Contract Schedule










	
Owner:

	
[John Doe]

	
Contract Number:

	
[??687456]


	
[Joint Owner:

	
[Jane Doe]]

	
Issue Date:

	
[04/15/10]


	
Annuitant:

	
[John Doe]

	
Scheduled Annuity Date:

	
[04/01/65]


	
Determining Life (Lives):

	
[John Doe]

	
Maximum Issue Age:

	
[80]


	 	
[Jane Doe]

	 	 








	
Purchase Payments

	 
	
Initial Purchase Payment:

	
$[10,000.00]


	
Minimum Additional Purchase Payment:

	
$[50.00]


	
Maximum Total Purchase Payments:

	
$[1 million; higher amounts may be accepted with our approval]


	 	 
	
Transfers

	 
	
Number of Free Transfers Permitted:

	
[12] each Contract Year


	
Transfer Fee:

	
$[25.00] for each transfer in excess of the free transfers permitted


	
Transfer Index Anniversary:

	
Every [Sixth] Index Anniversary


	 	 
	
Contract Charges

	 
	
Product Fee:

	
[0.25]%


	
Contract Maintenance Charge:

	
$[50.00] each Contract Year


	
Designated Amount:

	
Contract Value must be $[100,000.00] to waive the Contract Maintenance Charge


	 	 
	
Withdrawals

	 
	
Minimum Partial Withdrawal:

	
$[100.00]


	
Minimum Required Value:

	
$[2,000.00]


	
Free Withdrawal Amount:

	
[10]% of total Purchase Payments


	
Only Withdrawals from the Index Options are counted towards the Free Withdrawal Amount.

	 








Withdrawal Charge Percentages Table







	 	
Number of Complete Years Since Receipt of Purchase Payment

	
Charge

	 	
 


 


	 	 [0	 	6.50% 	 	
 


	 	 1	 	 6.00%	 	
 


	 	 2	 	 5.00%	 	
 


	 	 3	 	 4.00%	 	
 


	 	 4	 	 3.00%	 	
 


	 	 5	 	 2.00%	 	
 


	
6 years or more

	
0%]


 

	 



The Withdrawal Charge applies only to the Index Options. The Variable Options are not subject to a Withdrawal Charge.







	
Annuity Payments

	 
	
Minimum Annuity Payment:

	
$[100.00]


	
Annuity Mortality Table:

	
[Annuity 2000 Mortality Table]


	
Minimum Annual Annuity Payment Rate:

	
[1.00]%


	 	 



Riders:


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



















S40875-01-ADV 3

























Guaranteed Purchase Rate Table


Upon request, we will furnish rates for ages and guaranteed periods not shown.







	
Annuity Options - Guaranteed monthly annuity payments per $1,000


 


	 	
Option 1

	
Option 2

	
Option 3

	
Option 4

	
Option 5


	 	 	
10-year guaranteed period

	
20-year guaranteed period

	
100% joint and survivor

	
10-year guaranteed period

	 
	
Age on


Annuity Date

	
Male

	
Female

	
Male

	
Female

	
Male

	
Female

	
Male & Female


Same Age

	
Male & Female


Same Age

	
Male

	
Female


	
30

	
[2.08

	
1.97

	
2.08

	
1.97

	
2.07

	
1.97

	
1.84

	
1.84

	
2.00

	
1.92


	
40

	
2.45

	
2.29

	
2.45

	
2.29

	
2.42

	
2.28

	
2.10

	
2.10

	
2.29

	
2.19


	
50

	
3.02

	
2.78

	
3.00

	
2.77

	
2.92

	
2.73

	
2.49

	
2.49

	
2.70

	
2.57


	
60

	
3.95

	
3.57

	
3.87

	
3.53

	
3.59

	
3.37

	
3.12

	
3.11

	
3.29

	
3.14


	
70

	
5.66

	
5.03

	
5.28

	
4.83

	
4.24

	
4.13

	
4.22

	
4.20

	
4.18

	
4.00


	
80

	
8.93

	
8.09

	
7.07

	
6.79

	
4.55

	
4.53

	
6.37

	
6.04

	
5.54

	
5.38


	
90

	
15.24

	
14.64

	
8.36

	
8.30

	
4.59

	
4.59

	
10.68

	
7.98

	
7.66

	
7.50]











S40875-01-ADV [3A]