EX-99.(4)(A)(1) 3 a22-27667_1ex99d4a1.htm EX-99.(4)(A)(1)

Exhibit 99.(4)(a)(1)

 

CONTRACT SPECIFICATIONS

 

CONTRACT DATA

 

Contract Number:

[VR99999999]

Contract Date:

[11-30-2022]

 

Contract Type:

 

[Non-Qualified]

Minimum Issue Age:

 

Maximum Issue Age:

 

[45]

 

[80]

 

Owner(s):

[John Doe]

[Jane Doe]

 

Owner’s Age:

[45]

[45]

 

Annuitant(s):

[John Doe]

[Jane Doe]

 

Annuitant’s Age:

[45]

[45]

 

Annuity Date:

[01-01-2072]

 

Annuitant’s Sex:

[Male]

[Female]

 

 

 

PURCHASE PAYMENTS

 

Initial Purchase Payment Amount:

 

[$100,000]

 

Minimum Purchase Payment Amount for Non-Qualified Contracts:

[$50,000]

 

 

Minimum Purchase Payment Amount for Qualified Contracts:

[$50,000]

 

 

Maximum Purchase Payment Amount Without Pacific Life Home Office Approval:

 

[$1,000,000]

 

Number of Days to Receive Purchase Payments from Pacific Life

Initiated Transfers:

 

 

 

[90]

 

 

 

 

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

[1.50%]

 

Basis of Computations Interest Rate:

 

Minimum Contract Value to Avoid Contract Termination:

[1.0%]

 

[$1,000]

 

Minimum Withdrawal Amounts:

·                  [$500] for each unscheduled Withdrawal

·                  [$250] for each systematic Withdrawal

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

 

Maximum Annuitization Age:

 

 

[95]

Minimum Annuitization Amount:

 

[$10,000]

 

Minimum Annuity Payment Amount:

 

[$240]

 

 

ICC22:10-1021-CS5

 

3A

 

CONTRACT SPECIFICATIONS (continued)

 

FEES AND CHARGES

 

 

 

Mortality and Expense Risk Charge:

[0.60%]

Administrative Fee:

[0.25%]

 

 

WITHDRAWAL CHARGE PERIOD / TABLE OF WITHDRAWAL CHARGE PERCENTAGES

 

[10-year]:

[

 

From Issue Date

Withdrawal Charge
Percentages

Contract Year 1

10%

Contract Year 2

9%

Contract Year 3

8%

Contract Year 4

7%

Contract Year 5

6%

Contract Year 6

5%

Contract Year 7

4%

Contract Year 8

3%

Contract Year 9

2%

Contract Year 10

1%

Contract Year 11 and later

0%

]

 

[ Eligibility Dates for The Withdrawal Charge Waivers

[Nursing Home Confinement Waiver:]                                                                                                                                                                                                                                                                                             [2/28/2023]

[Terminal Illness Waiver:]                                                                                                                                                                                                                                                                                                                                                                      [11/30/2023]  ]

 

 

RIDER(S)

 

Name

Current
Annual
Charge %

 

[Return of Purchase Payment Death Benefit Rider]

0.15%]

 

[Guaranteed Withdrawal Benefit XXVII Rider]

0.95%]

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

INVESTMENT OPTION

[Fund 1]

 

ICC22:10-1021-CS5

 

3B

 

CONTRACT SPECIFICATIONS (continued)

 

 

SERVICE CENTER

 

Send Forms and written requests to:

 

Send Payments to:

[Pacific Life Insurance Company

 

[Pacific Life Insurance Company

P.O. Box 2378

 

P.O. Box 2290

Omaha, Nebraska  68103-2378]

 

Omaha, Nebraska  68103-2290]

 

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

Toll-Free Number for Contract Owners:  [1-800-722-4448]

Toll-Free Number for Financial Professionals:  [1-844-557-2233]

Website: [www.PacificLife.com]

 

Please use our toll-free telephone number for questions about your annuity contract and benefit riders, or you may call your state insurance department at [1-xxx-xxx-xxxx].

 

ICC22:10-1021-CS5

 

3C