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                 THE AMERICAN LIFE INSURANCE COMPANY OF NEW YORK
                         435 HUDSON STREET, SECOND FLOOR
                            NEW YORK, NEW YORK 10014
                        (HEREAFTER CALLED THE "COMPANY")

                    FLEXIBLE PREMIUM DEFERRED ANNUITY POLICY

The Company will pay the annuity benefits provided under this policy. Upon the
death of the annuitant before the Annuity Commencement Date, the company will
pay the death benefit provided under this policy.

RIGHT TO EXAMINE POLICY. This policy may be returned for cancellation within 10
days after the date it is received by the Owner. It may be delivered or mailed
to the Company or to any agent of the company. This policy will then be
cancelled as of the Date of Issue and the Company will refund to the Owner an
amount equal to (a) all premiums allocated to the Interest Accumulation Account,
with no deductions; plus (b) the value on the date of surrender of all premiums
allocated to any Investment Account associated with an Investment Fund of the
Separate Account. For the purpose of this provision, the date of surrender will
be the date this policy is delivered or mailed to the Company for cancellation.

This policy is issued in consideration of the application for this policy and
payment of the first premium of at least $10. This policy will take effect on
the Effective Date shown below.

This page and the following pages are a part of this policy. All benefits
payable are subject to the provisions of this policy.

This policy is executed by the Company at its Home Office in New York, New York
on the Date of Issue of this policy.



Signed Craig A. Hawley                             Signed Tracey Hecht
Secretary                                          President


ASSETS HELD IN CONNECTION WITH THIS POLICY MAY BE HELD IN THE COMPANY'S GENERAL
ACCOUNT AND/OR THE COMPANY'S SEPARATE ACCOUNT THAT THE COMPANY MAINTAINS IN
CONNECTION WITH THIS POLICY AND CERTAIN OTHER POLICIES. THE ASSETS OF THE
SEPARATE ACCOUNT ARE NOT GUARANTEED AS TO FIXED DOLLAR AMOUNTS AND WILL INCREASE
OR DECREASE IN VALUE BASED UPON THE INVESTMENT RESULTS OF THE SEPARATE ACCOUNT.
A DESCRIPTION OF THE SEPARATE ACCOUNT IS DESCRIBED IN THIS POLICY.

PREMIUMS PAYABLE AS STATED IN THE PREMIUMS PROVISIONS OF THIS POLICY, DEATH
BENEFIT PAYABLE UPON ANNUITANT'S DEATH BEFORE THE ANNUITY COMMENCEMENT DATE.

ANNUITANT:                                  EFFECTIVE DATE:

OWNER:                                      DATE OF ISSUE:

POLICY NUMBER:


3805-FPA-AX                                                                05/01

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TABLE OF CONTENTS


INSURING CLAUSE.............................

RIGHT TO EXAMINE CONTRACT...................

POLICY SPECIFICATIONS.......................

BENEFIT PROVISION...........................
     Monthly Annuity Benefits
     Amount of Annuity Benefit
     Death Benefit Before the Annuity
        Commencement Date
     Fixed Amount Option
     Annuity Commencement Date
     Valid Transaction Date
     Payment of Small Annuities
     Distribution

PREMIUMS....................................
     Premiums

ALLOCATION OF PREMIUMS......................
     Allocations
     Change of Allocations

ACCUMULATION VALUE..........................

DESCRIPTION OF ACCOUNTS.....................
     Types of Accounts
     General Account
     Separate Account
     Accumulation Units
     Accumulation Unit Value
     Accumulation Unit Value Change
     Valuation Day and Valuation Period
     Changes to Separate Account
     Valuation of Assets
     Statement of Accounts

CHARGES
     Types and Amounts
        Administrative Charges
        Mortality Risk Charge
     Change in the Amount of Charges

SPECIFIED PAYMENTS OPTION...................
     Election of Specified Payments Option
     Payment of Specified Amount

WITHDRAWALS AND TRANSFERS...................
     Withdrawals and Transfers
     Withdrawals
     Transfers
     Amount of Withdrawal or Transfer
     Requests
     Postponement of Payments, Withdrawals
        Or Transfers

ANNUITY OPTIONS.............................
     Election of Form of Annuity
     Options

OWNER AND BENEFICIARY.......................
     Owner
     Beneficiary
     Change of Owner or Beneficiary

GENERAL PROVISION...........................
     The Contract
     Incontestability
     Misstatements of Age
     Assignment
     Changes to This Policy
     Survival of Payee
     Claims of Creditors
     Correspondence
     Required Information
     Non-Waiver

TABLE OF RATES..............................
     Certain Period and Continuous Annuity
     Joint and Survivor Annuity
     Full Cash Refund Annuity

TABLE OF GUARANTEED VALUES..................

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                              POLICY SPECIFICATIONS


     TYPE OF CHARGE                                          AMOUNT OF CHARGE

--------------------------------------------------------------------------------
ADMINISTRATIVE CHARGES
   CHARGE A                                 None

   CHARGE B                                 None

--------------------------------------------------------------------------------

MORTILITY RISK CHARGE                       None
--------------------------------------------------------------------------------

An explanation of all charges appears in the provision of this policy entitled
"CHARGES."


The Company reserves the right to change the amount of the charges subject to
the section entitled "Change in the Amount of Charges" appearing in the
provision of this policy entitled "Charges." However, the total of the
Administrative Charge A and the Mortality Risk Charge will not exceed a maximum
daily charge at an annual rate of 2%, and Administrative Charge B will not
exceed a maximum charge of $2.00 per month for each fund.

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                               BENEFIT PROVISIONS

MONTHLY ANNUITY BENEFITS. Annuity payments will be made each month to the
Annuitant. Annuity payments will begin on the Annuity Commencement Date and will
continue subject to the form of annuity under which payments are made. All
payments will be made directly to the payee at the last address shown in the
Company's records.

AMOUNT OF ANNUITY BENEFIT. The amount of the annuity benefit will be based on:
(a) the Accumulation Value of this policy on the Annuity Commencement Date; (b)
the form of annuity under which payment is made; and (c) the Table of Annuity
Payments in effect at the time the form of annuity is selected. However, the
Table of Annuity Payments will never be less than those provided by the Table of
Rates of this policy. The company will withdraw the Accumulation Value of this
policy and apply it under the Annuity Options provisions of this policy on the
later of: (a) the Valid Transaction Date; or (b) the Annuity Commencement Date.

DEATH BENEFIT BEFORE THE ANNUITY COMMENCEMENT DATE. A death benefit will be paid
to the beneficiary upon the Annuitant's death before the Annuity Commencement
Date. The amount of the death benefit will be the Accumulation Value of this
policy on the date the Company receives due proof of death.

Upon the Annuitant's death the designated beneficiary may elect the manner in
which any death benefit is payable, subject to the Distribution provision of
this section. The death benefit may be paid; (a) in a single sum; or (b) in a
form of annuity offered by the company at the time the election is made; or (c)
under the Fixed Amount Option described below. If no beneficiary has been
designated, or if the designated beneficiary is not living upon the death of the
Annuitant, then payment option (b) is not available for election.

FIXED AMOUNT OPTION. The beneficiary may elect this option as a method of
payment of any death benefit payable under this policy. This option provides
monthly payments of a fixed amount.

Upon receipt of due proof of the Annuitant's death, the Company will transfer
the Accumulation Value of this policy associated with any Investment Fund of the
Separate Account to the Interest Accumulation Account. The Company will then
make monthly payments to the beneficiary of the fixed amount from the Interest
Accumulation Account.

The beneficiary must elect this option on the Company's prescribed form filed at
the Home Office of the Company. Such election from must specify the amount to be
withdrawn each month from the Interest Accumulation Account. The amount of each
monthly payment will be the greater of: (a) $100; or (b) the amount specified in
the election form.

Payment of the fixed amount will begin on the later of: (a) the date designated
in the election form; or (b) the date the company receives the election form.
The value of the Interest Accumulation Account will be reduced each month by the
amount of the fixed payment.

Payments will continue to the designated beneficiary until the earliest of: (a)
the death of the designated beneficiary; (b) the date on which the value of the
Interest Accumulation Account is depleted; (c) if payment is made to the
designated beneficiary, the end of a period not extending beyond the life
expectancy of the beneficiary, or the combined life expectancies of more than
one designated beneficiary; or (d) if no beneficiary is designated or if the
designated beneficiary is not living upon the Annuitant's death, the end of the
60-month period following the date on which payments of the beneficiary begin
under this option. If payments to the beneficiary cease under this option
pursuant to (a), any amount then remaining in the Interest Accumulation Account
will be paid to the beneficiary's estate. If payments to the beneficiary cease
under this option pursuant to (c) or (d), the beneficiary will receive a lump
sum cash payment equal to any amount then remaining in the Interest Accumulation
Account.

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                         BENEFIT PROVISIONS (CONTINUED)

Once this option has been elected by the beneficiary: (a) it may not be
cancelled; and (b) the amount of the fixed payment may not be changed.

ANNUITY COMMENCEMENT DATE. The Annuity Commencement Date is the first day of the
calendar month on which annuity payments begin under this policy. It will be the
date designated in writing by the Owner.

VALID TRANSACTION DATE. The Valid Transaction Date is the valuation day on which
all the requirements for completion of a transaction have been met. This
includes receipt by the company of all information, premiums, notices and papers
necessary to process a transaction.

PAYMENT OF SMALL ANNUITIES. If any benefit payable under this policy is less
than $20 each month ($240 each year), at the Company's option the present value
of the annuity benefit may be paid in one payment to the payee.

DISTRIBUTION. Anything in this policy to the contrary notwithstanding, the
following distribution rules shall apply to the benefits payable under this
policy.

     (1)  If the Owner of this policy is the same individual as the named
          Annuitant, the following rules shall apply:

          (a)  If said Owner dies on or after the Annuity Commencement Date and
               before the entire interest under this policy has been distributed
               to the Owner, the remaining portion of such interest shall be
               distributed either (i) as continued payments to the beneficiary,
               if the payment option to the Owner was the Period Certain and
               Continuous Annuity Option; or (ii) as continued payments to the
               joint annuitant, if the payment option to the Owner was the Joint
               and Survivor Annuity - 66-2/3% Benefit to Joint Annuitant Option.

          (b)  If said Owner dies before the Annuity Commencement Date, the
               entire interest under this policy will be distributed to the
               beneficiary within five years after the death of the Owner,
               except that, if payments to a named beneficiary begin within one
               year after the death of the Owner, then such payments may be made
               over (i) the life of the beneficiary; or (ii) a period not
               extending beyond the life expectancy of the beneficiary.

     If the named beneficiary is the spouse of the Owner, the provisions of this
     Paragraph (1) shall apply to such spouse as if the spouse were the Owner of
     this policy.

     The named beneficiary shall be the beneficiary named by the Owner.

     (2)  If the Owner of this policy and the named Annuitant are different
          individuals, the following rules shall apply:

          (a)  If the Owner dies on or after the Annuity Commencement Date, and
               before the entire interest under this policy has been
               distributed, the remaining portion of such interest will be
               distributed at least as rapidly as under the method of
               distributions being used as of the date of the Owner's death.

          (b)  If the Owner dies before the Annuity Commencement Date the entire
               interest under this policy will be distributed within five years
               after the death of the Owner, except

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               that, if payments to a named beneficiary begin within one year
               after the death of the Owner, then such payments may be made over
               (i) the life of the beneficiary; or (ii) a period not extending
               beyond the life expectancy of the beneficiary.

     If the Annuitant has been designated in writing by the Owner to receive the
     proceeds under this policy, then the Annuitant will be deemed to be the
     named beneficiary for purposes of this Paragraph (2).

     If the named beneficiary is the spouse of the Owner, the provisions of this
     Paragraph (2) shall apply to such spouse as if the spouse were the Owner of
     this policy.

                                    PREMIUMS

PREMIUMS. The first premium must be paid on or before the Effective Date of this
policy to place this policy in force. At any time before the Annuity
Commencement Date the Owner may pay premiums on the dates and in the amounts the
Owner wishes. However, no premium payment may be less than $10. In any event, no
premiums may be paid at any time while payments are being made in connection
with an election for the Specified Payments Option as describe in this policy.

Premiums must be paid to the Company's Home Office or to a duly authorized
representative of the Company. The Owner is entitled to an official receipt
signed by and Officer of the Company and countersigned by the person to whom the
premium was paid.

                             ALLOCATION OF PREMIUMS

ALLOCATIONS. The Owner has the right to designate the percentage of the premium
that is to be allocated to any of the Investment Accounts described under the
"Description of Accounts" provision. The company will allocate all premiums paid
under this policy in the manner designated by the Owner. Allocation designations
must be shown as a percentage of the total premium, in any multiple of 1%, up to
100%.

Any premiums that are allocated to the Interest Accumulation Account will be
credited as of the date that they are received by the company. Any premiums
allocated to any Investment Account associated with an Investment Fund of the
Separate Account will be credited as of the valuation day in which they are
received by the Company.

CHANGE OF ALLOCATIONS. The Owner may change the manner in which premiums are
allocated under this policy at anytime. A request for a change of allocation
must be in a manner satisfactory to the Company. No change of allocation will be
effective until the request for the change has been received and recorded by the
Company. All premiums paid on or after the effective date of the change will be
allocated in the manner requested.

                               ACCUMULATION VALUE

ACCUMULATION VALUE. The Accumulation Value of this policy at any time is the
total current value of the Investment Accounts as described below.

     The current value of the Interest Accumulation Account at any time on or
     before the Annuity Commencement Date is equal to: (a) the total of all
     premiums allocated or transferred under this policy to the Interest
     Accumulation Account; plus (b) all interest accrued on such premiums; less
     (c) any withdrawals or transfers under this policy from the Interest
     Accumulation Account; less (d) the total of all charges from the Interest
     Accumulation Account permitted under the "Charges" provisions.

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     The current value of any Investment Account associated with an Investment
     Fund of the Separate Account on any valuation day on or before the Annuity
     Commencement Date is equal to: (a) the number of accumulation units
     credited to this policy for that Investment Account on that valuation day;
     multiplied by (b) the accumulation unit value for that Investment Fund for
     the valuation period which includes that day.

     Premiums allocated to any Investment Account associated with an Investment
     Fund of the Separate Account will credit this policy with accumulation
     units. On any valuation day when an amount is allocated to, or withdrawn or
     transferred from, such Investment Account, the number of accumulation units
     to be credited to or charged against this policy will be: (a) the amount
     allocated, withdrawn or transferred; divided by (b) the accumulation unit
     value for the specified Investment Fund for the current valuation day. The
     number of accumulation units credited to such Investment Account on any
     valuation day will be: (a) the sum of any accumulation units credited to
     that Investment Account; minus (b) the sum for any accumulation units
     charged against that Investment Account.

TERMINATION OF THIS POLICY. This policy will continue in force provided that the
Accumulation Value of this policy has not been withdrawn in its entirety. The
Company may terminate this policy after the Annuitant has attained age 59 1/2
and before the Annuity Commencement Date by payment of the Accumulation Value of
this policy in one payment to the Owner if: (a) the Accumulation Value is less
than $500; and (b) no premiums have been paid toward this policy for thirty-six
consecutive months (three years). The Company will then be released from further
liability under this policy.

                             DESCRIPTION OF ACCOUNTS

TYPES OF ACCOUNTS. The Company maintains the following Investment Accounts under
this policy.

     INVESTMENT ACCOUNT                              INVESTMENT MEDIUM
     Interest Accumulation Account                   The General Account
     Variable Investment Funds                       Separate Account

The current Variable Investment Funds for this product offering are included in
the variable annuity product prospectus. Please see the current PROSPECTUS HERE.

GENERAL ACCOUNT. All premiums allocated to the Interest Accumulation Account
will become part of the Company's general assets. All premiums allocated to the
Interest Accumulation Account will be credited with interest at the current rate
of interest described below. Such interest will be credited on dates determined
by the Company, but not less frequently than once each calendar month.

The current rate of interest will be: (a) the rate declared from time to time by
the Company for the class of policies to which this policy belongs; or (b) if
the Fixed Amount Option described in this policy is in effect, the rate declared
by the Company for such option as of the date on which the first payment is made
to the beneficiary under such option. In no event will the current rate of
interest be less than a daily rate based on an effective annual rate of 3%.

SEPARATE ACCOUNT. All premiums allocated to the Variable Investment Funds will
become part of the Separate Account. The Company maintains the Separate Account
under the designation of The American Separate Account 5. The Separate Account
is a separate investment account into which a portion of the Company's assets in
connection with this and certain other polices may be allocated. The Separate
Account consists of the following Investment Accounts:

     -    Stock Fund - No longer available.

     -    Money Market Fund - No longer available.

     -    Bond Fund - No longer available.

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     -    Composite Fund - No longer available.

     -    Variable Investment Funds --- The Variable Investment Funds own shares
          of the various fund of the Investment Company that is invested
          primarily in a portfolio of common stocks that are listed on national
          securities exchanges or on the National Association of Securities
          Dealers Automated Quotations; however, amounts may be invested in: (a)
          stocks traded over-the-counter or other equity-related securities; (b)
          foreign equity or equity-type securities traded in U.S. markets; and
          (c) the types of money-market instruments in which the Money Market
          Fund of the Investment Company may invest pending more permanent
          investment or to utilize cash reserves effectively. The Variable
          Investment Funds may also invest in publicly-traded debt securities
          such as: bonds; notes; debentures; and equipment trust certificates.
          Such investments are primarily of the quality of the four highest
          categories according to the ratings of a nationally recognized rating
          service. However, to a lesser extent the fund may be invested in lower
          rated or unrated securities.

The value of the assets in any Variable Investment Fund of the Separate Account
will increase or decrease based upon the investment results of that Investment
Fund during each valuation period.

The assets of each Variable Investment Fund of the Separate Account are the
exclusive property of the Company. The Company will not be considered a trustee
of the assets for the benefit of any person allocating premiums to the Separate
Account. All income, gains and losses of a Variable Investment Fund of the
Separate Account will be credited to or charged against that Variable Investment
Fund without regard to other income, gains or losses of the Company. The assets
of each Variable Investment Fund of the Separate Account are not chargeable with
any liabilities arising out of any other business the Company may conduct.

ACCUMULATION UNITS. Each Variable Investment Fund of the Separate Account is
maintained in accumulation units. Accumulation units will be used to calculate
the value of each Variable Investment Fund of the Separate Account. The number
of accumulation units will change based on any amounts allocated to, or
withdrawn or transferred from, each Variable Investment Fund of the Separate
Account during each valuation period. The number of accumulation units to be
added to or deducted from each Investment Fund at the end of each valuation
period is: (a) the amount allocated, withdrawn or transferred during the present
valuation period, divided by (b) the accumulation unit value for that valuation
period.

ACCUMULATION UNIT VLAUE. Each Variable Investment Fund of the Separate Account
has its own distinct unit value. The value of each accumulation unit was
arbitrarily set at $1.00 when the first investment was made in each Variable
Investment Fund. The accumulation unit value for each Variable Investment Fund
will change for each valuation day based upon the investment results of that
Variable Investment Fund on that valuation day. For any valuation period, the
accumulation unit value is: (a) the accumulation unit value applicable to that
Investment Fund for the preceding valuation period; multiplied by (b) the
accumulation unit value change factor for that Variable Investment Fund for the
current valuation period.

ACCUMULATION UNIT VALUE CHANGE FACTOR. For any valuation period, the
accumulation unit value change factor for each Variable Investment Fund of the
Separate Account is: (a) the ratio of (i) the asset value of the Variable
Investment Fund at the end of the current valuation period before any amounts
are allocated to, or withdrawn or transferred from, that Variable Investment
Fund during that valuation period; to (ii) the asset value of that Variable
Investment Fund at the end of the last valuation period after any change in the
number of accumulation units for that period; divided by (b) 1.00 plus the total
of all charges other than Administrative Charge B, as described under the
"Charges" provisions, for the number of days from the end of the last valuation
period to the end of the current valuation period.

VALUATION DAY AND VALUATION PERIOD. A valuation day for each Variable Investment
Fund of the Separate Account is each day the New York Stock Exchange is open for
business, or any other day on which a share value is declared by the Investment
Company for the Investment Company's shares in which that Variable Investment
Fund is invested. A valuation period will start at the close of business on each
valuation day and will end at the close of business on the next valuation day.

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CHANGES TO SEPARATE ACCOUNT. The Company reserves the right, subject to
compliance with applicable laws and regulations governing separate account
operations; (a) to have the Separate Account invest at any time in any new
Variable Investment Fund offered by the Company; (b) to create additional
separate accounts or combine any two or more separate accounts, including the
Separate Account; (c) to transfer assets determined by the Company to be
attributable to the class of contracts to which the contract belongs from the
Separate Account to another separate account of the Company; and (d) to cause
the registration or deregistration of any of the Company's separate accounts
under the Investment Company Act of 1940.

VALUATION OF ASSETS. The asset value of each Variable Investment Fund of the
Separate Account is the total value of the shares owned in the corresponding
Fund of the Investment Company.

STATEMENT OF ACCOUNTS. Prior to the Annuity Commencement Date, the Company will
send the Owner a statement at least once every three months. The statement will
show for the period covered by the statement: (a) the amount of all premiums
paid under the policy; (b) the interest accrued on any amounts held under this
policy in the Interest Accumulation Account; (c) any amounts held under this
policy under each Investment Account associated with an Investment Fund of the
Separate Account; and (d) the total of all withdrawals or transfers under any
Investment Account. The statement will also show as of the date of the statement
the Accumulation Value available to provide; (a) an annuity benefit; (b) cash
return; or (c) death benefit. The Company will always send a statement showing
the status of each Investment Account at the end of each calendar year.

                                     CHARGES

TYPES AND AMOUNTS OF CHARGES. The amount of each charge which the Company may
deduct under this policy is described below.

     -    ADMINISTRATIVE CHARGES. The Company will deduct the following charges
          incurred for the administration of this policy:

     -    CHARGE A. The company will deduct from each Investment Fund of the
          Separate Account a charge for expenses incurred for marketing and
          administration of this policy and any state or other taxes. This is a
          daily charge expressed as a percentage of the value of the net assets
          in each Investment Fund of the Separate Account at the annual rate
          shown in the Policy Specifications.

     -    CHARGE B. Each month the Company will deduct a charge to reimburse it
          for the administration of this policy. The Company will deduct the
          amount shown in the Policy Specifications from the value of each
          Investment Account in which any portion of the Accumulation Value of
          this policy is held at the end of each calendar month.

     -    MORTALITY RISK CHARGE. The Company will deduct from each Investment
          Fund of the Separate Account a charge to compensate it for assuming
          the mortality risks under this policy. This is a daily charge
          expressed as a percentage of the value of the net assets in each
          Investment Fund of the Separate Account at the annual rate shown in
          the Policy Specifications.

CHANGE IN THE AMOUNT OF CHARGES. The Company reserves the right to: (a) increase
or decrease the Administrative Charges; and (b) decrease the Mortality Risk
Charge.

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                            SPECIFIED PAYMENTS OPTION

ELECTION OF SPECIFIED PAYMENTS OPTION. This option may be elected by the Owner
for monthly payments to the Annuitant at any time before the Annuity
Commencement Date.

The Owner must elect this option on the Company's prescribed form filed at the
Home Office of the Company. Such election must specify the amount to be
withdrawn each month from each Investment Account.

PAYMENT OF SPECIFIED AMOUNT. This option provides monthly payments to the
Annuitant of the specified amount. The amount of each monthly payment will be
the greater of: (a) $100; or (b) the amount specified in the form electing this
option.

Payment of the specified amount will begin on the later of: (a) the date
designated in the election form; or (b) the date the Company receives the
election form. The amount of the specified payment will be deducted from the
Investment Accounts designated in the election form. The value of the designated
Investment Accounts will be reduced each month by the amount of the specified
payment. Payments will continue until the earliest of: (a) the death of the
Annuitant; (b) the date of receipt by the Company of the Owner's request to
cancel this option; (c) the first date on which the value of the designated
Investment Account is depleted; (d) the first date on which the value of the
designated Investment Account is not sufficient to provide payment of the
specified amount; or (e) the Annuity Commencement Date.

No premiums may be made under this policy at any time while this option is in
effect.

At any time before payments cease the Owner has the right to: (a) request a
change in the amount of the monthly payment; or (b) cancel this option.

                            WITHDRAWALS AND TRANSFERS

WITHDRAWALS AND TRANSFERS. At any time before the Annuity Commencement Date the
Owner may: (a) withdraw all or any part of the Accumulation Value of this
policy; or (b) transfer all or any part of the Accumulation Value of this policy
between any of the Investment Accounts. No withdrawal or transfer may be made on
or after the Annuity Commencement Date.

WITHDRAWALS. Any withdrawal under this policy from the Interest Accumulation
Account will result in a decrease in the Accumulation Value of this policy based
on the interest Accumulation Account. Any withdrawal under this policy from any
Investment Account associated with a Variable Investment Fund of the Separate
Account will result in a decrease in the number of accumulation units credited
to this policy for the Investment Account of the Separate Account from which the
withdrawal is made. This policy will continue in force provided that the
Accumulation Value of this policy has not been withdrawn in its entirety.

TRANSFERS. Transfers may be made between any of the Investment Accounts. A
transfer under this policy involving the Interest Accumulation Account will
result in a change in the Accumulation Value of this policy based on the
Interest Accumulation Account. A transfer involving any Investment Account
associated with a Variable Investment Fund of the Separate Account will result
in a change in the number of accumulation units credited to this policy for that
Investment Account.

AMOUNT OF WITHDREAWAL OR TRANSFER. The amount to be withdrawn or transferred may
be designated as: (a) dollar amount; or (b) a number of accumulation units; or
(c) as a percentage of the value of the selected Investment Account. The amount
to be withdrawn or transferred from any Investment Account will be the lesser
of: (a) the amount requested; or (b) the amount in that Investment Account on
the date of payment.

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REQUESTS. All requests for withdrawal or transfer must be in a manner
satisfactory to the Company. A request for any transfer or partial withdrawal
must state which of the Investment Accounts will be affected by the request. All
requests for withdrawal or transfer will be effective on the later of: (a) the
date the Company receives the request; or (b) the date specified in the request.
No request for withdrawal or transfer will be binding until the request and all
information necessary to process the request have been received by the Company.

POSTPONEMENT OF PAYMENTS, WITHDRAWALS OR TRANSFERS. The Company may postpone the
transfer, or payment of any withdrawal, involving the Interest Accumulation
Account for up to six months following the date of request for a transfer or
withdrawal.

The Company will transfer or pay the amount of any withdrawal or benefit
involving any Investment Account associated with a Variable Investment Fund of
the Separate Account within 7 days; except that the Company may defer any such
transfer or payment if: (a) the New York Stock Exchange is closed for other than
usual weekends or holidays; or (b) trading on the Exchange is restricted as
determined by the Securities and Exchange Commission; or (c) an emergency exists
as determined by the Securities and Exchange Commission, whereby: (i) disposing
of securities is not practicable; or (ii) it is not reasonably practicable to
determine the share value of each of the Funds of the Investment Company in
which the Separate Account is invested; or (d) the Securities and Exchange
Commission by order permits postponement for the protection of the interest of
all parties involved in the Separate Account.

                                 ANNUITY OPTIONS

Election of form of annuity. Election of the form of annuity is to be made by
the Owner before the Annuity Commencement Date. Following such election the
Accumulation Value of this policy will be withdrawn by the Company and applied
under one of the forms of annuity described below.

     -    SINGLE PAYMENT. The Accumulation Value will be paid in a single
          payment.

     -    CERTAIN PERIOD AND CONTINUOUS ANNUITY. Annuity payments are payable
          each month during the Annuitant's lifetime. Upon the Annuitant's death
          before the end of the certain period (10 years or 15 years), annuity
          benefits will continue to be paid to the beneficiary until the end of
          such certain period.

     -    JOINT AND SURVIVIOR ANNUITY. 66-2/3% BENEFIT TO JOINT ANNUITANT.
          Annuity payments are payable each month during the Annuitant's
          lifetime. Upon the Annuitant's death, monthly annuity payments equal
          to 66-2/3% of the Annuitant's monthly annuity benefit are payable
          during the lifetime of the Joint Annuitant. If both the Annuitant and
          the Joint Annuitant die before annuity benefits have been paid for ten
          years, annuity payments will continue to be paid each month to the
          beneficiary until the end of such ten-year period. The amount of the
          monthly annuity benefit payable to the beneficiary is the amount of
          the monthly annuity benefit being paid under this policy immediately
          before the date payments to the beneficiary begin.

     -    FULL CASH REFUND ANNUITY. Annuity payments are payable each month
          during the Annuitant's lifetime. Upon the Annuitant's death the
          beneficiary will receive a payment of: (a) the Accumulation Value of
          this policy on the Annuity Commencement Date; less (b) the total of
          all monthly payments made to the Annuitant since the Annuity
          Commencement Date. Payments to the beneficiary may be: (a) in a single
          payment; or (b) as a Ten Years Certain and Continuous Annuity; or (c)
          as a combination of these methods of payments. However, if the
          beneficiary is not the Annuitant's spouse, the only form of payment
          under this provision will be a single sum payment.

     -    OTHER OPTIONS. Any other reasonable from of payments as may be agreed
          to by the Company.

<PAGE>

The table used to purchase annuities: (a) will be the table in effect on the
date of election of payment of benefits; but (b) will not be less than the
annuity purchase rate shown on page 14 of this policy.

If the Company is issuing a single premium immediate annuity on the date of
election of payment, of benefits the Company will: (a) determine if the interest
and mortality tables for the single premium immediate annuity are more
favorable; and (b) use the more favorable table in calculating benefit payments
under this policy.

In no event will the annuity purchase rates be less favorable than those
provided by the Group Annuity Table for 1951 (male): (a) with Projection C to
1971; (b) with ages set back two years for males and seven years for females;
(c) at 3% interest; and (c) an expense loading of 2% of the net premium.

The values and benefits are not less than the minimum values and benefits
required by or pursuant to any federal statute or any statute of the state in
which this policy is delivered.

                              OWNER AND BENEFICIARY

OWNER. The Owner will be the Annuitant unless a different Owner is named in the
application. The Owner has all rights under this policy. If the Owner is an
individual and dies before the Annuitant, all rights of the Owner will belong to
the state or heirs of the Owner unless otherwise provided in the form naming the
Owner.

BENEFICIARY. The Owner may designate, with the right to change such designation,
a beneficiary to receive any benefits payable upon the death of the Annuitant.
The beneficiary is the person or persons named in the application. In a class of
beneficiaries of more than one person, benefits will be paid in equal shares
unless otherwise stated. The term "children", when used to designate a
beneficiary without naming such children, will mean all lawful children,
including legally adopted children.

If no designated beneficiary is living at the time any payments become payable
to the beneficiary under this policy, the Company will pay such benefits to the
first surviving class of the following beneficiaries: (a) to the Annuitant's
surviving spouse; or (b) to the Annuitant's surviving children in equal shares;
or (c) to the Annuitant's surviving parents in equal shares; or (d) to the
Annuitant's surviving brothers and sisters in equal shares; or (e) to the
executor or administrator of the Annuitant's estate.

CHANGE OF OWNER OR BENEFICIARY. The Owner may change the Owner of this policy or
the beneficiary at any time. A change form will be binding only after the change
form has been received and recorded by the Company at its Home Office. The
change will be effective on the date the notice is recorded by the Company
whether or not the Annuitant is living on the date such notice is received. The
Company will not be liable for any payment made before any change has been
received and recorded.

                               GENERAL PROVISIONS

THE CONTRACT. This policy is issued in consideration of the application and the
payment of the first premium. A copy of the application is attached as part of
this policy. This policy, including any application or rider now attached or
later added, constitute the entire contract. This policy will be in force on the
Effective Date if: (a) the first premium has been paid, and (b) this policy has
been issued and delivered to the Owner. This policy may not be changed, nor any
rights or requirements waived or extended, without the written consent of the
Company.

INCONTESTABILITY. After the Date of Issue the Company will not contest this
policy.

MISSTATEMENTS OF AGE. If the age or sex of any payee has been misstated, all
benefits under this policy will be adjusted to the amount of benefit which would
have been purchased at the correct age or under the correct sex. The amount of
any underpayment or overpayment will be calculated with interest at the rate of
6% per year. The amount of any overpayments by the company, plus interest, will
be

<PAGE>

deducted from the next payments made under this policy. The dollar amount of any
underpayments, plus interest, will be added in a single sum to the next payment
made under this policy.

ASSIGNMENT. The Owner may assign this policy. No assignment may be binding until
it has been received and recorded by the Company at its Home Office. It will not
apply to any payment made before the assignment was recorded. The Company will
not be responsible for its validity.

An assignment will not, and an assignee cannot, change the beneficiary. The
rights of the beneficiary will be subject to the rights of any assignee. An
assignment is not a change in Owner. An assignee is not an Owner as used in this
policy.

CHANGES TO THIS POLICY. No change to this policy will be valid without the
written consent of the Company. No change will affect any benefits which became
payable prior to the effective date of such change.

SURVIVAL OF PAYEE. Proof acceptable to the Company may be required to establish
that any payee is living on any date a benefit is payable under this policy.
Such proof may be by personal endorsement of the check drawn for payment or by
any other means acceptable to the Company.

CLAIMS OF CREDITORS. To the extent permitted by law, no payment by the Company
under this policy will be subject to: (a) the claims of any creditors; (c)
alienation; (c) attachment; (d) garnishment; or (e) levy (other than a Federal
tax levy in accordance Section 6331 of the Internal Revenue Code); (f)
execution; or (g) other legal process. Also, no payment will be subject to any
legal process to enforce any such claim.

CORRESPONDENCE. Any request, change, notice or proof must be received and
recorded at the Home Office of the Company. Receipt will be deemed to take place
on the business day such information is received by the Company at its Home
Office.

REQUIRED INFORMATION. The Owner must furnish the Company with any facts and
information that may be required for the operation of this policy. Such
information may be the original or photocopy of any pertinent records. The
Company will be fully protected in relying upon the information furnished, even
if the Company does not inquire as to the accuracy or completeness of such
information.

NON-WAIVER. The Company's rights under this policy will not be reduced or denied
due to its failure to perform or insist upon the strict performance of ay
provision or condition of this policy.

<PAGE>

                             TABLE OF RATES (MALES)

The following table shows the amount of monthly annuity benefits provided by
each $1,000 of Accumulation Value at the age of the payee on the date payments
begin.
<TABLE>
<CAPTION>
--------------------------------------------------------------------------------------------------------------------
               CERTAIN PERIOD AND                                            JOINT AND SURVIVOR ANNUITY
               CONTINUOUS ANNUITY                                         66 2/3% BENEFIT TO JOINT ANNUITANT
               ------------------                                         ----------------------------------

                                                            AGES OF ANNUITANT AND
                                                            JOINT ANNUITANT ON THE
                                                            ANNUITY COMMENCEMENT DATE
                                                            -------------------------

                  10 YEARS        15 YEARS
                  --------        --------                                                AMOUNT OF      AMOUNT OF
                                                                                           MONTHLY        MONTHLY
                  AMOUNT OF       AMOUNT OF                                 AGE          ANNUITY AT      ANNUITY TO
                   MONTHLY         MONTHLY               AGE OF            JOINT          AGE 65 OF        JOINT
     AGE           ANNUITY         ANNUITY              ANNUITANT        ANNUITANT        ANNUITANT      ANNUITANT
     ---           -------         -------              ---------        ---------        ---------      ---------
<S>               <C>             <C>                   <C>              <C>             <C>            <C>
      59            $5.18           $4.98                   65              59             $4.91           $3.27
      60             5.30            5.07                   65              60              4.97            3.31
      61             5.44            5.17                   65              61              5.02            3.35
      62             5.57            5.27                   65              62              5.08            3.39
      63             5.72            5.38                   65              63              5.14            3.43
      64             5.87            5.48                   65              64              5.20            3.47

      65             6.02            5.58                   65              65              5.26            3.51
      66             6.19            5.69                   65              66              5.32            3.55
      67             6.35            5.79                   65              67              5.37            3.58
      68             6.53            5.89                   65              68              5.43            3.62
      69             6.70            5.98                   65              69              5.49            3.66
      70             6.89            6.07                   65              70              5.55            3.70

      71             7.07            6.16                   65              71              5.60            3.73
      72             7.26            6.24
      73             7.44            6.31
      74             7.63            6.38
      75             7.81            6.44
--------------------------------------------------------------------------------------------------------------------
</TABLE>

                            FULL CASH REFUND ANNUITY
<TABLE>
<CAPTION>

                  AMOUNT                   AMOUNT                            AMOUNT                       AMOUNT
                OF MONTHLY               OF MONTHLY                        OF MONTHLY                   OF MONTHLY
     AGE          ANNUITY        AGE       ANNUITY           AGE             ANNUITY        AGE           ANNUITY
     ---          -------        ---       -------           ---             -------        ---           -------
<S>             <C>              <C>     <C>                 <C>           <C>              <C>         <C>
      59          $4.79           64       $5.34              69             $6.05           74           $6.96
      60           4.88           65        5.46              70              6.21           75            7.18
      61           4.99           66        5.60              71              6.39           76            7.40
      62           5.10           67        5.74              72              6.57           77            7.63
      63           5.21           68        5.89              73              6.76           78            7.87
--------------------------------------------------------------------------------------------------------------------
</TABLE>

The amount of monthly annuity benefit provided by these tables is based on the
guaranteed interest rate of 3% per year. If a higher amount of interest is
declared by the Company, the amount of each monthly annuity benefit will be
increased.

The Company will calculate amounts for ages and other forms of annuities not
shown. These calculations will be based on the same actuarial assumptions. Such
information will be furnished upon request.

<PAGE>

                            TABLE OF RATES (FEMALES)

The following table shows the amount of monthly annuity benefits provided by
each $1,000 of Accumulation Value at the age of the payee on the date payments
begin.

<TABLE>
<CAPTION>
--------------------------------------------------------------------------------------------------------------------
               CERTAIN PERIOD AND                                            JOINT AND SURVIVOR ANNUITY
               CONTINUOUS ANNUITY                                         66 2/3% BENEFIT TO JOINT ANNUITANT
               ------------------                                         ----------------------------------

                                                            AGES OF ANNUITANT AND
                                                            JOINT ANNUITANT ON THE
                                                            ANNUITY COMMENCEMENT DATE
                                                            -------------------------

                    10 YEARS        15 YEARS
                    --------        --------                                              AMOUNT OF      AMOUNT OF
                                                                                           MONTHLY        MONTHLY
                    AMOUNT OF       AMOUNT OF                               AGE          ANNUITY AT      ANNUITY TO
                     MONTHLY         MONTHLY             AGE OF            JOINT          AGE 65 OF        JOINT
     AGE             ANNUITY         ANNUITY            ANNUITANT        ANNUITANT        ANNUITANT      ANNUITANT
     ---             -------         -------            ---------        ---------        ---------      ---------
<S>                 <C>             <C>                 <C>              <C>             <C>             <C>
      59             $4.64            $4.53                 65               59             $4.80           $3.20
      60              4.74             4.61                 65               60              4.84            3.23
      61              4.84             4.70                 65               61              4.88            3.25
      62              4.95             4.79                 65               62              4.92            3.28
      63              5.06             4.88                 65               63              4.96            3.31
      64              5.18             4.98                 65               64              4.99            3.33

      65              5.30             5.07                 65               65              5.03            3.35
      66              5.44             5.17                 65               66              5.06            3.37
      67              5.57             5.27                 65               67              5.09            3.39
      68              5.72             5.38                 65               68              5.13            3.42
      69              5.87             5.48                 65               69              5.16            3.44
      70              6.02             5.58                 65               70              5.18            3.45

      71              6.19             5.69                 65               71              5.21            3.47
      72              6.35             5.79
      73              6.53             5.89
      74              6.70             5.98
      75              6.89             6.07
--------------------------------------------------------------------------------------------------------------------
</TABLE>
                            FULL CASH REFUND ANNUITY

<TABLE>
<CAPTION>
                  AMOUNT                   AMOUNT                            AMOUNT                       AMOUNT
                OF MONTHLY               OF MONTHLY                        OF MONTHLY                   OF MONTHLY
     AGE          ANNUITY        AGE       ANNUITY           AGE             ANNUITY        AGE           ANNUITY
     ---          -------        ---       -------           ---             -------        ---           -------
<S>             <C>              <C>     <C>                 <C>           <C>              <C>         <C>
      59           $4.78          64       $5.32              69             $6.02           74           $6.94
      60            4.88          65        5.45              70              6.19           75            7.12
      61            4.98          66        5.58              71              6.37           76            7.35
      62            5.09          67        5.72              72              6.53           77            7.59
      63            5.21          68        5.87              73              6.73           78            7.79
--------------------------------------------------------------------------------------------------------------------
</TABLE>

The amount of monthly annuity benefit provided by these tables is based on the
guaranteed interest rate of 3% per year. If a higher amount of interest is
declared by the Company, the amount of each monthly annuity benefit will be
increased.

The Company will calculate amounts for ages and other forms of annuities not
shown. These calculations will be based on the same actuarial assumptions. Such
information will be furnished upon request.

<PAGE>

                           TABLE OF GUARANTEED VALUES

The Table of Guaranteed Accumulation Values shown below illustrates the
guaranteed accumulation value that would apply to an Annuitant on each
anniversary of Issue Age, as hereinafter defined, if (a) $100 has been remitted
under this policy at the beginning of each month on and after said Issue Age,
and (b) such remittances had been accumulated in the Interest Accumulation
Account at an interest rate of 3% per year.

The term "Issue Age" as used in the preceding paragraph means the age of an
Annuitant at the date of the first remittance made under this policy.

<TABLE>
<CAPTION>
    ANNIVERSARY          GUARANTEED          ANNIVERSARY          GUARANTEED
     OF ISSUE           ACCUMULATION          OF ISSUE           ACCUMULATION
       AGE                  VALUE                AGE                 VALUE
--------------------------------------------------------------------------------
<S>                     <C>                  <C>                 <C>
        1                $1,219.41               26                $47,012.04
        2                 2,475.41               27                 49,641.82
        3                 3,769.08               28                 52,350.08
        4                 5,101.56               29                 55,140.41
        5                 6,474.02               30                 58,014.03

        6                 7,887.66               31                 60,973.87
        7                 9,343.70               32                 64,022.49
        8                10,843.42               33                 67,162.58
        9                12,388.14               34                 70,396.87
       10                13,979.19               35                 73,728.19

       11                15,617.98               36                 77,159.45
       12                17,305.93               37                 80,693.64
       13                19,044.52               38                 84,333.66
       14                20,835.27               39                 88,083.29
       15                22,679.74               40                 91,945.20

       16                24,579.54               41                 95,922.97
       17                26,536.34               42                100,020.07
       18                28,551.84               43                104,240.09
       19                30,627.81               44                108,586.70
       20                32,766.06               45                113,063.71

       21                34,968.45               46                117,675.04
       22                37,236.92               47                122,424.70
       23                39,573.44               48                127,316.86
       24                41,980.05               49                132,355.77
       25                44,458.86               50                137,545.86

</TABLE>