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THE UNITED STATES LIFE INSURANCE COMPANY IN THE CITY OF NEW YORK




RIDER


Notwithstanding any provision in the Contract to the contrary, this Rider becomes a part of the
Contract to which it is attached. Should any provision in this Rider conflict with the Contract,
the provisions of this Rider will prevail.




EFFECTIVE DATE: [date] ¬1



Prior to the Annuity Date, We will waive the Contingent Deferred Sales Charge or Withdrawal
Charge upon the Owner’s request for full or partial surrender of the Contract Value. Such benefit
shall be available if:





	1.	 	The Owner is confined to a Nursing Home and/or Hospital for at least 60 consecutive days
while the Contract is in force;
	 
	2.	 	A surrender or partial withdrawal request and adequate proof of confinement are received by
Us either while the Owner is confined or within 90 days of the Owner’s discharge from the
Nursing Home or Hospital; and
	 
	3.	 	Confinement in a Nursing Home and/or Hospital is prescribed by a Physician and is Medically
Necessary.




A Market Value Adjustment (MVA), if any, shall not be applied to amounts withdrawn from the Fixed
Account whether such application results in a gain or a loss in the Contract Value.



This Rider may not be exercised before the expiration of 90 days from the Contract Date.



A new 60 day confinement period must be satisfied each time the Owner becomes newly confined
(whether for the same or unrelated causes), if services by a Nursing Home and/or Hospital have not
been provided for a period of at least six months. If services for related causes were provided
less than six months from current receipt of services, a new 60 day confinement need not be
satisfied.



If the Owner’s request for waiver of Contingent Deferred Sales Charges or Withdrawal Charges is
denied, the surrender proceeds will not be dispersed until the Owner is notified by Us of the
denial and provided with the opportunity to reapply for the surrender proceeds or reject the
surrender proceeds.




DEFINITIONS



For purposes of this Rider, the following definitions apply. Terms not defined in this Rider shall
have the same meaning given to them in the Contract.




	 	 	 	 	 

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“Nursing Home” means a Skilled Nursing Facility, an Intermediate Care Facility, or a
Residential Care facility. Nursing Home does not mean:





	1.	 	A home for the aged, a community living center, or a place that primarily provides
domiciliary, residency or retirement care; or
	 
	2.	 	A place owned or operated by a member of the Owner’s immediate family. Immediate family
members include the Owner’s spouse, children, parents, grandparents, grandchildren, siblings,
and in-laws.




“Skilled Nursing Facility” is a facility which:





	1.	 	Is located in the United States or its territories;
	 
	2.	 	Is licensed and operated as a Skilled Nursing Facility according to the laws of the
jurisdiction in which it is located;
	 
	3.	 	Provides skilled nursing care under the supervision of a licensed physician;
	 
	4.	 	Provides continuous 24 hours a day nursing services by or under the supervision of a
registered graduate professional nurse (R.N.); and
	 
	5.	 	Maintains a daily medical record of each patient.




“Intermediate Care Facility” is a facility which:





	1.	 	Is located in the United States or its territories;
	 
	2.	 	Is licensed and operated as an Intermediate Care Facility according to the laws of the
jurisdiction in which it is located;
	 
	3.	 	Provides continuous 24 hours a day nursing service by or under the supervision of a
registered graduate professional nurse (R.N.), or a licensed practical nurse (L.P.N.); and
	 
	4.	 	Maintains a daily medical record of each patient.




“Residential Care Facility” is a facility which:





	1.	 	Is located in the United States or its territories;
	 
	2.	 	Is licensed and operated as an Residential Care Facility according to the laws of the
jurisdiction in which it is located; and
	 
	3.	 	Provides nursing care under the supervision of a registered graduate professional nurse
(R.N.).




“Hospital” is a facility which:





	1.	 	Is located in the United States or its territories;
	 
	2.	 	Is licensed as a Hospital by the jurisdiction in which it is located;
	 
	3.	 	Is supervised by a staff of licensed physicians;
	 
	4.	 	Provides nursing services 24 hours a day by, or under the supervision of, a registered nurse
(R.N.);
	 
	5.	 	Operates primarily for the care and treatment of sick and injured persons as inpatients for a
charge; and
	 
	6.	 	Has access to medical and diagnostic facilities.





	 	 	 	 	 

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“Physician” is any person duly licensed and legally qualified to diagnose and treat sickness and
injuries. He or she must be providing services within the scope of his or her license. Physicians
do not include members of the Owner’s immediate family.



“Medically Necessary” means appropriate and consistent with the diagnosis in accord with accepted
standards of practice and which could not have been omitted without adversely affecting the
individual’s condition.



This Rider shall take effect on the Contract Date. This Rider shall terminate on the date a life
contingent annuity option is elected, since Contract Value will cease to be available on that date.




THE UNITED STATES LIFE INSURANCE COMPANY IN THE CITY OF NEW YORK




	 	 	 	 	 

	 
	 		 	 
	 
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