<PAGE>

                                 CONTRACT DATA

<TABLE>
<S>                         <C>             <C>                <C>
Contract Number:            [9920-SAMPLE]   Contract Date:     [November 1, 2004]
Initial Purchase Payment:   [$25,000]       Retirement Date:   [November 1, 2044]
Annuitant:                  [John Doe]      Contract Type:     [Non-Qualified]
Contract Owner:             [John Doe]
</TABLE>

Upon issuance of this contract your initial purchase payment has been as shown
below. You may make additional payments and change the purchase payment
allocation as provided in this contract. Refer to the Purchase Payments
Provision.

<TABLE>
<CAPTION>
                                                                     Purchase
                                                                      Payment
                                                                    Allocation
Allocation                                                          Percentage
<S>                                                                   <C>
ACL One Year Fixed Account                                            [___%
[AXP(R) VP - Cash Management Fund                                      ___%
AXP(R) VP - Diversified Equity Income Fund                             ___%
AXP(R) VP - Equity Select Fund                                         ___%
AXP(R) VP - High Yield Bond Fund                                       ___%
AXP(R) VP - New Dimensions Fund(R)                                     ___%
AXP(R) VP - Partners Small Cap Value Fund                              ___%
AXP(R) VP - S & P 500 Index Fund                                       ___%
AIM V.I. Basic Value Fund, Series II Shares                            ___%
AIM V.I. Capital Development Fund, Series II Shares                    ___%
AIM V.I. Mid Cap Core Equity Fund, Series II Shares                    ___%
AllianceBernstein VP Growth and Income Portfolio (Class B)             ___%
AllianceBernstein VP International Value Portfolio (Class B)           ___%
AllianceBernstein VP Total Return Portfolio (Class B)                  ___%
American Century(R) VP Inflation Protection, Class II                  ___%
American Century(R) VP Ultra, Class II                                 ___%
American Century(R) VP Value, Class II                                 ___%
Colonial Small Cap Value Fund, Variable Series, Class B                ___%
Columbia High Yield Fund, Variable Series, Class B                     ___%
Dreyfus VIF Appreciation Portfolio - Service Share Class               ___%
Dreyfus VIF International Value Portfolio - Service Share Class        ___%
Dreyfus VIF Midcap Stock Portfolio - Service Share Class               ___%
Fidelity VIP Contrafund(R) Portfolio Service Class 2                   ___%
Fidelity VIP Growth Portfolio Service Class 2                          ___%
Fidelity VIP Investment Grade Bond Fund Service Class 2                ___%
Fidelity VIP Mid Cap Portfolio Service Class 2                         ___%
Fidelity VIP Overseas Portfolio Service Class 2 ]                      ___%]
[FTVIPT Franklin Income Securities Fund - Class 2                     [___%
FTVIPT Franklin Rising Dividends Securities Fund - Class 2             ___%
FTVIPT Franklin Small Cap Fund - Class 2                               ___%
FTVIPT Mutual Shares Securities Fund - Class 2                         ___%
FTVIPT Templeton Global Income Fund - Class 2                          ___%
FTVIPT Templeton Growth Securuties Fund  - Class 2                     ___%
Goldman Sachs VIT Mid Cap Value Fund                                   ___%
MFS(R) New Discovery Series - Service Class                            ___%
MFS(R) Total Return Series - Service Class                             ___%
MFS(R) Utilities Series - Service Class                                ___%
Oppenheimer Capital Appreciation Fund/VA, Service Shares               ___%
Oppenheimer Global Securities Fund/VA, Service Shares                  ___%
Oppenheimer Main Street Small Cap Fund/VA, Service Shares              ___%
Oppenheimer Strategic Bond Fund/VA, Service Shares                     ___%
Putnam VT Health Sciences Fund -  Class IB Shares                      ___%
Putnam VT International Equity Fund - Class IB Shares                  ___%
Putnam VT Small Cap Value Fund - Class IB Shares                       ___%
Putnam VT Vista Fund - Class IB Shares                                 ___%
Van Kampen LIT Comstock Portfolio Class II Shares                      ___%
Van Kampen UIF U.S. Real Estate Portfolio, Class II Shares             ___%
Wanger International Small Cap                                         ___%
Wanger US Smaller Companies]                                           ___%]

[ ] Text prints if a Portfolio Navigator model is elected
</TABLE>

<TABLE>
<S>                                                     <C>                               <C>
[PORTFOLIO NAVIGATOR ASSET ALLOCATION MODEL PORTFOLIO   [CONSERVATIVE MODEL           ]   Applicable model prints
                                                        [MODERATELY CONSERVATIVE MODEL]   Applicable model prints
                                                        [MODERATE MODEL               ]   Applicable model prints
                                                        [MODERATELY AGGRESSIVE MODEL  ]   Applicable model prints
                                                        [AGGRESSIVE MODEL             ]   Applicable model prints
</TABLE>


272877-NYDPE                                                         Page 2[.0]

<PAGE>

                           CONTRACT DATA - Continued

<TABLE>
<S>                <C>             <C>              <C>
Contract Number:   [9920-SAMPLE]   Contract Date:   [November 1, 2004]
</TABLE>

[ ] Text prints if a Portfolio Navigator model is elected

[

o     You may not use more than one asset allocation model portfolio at a
      time.

o     You are allowed to request a change to another asset allocation model
      portfolio twice per contract year.

o     You may discontinue participation in the asset allocation program at any
      time by written notice, but cannot elect to participate in the program
      again until nine months after the date you discontinue participation.
      However, if you've elected either the Guarantor(SM) Withdrawal Benefit
      rider or one of the Income Assurer Benefit(SM) riders, you may not
      discontinue participation as long as the rider is in effect.

o     American Centurion Life Assurance Company (ACL) may change the terms and
      conditions of the asset allocation program upon written notice to you.
      If permitted under applicable securities law, ACL may: (1) automatically
      reallocate your current asset allocation model portfolio to an updated
      version of your current asset allocation model portfolio; or, reallocate
      your current asset allocation model portfolio to an updated version of
      your current asset allocation model portfolio with your consent.

o     ACL may discontinue, with 30 days' written notice, the asset allocation
      program for those who elect to participate in it while maintaining the
      asset allocation program, or a similar program, for contract owners who
      have selected an optional Guarantor(SM) Withdrawal Benefit rider or
      Income Assurer Benefit(SM) rider. ]

[ ] Text prints if applicant elects the seven year withdrawal charge schedule

                           [Purchase Payment Credits

<TABLE>
<CAPTION>
         Cumulative Net Purchase Payment Amount   Net Purchase Payment Credit Percentage
         --------------------------------------   --------------------------------------
<S>                                                                 <C>
                    [$0  -  $99,999                                 [1%
                      $100,000 +]                                    1%]
</TABLE>

Purchase payment credits shall be reversed from the contract value for
exercise of the Right to Examine Contract (Free-look) provision or for any
purchase payment that is not honored.]

<TABLE>
<S>                                            <C>
[Death Benefit:  Return of Purchase Payment]   Applicable Death Benefit prints
[Death Benefit:  Maximum Anniversary Value]    Applicable Death Benefit prints
</TABLE>

[ ] Text prints if GMWB rider elected

<TABLE>
<S>                                            <C>
[Guaranteed Minimum Withdrawal Benefit Rider

Initial Annual Charge of [0.55%].              Range is .25% to 2.50%

The maximum RBA and GBA is [$5,000,000].       Range is $0 to $5,000,000

Maximum Annual Charge of [1.50%].              Range is .25% to 2.50%
</TABLE>

o     This rider requires participation in an Asset Allocation Model. There is
      no additional charge for such participation. You may not discontinue
      participation in the asset allocation program as long as the rider is in
      effect, however you have the right at all times to make a full
      withdrawal of your contract value and thus, terminate your contract.

o     Because the Guarantor(SM) Withdrawal Benefit requires that your contract
      value be invested in one of the asset allocation model portfolios for
      the life of the contract, and you cannot terminate the Guarantor(SM)
      Withdrawal Benefit rider once you have selected it, you must terminate
      your contract by requesting a full withdrawal if you do not want to
      participate in any of the asset allocation model portfolios. Withdrawal
      charges and tax penalties may apply. Therefore, you should not select
      the Guarantor(SM) Withdrawal Benefit rider if you do not intend to
      continue participating in one of the asset allocation model portfolios
      for the life of the contract.

o     Rider charges may vary by asset allocation model selection and will
      change if you change your asset allocation model to one for which the
      price is higher. Rider charges will change if you elect to Step-up the
      Remaining Benefit Amount (RBA) and the charge for new riders is higher.
      Rider charges will never exceed the Maximum Annual Charge shown above.]


272877-NYDPE                                                       Page 2[.1 ]

<PAGE>

                           CONTRACT DATA - Continued

<TABLE>
<S>                <C>             <C>              <C>
Contract Number:   [9920-SAMPLE]   Contract Date:   [November 1, 2004]
</TABLE>

[ ] Text prints if GMWB rider elected and the Contract Type is Tax-Qualified

[FOR TAX-QUALIFIED CONTRACTS: The benefit provided by the optional
Guarantor(SM) Withdrawal Benefit rider may have limited usefulness in
contracts funding tax-qualified programs because partial withdrawals made to
satisfy minimum distribution rules might result in a dollar-for-dollar or
proportional reduction in the benefit base, and because you may be unable to
exercise the benefit altogether. If you plan to exercise the benefit before or
after your required minimum distribution date, you should consulted your tax
advisor to consider whether the benefit is appropriate for your
circumstances.]

[ ] Text prints if MAV GMIB rider elected

<TABLE>
<S>                                        <C>
[Guaranteed Minimum Income Benefit Rider
(Maximum Anniversary Value Benefit Base)

Initial Annual Charge of [0.30%].          Range is .10% to 2.50%

Maximum Annual Charge of [1.50%].          Range is .10% to 2.50%
</TABLE>

o     This rider requires participation in an Asset Allocation Model. There is
      no additional charge for such participation.

o     You may not discontinue your participation in the asset allocation
      program as long as your rider is in effect, however you have the right
      at all times to make a full withdrawal of your contract value and thus,
      terminate your contract.

o     You may terminate the Income Assurer Benefit(SM) rider during a 30-day
      period after the first rider anniversary and at any time after the
      expiration of the waiting period.

o     Because the Income Assurer Benefit(SM) requires that your contract value
      be invested in one of the asset allocation model portfolios as long as
      the rider is in effect, and you cannot terminate the Income Assurer
      Benefit(SM) rider during the first contract year, nor between the 30-day
      period after the first rider anniversary and the expiration of the
      waiting period, you must terminate your contract by requesting a full
      withdrawal if you do not want to participate in any of the asset
      allocation model portfolios during those time periods. Withdrawal
      charges and tax penalties may apply. Therefore, you should not select
      the Income Assurer Benefit(SM) rider if you do not intend to continue
      participating in one of the asset allocation model portfolios during the
      period of time the Income Assurer Benefit(SM) is in effect.

o     Rider charges may vary by asset allocation model selection and will
      change if you change your asset allocation model to one for which the
      price is higher. Rider charges will never exceed the Maximum Annual
      Charge shown above. Your waiting period will restart if you elect to
      change your asset allocation model to one that causes the rider charge
      to increase more than 0.20% whenever the remaining waiting period just
      prior to the change is less than three years.

Excluded payments are purchase payments and purchase payment credits (if
applicable) paid in the last five years before exercise of the benefit. These
payments are excluded from the calculation of the Guaranteed Income Benefit
Base whenever they total $50,000 or more or if they are 25% or more of total
purchase payments and purchase payment credits (if applicable) paid into the
contract.]

[ ] Text prints if 5% Accum GMIB rider elected

<TABLE>
<S>                                        <C>
[Guaranteed Minimum Income Benefit Rider
(5% Accumulation Benefit Base)

Initial Annual Charge of [0.60%].          Range is .25% to 2.75%

Maximum Annual Charge of [1.75%].          Range is .25% to 2.75%
</TABLE>


272877-NYDPE                                                      Page 2[.2 ]

<PAGE>

                           CONTRACT DATA - Continued

<TABLE>
<S>                <C>             <C>              <C>
Contract Number:   [9920-SAMPLE]   Contract Date:   [November 1, 2004]
</TABLE>

o     This rider requires participation in an Asset Allocation Model. There is
      no additional charge for such participation.

o     You may not discontinue your participation in the asset allocation
      program as long as your rider is in effect, however you have the right
      at all times to make a full withdrawal of your contract value and thus,
      terminate your contract.

o     You may terminate the Income Assurer Benefit(SM) rider during a 30-day
      period after the first rider anniversary and at any time after the
      expiration of the waiting period.

o     Because the Income Assurer Benefit(SM) requires that your contract value
      be invested in one of the asset allocation model portfolios as long as
      the rider is in effect, and you cannot terminate the Income Assurer
      Benefit(SM) rider during the first contract year, nor between the 30-day
      period after the first rider anniversary and the expiration of the
      waiting period, you must terminate your contract by requesting a full
      withdrawal if you do not want to participate in any of the asset
      allocation model portfolios during those time periods. Withdrawal
      charges and tax penalties may apply. Therefore, you should not select
      the Income Assurer Benefit(SM) rider if you do not intend to continue
      participating in one of the asset allocation model portfolios during the
      period of time the Income Assurer Benefit(SM) is in effect.

o     Rider charges may vary by asset allocation model selection and will
      change if you change your asset allocation model to one for which the
      price is higher. Rider charges will never exceed the Maximum Annual
      Charge shown above. Your waiting period will restart if you elect to
      change your asset allocation model to one that causes the rider charge
      to increase more than 0.20% whenever the remaining waiting period just
      prior to the change is less than three years.

Excluded payments are purchase payments and purchase payment credits (if
applicable) paid in the last five years before exercise of the benefit. These
payments are excluded from the calculation of the Guaranteed Income Benefit
Base whenever they total $50,000 or more or if they are 25% or more of total
purchase payments and purchase payment credits (if applicable) paid into the
contract.

Excluded investment options from the variable account floor are: [AXP Cash
Management Fund and the Fixed Account, if applicable.] These very conservative
investment options typically have low returns or/and are separately
guaranteed.]

[ ] Text prints if Enhanced GMIB rider elected

<TABLE>
<S>                                             <C>
[Guaranteed Minimum Income Benefit Rider
(Greater of Maximum Anniversary Value Benefit
Base and 5% Accumulation Benefit Base)

Initial Annual Charge of [0.65%].               Range is .30% to 3.00%

Maximum Annual Charge of [2.00%].               Range is .30% to 3.00%
</TABLE>

o     This rider requires participation in an Asset Allocation Model. There is
      no additional charge for such participation.

o     You may not discontinue your participation in the asset allocation
      program as long as your rider is in effect, however you have the right
      at all times to make a full withdrawal of your contract value and thus,
      terminate your contract.

o     You may terminate the Income Assurer Benefit(SM) rider during a 30-day
      period after the first rider anniversary and at any time after the
      expiration of the waiting period.

o     Because the Income Assurer Benefit(SM) requires that your contract value
      be invested in one of the asset allocation model portfolios as long as
      the rider is in effect, and you cannot terminate the Income Assurer
      Benefit(SM) rider during the first contract year, nor between the 30-day
      period after the first rider anniversary and the expiration of the
      waiting period, you must terminate your contract by requesting a full
      withdrawal if you do not want to participate in any of the asset
      allocation model portfolios during those time periods. Withdrawal
      charges and tax penalties may apply. Therefore, you should not select
      the Income Assurer Benefit(SM) rider if you do not intend to continue
      participating in one of the asset allocation model portfolios during the
      period of time the Income Assurer Benefit(SM) is in effect.

o     Rider charges may vary by asset allocation model selection and will
      change if you change your asset allocation model to one for which the
      price is higher. Rider charges will never exceed the Maximum Annual
      Charge shown above. Your waiting period will restart if you elect to
      change your asset allocation model to one that causes the rider charge
      to increase more than 0.20% whenever the remaining waiting period just
      prior to the change is less than three years.


272877-NYDPE                                                       Page 2[.3 ]

<PAGE>

                           CONTRACT DATA - Continued

<TABLE>
<S>                <C>             <C>              <C>
Contract Number:   [9920-SAMPLE]   Contract Date:   [November 1, 2004]
</TABLE>

Excluded payments are purchase payments and purchase payment credits (if
applicable) paid in the last five years before exercise of the benefit. These
payments are excluded from the calculation of the Guaranteed Income Benefit
Base whenever they total $50,000 or more or if they are 25% or more of total
purchase payments and purchase payment credits (if applicable) paid into the
contract.

Excluded investment options from the variable account floor: [AXP Cash
Management Fund and the Fixed Account, if applicable.] These very conservative
investment options typically have low returns or/and are separately
guaranteed.]

[ ] Text prints if MAV or 5% Accum or Enhanced GMIB rider elected and the
    Contract Type is Tax-Qualified

[FOR TAX-QUALIFIED CONTRACTS: The benefit provided by the optional Income
Assurer Benefit(SM) rider may have limited usefulness in contracts funding
tax-qualified programs because partial withdrawals made to satisfy minimum
distribution rules might result in a dollar-for-dollar or proportional
reduction in the benefit base, and because you may be unable to exercise the
benefit altogether. If you plan to exercise the benefit before or after your
required minimum distribution date, you should consulted your tax advisor to
consider whether the benefit is appropriate for your circumstances.]

[ ] Applicable seven year or five year withdrawal charge schedule text prints
    depending on applicant election

Withdrawal Charge: If you withdraw all or a portion of this contract, a
withdrawal charge may apply. A withdrawal charge applies if all or part of the
contract value withdrawn is from payments received during the [seven/five]
years before withdrawal.

<TABLE>
<CAPTION>
         Years From Purchase Payment Receipt        Withdrawal Charge
         -----------------------------------        -----------------------------------
<S>                                                 <C>
                       [1                           8.0% of purchase payment withdrawn
                        2                           8.0% of purchase payment withdrawn
                        3                           7.0% of purchase payment withdrawn
                        4                           7.0% of purchase payment withdrawn
                        5                           6.0% of purchase payment withdrawn
                        6                           5.0% of purchase payment withdrawn
                        7                           3.0% of purchase payment withdrawn
                        8 +                         0.0% of purchase payment withdrawn]
                                     OR
                        [1                          8.0% of purchase payment withdrawn
                        2                           7.0% of purchase payment withdrawn
                        3                           6.0% of purchase payment withdrawn
                        4                           4.0% of purchase payment withdawn
                        5                           2.0% of purchase payment withdrawn
                        6 +                         0.0% of purchase payment withdrawn]
</TABLE>

You may withdraw the greater of 10 percent of your prior contract anniversary
contract value or contract earnings each contract year without incurring a
withdrawal charge. Refer to the Withdrawal Charge Provision.


272877-NYDPE                                                       Page 2[.4 ]

<PAGE>

                           CONTRACT DATA - Continued

<TABLE>
<S>                <C>             <C>              <C>
Contract Number:   [9920-SAMPLE]   Contract Date:   [November 1, 2004]
</TABLE>

<TABLE>
<S>                                              <C>
Annual Mortality and Expense Risk Charge:        [1.00% - 1.55%] of the daily net asset value

                                                    [The M&E's that will print are:
                                                    Tax-qualified - 7 year withdrawal charge - ROP = 1.00%
                                                    Tax-qualified - 7 year withdrawal charge - MAV = 1.20%
                                                    Tax-qualified - 5 year withdrawal charge - ROP = 1.20%
                                                    Tax-qualified - 5 year withdrawal charge - MAV = 1.40%
                                                    Non-qualified - 7 year withdrawal charge - ROP = 1.15%
                                                    Non-qualified - 7 year withdrawal charge - MAV = 1.35%
                                                    Non-qualified - 5 year withdrawal charge - ROP = 1.35%
                                                    Non-qualified - 5 year withdrawal charge - MAV = 1.55%]
</TABLE>

Annual Variable Account Administrative Charge: 0.15% of the daily net asset
value

With the combined subaccount charges of [1.7%], the smallest rate of
investment return required to ensure that the dollar amount of variable
annuity payments does not decrease is [5.2%] for the subaccounts of the
separate account based on an assumed interest rate of 3.5%.

<TABLE>
<S>                                                 <C>     <C>
[The %'s that will print above are:
Tax-qualified - 7 year withdrawal charge - ROP =    1.15%   4.65%
Tax-qualified - 7 year withdrawal charge - MAV =    1.35%   4.85%
Tax-qualified - 5 year withdrawal charge - ROP =    1.35%   4.85%
Tax-qualified - 5 year withdrawal charge - MAV =    1.55%   5.50%
Non-qualified - 7 year withdrawal charge - ROP =    1.30%   4.80%
Non-qualified - 7 year withdrawal charge - MAV =    1.50%   5.00%
Non-qualified - 5 year withdrawal charge - ROP =    1.50%   5.00%
Non-qualified - 5 year withdrawal charge - MAV =    1.70%   5.20%]
</TABLE>

<TABLE>
<S>                                         <C>
Annual Contract Administrative Charge:      $40, waived at contract values of $50,000 or more
                                            See Contract Administrative Charge provision

The Maximum Total Purchase Payment:         $1,000,000

The Minimum Additional Purchase Payment:    $100
</TABLE>

<TABLE>
<S>                                                                <C>
Fixed Account Guaranteed Minimum Effective Annual Interest Rate:   [1.5]%
</TABLE>

      As of the date this contract was issued, any purchase payments and
      purchase payment credits allocated to the One Year Fixed Account will
      earn interest, for the first year, at the annual effective rate of
      [xx]%. New rates will be declared from time to time.

      [ ] Text prints if Special DCA is then offered by ACL and is elected by
          contract owner

      [As of the date this contract was issued, any purchase payments
      allocated to the Special DCA fixed account will earn interest at the
      annual effective rate of [xx]% for the 6-month option and [xx]% for the
      12-month option. New rates will be declared from time to time.]


272877-NYDPE                                                       Page 2[.5 ]

<PAGE>

                           CONTRACT DATA - Continued

<TABLE>
<S>                <C>             <C>              <C>
Contract Number:   [9920-SAMPLE]   Contract Date:   [November 1, 2004]
</TABLE>

Fixed Account Purchase Payment and Transfer Limits:

   1. Payments to the Fixed Account:

      Limited to [30%] of each payment.

   2. Transfers to the Fixed Account:

      Limited to transfer amounts which result in the Fixed Account Contract
      Value (after the transfer) being no more than [30%] of the total
      Contract Value.

   3. Transfers (including automated transfers under a dollar cost averaging
      arrangement) from the Fixed Account:

      Limited to the greater of:

         a. $10,000; or

         b. [30%] of the Fixed Account Contract Value at the beginning of the
            contract year.

We may decrease the above percentage limits. We will provide 30 days advance
written notification if we do so, and will notify you in writing when the
restrictions are lifted.


272877-NYDPE                                                       Page 2[.6 ]