Page 3, or as subsequently changed, may exercise all rights under this Contract including the right to transfer ownership. These rights may be subject to the consent of any assignee or irrevocable beneficiary. CHANGE OF We will not be bound by any requested change in the OWNERSHIP ownership designation unless it is made by Written UPON REQUEST Notice. The change will be effective on the date the Written Notice is signed and recorded by Us. If We request, this Contract must be returned to Our Office for endorsement. Changing the Owner cancels any prior Ownership designation, but it does not change the beneficiary or the Annuitant. CHANGE OF Should the Owner die during the Accumulation Period, We will OWNERSHIP be bound by the following: UPON DEATH OF OWNER 1. If the Owner is the Annuitant, then the Death Benefit Proceeds are payable as provided in the Death Benefit Provisions. 2. If the Owner is not the Annuitant and dies before the Annuitant: (a) If no Beneficiary is named and alive, the Owner's estate will become the new Owner. The Cash Value must be distributed within five years of the former Owner's death; or (b) If the Beneficiary is alive and is the Owner's spouse, this Contract will continue with the spouse as the new Owner; or (c) If the Beneficiary is alive and is not the Owner's spouse, the Beneficiary will become the new Owner. The Cash Value must be distributed either: (1) within five years of the former Owner's death; or (2) over the lifetime of the new Owner, if a natural person, with payments beginning within one year of the former Owner's death; or (3) over a period that does not exceed the life expectancy (as defined by the Internal Revenue Code and Regulations adopted under the Code) of the new Owner, if a natural person, with payments beginning within one year of the former Owner's death. Page 9 ASSIGNMENT This Contract may be assigned prior to the Maturity Date. We will not be bound by any assignment unless made by Written Notice. The assignment will be effective on the date the Written Notice is received at Our Office and accepted by Us. We assume no responsibility for the validity of any assignment. INCONTESTABILITY This Contract is incontestable from the Contract Date. BENEFICIARY The Beneficiary, as named in the application or subsequently changed, is entitled to receive the Death Benefit Proceeds or the Cash Value, if any, as provided in 2(c) above as provided in the Death Benefit Provisions of this Contract. If no Beneficiary is alive, the benefits payable to the Beneficiary will be paid to the Owner, if surviving, otherwise to the Owner's estate. CHANGE OF We will not be bound by any change in the BENEFICIARY Beneficiary designation unless it is made by Written Notice. The change will be effective on the date the Written Notice was signed; however, no change will apply to any payment We made before the Written Notice is received. If We request, this Contract must be returned to Our Office for endorsement. AGE AND SEX If a date of birth or sex has been misstated, any amount payable will be adjusted to conform to the correct date of birth and sex. Any underpayment made by Us will be paid with the next payment. Any overpayment made by Us will be deducted from future payments. Any underpayment or overpayment will include interest at 5% per year, from the date of adjustment. CONTRACT YEARS Contract years and anniversaries are measured from the Contract Date. REPORTS The report will also show any other information required by the laws or regulations of the state in which the contract is issued. CONTRACT PAYMENT All payments from the Fixed Account will be paid in one sum unless otherwise elected under the Annuity Provisions of this Contract. We have the right to postpone payments and transfers from the Fixed Account for up to six months. We reserve the right, at Our option, to defer the payment of any cash surrender value in accordance with the deferral provisions of the Investment Company Act of 1940. All payments and transfers from the Subaccounts will be processed as provided in this Contract unless one of the following situations exist: 1. The New York Stock Exchange is closed; or 2. The SEC requires that trading be restricted or declares an emergency. PROTECTION OF Unless the Owner directs by filing Written Notice, no PROCEEDS Beneficiary may assign any payments under this Contract before the same are due. To the extent permitted by law, no payments under this Contract will be subject to the claims of creditors of any Beneficiary. Page 10 PURCHASE PAYMENT PROVISIONS ================================================================================ PURCHASE PAYMENTS Payments after the first are payable at Our Office. The amount of payment which may be paid during any contract year may not exceed the Maximum Additional Payment shown on Page 3 without Our consent. Payments will not be accepted in an amount less than the Minimum Additional Payment shown on Page 3 without Our consent. Our acceptance of any payment shall not constitute a waiver of these limits with respect to subsequent payments. CONTRACT VALUE PROVISIONS ================================================================================ NET PAYMENT The net payment will be the payment received less Premium Tax, if any. ALLOCATION OF NET Net payments will be allocated to the Accounts on the first PAYMENTS Valuation Date on or following the date the payment is received at Our Office. Any purchase payments received prior to the Reallocation Date will be allocated to the Reallocation Account. On the first Valuation Date on or following the Reallocation Date, the values in the Reallocation Account will be transferred in accordance with the Owner's current purchase payment allocation instructions. Any allocation to an Account must not be less than the Minimum Allocation Percentage shown on Page 3. No fractional percentages are permitted. The allocation of future net payments may be changed by the Owner. We reserve the right to limit such change to once each year. The request for change of allocations must be in a manner satisfactory to Us. The allocation change will be effective the date the request for change is recorded by Us. SUBACCOUNT VALUE At the end of any Valuation Period, the Subaccount value is equal to the number of units that the Contract has in the Subaccount, multiplied by the Accumulation Unit Value of that Subaccount. The number of units that the Contract has in each Subaccount is equal to: 1. The initial units purchased on the Contract Date; plus 2. Units purchased at the time additional net payments are allocated to the Subaccount; plus 3. Units purchased through transfers from another Account; minus 4. Any units that are redeemed to pay for partial withdrawals; minus 5. Any units that are redeemed as part of a transfer to another Account; minus 6. Any units that are redeemed to pay the Annual Contract Charge, Premium Tax and transfer fees, if any. Page 11 FIXED ACCOUNT At the end of any Valuation Period, the value is equal to: 1. The sum of all net payments allocated to the Fixed Account; plus 2. Any amounts transferred from a Subaccount to the Fixed Account; plus 3. Total interest credited to the Fixed Account; minus 4. Any amounts withdrawn from the Fixed Account to pay for partial withdrawals; minus 5. Any amounts transferred to a Subaccount from the Fixed Account; minus 6. Any amounts charged to pay the Annual Contract Charge, Premium Tax and transfer fees, if any. Interest on the Fixed Account will be compounded daily at a minimum guaranteed effective annual interest rate as shown on Page 3. We may declare from time to time higher current interest rates. The interest rates We set will be credited for increments of at least one year measured from each purchase payment or transfer date. On transfers from the Fixed Account to a Subaccount, unless We otherwise consent: 1. Written Notice must be within 30 days after a contract anniversary. 2. The transfer will ordinarily take place on the first Valuation Date on or following the date We receive such Written Notice. 3. The amount that may be transferred is the greater of (a) 25% of the amount in the Fixed Account; or (b) the amount transferred in the prior policy year from the Fixed Account. Unless We otherwise consent, transfers to the Fixed Account or allocation of Net Premiums to the Fixed Account may be restricted if the Fixed Account value following the transfer or allocation would exceed $500,000. We reserve the right to defer payment of any amounts from the Fixed Account for no longer than six months after We receive such Written Notice. ANNUAL CONTRACT During the Accumulation Period, the Annual Contract Charge CHARGE shown on Page 3 will be made once a year on each contract anniversary from the Annuity Value. ANNUITY VALUE At the end of any Valuation Period, the Annuity Value is equal to the sum of the Subaccount value for each Subaccount plus the Fixed Account Value. PARTIAL WITHDRAWAL Prior to the Maturity Date, a partial withdrawal may be made by the Owner without surrender of this Contract. Unless We otherwise consent: 1. The request must be made by Written Notice. 2. The partial withdrawal may not reduce the Cash Value to less than the Minimum Balance shown on Page 3. 3. No amount from the Fixed Account may be withdrawn. Page 12 The amount payable will be the partial withdrawal less any applicable Premium Tax. The Subaccount(s) for the withdrawal may be specified. If not specified, withdrawals will be based on the current allocation election. CASH VALUE This Contract may be surrendered by the Owner for its Cash Value upon Written Notice at any time prior to the then current Maturity Date. The Cash Value at any time equals the Annuity Value on the Valuation Date coincident with or next following the date We receive Written Notice of surrender less any applicable Premium Tax. Payment will usually be made within seven days of Written Notice subject to the Contract Payment section of the General Provisions and the Fixed Account section of these provisions. BASIS OF A detailed statement of the method of computation of COMPUTATION values has been filed with the insurance supervisory official of the jurisdiction in which this Contract is delivered. All values for this Contract are equal to or greater than the values required by statutes in such jurisdiction. DEATH BENEFIT PROVISIONS ================================================================================ DEATH OF ANNUITANT If the Annuitant dies during the Accumulation Period and the ACCUMULATION Owner is a natural person other than the Annuitant, the PERIOD Owner will automatically become the Annuitant and the Contract will continue. If the Annuitant dies during the Accumulation Period and the Owner is either (1) the same individual as the Annuitant; or (2) other than a natural person, then the Death Benefit Proceeds as calculated below are payable to the Beneficiary. DEATH BENEFIT The Death Benefit Proceeds during the Accumulation Period is PROCEEDS the greater of: 1. The Annuity Value as of the Death Report Day; or 2. The excess of (a) the amount of purchase payments paid less (b) any amounts withdrawn from the Contract to pay for partial withdrawals. ALTERNATIVE If the Beneficiary is entitled to receive the Death Benefit ELECTION Proceeds, the Beneficiary may elect in lieu of a lump sum payment, one of the following options that provide for complete distribution and termination of this Contract at the end of the distribution period: Page 13 1. Within 5 years of the date of death of the Annuitant; or 2. Over the lifetime of the Beneficiary; or 3. Over a period that does not exceed the life expectancy (as defined by the Internal Revenue Code and Regulations adopted under the Code) of such Beneficiary. Multiple beneficiaries may choose individually among any of the three options. For subparagraphs (1) and (3), the Annuity Value as of the Death Report Day will be adjusted to equal the Death Benefit Proceeds and this Contract will remain in force as a deferred annuity until the end of the elected distribution period. For subparagraph (2), the Maturity Date will be changed to the Death Report Day and the Death Benefit Proceeds will be used to purchase annuity payments under the Annuity Provisions of this Contract. For elections made under subparagraph (1), We will: a. at the time of election, allow one partial withdrawal and one transfer of all or a portion of the Contract's value among Subaccounts or the Fixed Account without a transfer charge. Additional partial withdrawal and transfers are not permitted; b. not permit payment of the Death Benefit Proceeds under the Annuity Provisions of this Contract upon complete distribution. The Beneficiary may not name a Beneficiary for payment of the Death Benefit Proceeds. In the event the Beneficiary dies prior to distribution of all Death Benefit Proceeds, We will pay the remaining value of the Death Benefit Proceeds to the Contingent Beneficiary, if named by the Owner. If no Contingent Beneficiary is named, such payment will be made to the Beneficiary's estate. Subparagraphs (2) and (3) may be elected only if the Beneficiary is a natural person and payments start within one year of the date of death of the Annuitant. In addition, if the Beneficiary is entitled to receive the Death Benefit Proceeds and is the spouse of the deceased Annuitant, then the Beneficiary may elect to become the new Annuitant and Owner and keep the Contract in force in lieu of receiving the Death Benefit Proceeds. ANNUITY PROVISIONS ================================================================================ COMMENCEMENT OF Monthly annuity payments will begin as of the Maturity Date ANNUITY PAYMENTS shown on Page 3, unless another Maturity Date has been elected as provided in these provisions. Page 14 MATURITY DATE The Maturity Date shown on Page 3 may be changed to a different Maturity Date, subject to all of the following: 1. Written Notice prior to the Maturity Date. 2. The new Maturity Date is at least 13 months after the Contract Date. 3. The attained age of the Annuitant as of the new Maturity Date is not greater than 90 On the Maturity Date the contract must annuitize. The Systematic Payout Option cannot be used to continue the contract In Force beyond the Maturity Date. ANNUITY OPTION The Annuity Option shown on Page 3 may be changed to any other option available upon Written Notice prior to the Maturity Date. If a variable account annuity payment option is chosen, the Owner must include in the Written Notice the Subaccount allocation of the Annuity Proceeds as of the Maturity Date. CHANGE OF As of the Maturity Date and upon agreement with Us, the ANNUITANT Owner may elect a different Annuitant or add a joint annuitant who will be a joint payee under either Option C or Option E. PAYEE The Annuitant(s) on the Maturity Date will become the payee(s) and receive the annuity payments. AVAILABILITY If the payee is not a natural person, an Annuity Option is only available with Our permission. No Annuity Option is available if: 1. The payee is an assignee; or 2. The periodic payment is less than $20. AGE Age, when required, means age nearest birthday on the effective date of the option. We will furnish rates for ages or combination of ages not shown upon request. PROOF OF AGE Prior to making the first monthly annuity payment under this AND SEX Contract, We reserve the right to require satisfactory evidence of the birthdate and the sex of any payee. If required by law to ignore differences in sex of any payee, annuity payments will be determined using unisex rates. PROOF OF SURVIVAL Prior to making any payment under this Contract, We reserve the right to require satisfactory evidence that the payee is: Page 15 1. Alive on the due date of such payment; and 2. Legally qualified to receive such payment. DEATH BENEFIT The death benefit after the Maturity Date and after the AFTER THE commencement of annuity payments depends upon the annuity MATURITY DATE option selected. If a payee dies on or after the commencement of annuity payments, the remaining portion of any interest in the Contract will be distributed at least as rapidly as under the method of distribution being used as of the date of the payee's death. RESTRICTIONS After the Maturity Date, no additional purchase payments, partial withdrawals, transfers, full surrenders, change of Annuitants nor Annuity Options may be made under this Contract. FIXED ACCOUNT ANNUITY PAYMENTS ================================================================================ Annuity payments at the time of annuitization will not be less than those that would be provided by the application of "an amount" to purchase any single consideration immediate annuity contract. "An amount" will be the greater of the Cash Value or 95% of the Annuity Value. INTEREST AND All Fixed Account annuity option payments are based on a MORTALITY guaranteed interest rate of 3%. Mortality is based on the "Annuity 2000" (male, female, and unisex if required by law) mortality table projected for improvement using projection scale G. AMOUNT OF MONTHLY The amount of each monthly annuity payment will be FIXED ACCOUNT determined by multiplying: ANNUITY PAYMENT 1. The appropriate rate based on the guaranteed interest rate and, for Options B and C, the mortality table for Fixed Account annuity payments; multiplied by 2. The Annuity Proceeds as of the Maturity Date. FIXED ACCOUNT The following options are available for payment of Fixed ANNUITY OPTIONS Account monthly annuity payments. The rates shown are the guaranteed rates for each $1,000 of Annuity Proceeds at adjusted ages. The adjusted age is the Annuitant's actual age nearest birthday at the Maturity Date, adjusted as follows:
Maturity Date Adjusted Age Before 2010 Actual Age 2010 - 2019 Actual Age minus 1 2020 - 2026 Actual Age minus 2 2027 - 2033 Actual Age minus 3 2034 - 2040 Actual Age minus 4
After the year 2040 as determined by us. Page 16 Any guaranteed rates not shown for the options above will be available upon request. Higher current rates may be available at the Maturity Date. Option A - Fixed The Annuity Proceeds will be paid in equal installments. Period. The installments will be paid over a fixed period determined from the following table:
Fixed Period Rate (in Months) ----------- 60 17.91 120 9.61 180 6.87 240 5.51
Option B - Life The Annuity Proceeds will be paid in equal installments Income. determined from the following table. Such installments are payable: 1. during the payee's lifetime only (Life Annuity); or 2. during a 10 Year fixed period certain and for the payee's remaining lifetime (Certain Period); or 3. until the sum of installments paid equals the Annuity Proceeds applied and for the payee's remaining lifetime (Installment Refund).
Option B: Life Income Monthly Income Payments Guaranteed for Life Guaranteed for 10 Years Guaranteed Return of Policy Proceeds ------------------------------------------------------------------------------------------------------- Age* Male Female Unisex Male Female Unisex Male Female Unisex 50 $ 3.82 3.70 3.74 3.80 3.69 3.72 3.70 3.62 3.65 55 4.18 4.01 4.06 4.13 3.99 4.03 3.99 3.89 3.92 60 4.64 4.42 4.49 4.57 4.38 4.44 4.36 4.23 4.27 65 5.30 4.98 5.08 5.14 4.89 4.97 4.83 4.67 4.72 70 6.21 5.78 5.90 5.86 5.58 5.66 5.43 5.26 5.31
*Adjusted Age as defined in Fixed Account Annuity Options Provision Option C - Joint Survivor The Annuity Proceeds will be paid in equal and Life Income installments during the joint lifetime of two payees and continuing upon the death of the first payee for the remaining lifetime of the survivor. Page 17 Option C: Joint and Survivor Life Income
Monthly Payments for Each $1,000 of Amount Retained Age of Other Payee (Female) Age of One 15 Years Less 12 Years Less 9 Years Less 6 Years Less 3 Years Less Same as Payee* (Male) Than Male Than Male Than Male Than Male Than Male Male Payee's Payee's Payee's Payee's Payee's Payee's ------- ------- ------- ------- ------- 50 $3.06 $3.12 $3.19 $3.25 $3.31 $3.38 55 3.20 3.27 3.35 3.44 3.52 3.61 60 3.37 3.47 3.57 3.68 3.79 3.91 65 3.59 3.72 3.86 4.01 4.16 4.32 70 3.88 4.06 4.25 4.45 4.67 4.89
*Adjusted Age as defined in Fixed Account Annuity Options Provision
UNISEX MONTHLY PAYMENTS FOR EACH $1,000 OF AMOUNT RETAINED Age of Other Payee* Age of First 15 Years Less 12 Years Less 9 Years Less 6 Years Less 3 Years Less Same as Payee* Than First Than First Than First Than First Than First First Payee's Payee's Payee's Payee's Payee's Payee's ------- ------- ------- ------- ------- 50 $3.07 $3.13 $ 3.19 $3.25 3.31 3.37 55 3.20 3.28 3.36 3.44 3.52 3.60 60 3.38 3.48 3.58 3.68 3.79 3.89 65 3.61 3.73 3.87 4.01 4.16 4.30 70 3.90 4.07 4.26 4.46 4.66 4.86
*Adjusted Age as defined in Fixed Account Annuity Options Provision VARIABLE ACCOUNT ANNUITY PAYMENTS ================================================================================ Annuity payments at the time of annuitization will not be less than those that would be provided by the application of "an amount" to purchase any single consideration immediate annuity contract. "An amount" will be the greater of the Cash Value or 95% of the Annuity Value. ANNUITY UNIT The Annuity Proceeds will be used to purchase variable VALUE annuity units in the chosen Subaccount(s). The Annuity Unit Value in any Subaccount will increase or decrease reflecting the investment experience of that Subaccount. The Annuity Unit Value of any Subaccount at the end of a Valuation Period is equal to (a) multiplied by (b) multiplied by (c), where: (a) is the Annuity Unit Value for that Subaccount at the end of the immediately preceding Valuation Period; (b) is the net investment factor for the Subaccount for the Valuation Period; and (c) is the Assumed Investment Return adjustment factor for the Valuation Period. Page 18 The Assumed Investment Return adjustment factor for the Valuation Period is the product of discount factors of .99986634 per day to recognize the 5.0% effective annual Assumed Investment Return. The net investment factor used to calculate the value of the Annuity Unit Value in each Subaccount for the Valuation Period is determined by dividing (d) by (e) and subtracting (f) from the result, where: (d) is the net result of: (1) the net asset value of a Series Fund share held in that Subaccount determined as of the end of the current Valuation Period; plus (2) the per share amount of any dividend or capital gain distributions made by the Series Fund for shares held in that Subaccount if the ex-dividend date occurs during the Valuation Period; plus or minus (3) a per share charge or credit for any taxes reserved for, which We determine to have resulted from the investment operations of the Subaccount. (e) is the net asset value of a Series Fund share held in the Subaccount determined as of the end of the immediately preceding Valuation Period. (f) is a factor representing the mortality and expense risk fee, and administrative charge. This factor is equal, on an annual basis, to 0.65% of the daily net asset value of a Series Fund share held in the Separate Account for that Subaccount. DETERMINATION OF The amount of the first variable payment is determined by THE FIRST multiplying the Annuity Proceeds times the appropriate VARIABLE PAYMENT rate from the variable option selected. The tables are based on the "Annuity 2000" (male, female, and unisex if required by law) mortality table projected for improvement using projection scale G. Neither expenses actually incurred, other than taxes on the investment return, nor mortality actually experienced, shall adversely affect the dollar amount of variable annuity payments after such payments have commenced. The amount of the first payment depends upon the adjusted age of the Annuitant. The adjusted age is the Annuitant's actual age nearest birthday at the Maturity Date, adjusted as follows:
Maturity Date Adjusted Age Before 2010 Actual Age ----------- ---------- 2010 - 2019 Actual Age minus 1 2020 - 2026 Actual Age minus 2 2027 - 2033 Actual Age minus 3 2034 - 2040 Actual Age minus 4
After the year 2040 as determined by us. Page 19 DETERMINATION The amount of variable annuity payments after the first will OF SUBSEQUENT increase or decrease according to the Annuity Unit Value VARIABLE PAYMENTS which reflects the investment experience of the selected Subaccount(s). Each variable annuity payment after the first will be equal to the number of variable annuity units in each selected Subaccount multiplied by the Annuity Unit Value of that Subaccount on the date the payment is processed. The number of variable annuity units in any selected Subaccount is determined by dividing the first variable annuity payment allocated to that Subaccount by the variable Annuity Unit Value of that Subaccount on the date the first annuity payment is processed. VARIABLE ACCOUNT The following options are available for payment of Variable ANNUITY OPTIONS Account monthly annuity payments. The rates shown are the guaranteed rates for each $1,000 of Annuity Proceeds at adjusted ages. These rates are used to determine the first variable payment under each option. Any guaranteed rates not shown for the options below will be available upon request. Option D - Variable The Annuity Proceeds will be paid in installments determined Life Income. from the following table. Such installments are payable: 1. during the payee's lifetime only (Variable Life Annuity); or 2. during a 10 year fixed period certain and for the payee's remaining lifetime (Variable Certain Period).
Variable Life Annuity Variable Certain Period --------------------- ----------------------- Payee's Age* Male Female Unisex Male Female Unisex ------------ ---- ------ ------ ---- ------ ------ 50 5.07 4.93 4.98 5.04 4.92 4.95 55 5.40 5.22 5.27 5.34 5.18 5.23 60 5.85 5.61 5.68 5.75 5.55 5.61 65 6.50 6.16 6.26 6.29 6.03 6.11 70 7.41 6.94 7.08 6.98 6.69 6.77
*Adjusted Age as defined in Variable Account Annuity Options Provision Page 20 Option E - The Annuity Proceeds will be paid in installments during the Variable Joint joint lifetime of two payees and continuing upon the death and Survivor Life of the first payee for the remaining lifetime of the Income survivor. Option E: Monthly Installment For Joint and Full Survivor Monthly Payments for Each $1,000 of Amount Retained
AGE OF OTHER PAYEE (FEMALE)* Age of First 15 Years Less 12 Years Less 9 Years Less 6 Years Less 3 YEARS LESS Same as Payee*(Male) Than Male Than Male Than Male Than Male Than Male Male Payee's Payee's Payee's Payee's Payee's Payee's ------- ------- ------- ------- ------- 50 $4.37 $4.42 $4.46 $4.51 $4.56 $4.62 55 4.48 4.54 4.60 4.67 4.74 4.81 60 4.62 4.70 4.79 4.88 4.98 5.08 65 4.81 4.92 5.04 5.17 5.31 5.46 70 5.07 5.23 5.40 5.59 5.79 6.00
*Adjusted Age as defined in Variable Account Annuity Options Provision
UNISEX MONTHLY PAYMENTS FOR EACH $1,000 OF AMOUNT RETAINED Age of Other Payee* Age of First 15 Years Less 12 Years Less 9 Years Less 6 Years Less 3 Years Less Same as Payee* Than First Than First Than First Than First Than First First Payee's Payee's Payee's Payee's Payee's Payee's ------- ------- ------- ------- ------- 50 $4.38 $4.42 $4.47 $4.51 $4.56 $4.61 55 4.48 4.54 4.60 4.67 4.73 4.80 60 4.63 4.70 4.79 4.88 4.97 5.07 65 4.82 4.93 5.05 5.17 5.30 5.44 70 5.09 5.24 5.41 5.59 5.78 5.97
*Adjusted Age as defined in Variable Account Annuity Options Provision Page 21 AUSA LIFE INSURANCE COMPANY, INC. Home Office: 4 Manhattanville Road Purchase, New York 10577 Administrative Office: P.O. Box 9054 Clearwater, Florida 33758-9054 FLEXIBLE PAYMENT VARIABLE ACCUMULATION DEFERRED ANNUITY Death Benefit prior to Maturity. Monthly Annuity commencing on Maturity Date. Non-participating - No Dividends