<PAGE>

                                  Exhibit 4(a)
                                 Form of Policy


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WESTERN RESERVE LIFE                                 Home Office: Columbus, Ohio
ASSURANCE CO. OF OHIO                                     Administrative Office:
A Stock Company                                                    P.O. Box 5068
(Hereafter called the Company, We, Our or Us)    Clearwater, Florida  33758-5068
                                                            (727) 299-1800
                              ANNUITANT:  John Doe
                               OWNER(S):  John Doe

                          POLICY NUMBER:  07 - 12345
                            POLICY DATE:  December 15, 2003

                                    WE AGREE

..    To pay Partial Withdrawal and Surrender benefits in accordance with Section
     6 of this policy;

..    To pay death proceeds in accordance with Section 10 of this policy; and

..    To provide annuity payments as set forth in Section 11 of this policy.

These agreements are subject to the provisions of this policy. This policy
is issued in consideration of the payment of the initial premium.

Partial Withdrawals may be subject to surrender charges and / or an Excess
Interest Adjustment reflecting changes in interest rates in accordance with
Sections 5 and 6 of this policy. Transfers and amounts applied to an Income
Option may also be subject to an Excess Interest Adjustment in accordance with
Sections 9 and 11, respectively, of this policy.

                             20 DAY RIGHT TO CANCEL

You may cancel this policy by delivering or mailing a written notice or sending
a telegram to Us or Your agent. You must return the policy before midnight of
the twentieth day after the day You receive it. Notice given by mail and return
of the policy by mail are effective on being postmarked, properly addressed, and
postage prepaid.

Unless otherwise required by law, We will pay You an amount equal to the sum of:

..    the premiums paid;

..    less prior Partial Withdrawals, if any;

..    plus or minus the gains or losses, if any, in the Separate Account as of
     the date of cancellation.

                        Signed for us at Our home office.


         /s/ William H. Geiger                     /s/ Jerome C. Vahl
               SECRETARY                                PRESIDENT


    This policy is a legal contract between the policyowner and the Company.
                           READ YOUR POLICY CAREFULLY

                   FLEXIBLE PREMIUM DEFERRED VARIABLE ANNUITY
                   INCOME PAYABLE AT ANNUITY COMMENCEMENT DATE
          BENEFITS BASED ON THE PERFORMANCE OF THE SEPARATE ACCOUNT ARE
                         VARIABLE AND ARE NOT GUARANTEED
                  AS TO DOLLAR AMOUNT (SEE SECTIONS 7 AND 11C)
                                NON-PARTICIPATING

AV1086 101 183 1203

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                             SECTION 1 - DEFINITIONS

ADJUSTED POLICY VALUE - The Policy Value increased or decreased by any Excess
Interest Adjustment.

ANNUITANT - The person upon whose life annuity payments will be based.

ANNUITY COMMENCEMENT DATE - The Date the payments under an Income Option will
begin. This date may be changed by the owner as described in Section 3.

CASH VALUE - The amount, defined in Section 6, that is available for Partial
Withdrawals or Surrenders.

DISTRIBUTION - A Partial Withdrawal or Surrender.

EARNINGS or GAINS - The amount, if any, by which the Policy Value exceeds the
premium payments not considered previously withdrawn.

FIXED ACCOUNT - Guaranteed Period Options and Dollar Cost Averaging Fixed
Account Option as described in Section 8.

INCOME OPTIONS - Options through which the distribution of the Adjusted Policy
Value can be directed.

INVESTMENT OPTIONS - Any of the Guaranteed Fixed Account Options and any of the
Subaccounts of the Separate Account.

PARTIAL WITHDRAWAL - A disbursement of a portion of the Cash Value. Any Partial
Withdrawal will reduce the Policy Value and Cash Value.

PAYEE - The person to whom annuity payments will be made.

POLICY ANNIVERSARY - The anniversary of the Policy Date for each year the policy
remains in force.

POLICY DATE - The date shown on the Policy Data page of this policy and the date
on which this policy becomes effective.

POLICY VALUE - Amount defined in Section 5.

POLICY YEAR - Each 12-month period following the Policy Date. The first Policy
Year starts on the Policy Date. Each subsequent Policy Year starts on the next
Policy Anniversary.

SEPARATE ACCOUNT - The separate investment account(s) established by Us, as
described in Section 7.

SUBACCOUNT - A division of the Separate Account, as described in Section 7.

SURRENDER - A full disbursement of the Cash Value.

YOU, YOUR - The owner of this policy. Unless otherwise specified, the Annuitant
and the owner shall be one and the same person. If a joint owner is named,
reference to "You" or "Your" in this policy will apply to both the owner and
joint owner.

AVB1086                              Page 2

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                             SECTION 2 - POLICY DATA

POLICY NUMBER:   [07 - 12345]                         ANNUITANT:  [John Doe]

INITIAL PREMIUM
PAYMENT:         [$5,000.00]                      ISSUE AGE/SEX:  [35 / Male]

POLICY DATE:     [December 15, 2003]                   OWNER(S):  [John Doe]

ANNUITY
COMMENCEMENT                                          GUARANTEED
DATE:            [July 5, 2064]                          MINIMUM
                                                   DEATH BENEFIT
                                                         OPTION:  [Policy Value]
BENEFICIARY:     [Jane Doe]

Fixed Account Guaranteed Minimum Effective Annual Interest Rate:  [1.50%]

Before the Annuity Commencement Date:

   [Death Benefit - Policy Value]
      Mortality and Expense Risk Fee and Administrative Charge:   [1.25%]

After the Annuity Commencement Date:

      Mortality and Expense Risk Fee and Administrative Charge:   [1.25%]


AV1086 101 183 1203SP                Page 3

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                         SECTION 3 - GENERAL PROVISIONS

THE CONTRACT
This policy, which includes any attached endorsements and riders, constitutes
the entire contract between You and Us.

MODIFICATION OF POLICY
No change in this policy is valid unless made in writing by Us and approved by
one of Our authorized officers. No agent or registered representative has
authority to change or waive any provision of Your policy.

TAX QUALIFICATION
This policy is intended to qualify as an annuity contract for federal income tax
purposes. The provisions of this policy are to be interpreted to maintain such
qualification, notwithstanding any other provisions to the contrary. To maintain
such tax qualification, We reserve the right to amend this policy to reflect any
clarifications that may be needed or are appropriate to maintain such tax
qualification or to conform this policy to any applicable changes in the tax
qualification requirements. We will send You a copy in the event of any such
amendment. If You refuse such an amendment it must be by giving Us written
notice, and Your refusal may result in adverse tax consequences.

NON-PARTICIPATING
This policy will not share in Our profits or surplus.

AGE OR SEX CORRECTIONS
If the age or sex of the Annuitant has been misstated, the benefits will be
those, which the premiums paid, would have purchased for the correct age and
sex. Any underpayment made by Us will be paid with the next payment. Any
overpayment made by Us will be deducted from future payments. Any underpayment
or overpayment will include interest from the date of the incorrect payment to
the date of the adjustment.

INCONTESTABILITY
This policy shall be incontestable from the Policy Date.

EVIDENCE OF SURVIVAL
We have the right to require evidence satisfactory to Us that a person was alive
if a payment is based on that person being alive. No payment will be made until
We receive the evidence of continued survival.

SETTLEMENT
Any payment by Us under this policy is payable at Our Administrative Office.

RIGHTS OF OWNER
Prior to the Annuity Commencement Date, the owner may, while the Annuitant is
living:

     1.   Assign this policy.
     2.   Surrender the policy to Us.
     3.   Amend or modify the policy with Our consent.
     4.   Elect to receive annuity payments or name a Payee to receive the
          payments.
     5.   Exercise, receive, and enjoy every other right and benefit contained
          in the policy.

The use of these rights may be subject to the consent of any assignee,
irrevocable beneficiary, and of the spouse in a community or marital property
state.

CHANGE OF OWNERSHIP
As permitted by law, You can change the owner of this policy by notifying Us in
writing in a form and manner acceptable to Us. When a change takes effect, all
rights of ownership in this policy will pass to the new owner.

A change of owner will not be effective until it is recorded in Our records.
After it has been so recorded, the change will take effect as of the date You
signed the notice. However, if the Annuitant dies before the notice has been so
recorded, it will not be effective as to those proceeds We have paid before the
change was recorded in Our records.

We may require that the change be endorsed in the policy. Changing the owner
does not change the beneficiary or the Annuitant.

A change of ownership may result in adverse tax consequences.

COMMUNITY OR MARITAL PROPERTY
Unless We are notified in accordance with applicable law of a community or
marital property interest in this policy, We are not bound by any such interest.

ANNUITY COMMENCEMENT DATE
The Annuity Commencement Date is the date payments begin under an Income Option.
In no event can this date be later than the last day of the month following the
month in which the Annuitant attains age 95. You may change the Annuity
Commencement Date at any time after the third Policy Year, by giving Us 30 days'
written notice.

ASSIGNMENT
Before the Annuity Commencement Date, You may assign this policy as permitted by
law. The assignment must be in writing and filed with Us. We assume no
responsibility for the validity of any assignment. Any claim made under an
assignment shall be subject to proof of interest and the extent of the
assignment.

Assignment of this policy may result in adverse tax consequences.

R335                                 Page 4

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                              SECTION 3 - CONTINUED
BENEFICIARY
Death proceeds, when payable in accordance with Section 10, are payable to the
designated beneficiary or beneficiaries. Prior to the Annuitant's death, You may
name or change a beneficiary, without the beneficiary's consent (unless
irrevocably designated or required by law) at any time by notifying Us in
writing in a form and manner acceptable to Us. The change will take effect upon
the date You sign it, whether or not You are living when We receive it. The
notice must have been postmarked (or show other evidence of delivery that is
acceptable to Us) on or before the date of the Annuitant's death. Your most
recent change of beneficiary notice will replace any prior beneficiary
designations in their entirety. No change will apply to any payment We made
before the written notice was received. If an irrevocable beneficiary dies, You
may designate a new beneficiary.

You may direct the manner of payment of death proceeds pursuant to the terms of
this policy, subject to applicable law. In the absence of such direction, the
beneficiary may elect the manner of payment or make an election of any option.

Only those beneficiaries living at the time of the Annuitant's death will be
eligible to receive a share of the death proceeds. If both primary and
contingent beneficiaries have been named, payment will be made to the named
primary beneficiaries living at the time the death proceeds become payable.
Payment will be made to the named contingent beneficiaries only if all primary
beneficiaries have died before the death proceeds become payable.

If death proceeds are payable to more than one beneficiary and You failed to
specify their interest, they will share equally. If any beneficiary is alive at
the time the death proceeds become payable, but dies before receiving their
payment, their share will be paid to their estate.

PROTECTION OF PROCEEDS
The policy and payments under it will be exempt from the claims of creditors to
the extent permitted by law. Unless You so direct by filing written notice with
Us, no beneficiary may assign any payments under this policy before the payments
are due. To the extent permitted by law, no payments under this policy will be
subject to the claims of creditors of any beneficiary.

DEFERMENT
We will pay any Partial Withdrawal or Surrender proceeds from the Separate
Account within 7 days after all requirements have been met. However, it may
happen that the New York Stock Exchange is closed for trading (other than the
usual weekend or holiday closings), or the Securities and Exchange Commission
restricts trading or determines that an emergency exists. If so, it may not be
practical for Us to determine the investment experience of the Separate Account.
In that case, We may defer transfers among the Subaccounts and to the Fixed
Account, and determination or payment of Partial Withdrawals or Surrender
proceeds.

When permitted by law, We may defer paying any Partial Withdrawal or Surrender
proceeds from the Fixed Account for up to 6 months from the date We receive Your
request. If the Annuitant dies after the request is received, but before the
request is processed, the request will be processed before the death proceeds
are determined. Interest will be paid on any amount deferred for 30 days or
more. This rate will be the Fixed Account Guaranteed Minimum Effective Annual
Interest Rate shown on Page 3, unless otherwise required by law.

REPORTS TO OWNER
We will give You an annual report at least once each Policy Year. This report
will show the number and value of the accumulation units held in each of the
Subaccounts as well as the value of the Fixed Account. It will also show the
Death Benefit, Cash Value, and any other facts required by law or regulation.

                          SECTION 4 - PREMIUM PAYMENTS
PAYMENT OF PREMIUMS
Premium payments may be made any time while this policy is in force before the
Annuity Commencement Date. You may start or stop, increase or decrease, or skip
any premium payments.

MAXIMUM AND MINIMUM PREMIUM PAYMENT
The minimum initial premium payment is $5,000. If this policy is being issued in
connection with certain tax-qualified plans (such as IRAs, pension plans, or
specially sponsored programs), the minimum initial premium payment is $1,000. No
minimum initial premium payment will be required for 403(b) annuities. The
minimum subsequent premium payment We will accept is $50. The maximum total
premium payments which We will accept without prior Company approval is
$1,000,000 for issue ages 0-80. For issue ages over 80, the maximum total
premium payments which We will accept without prior Company approval is
$500,000. The premium payments may not be more than the amount permitted by law
if this is a tax-qualified annuity. We reserve the right to limit or refuse any
premium payment.

RB335                                Page 5

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                              SECTION 4 - CONTINUED

PREMIUM PAYMENT DATE
The premium payment date is the date on which We credit the premium payment to
the policy. We will credit the initial premium payment less any applicable
premium taxes to the policy within two business days after receipt of the
premium payment and the information needed. We will credit subsequent premium
payments less any applicable premium taxes to the policy as of the business day
the premium payment and required information are received. A business day is any
day that the New York Stock Exchange is open for trading.

ALLOCATION OF PREMIUM PAYMENTS
When You purchase Your policy, We will allocate Your premium payment to the
Investment Options You select. Your allocation must be in whole percentages and
must total 100%. We will allocate subsequent premium payments the same way
unless You request a different allocation.

CHANGE OF ALLOCATION
You may change the allocation of premium payments by notifying Us in a form and
manner acceptable to Us. Premium payments received after the date on which We
receive Your notice will be applied on the basis of the new allocation.

PREMIUM AND OTHER TAXES
Any taxes paid by Us to any governmental entity relating to this policy will be
deducted from the premium payment or Policy Value when incurred. We will, at Our
sole discretion, determine when taxes relate to the policy, including when they
have resulted from: the investment experience of the Separate Account; receipt
by Us of the premium payments; or commencement of annuity payments. We may, at
Our sole discretion, pay taxes when due and deduct that amount from Your Policy
Value at a later date. Payment at an earlier date does not waive any right We
may have to deduct amounts at a later date. We will deduct any withholding taxes
required by applicable law.

                            SECTION 5 - POLICY VALUE

POLICY VALUE
On or before the Annuity Commencement Date, the Policy Value is the sum of Your
Separate Account value and Your Fixed Account value, minus service charges,
premium taxes, rider fees, and transfer fees, if any.

SERVICE CHARGE
On each Policy Anniversary and at the time of Surrender during any Policy Year
before the Annuity Commencement Date, We reserve the right to assess a Service
Charge up to $30 for policy administration expenses. The Service Charge will be
deducted from each Investment Option in proportion to the amount of Policy Value
(prior to such charge) in each Investment Option. In no event will the Service
Charge exceed 2% of the Policy Value on the Policy Anniversary or at the time of
Surrender.

The Service Charge will not be deducted on a Policy Anniversary or at the time
of Surrender if at that time the sum of all premium payments less the sum of all
Partial Withdrawals taken equals or exceeds $50,000 or the Policy Value equals
or exceeds $50,000.

ADJUSTED POLICY VALUE
The Adjusted Policy Value is the Policy Value increased or decreased by any
Excess Interest Adjustment.

You may use the Adjusted Policy Value on the Annuity Commencement Date to
provide lifetime income or income for a period of no less than 60 months under
the Income Options in Section 11.

EXCESS INTEREST ADJUSTMENT
Surrender, Partial Withdrawals, transfers, death proceeds, and amounts applied
to an Income Option (prior to the end of any Guaranteed Period Option) from
Guaranteed Period Options of the Fixed Account described in Section 8 will be
subject to an Excess Interest Adjustment except as provided below.

An Excess Interest Adjustment also applies when death proceeds are calculated.
However, if the net effect of all Excess Interest Adjustments is negative, We
will not reduce the death proceeds.

M1704                                Page 6

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                              SECTION 5 - CONTINUED

The Excess Interest Adjustment is based on any change in interest rates from the
time the affected Guaranteed Period Option started until the time the Excess
interest Adjustment occurs. The Excess Interest Adjustment is applied as
follows:

1)   The Excess Interest Adjustment is only applied when a transaction occurs
     prior to the end of a Guaranteed Period Option;
2)   Transfers to the Guaranteed Period Options of the Fixed Account are
     considered Premium Payments for purposes of determining the Excess Interest
     Adjustment;
3)   The Excess Interest Adjustment is distinct from, and is applied prior to,
     the surrender charge;
4)   If interest rates have decreased from the time the affected Guaranteed
     Period Option started until the time the transaction occurs, the Excess
     Interest Adjustment will result in increased funds available to You;
5)   If interest rates have increased from the time the affected Guaranteed
     Period Option started until the time the transaction occurs, the Excess
     Interest Adjustment will result in decreased funds available to You;
6)   Certain amounts are not subject to the Excess Interest Adjustment as
     provided in Sections 6, 9, and 11; and
7)   The Excess Interest Adjustment for each Guaranteed Period Option will not
     reduce the Adjusted Policy Value for that Guaranteed Period Option below
     the amount paid into that Guaranteed Period Option, less any prior
     Withdrawals and transfers from that Guaranteed Period Option, as they
     occur, all accumulated at the Fixed Account Guaranteed Minimum Effective
     Annual Interest Rate shown on Page 3.

The formula for determining the amount of the Excess Interest Adjustment is as
follows:

Excess Interest Adjustment = S x (G-C) x (M/12)
where:
     S    is the amount (before surrender charges and premium taxes, if any) of
          the Surrender, Partial Withdrawal, transfer, or amount applied to an
          Income Option that is subject to the Excess Interest Adjustment.
     G    is the guaranteed effective annual interest rate for the Guaranteed
          Period Option applicable to "S."
     C    is the current guaranteed effective annual interest rate then being
          offered on new premium payments for the next longer Guaranteed Period
          Option than "M". If this policy form or such a Guaranteed Period
          Option is no longer offered, "C" will be the U.S. Treasury rate for
          the next longer maturity (in whole years) than "M" on the 25th day of
          the previous calendar month, plus 2% (or a lesser amount determined by
          Us).
     M    is the number of months remaining in the Guaranteed Period Option for
          "S", rounded up to the next higher whole number of months.

EXCESS INTEREST ADJUSTMENT-FREE AMOUNTS
There is no Excess Interest Adjustment for transactions involving:

1)   Partial Withdrawals or transfers of interest credited to a Guaranteed
     Period Option;
2)   Minimum required distributions;
3)   Nursing Care and Terminal Condition Withdrawal Options; and
4)   Unemployment Waivers.

                       SECTION 6 - CASH VALUE, SURRENDERS,
                            AND PARTIAL WITHDRAWALS

CASH VALUE
On or before the Annuity Commencement Date, You may make a Partial Withdrawal or
Surrender this policy for its Cash Value. The Cash Value is equal to the
Adjusted Policy Value less any surrender charges. Information about Your
policy's Cash Value is available upon request. After the Annuity Commencement
Date, there is no Cash Value.

SURRENDER CHARGES
Amounts withdrawn in excess of the surrender charge-free amount specified herein
are subject to a surrender charge. The amount of this charge, if any, will be a
percentage, as shown in the table below, of the amount of premium payment
withdrawn.

For a Partial Withdrawal, the surrender charge will be based on the dollar
amount of premium withdrawn. For a Surrender, the surrender charge will be based
on the total premium payment(s), less any previous Partial Withdrawal(s), deemed
to be from premium.

Number of Years         Percentage
 Since Premium          Premium of
 Payment Date           Withdrawn

1 year or less                   9%
greater than 1 to 2              8%
greater than 2 to 3              7%
greater than 3                   0%

U1704                                Page 7

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                              SECTION 6 - CONTINUED

For surrender charge purposes, all earnings are considered to be withdrawn
first. After all earnings are withdrawn then the oldest premium payment is the
first premium payment considered to be withdrawn. If the amount withdrawn
exceeds the earnings plus the oldest premium payment, the next oldest premium
payment is considered to be withdrawn, and so on until the most recent premium
payment is deemed to be withdrawn (the procedure being applied to Partial
Withdrawals of premium is a "First-ln, First-Out" or FIFO procedure).

SURRENDER CHARGE - FREE AMOUNTS
Amounts withdrawn under one of the options described below are free of surrender
charges. Any amounts withdrawn under one option may reduce the amount available
free of surrender charges under that option or another option. Any amount
requested in excess of that option's free amount will have the appropriate
surrender charges applied, unless the excess amount qualifies as surrender
charge-free under another option.

1.   LUMP SUM
     Beginning in the first Policy Year, You may take a Partial Withdrawal equal
     to the greater of A or B free of surrender charges, where:

          A    is the Earnings, if any; and

          B    is an amount equal to 10% of the premium payments.

     The minimum Partial Withdrawal under this option is $500. We reserve the
     right to limit the availability of this Partial Withdrawal option to the
     first Partial Withdrawal in any Policy Year.

2.   SYSTEMATIC PAYOUT OPTION
     Beginning in the first Policy Year, You may take Partial Withdrawals on a
     monthly, quarterly, semi-annual, or annual basis through a systematic
     payout option free of surrender charges. At the time a systematic payout
     option withdrawal is made, each Partial Withdrawal must be at least $50 and
     may not exceed the greater of A or B, divided by the number of systematic
     payout option withdrawals made per year (e.g. 12 for monthly), where:

          A    is the Earnings, if any; and

          B    is an amount equal to 10% of the premium payments.

     Monthly and quarterly systematic payout option withdrawals must be sent
     through electronic funds transfer directly to a checking or savings
     account. You may stop systematic payout option withdrawals by giving Us 30
     days' written notice.

     Once You have elected a systematic payout option, You must wait a minimum
     time before the first systematic payout option payment: 1 month for
     monthly, 3 months for quarterly, 6 months for semi-annual, or 12 months for
     annual.

     If You are receiving systematic payout option withdrawals and a lump sum
     Partial Withdrawal is taken, such that future systematic payout option
     withdrawals will cause the total amount of Partial Withdrawals in that
     Policy Year to exceed the total amount allowed under A or B above, then We
     will adjust future systematic payout option withdrawals to reflect the
     remaining amount allowed under A or B above for that Policy Year. Your
     systematic payout option withdrawals will be adjusted on Your next
     scheduled systematic payout option withdrawal, based on the remaining
     amount.

3.   MINIMUM REQUIRED DISTRIBUTION
     Partial Withdrawals taken to satisfy minimum distribution requirements with
     respect to this policy under Section 401(a)(9) of the Internal Revenue Code
     are available free of surrender charges. The amount available from this
     policy with respect to the minimum distribution requirement is based solely
     on this policy.

     Systematic minimum required distributions must be at least $50 or a lump
     sum distribution is available if systematic minimum required distributions
     are less than $50.

4.   NURSING CARE AND TERMINAL CONDITION WITHDRAWAL OPTIONS

     Definitions applicable to this option:

     HOSPITAL - An institution which 1) is operated pursuant to the laws of the
     jurisdiction in which it is located, 2) operates primarily for the care and
     treatment of sick and injured persons on an inpatient basis, 3) provides
     24-hour nursing service by or under the supervision of registered graduate
     professional nurses, 4) is supervised by a staff of one or more licensed
     Physicians, and 5) has medical, surgical and diagnostic facilities or
     access to such facilities.

     NURSING FACILITY - A facility which 1) is operated pursuant to the laws of
     the jurisdiction in which it is located, 2) provides care prescribed by a
     Physician and performed or supervised by a registered graduate nurse on a
     24 hour basis, or provides care designed essentially to help a person with
     the activities of daily living which does require the continuous attention
     of trained medical or paramedical personnel, and 3) is not, other than
     incidentally, a Hospital, a home for the aged, a retirement home, a rest
     home, a community living center or a place mainly for the treatment of
     alcoholism, mental illness, or drug abuse.

P1661                                Page 8

<PAGE>

                              SECTION 6 - CONTINUED

     PHYSICIAN - A Doctor of Medicine or Doctor of Osteopathy who is licensed as
     such and operating within the scope of the license.

     TERMINAL CONDITION - A condition resulting from an accident or illness
     which, as determined by a Physician, has reduced life expectancy to not
     more than 12 months, despite appropriate medical care.

     Beginning in the second Policy Year, if You or Your spouse (Annuitant or
     Annuitant's spouse if the owner is not a natural person) has been 1)
     confined in a Hospital or Nursing Facility for 30 consecutive days or 2)
     diagnosed as having a Terminal Condition, You may elect to withdraw all or
     a portion of the Policy Value free of surrender charges. The minimum
     Partial Withdrawal under this option is $1000. This option is available
     even during the policy years other Partial Withdrawal options were
     exercised.

     For Nursing Care Withdrawal, We must receive each Partial Withdrawal or
     Surrender request and proof of eligibility with each request no later than
     90 days following the date that confinement has ceased, unless it can be
     shown that it was not reasonably possible to provide the notice and proof
     within the above time period and that the notice and proof were given as
     soon as reasonably possible. However, in no event, except the absence of
     legal capacity, shall the notice and proof be provided later than one year
     following the date that confinement has ceased. Proof of confinement may be
     a treating Physician's statement or a statement from a Hospital or Nursing
     Facility administrator. Systematic Nursing Care Withdrawals are not
     permitted.

     For a Terminal Condition Withdrawal, We must receive each Partial
     Withdrawal or Surrender request and the applicable proof of eligibility no
     later than one year following diagnosis of the Terminal Condition. Proof of
     a Terminal Condition is required only with the initial Partial Withdrawal
     request and must be furnished by the treating Physician. Systematic
     Terminal Condition Withdrawals are not permitted.

5.   UNEMPLOYMENT WAIVER
     Beginning in the second Policy Year, You may withdraw all or a portion of
     the Policy Value free of surrender charges if You or Your spouse (Annuitant
     or Annuitant's spouse, if the owner is not a natural person) becomes
     unemployed. In order to qualify, such person 1) must have been employed
     full-time for at least two years prior to becoming unemployed, 2) must have
     been employed full-time on the Policy Date, and 3) must have been
     unemployed for at least 60 consecutive days and receiving unemployment
     benefits at the time of Partial Withdrawal. Proof of unemployment will
     consist of providing Us with a determination letter from the applicable
     State's Department of Labor, which verifies that the person qualifies for
     and is receiving unemployment benefits at the time of Partial Withdrawal.
     The determination letter must be received by Us no later than 15 days
     following the date of the Partial Withdrawal request.

PARTIAL WITHDRAWALS
We will pay You a portion of the Cash Value as a Partial Withdrawal provided We
receive Your written request while the policy is in effect and before the
Annuity Commencement Date. Partial Withdrawals will be deducted in proportion to
the amount of Policy Value in each Investment Option unless You tell Us
otherwise. If Your request for a Partial Withdrawal from an Investment Option is
less than or equal to the amount of Cash Value in that option, We will pay the
amount of Your request. However, if Your request for a Partial Withdrawal from
an investment Option is greater than the amount of Cash Value in that option, We
will pay You only the amount of Cash Value in that Investment Option.

The "Gross Partial Withdrawal" is the total amount deducted from Your Policy
Value as a result of each Partial Withdrawal. The Gross Partial Withdrawal may
be more or less than Your requested Partial Withdrawal amount, depending on
whether surrender charges and/or Excess Interest Adjustments apply at the time
You request the Partial Withdrawal.

The formula for determining the Gross Partial Withdrawal is as follows:

Gross Partial Withdrawal = R - E + SC, where:

R    is the requested Partial Withdrawal;
E    is the Excess Interest Adjustment;
SC   is the surrender charge on (EPW - E); where
EPW  is the Excess Partial Withdrawal amount (the portion of the requested
     Partial Withdrawal subject to surrender charge).

The Excess Partial Withdrawal amount is the portion of the requested Partial
Withdrawal that is subject to surrender charge. For example, if the requested
Partial Withdrawal amount is $1,000, and the surrender charge-free amount is
$200, then the Excess Partial Withdrawal amount would be $800.

PB1661                               Page 9

<PAGE>

                              SECTION 6 - CONTINUED

Excess  Partial  Withdrawals  will reduce the Policy Value by an amount equal to
(X-Y+Z) where:

X    is Excess Partial Withdrawal;
Y    is Excess Interest Adjustment = (A) x (G-C) x (M/12) where G, C and M are
     defined in the Excess Interest Adjustment provision above, with "A"
     substituted for "S" in the definitions of G and M;
A    is Amount of Partial Withdrawal subject to Excess Interest Adjustment; and
Z    is surrender charge on X minus Y.

If any Partial Withdrawal reduces the Cash Value below $500, We reserve the
right to pay the full Cash Value and terminate the policy.

We may delay payment of the Cash Value from the Fixed Account for up to 6 months
after We receive the request. If the Annuitant dies after We receive the
request, but before the request is processed, the request will be processed
before the death proceeds are determined.

Partial Withdrawals and Surrenders may be subject to a surrender charge.

MINIMUM VALUES
Benefits available under this policy, including any paid up annuity or death
benefits that may be available, are not less than those required by any statute
of the state in which the policy is delivered.

                          SECTION 7 - SEPARATE ACCOUNT

SEPARATE ACCOUNT
We have established and will maintain one or more Separate Accounts, under the
laws of the state of Ohio. The Separate Account consists of assets which We keep
separate from Our general account assets and all of Our other segregated asset
accounts. Any realized or unrealized income, net gains, and losses from the
assets of the Separate Account are credited to or charged against it without
regard to Our other income, gains, or losses. Assets are placed in the Separate
Account for this policy, as well as for other variable annuity policies. Any
Separate Account may invest assets in shares of one or more mutual fund
portfolios, or in the case of a managed Separate Account, direct investments in
stocks or other securities as permitted by law. "Fund shares" refers to shares
of underlying mutual fund portfolios or pro rata ownership of the assets held in
a Subaccount of a managed Separate Account. We purchase, redeem, and value fund
shares on behalf of the Separate Account.

The Separate Account is divided into Subaccounts. The assets in each Subaccount
are invested exclusively in shares of one of the portfolios of an underlying
mutual fund. We reserve the right to add Subaccounts to, or remove any
Subaccount from, the Separate Account.

The assets of the Separate Account are Our property. These assets will equal or
exceed the reserves and other contract liabilities of the Separate Account.
These assets will not be chargeable with liabilities arising out of any other
business We conduct. We reserve the right, subject to regulations governing the
Separate Account, to transfer assets of a Subaccount, in excess of the reserves
and other contract liabilities with respect to that Subaccount, to another
Subaccount, or to Our general account.

We will determine the fair market value of the assets of the Separate Account in
accordance with a method of valuation, which We establish in good faith.
"Valuation Period" means the period of time from one determination of the value
of each Subaccount to the next determination. Such determinations are made when
the value of the assets and liabilities of each Subaccount is calculated.
This is generally the close of business on each day on which the New York Stock
Exchange is open. You bear the entire investment risk for all amounts You
allocate to the separate account.

We also reserve the right to transfer assets of the Separate Account, which We
determine to be associated with the class of policies to which this policy
belongs, to another Separate Account. If this type of transfer is made, the term
"Separate Account," as used in the policy, shall then mean the Separate Account
to which the assets were transferred

We also reserve the right, when permitted by law, to:

(a)  deregister the Separate Account under the Investment Company Act of 1940;
(b)  manage the Separate Account under the direction of a committee at any time;
(c)  restrict or eliminate any voting rights of policy owners or other persons
     who have voting rights as to the Separate Account;
(d)  combine the Separate Account with one or more other Separate Accounts;
(e)  create new Separate Accounts;
(f)  add new Subaccounts to or remove existing Subaccounts from the Separate
     Account, or combine Subaccounts; and
(g)  add new underlying mutual funds, remove existing mutual funds, or
     substitute a new fund for an existing fund.

V1572                                Page 10

<PAGE>

                              SECTION 7 - CONTINUED

The Net Asset Value of a fund share is the per-share value calculated by the
mutual fund or, in the case of a managed Separate Account, by the Company. The
Net Asset Value is computed by adding the value of the Subaccount's investments,
cash and other assets, subtracting its liabilities, and then dividing by the
number of shares outstanding. Net Asset Values of fund shares reflect investment
advisory fees and other expenses incurred in managing a mutual fund or a managed
Separate Account.

CHANGE IN INVESTMENT OBJECTIVE OR POLICY OF A MUTUAL FUND
If required by law or regulation, an investment policy of the Separate Account
will only be changed if approved by the appropriate insurance official of the
state of Ohio or deemed approved in accordance with such law or regulation. If
so required, the process for obtaining such approval is filed with the insurance
official of the state or district in which this policy is delivered.

CHARGES AND DEDUCTIONS
The Mortality and Expense Risk Fee and the Administrative Charge are each
deducted daily both before and after the Annuity Commencement Date. The Service
Charge is deducted prior to the Annuity Commencement Date only. If the Mortality
and Expense Risk Fee is more than sufficient to cover Our expenses, We will
retain the balance as profit or may reduce this fee in the future.

ACCUMULATION UNITS
The Policy Value in the Separate Account before the Annuity Commencement Date is
represented by accumulation units. The dollar value of accumulation units for
each Subaccount will change from Valuation Period to Valuation Period reflecting
the investment experience of the Subaccount. Accumulation Units shall be used to
account for all amounts allocated to or withdrawn from a Subaccount of the
Separate Account as a result of premium payments, Partial Withdrawals,
transfers, or fees and charges.

Transfers and premium payments allocated to the Subaccounts will be applied to
provide accumulation units in those Subaccounts. The number of accumulation
units purchased in a Subaccount will be determined by dividing the dollar amount
allocated to or transferred to that Subaccount, by the value of an accumulation
unit for that Subaccount on the premium payment or transfer date.

The number of accumulation units withdrawn or transferred from the Subaccounts
will be determined by dividing the amount withdrawn or transferred by the value
of an accumulation unit for that Subaccount on the Partial Withdrawal or
transfer date.

We set the initial accumulation unit value for each Subaccount. Subsequent
accumulation unit values for each Subaccount are determined by multiplying the
accumulation unit value for the immediately preceding Valuation Period by the
Net Investment Factor of the Subaccount for the current Valuation Period.

The net investment factor used to calculate the value of an accumulation unit in
each Subaccount for the Valuation Period is determined by dividing (a) by (b)
and subtracting (c) from the result, where:

(a)  is the result of:
     (1)  the net asset value of a fund share held in that Subaccount determined
          as of the end of the current Valuation Period; plus
     (2)  the per share amount of any dividend or capital gain distributions
          made by the fund for shares held in that Subaccount if the ex-dividend
          date occurs during the Valuation Period; plus or minus
     (3)  a per share credit or charge for any reservation for taxes which We
          determine to have resulted from the investment operations of that
          Subaccount.
(b)  is the net asset value of a fund share held in that Subaccount determined
     as of the end of the immediately preceding valuation period.
(c)  is a factor representing the Mortality and Expense Risk Fee and
     Administrative Charge before the Annuity Commencement Date for each day
     since the last Valuation Period. This factor is less than or equal to, on
     an annual basis, the percentage shown on the Policy Data Page of the daily
     net asset value of a fund share held in that Subaccount.

Since the net investment factor may be greater or less than one, the
accumulation unit value may increase or decrease.

VB1572                               Page 11

<PAGE>

                            SECTION 8 - FIXED ACCOUNT

FIXED ACCOUNT
The Fixed Account is comprised of Guaranteed Period Options and Dollar Cost
Averaging Fixed Options that We may choose to offer. Premium payments applied to
and any amounts transferred to the Fixed Account will be credited daily with an
interest rate equivalent to the effective annual interest rate then in effect.
The interest rates We set will be credited daily for increments of at least one
year measured from each premium payment or transfer date. These rates will never
be less than the Fixed Account Guaranteed Minimum Effective Annual Interest Rate
shown on Page 3.

We reserve the right, at Our sole discretion, to limit or refuse premium
payments or transfers allocated to any of the Fixed Account options.

GUARANTEED PERIOD OPTIONS
We may offer Guaranteed Period Options in the Fixed Account, into which premium
payments may be paid or amounts transferred. The current interest rate We set
for funds entering each Guaranteed Period Option is guaranteed until the end of
that option's guaranteed period. At that time, the premium payment made or
amount transferred into the Guaranteed Period Option, less any Partial
Withdrawals or transfers from that Guaranteed Period Option, plus accrued
interest, must be transferred into a new Guaranteed Period Option (subject to
availablilty of any Guaranteed Period Option for such rollovers) or may be
transferred to any Subaccount(s) within the Separate Account(s).

You may choose the Investment Option(s) You want the funds transferred into by
giving Us a written notice within 30 days before the end of the expiring
guaranteed period. However, any available Guaranteed Period Option elected may
not extend beyond the latest Annuity Commencement Date defined in Section 3. In
the absence of such election, the funds will be transferred into a new
Guaranteed Period Option which has the same guaranteed period as the expiring
Guaranteed Period Option unless that Guaranteed Period Option is no longer
offered. In that case, the funds will be transferred into the next shorter
Guaranteed Period Option available, or, if none, into the next longer Guaranteed
Period Option available. We will mail You a notice of completion of the transfer
with the new interest rate applicable. We will deem You to have accepted the
new Guaranteed Period Option if We do not receive a written rejection from You
within 30 days from the postmark date of the completion notice. We reserve the
right, at Our sole discretion, for new premium payments, or transfers, to offer
or not to offer any Guaranteed Period Option. If We do not offer a Guaranteed
Period Option and We have not received directions from You in a form and manner
acceptable to Us, how the premium payments or funds transferred are to be
allocated, the funds will be placed in a Fixed Account Option at the lowest
crediting rate then applicable, or may be refused.

When funds are withdrawn or transferred from a Guaranteed Period Option, the
Policy Value associated with the oldest premium payment or transfer in that
Guaranteed Period Option is considered to be withdrawn or transferred first. If
the amount withdrawn or transferred exceeds the Policy Value associated with the
oldest premium or transfer, the Policy Value associated with the next oldest
premium payment or transfer is considered to be withdrawn or transferred next,
and so on until the Policy Value associated with the most recent premium payment
or transfer is considered to be withdrawn or transferred.

Partial Withdrawals, Surrenders, transfers (except those transfers made at the
end of a Guaranteed Period Option), and amounts applied to an Income Option from
a Guaranteed Period Option are subject to an Excess Interest Adjustment as
described in Sections 5 and 6.

DOLLAR COST AVERAGING FIXED ACCOUNT OPTION
We may offer one or more Dollar Cost Averaging Options in the Fixed Account
separate from the Guaranteed Period Options. The Dollar Cost Averaging Fixed
Account Options will have a one-year interest rate guarantee. The current
interest rate We set for a Dollar Cost Averaging Fixed Account Option may differ
from the rates credited on Guaranteed Period Options. In addition, the current
interest rate We credit may vary on different Dollar Cost Averaging Fixed
Account Options. The credited interest rate will never be less than the Fixed
Account Guaranteed Minimum Effective Annual Interest Rate shown on Page 3.
Dollar Cost Averaging Fixed Account Options will only be available under a
Dollar Cost Averaging program as described in Section 9.

L1157                                Page 12

<PAGE>

                              SECTION 9 - TRANSFERS

A.   TRANSFERS BEFORE THE ANNUITY COMMENCEMENT DATE
Prior to the Annuity Commencement Date, You may transfer Policy Values from one
Investment Option to another by notifying Us in a form and manner acceptable to
Us.

Transfers of Policy Value from the Guaranteed Period Options of the Fixed
Account prior to the end of that Guaranteed Period Option are subject to an
Excess Interest Adjustment. No Excess Interest Adjustment will apply to Policy
Value transfers at the end of a Guaranteed Period Option.

If the Excess Interest Adjustment at the time of such Policy Value transfer
results in a decrease in the funds available to You, then the maximum Policy
Value transfer is 25% of that Guaranteed Period Option's Policy Value, less
Policy Values previously transferred out of that Guaranteed Period Option during
the current Policy Year. Each such transfer must be separated by a period of 12
months.

If the Excess Interest Adjustment at the time of such Policy Value transfer
results in additional funds available to You, no maximum will apply to such
Policy Values transferred from the Guaranteed Period Option.

Transfers of Policy Value from the Separate Account are subject to a minimum of
$500 or the entire Subaccount's Policy Value, if less. However, if the remaining
Subaccount's Policy Value is less than $500, We reserve the right to include
that amount as part of the transfer.

Transfers of interest credited in the Guaranteed Period Options to other
Investment Options are allowed on a "First-In, First-Out" basis. Such transfers
may be made monthly, quarterly, semi-annually, or annually. Each such transfer
must be at least $50 and will not be subject to an Excess Interest Adjustment.

You may choose which Guaranteed Period Option to transfer to or from, however,
any Guaranteed Period Option elected may not extend beyond the Annuity
Commencement Date defined in Section 3.

We reserve the right to limit transfers to no more than 12 in any one Policy
Year. Any transfers in excess of 12 per Policy Year may be charged a $10 fee per
transfer. Transfers among multiple Investment Options will be treated as one
transfer in determining the number of transfers that have occurred. We also
reserve the right, in our sole discretion, to limit or refuse premium payments
or transfers allocated to any of the Fixed Account Options.

Certain Subaccounts are not designed for professional market timing
organizations or other persons that use programmed, large, or frequent
transfers. The use of such transfers may be disruptive to an underlying
portfolio. We reserve the right to reject any transfer request from any person
in the interest of overall fund management or, if, in our judgment, an
underlying fund would be unable to invest effectively in accordance with its
investment objectives and policies or would otherwise be potentially adversely
affected or if an underlying fund would reject our purchase order. We also
reserve the right to revoke Your telephone, fax, and electronic transfer
privileges at any time without revoking all owners' telephone, fax and
electronic transfer privileges.

DOLLAR COST AVERAGING PROGRAM
Prior to the Annuity Commencement Date, You may instruct Us to automatically
transfer a specified amount from source accounts made available by Us to any
other Subaccounts of the Separate Account. The automatic transfers can occur
monthly or quarterly. You may change the Subaccounts to which these transfers
are allocated as permitted by Us from time to time.

Transfers will continue until the elected source account is depleted. The amount
transferred each time must be at least $500. All transfers from the source
account will be the same amount as the initial transfer. Transfers must be
scheduled for at least 6 months, but not more than 24 months or for at least 4
quarters, but not more than 8 quarters each time the Dollar Cost Averaging
program is started or restarted following termination of the program for any
reason.

Dollar Cost Averaging results in the purchase of more accumulation units when
the value of the accumulation unit is low, and fewer accumulation units when the
value of the accumulation unit is high. However, there is no guarantee that the
Dollar Cost Averaging program will result in higher Policy Values or will
otherwise be successful.

Dollar Cost Averaging may be discontinued before its scheduled completion by
sending written notice to Us. If Dollar Cost Averaging is discontinued prior to
the end of the scheduled period, all remaining funds in the Dollar Cost
Averaging Fixed Account will be transferred at that time. Unless We are notified
otherwise the funds remaining in the Dollar Cost Averaging Fixed Account will be
transferred to the Subaccounts in the percentages currently indicated. While
Dollar Cost Averaging is in effect, Asset Rebalancing is not available.

LB1157                               Page 13

<PAGE>

                              SECTION 9 - CONTINUED

ASSET REBALANCING
Prior to the Annuity Commencement Date, You may instruct Us to automatically
transfer amounts among the Subaccounts of the Separate Account on a regular
basis to maintain a desired allocation of the Policy Value among the various
Subaccounts offered. Rebalancing will occur on a monthly, quarterly,
semi-annual, or annual basis, beginning on a date selected by You. You must
select the percentage of the Policy Value desired in each of the various
Subaccounts offered (totaling 100%). Any amounts in the Fixed Account are
ignored for the purposes of Asset Rebalancing. Rebalancing can be started,
stopped, or changed at any time. Asset Rebalancing is not available while Dollar
Cost Averaging is in effect. Rebalancing will cease as soon as We receive a
request for any other transfer.

B.   TRANSFERS AFTER THE ANNUITY COMMENCEMENT DATE
After the Annuity Commencement Date, You may transfer Policy Values from one
Subaccount to another within the Separate Account or to the Fixed Account. If
You want to transfer the value of the variable annuity units, You must notify Us
in a form and manner acceptable to Us. We reserve the right to limit transfers
between the Subaccounts or to the Fixed Accounts to once per Policy Year.

The minimum amount which may be transferred is the lesser of $10 monthly income
or the entire monthly income of the variable annuity units in the Subaccount
from which the transfer is being made. If the monthly income of the remaining
units in a Subaccount is less than $10, We have the right to include the value
of those variable annuity units as part of the transfer.

After the Annuity Commencement Date, no transfers may be made from the Fixed
Account to any other Investment Options.

                           SECTION 10 - DEATH PROCEEDS

A.   DEATH PROCEEDS PRIOR TO ANNUITY COMMENCEMENT DATE
The amount of death proceeds will be the greatest of (a), (b), or (c) where:

(a)  is the Policy Value on the date We receive due proof of death and an
     election of a method of settlement;
(b)  is the Cash Value on the date We receive due proof of death and an election
     of a method of settlement; and,
(c)  is the Guaranteed Minimum Death Benefit, if any, plus any additional
     premium payments received, less any Gross Partial Withdrawals, from the
     date of death to the date of payment of death proceeds.

Until the death proceeds are paid, the Policy Value will remain in the
subaccounts as previously specified by the owner or as reallocated pursuant to
instructions received by Us from all beneficiaries (due proof of death is
required before we will accept such instructions). Therefore, the Policy Value
(and Cash Value) will fluctuate with the investment performance of the
applicable subaccounts and accordingly, the amount of the death proceeds will
also vary until the proceeds are paid.

For purposes of this policy, proof of death means:
(a)  a certified copy of the death certificate, or;
(b)  a certified copy of a decree of a court of competent jurisdiction as to a
     finding of death, and;
(c)  any other proof or other documents required by Us.

Where there are joint Annuitants, the death proceeds becomes payable only upon
the death of the surviving Annuitant, subject to the distribution requirements
under Subsection C.II. below.

If You have not selected an Income Option by the date of death, the beneficiary
may make such election within one year of the date We receive due proof of the
owner's or Annuitant's death as described in Subsection C below. The beneficiary
may elect to receive the death proceeds as a lump sum payment or may use the
death proceeds to provide any of the Income Options described in Section 11. We
will pay interest on death proceeds as required by law.

We must distribute death proceeds or continue making payments under an Income
Option under this annuity policy as required in internal Revenue Code Section
72(s). The requirements of Internal Revenue Code Section 72(s) will override any
provision of this policy to the contrary.

B.   GUARANTEED MINIMUM DEATH BENEFIT
The amount of the Guaranteed Minimum Death Benefit, if any, is based on the
death benefit option shown on the Policy Data Page. The Guaranteed Minimum Death
Benefit is only payable upon the Annuitant's death. You may not change the
Guaranteed Minimum Death Benefit option after We issue the policy.

C.   DEATH PRIOR TO ANNUITY COMMENCEMENT DATE
Payment of death proceeds depends on the relationships between the owner,
Annuitant, and beneficiary as outlined below.

D582                                 Page 14

<PAGE>

                             SECTION 10 - CONTINUED

If there are surviving owners, the surviving owners automatically take the place
of any beneficiary designation.

I.   Annuitant Death

     When We have due proof that the Annuitant died before the Annuity
     Commencement Date, the death proceeds are payable to the beneficiary. If no
     beneficiary is designated and there is no surviving owner, the owner's
     estate will become the beneficiary.

     a)   When the beneficiary is the deceased Annuitant's surviving spouse. The
          beneficiary may elect to continue this policy as owner and Annuitant
          rather than receiving the death proceeds. If the policy is continued,
          an amount equal to the excess, if any, of the Guaranteed Minimum Death
          Benefit over the Policy Value will then be added to the Policy Value
          pro rata according to the amount of Policy Value in each investment
          Option at that time. This is a one-time only Policy Value adjustment
          applied at the time the policy is continued, and the Guaranteed
          Minimum Death Benefit previously selected will continue on as
          applicable.

          If the policy is continued, all current surrender charges will be
          waived; however, any premium received after the deceased Annuitant's
          death will be subject to any applicable surrender charges.

          If the beneficiary elects to have the death proceeds paid rather than
          continue the policy, the death proceeds must be distributed pursuant
          to subsections b)(1) and (2) below.

     b)   When the beneficiary is an individual who is not the deceased
          Annuitant's surviving spouse. The death proceeds must be distributed:
               (1)  by the end of 5 years after the date of the deceased
                    Annuitants death, or
               (2)  payments must begin no later than one year after the
                    deceased Annuitant's death and must be made for a period
                    certain or for this beneficiary's lifetime, so long as any
                    period certain does not exceed this beneficiary's life
                    expectancy. Election of this option must be made at least 60
                    days prior to the one year anniversary of the Annuitant's
                    death.

     c)   When the beneficiary is not a natural person. The death proceeds must
          be distributed within 5 years after the Annuitant's death.

II.  Owner Death

     At the death of any owner, all current surrender charges will be waived;
     however, any premium received after the deceased owner's death will be
     subject to any applicable surrender charges.

     If the deceased owner is also the Annuitant, Subsection C.I. "Annuitant
     Death" above applies.

     If an owner or joint owner who is not an Annuitant dies prior to the
     Annuity Commencement Date and before the entire interest in the policy is
     distributed, the successor owner as defined below will become the new
     owner, and no death proceeds are payable. The person or entity first listed
     below who is alive or in existence on the date of that death will become
     the successor owner:

     a)   surviving owner;
     b)   primary beneficiary;
     c)   contingent beneficiary; or
     d)   deceased owner's estate.

     The successor owner will need to take distributions according to a), b), or
     c) below:

     a)   If the sole successor owner is the deceased owner's spouse, We will
          continue this policy with the successor owner as the new owner.

     b)   If the successor owner is an individual who is not the deceased
          owner's spouse, the Adjusted Policy Value must be distributed:

          (1)  by the end of 5 years after the date of the deceased owner's
               death, or

          (2)  payments must begin no later than one year after the deceased
               owner's death and must be made for a period certain or for the
               successor owner's lifetime, so long as any period certain does
               not exceed the successor owner's life expectancy. Election of
               this option must be made at least 60 days prior to the one year
               anniversary of the deceased owner's death.

     c)   If the successor owner is not a natural person, the Adjusted Policy
          Value must be distributed within 5 years after the owner's death.

DB582                                Page 15

<PAGE>

                             SECTION 10 - CONTINUED

D.   DEATH ON OR AFTER THE ANNUITY COMMENCEMENT DATE
The death proceeds on or after the Annuity Commencement Date depend on the
payment option selected. If any owner dies on or after the Annuity Commencement
Date, but before the entire interest in the policy is distributed, the remaining
portion of such interest in the policy, if any, will be distributed to the
beneficiary at least as rapidly as under the method of distribution being used
as of the date of that death.

E.   AN OWNER IS NOT AN INDIVIDUAL
If any owner is not an individual, then for purposes of the provisions in
subsection C or D above, (1) the primary Annuitant will be treated as the owner
of the policy, and (2) the death of, or any change in, the primary Annuitant,
will be treated as the death of the owner.

                           SECTION 11 - INCOME OPTIONS

A.   GENERAL PAYMENT PROVISIONS
Payment
If this policy is in force on the Annuity Commencement Date, We will use the
Fixed Account portion and/or the Separate Account portion of the Adjusted Policy
Value to make payments under an Income Option to the Payee under Fixed Income
Option 2 and/or Variable Income Option 3-V, respectively, with 10 years certain,
or if elected, under one or more of the other Income Options described in this
section, or any other method of payment if We agree. However, the Income Option
elected must provide for lifetime income or income for a period of at least 60
months. You will become the Annuitant upon annuitization, unless the owner is
not a natural person. Payments will be made at 1, 3, 6, or 12-month intervals.
We reserve the right to change the frequency of payments to avoid making
payments of less than $50.

Before the Annuity Commencement Date, if the death proceeds become payable or if
You Surrender this policy, We will pay any proceeds in one sum, or if elected,
all or part of these proceeds may be applied to one or more of the income
Options described in this section.

Adjusted Age
Payments under Fixed Income Options 2 and 4 and the first payment under Variable
Income Options 3-V and 5-V are determined based on the adjusted age of the
Annuitant. The adjusted age is the Annuitant's actual age on the Annuitant's
nearest birthday, at the Annuity Commencement Date, adjusted as follows:

     Annuity
Commencement Date                         Adjusted Age
-----------------                      ------------------
   Before 2010                         Actual Age
   2010 - 2019                         Actual Age minus 1
   2020 - 2026                         Actual Age minus 2
   2027 - 2033                         Actual Age minus 3
   2034 - 2040                         Actual Age minus 4
   After 2040                          Determined by Us

Election of Optional Method of Payment
Before the Annuity Commencement Date, You can elect or change an Income Option.
You may elect, in a notice in a form and manner acceptable to Us, Income Options
that may be either variable, fixed, or a combination of both. If You elect a
combination, You must also tell Us what part of the Adjusted Policy Value on the
Annuity Commencement Date are to be applied to provide each type of payment.
(You must also specify which Subaccounts.) The amount of a combined payment will
be the sum of the variable and fixed payments. Payments under a variable Income
Option will reflect the investment performance of the selected Subaccount(s) of
the Separate Account.

Payee
Unless You specify otherwise, the Payee shall be the Annuitant, or the
beneficiary as described in Section 3.

In the event of the death of a Payee who is not the Annuitant prior to the end
of payments pursuant to the terms of the Income Option chosen, payments will be
continued to the beneficiary or their present value may be paid in a single sum.

Proof of Age
We may require proof of the age of any person who elects Income Options 2, 3-V,
4 and 5-V of this Section before We make the first payment.

Minimum Proceeds
If the proceeds are less than $2,000, We reserve the right to pay them out as a
lump sum instead of applying them to an Income Option.

Premium Tax
We may be required by law to pay premium tax on the amount applied to an Income
Option. If so, We will deduct the premium tax before applying the proceeds.

Supplementary Contract
Once proceeds become payable and an Income Option has been selected, We will
issue a supplementary contract to reflect the terms of the selected Income
Option. The supplemental contract will name the Payee(s) and will describe the
payment schedule.

S1279                                Page 16

<PAGE>

                             SECTION 11 - CONTINUED

B.   FIXED INCOME OPTIONS
Guaranteed Income Options
The amount of the fixed payment is determined by multiplying each $1,000 of
policy proceeds allocated to fixed Income Option 1, 2, or 4 by the amounts shown
on page 20 for the option You select. Income Options 1 and 3 are based on the
guaranteed interest rate shown on page 20. Income Options 2 and 4 are based on
the guaranteed interest rate shown on page 20 and the "Annuity 2000" (male,
female, and unisex if required by law) mortality table projected for improvement
using projection scale G.

Fixed Income Option 1 - Income for a Specified Period
We will make level payments only for the specific period You choose. The
specified period may not exceed Your life expectancy. No funds will remain at
the end of the specified period

Fixed Income Option 2 - Life Income
You may choose between:
(a)  No Period Certain - We will make level payments only during the Annuitant's
     lifetime.
(b)  10 Years Certain - We will make level payments for the longer of the
     Annuitant's lifetime or ten years.
(c)  Guaranteed Return of Policy Proceeds - We will make level payments for the
     longer of the Annuitant's lifetime or until the total dollar amount of
     payments equals the amount applied to this option.
(d)  Life with Emergency Cash (SM) - We will make level payments during the
     Annuitant's lifetime, but the annuity may be surrendered (in full or part).
     The Cash Value is equal to a multiple of the payment where that multiple
     reduces over time to zero at age 101. We will apply a surrender charge.
     Should the Annuitant die before age 101 (or, for qualified policies, the
     applicable age based on IRS Life Expectancy table(s) if earlier), the same
     Cash Value would be payable, but without the surrender charge.

Fixed Income Options 2(a) and 2(d) are not available for Annuitant Adjusted
Age(s) greater than 85.

Fixed Income Option 3 - Income of a Specified Amount
We will make payments for any specified amount You choose until the amount
applied to this option, with interest, is exhausted. The duration of the
payments may not exceed the Annuitants life expectancy. This will be a series of
level payments followed by a smaller final payment.

Fixed income Option 4 - Joint and Survivor Annuity
You may choose between:

(a)  No Period Certain - We will make payments during the joint lifetime of the
     Annuitant and a joint Annuitant of Your choosing. We will make payments as
     long as either person is living.

(b)  Life with Emergency Cash (SM) - We will make level payments during the
     joint lifetime of the Annuitant and a joint Annuitant of Your choosing. We
     will make payments as long as either person is living, but the annuity may
     be surrendered (in full or part). The Cash Value is equal to a multiple of
     the payment, where that multiple reduces over time to zero at age 101 of
     the younger Annuitant We will apply a surrender charge. Should the last
     surviving Annuitant die before age 101 (or, for qualified policies, the
     applicable age based on IRS Life Expectancy table(s) if earlier), the same
     Cash Value would be payable, but without the surrender charge.

Fixed Income Options 4(a) and 4(b) are not available for Annuitant Adjusted
Age(s) greater than 85.

Current Income Options
The amounts shown in the tables on page 20 are the guaranteed amounts. You may
obtain current amounts we offer to individuals of the same class, subject to
availability as described under "Guaranteed Income Options" above.

SB1279                               Page 17

<PAGE>

                             SECTION 11 - CONTINUED

C.   VARIABLE INCOME OPTIONS
Variable Annuity Units
We will use the Adjusted Policy Value You tell us to apply to a Variable Income
Option to purchase variable annuity units in Your chosen Subaccounts. The dollar
value of variable annuity units in Your chosen Subaccounts will increase or
decrease reflecting the investment experience of Your chosen Subaccounts. The
value of a variable annuity unit in a particular Subaccount on any business day
is equal to (a) multiplied by (b) multiplied by (c), where:

(a)  is the variable annuity unit value for that Subaccount on the immediately
     preceding business day;
(b)  is the net investment factor for that Subaccount for the Valuation Period;
     and
(c)  is the Assumed Investment Return adjustment factor for the Valuation
     Period.

The Assumed Investment Return adjustment factor for the valuation period is the
product of daily discount factors which reflect the effective annual Assumed
Investment Return shown on page 22.

The net investment factor used to calculate the value of a variable annuity unit
in each Subaccount for the Valuation Period is determined by dividing (a) by (b)
and subtracting (c) from the result where:

(a)  is the net result of:
     (1)  the net asset value of a fund share held in that Subaccount determined
          as of the end of the current valuation period; plus
     (2)  the per share amount of any dividend or capital gain distributions
          made by the fund for shares held in that Subaccount if the ex-dividend
          date occurs during the Valuation Period; plus or minus
     (3)  a per share credit or charge for any taxes reserved for, which we
          determine to have resulted from the investment operations of the
          Subaccount
(b)  is the net asset value of a fund share held in that Subaccount determined
     as of the end of the immediately preceding Valuation Period
(c)  is a factor representing the Mortality and Expense Risk Fee and
     Administrative Charge applicable after the Annuity Commencement Date. This
     factor is less than or equal to, on an annual basis, the percentage shown
     on the Policy Data Page, plus any additional fee applicable to the Initial
     Payment Guarantee of the daily net asset value of a fund share held in the
     Separate Account for that Subaccount.

Determination of the First Variable Payment
The amount of the first variable payment is determined by multiplying each
$1,000 of Adjusted Policy Value allocated to a variable income option by the
amounts shown on the Variable Income Option Table for the Variable Income Option
You select. The tables are based on the effective annual Assumed Investment
Return shown on page 22 and the "Annuity 2000" (male, female, and unisex if
required by law) mortality table projected for improvement using projection
scale G.

Variable Income Option 3-V - Life income
You may choose between:

(a)  No Period Certain - We will make payments during the lifetime of the
     Annuitant.

(b)  10 Years Certain - We will make payments for the longer of the Annuitant's
     lifetime or ten years.

(c)  Life with Emergency Cash (SM) - We will make payments during the
     Annuitant's lifetime, but the annuity may be Surrendered (in full or part).
     The Cash Value is equal to a multiple of the Supportable Payment (see
     definition below), where that multiple reduces over time to zero at age
     101. We will apply a surrender charge. Should the Annuitant die before age
     101 (or, for qualified policies, the applicable age based on IRS Life
     Expectancy table(s) if earlier), the same Cash Value would be payable, but
     without the surrender charge.

Variable Income Options 3-V(a) and 3-V(c) are not available for Adjusted Age(s)
greater than 85.

C947                                 Page 18

<PAGE>

                             SECTION 11 - CONTINUED

Variable Income Option 5-V - Joint and Survivor Annuity
You may choose between:

(a)  No Period Certain - We will make payments as long as either the Annuitant
     or the joint Annuitant is living.

(b)  Life with Emergency Cash (SM) - We will make payments during the joint
     lifetime of the Annuitant and a joint Annuitant of Your selection. Payments
     will be made as long as either person is living, but the annuity may be
     Surrendered (in full or part). The cash value is equal to a multiple of the
     Supportable Payment (see definition below), where that multiple reduces
     over time to zero at age 101 of the younger Annuitant. We will apply a
     surrender charge. Should the last surviving Annuitant die before age 101
     (or, for qualified policies, the applicable age based on IRS Life
     Expectancy table(s) if earlier), the same cash value would be payable, but
     without the surrender charge.

Variable Income Options 5-V(a) and 5-V(b) are not available for Annuitant
Adjusted Age(s) greater than 85.

Initial Payment Guarantee
At the time you annuitize, You may elect an Initial Payment Guarantee under
which we guarantee Your variable annuity payments will never be less than a
percentage of the initial variable annuity payment. You cannot terminate the
Initial Payment Guarantee after You have elected it. The percentage applicable
to the initial payment and the additional fee for this option will be those
currently applicable at the time of annuitization.

Supportable Payment
The Supportable Payment is the sum of each selected Subaccount's variable
annuity unit value times the number of variable annuity units. The variable
annuity units are adjusted to reflect the year-to-date difference between the
stabilized payment and the payment had they not been stabilized. Supportable
Payments are used to determine surrender values, death benefits and transfers.

Determination of Subsequent Variable Payments Without Stabilization
The number of variable annuity units in each selected Subaccount is determined
by dividing the first variable annuity payment allocated to the Subaccount by
the variable annuity unit value of that Subaccount on the Annuity Commencement
Date. The amount of each variable annuity payment after the first payment will
increase or decrease according to the value of the variable annuity units which
reflect the investment experience of the selected Subaccounts. Each variable
annuity payment after the first payment will be equal to the number of variable
annuity units in the selected Subaccounts multiplied by the variable annuity
unit value on the date the payment is made.

Determination of Subsequent Variable Payments With Stabilization
If "Life with Emergency Cash" is chosen (Variable Income Option 3-V(c) or
5-V(b)), or if the Initial Payment Guarantee is chosen, variable annuity
payments during the first year following the Annuity Commencement Date will be
stabilized to equal the initial payment. On each anniversary of the Annuity
Commencement Date, the stabilized variable annuity payment will be increased or
decreased (but never below the guaranteed payment if the Initial Payment
Guarantee is chosen) and held level for that year. On each anniversary of the
Annuity Commencement Date, the stabilized variable annuity payment will equal
the Supportable Payment at that time (or if the Initial Payment Guarantee is
chosen, the stabilized variable payment will equal the greater of the guaranteed
payment or the Supportable Payment at that time).

If the payment without stabilization (at any payment date during the year) is
greater than the stabilized variable annuity payment for that year, the excess
will be used to purchase additional annuity units (as described below). If the
payment without stabilization (at any payment date during the year) is less than
the stabilized variable annuity payment for that year, annuity units will be
redeemed (as described below) to fund the deficiency.

Purchase/Redemption of Annuity Units with Stabilized Variable Annuity Payments
The number of annuity units purchased or redeemed is equal to the annuity income
purchased or redeemed, respectively, divided by the annuity unit value for each
respective Subaccount. Purchases and redemptions of annuity income will be
allocated to each Subaccount on a proportionate basis. The amount of annuity
income purchased or redeemed is the difference between the payment without
stabilization during that year and the stabilized variable annuity payment,
times an attained adjusted age nearest birthday payment factor divided by
$1,000. The payment factor will reflect any remaining guaranteed payments, if
any, and is determined using the same assumptions for mortality and interest as
the payment factors listed in this policy for Variable Income Options 3-V and
5-V.

CB947                                Page 19

<PAGE>

                       GUARANTEED FIXED INCOME OPTIONS **

 The amounts shown in these tables are the guaranteed amounts for each 1,000 of
the proceeds. Higher current amounts may be available at the time of settlement.

<TABLE>
<CAPTION>
---------------------------------------------------------------------------------------------------------------------------------
  Option 1, Table I             Option 2, Table II        Option 2, Table III       Option 2, Table IV       Option 2, Table V
---------------------------------------------------------------------------------------------------------------------------------
 Number    Amount of            Monthly Installment                               Monthly Installment For    Monthly Installment
of Years    Monthly             For Life No Period      Monthly Installment For   Life Guaranteed Return       For Life With
Payable   Installment                Certain             Life 10 Years Certain      of Policy Proceeds       Emergency Cash (SM)
---------------------------------------------------------------------------------------------------------------------------------
                       Age*    Male   Female   Unisex    Male   Female   Unisex   Male    Female  Unisex    Male   Female  Unisex
---------------------------------------------------------------------------------------------------------------------------------
<S>       <C>          <C>   <C>      <C>      <C>      <C>     <C>     <C>      <C>     <C>      <C>      <C>     <C>     <C>
                        50   $  2.97  $  2.86  $  2.90  $ 2.96  $ 2.86  $  2.89  $ 2.79  $  2.74  $  2.76  $ 2.69  $ 2.66  $ 2.67
                        51      3.04     2.92     2.96    3.02    2.91     2.94    2.84     2.79     2.80    2.74    2.70    2.72
                        52      3.10     2.98     3.02    3.08    2.97     3.01    2.89     2.84     2.85    2.79    2.75    2.76
                        53      3.18     3.05     3.09    3.15    3.03     3.07    2.94     2.89     2.90    2.84    2.80    2.81
    5     17.28         54      3.25     3.11     3.15    3.22    3.10     3.14    3.00     2.94     2.96    2.89    2.85    2.86
    6     14.51         55      3.33     3.18     3.23    3.30    3.17     3.21    3.06     3.00     3.02    2.94    2.90    2.91
    7     12.53         56      3.41     3.26     3.30    3.38    3.24     3.28    3.12     3.06     3.07    3.00    2.96    2.97
    8     11.04         57      3.50     3.34     3.39    3.46    3.32     3.36    3.18     3.12     3.14    3.06    3.01    3.03
    9      9.89         58      3.60     3.42     3.47    3.55    3.39     3.44    3.25     3.18     3.20    3.12    3.07    3.08
   10      8.96         59      3.69     3.51     3.56    3.65    3.48     3.53    3.32     3.25     3.27    3.18    3.13    3.15
   11      8.21         60      3.80     3.60     3.66    3.75    3.57     3.62    3.39     3.32     3.34    3.25    3.20    3.21
   12      7.58         61      3.91     3.70     3.76    3.85    3.66     3.72    3.46     3.39     3.41    3.32    3.27    3.28
   13      7.05         62      4.03     3.81     3.87    3.96    3.76     3.82    3.54     3.47     3.49    3.39    3.34    3.35
   14      6.59         63      4.16     3.92     3.99    4.07    3.87     3.93    3.63     3.55     3.57    3.47    3.41    3.43
   15      6.20         64      4.30     4.04     4.12    4.20    3.98     4.04    3.72     3.63     3.66    3.55    3.49    3.51
   16      5.85         65      4.45     4.16     4.25    4.32    4.09     4.16    3.81     3.72     3.75    3.63    3.57    3.59
   17      5.55         66      4.60     4.30     4.39    4.46    4.22     4.29    3.91     3.81     3.84    3.72    3.66    3.68
   18      5.27         67      4.77     4.45     4.54    4.60    4.35     4.42    4.01     3.91     3.94    3.81    3.75    3.77
   19      5.03         68      4.95     4.60     4.71    4.75    4.49     4.57    4.11     4.01     4.04    3.90    3.85    3.86
   20      4.81         69      5.14     4.77     4.88    4.90    4.64     4.71    4.23     4.12     4.15    4.01    3.95    3.96
                        70      5.34     4.95     5.07    5.06    4.79     4.87    4.34     4.24     4.27    4.11    4.05    4.07
                        71      5.56     5.15     5.27    5.22    4.95     5.03    4.47     4.36     4.39    4.22    4.17    4.18
                        72      5.79     5.36     5.49    5.39    5.12     5.20    4.60     4.49     4.52    4.34    4.29    4.30
                        73      6.03     5.59     5.72    5.56    5.30     5.38    4.73     4.62     4.66    4.46    4.40    4.42
                        74      6.30     5.83     5.97    5.74    5.49     5.57    4.88     4.77     4.80    4.59    4.54    4.55
                        75      6.58     6.10     6.24    5.93    5.68     5.76    5.03     4.92     4.95    4.72    4.67    4.69
                        76      6.88     6.39     6.53    6.11    5.88     5.95    5.18     5.08     5.11    4.85    4.81    4.82
                        77      7.20     6.70     6.85    6.30    6.09     6.15    5.35     5.25     5.28    5.00    4.96    4.97
                        78      7.55     7.03     7.19    6.49    6.30     6.36    5.53     5.43     5.46    5.15    5.12    5.12
                        79      7.92     7.40     7.55    6.68    6.51     6.56    5.71     5.61     5.64    5.31    5.28    5.29
                        80      8.32     7.79     7.95    6.87    6.72     6.77    5.90     5.81     5.84    5.48    5.45    5.46
                        81      8.75     8.22     8.38    7.06    6.93     6.97    6.11     6.02     6.05    5.67    5.64    5.64
                        82      9.20     8.69     8.84    7.24    7.13     7.16    6.32     6.24     6.27    5.84    5.83    5.84
                        83      9.69     9.19     9.34    7.41    7.33     7.36    6.55     6.48     6.50    6.05    6.04    6.04
                        84     10.21     9.74     9.88    7.58    7.52     7.54    6.78     6.72     6.74    6.24    6.24    6.24
                        85     10.77    10.33    10.46    7.74    7.69     7.71    7.03     6.98     7.00    6.48    6.48    6.48
                        86                                7.89    7.86     7.87    7.29     7.26     7.27
                        87                                8.03    8.01     8.01    7.57     7.54     7.55
                        88                                8.16    8.15     8.15    7.86     7.84     7.85
                        89                                8.28    8.27     8.27    8.17     8.15     8.16
                        90                                8.38    8.38     8.38    8.49     8.48     8.48
                        91                                8.48    8.48     8.48    8.83     8.82     8.83
                        92                                8.57    8.57     8.57    9.19     9.18     9.19
                        93                                8.65    8.64     8.65    9.58     9.56     9.57
                        94                                8.72    8.71     8.71   10.00     9.97     9.98
                        95                                8.78    8.77     8.77   10.45    10.40    10.42
                        96                                8.83    8.82     8.82   10.94    10.87    10.89
                        97                                8.87    8.86     8.86   11.48    11.38    11.41
                        98                                8.90    8.90     8.90   12.07    11.95    11.99
---------------------------------------------------------------------------------------------------------------------------------
<FN>
<F1>
*Adjusted Age as defined in Section 11.A.

<F2>
**The guaranteed fixed income amounts are based on a guaranteed interest rate of
[1.5%.]
</FN>
</TABLE>

Dollar amounts of monthly, quarterly, semi-annual and annual installments not
shown in the above tables will be calculated on the same basis as those shown
and may be obtained from the Company (if the option is available based on
Adjusted Age as described in Section 11).

T1048                                Page 20

<PAGE>

<TABLE>
<CAPTION>
                               Fixed Income Option 4, Table VI
                       Monthly Installment For Joint and Full Survivor
--------------------------------------------------------------------------------------------
 Adjusted                            Adjusted Age of Female Annuitant*
   Age       -------------------------------------------------------------------------------
   of        15 Years    12 Years     9 Years     6 Years     3 Years               3 Years
  Male       Less Than   Less Than   Less Than   Less Than   Less Than   Same As   More Than
Annuitant*     Male        Male        Male        Male        Male        Male       Male
--------------------------------------------------------------------------------------------
<S>          <C>         <C>         <C>         <C>         <C>         <C>       <C>
    50       $    2.20   $    2.27   $    2.34   $    2.41   $    2.48   $  2.55   $    2.62
    55            2.35        2.44        2.52        2.61        2.71      2.80        2.88
    60            2.54        2.64        2.76        2.88        2.99      3.11        3.23
    65            2.77        2.91        3.06        3.22        3.38      3.54        3.69
    70            3.08        3.26        3.46        3.67        3.89      4.11        4.33
    75            3.47        3.72        3.99        4.29        4.60      4.93        5.24
    80            4.01        4.35        4.74        5.17        5.62      6.08        6.53
    85            4.75        5.25        5.81        6.44        7.09      7.75        8.36
--------------------------------------------------------------------------------------------
</TABLE>

<TABLE>
<CAPTION>
                   Monthly Installment For Unisex Joint and Full Survivor
--------------------------------------------------------------------------------------------
 Adjusted                             Adjusted Age of Joint Annuitant*
   Age       -------------------------------------------------------------------------------
   of        15 Years    12 Years     9 Years     6 Years     3 Years               3 Years
  First      Less Than   Less Than   Less Than   Less Than   Less Than   Same As   More Than
Annuitant*     First       First       First       First       First      First      First
--------------------------------------------------------------------------------------------
<S>          <C>         <C>         <C>         <C>         <C>         <C>       <C>
    50       $    2.20   $    2.27   $    2.34   $    2.41   $    2.48   $  2.55   $    2.61
    55            2.36        2.44        2.53        2.62        2.70      2.79        2.87
    60            2.55        2.65        2.76        2.88        2.99      3.10        3.20
    65            2.79        2.92        3.07        3.22        3.37      3.52        3.66
    70            3.10        3.28        3.47        3.67        3.88      4.09        4.28
    75            3.50        3.75        4.02        4.30        4.60      4.89        5.16
    80            4.06        4.40        4.78        5.19        5.62      6.04        6.44
    85            4.83        5.32        5.87        6.47        7.10      7.71        8.28
--------------------------------------------------------------------------------------------
</TABLE>

<TABLE>
<CAPTION>
                              Fixed Income Option 4, Table VII
       Monthly Installment For Joint and Full Survivor (Life with Emergency Cash (SM))
--------------------------------------------------------------------------------------------
 Adjusted                            Adjusted Age of Joint Annuitant*
   Age       -------------------------------------------------------------------------------
   of        15 Years    12 Years     9 Years     6 Years     3 Years               3 Years
  Male       Less Than   Less Than   Less Than   Less Than   Less Than   Same As   More Than
Annuitant*     Male        Male        Male        Male        Male        Male       Male
--------------------------------------------------------------------------------------------
<S>          <C>         <C>         <C>         <C>         <C>         <C>       <C>
    50       $    2.15   $    2.21   $    2.28   $    2.35   $    2.42   $  2.49   $    2.54
    55            2.28        2.36        2.45        2.53        2.62      2.70        2.77
    60            2.45        2.54        2.65        2.76        2.87      2.97        3.06
    65            2.64        2.77        2.90        3.04        3.18      3.31        3.42
    70            2.89        3.04        3.21        3.39        3.57      3.75        3.89
    75            3.19        3.39        3.61        3.84        4.08      4.30        4.47
    80            3.57        3.83        4.12        4.42        4.73      5.02        5.23
    85            4.06        4.41        4.78        5.17        5.57      5.98        6.23
--------------------------------------------------------------------------------------------
</TABLE>

<TABLE>
<CAPTION>
   Monthly Installment For Unisex Joint and Full Survivor (Life with Emergency Cash (SM))
--------------------------------------------------------------------------------------------
 Adjusted                           Adjusted Age of Joint Annuitant*
   Age       -------------------------------------------------------------------------------
   of        15 Years    12 Years     9 Years     6 Years     3 Years               3 Years
  First      Less Than   Less Than   Less Than   Less Than   Less Than   Same As   More Than
Annuitant*     First       First       First       First       First      First      First
--------------------------------------------------------------------------------------------
<S>          <C>         <C>         <C>         <C>         <C>         <C>       <C>
    50       $    2.15   $    2.22   $    2.28   $    2.35   $    2.42   $  2.43   $    2.54
    55            2.29        2.37        2.45        2.53        2.62      2.70        2.76
    60            2.45        2.55        2.65        2.76        2.87      2.97        3.05
    65            2.65        2.78        2.91        3.04        3.18      3.31        3.40
    70            2.90        3.06        3.22        3.40        3.57      3.74        3.86
    75            3.21        3.41        3.62        3.86        4.08      4.29        4.45
    80            3.60        3.86        4.14        4.44        4.73      5.02        5.21
    85            4.08        4.43        4.80        5.18        5.58      5.97        6.21
--------------------------------------------------------------------------------------------
<FN>
<F1>
*Adjusted Age as defined in Section 11.A.
</FN>
</TABLE>

Dollar amounts of monthly, quarterly, semi-annual, and annual installments not
shown in the above tables will be calculated on the same basis as those shown
and may be obtained from the Company (if the option is available based on
Adjusted Age as described in Section 11).

TB1048                               Page 21

<PAGE>

                             VARIABLE INCOME OPTIONS
                     BASED ON ASSUMED INVESTMENT RETURN **

  The amounts shown in these tables are the initial payment amounts based on a
        [5.0%] Assumed Investment Return for each $1,000 of the proceeds.

<TABLE>
<CAPTION>
-------------------------------------------------------------------------------------------------
          Option 3-V, Table II          Option 3-V, Table III       Option 3-V, Table IV
-------------------------------------------------------------------------------------------------
         Monthly Installment for       Monthly Installment for      Monthly Installment for
         Life No Period Certain         Life 10 Years Certain      Life With Emergency Cash (SM)
-------------------------------------------------------------------------------------------------
Age*     Male    Female    Unisex     Male     Female     Unisex    Male      Female      Unisex
-------------------------------------------------------------------------------------------------
<S>    <C>       <C>       <C>       <C>       <C>       <C>       <C>       <C>         <C>
 50    $  5.07   $  4.93   $  4.98   $  5.04   $  4.92   $  4.95   $  4.83   $    4.76   $   4.78
 51       5.13      4.99      5.03      5.09      4.96      5.00      4.87        4.80       4.82
 52       5.19      5.04      5.08      5.15      5.01      5.05      4.92        4.84       4.86
 53       5.26      5.10      5.14      5.21      5.07      5.11      4.96        4.88       4.91
 54       5.33      5.16      5.21      5.27      5.12      5.17      5.01        4.93       4.95
 55       5.40      5.22      5.27      5.34      5.18      5.23      5.06        4.98       5.00
 56       5.48      5.29      5.35      5.41      5.25      5.30      5.12        5.03       5.05
 57       5.57      5.36      5.42      5.49      5.32      5.37      5.18        5.08       5.11
 58       5.66      5.44      5.50      5.57      5.39      5.44      5.24        5.14       5.17
 59       5.75      5.52      5.59      5.66      5.47      5.52      5.31        5.20       5.23
 60       5.85      5.61      5.68      5.75      5.55      5.61      5.37        5.26       5.29
 61       5.97      5.70      5.78      5.85      5.63      5.70      5.45        5.33       5.37
 62       6.09      5.81      5.89      5.95      5.72      5.79      5.53        5.40       5.44
 63       6.21      5.91      6.00      6.06      5.82      5.89      5.61        5.48       5.52
 64       6.35      6.03      6.13      6.17      5.92      6.00      5.70        5.56       5.60
 65       6.50      6.16      6.26      6.29      6.03      6.11      5.79        5.65       5.69
 66       6.66      6.29      6.40      6.42      6.15      6.23      5.89        5.75       5.79
 67       6.83      6.43      6.55      6.55      6.27      6.36      6.00        5.85       5.89
 68       7.01      6.59      6.71      6.69      6.40      6.49      6.11        5.96       6.00
 69       7.21      6.76      6.89      6.83      6.54      6.63      6.23        6.07       6.12
 70       7.41      6.94      7.08      6.98      6.69      6.77      6.36        6.20       6.25
 71       7.63      7.14      7.28      7.13      6.84      6.93      6.49        6.33       6.38
 72       7.87      7.35      7.50      7.28      7.00      7.09      6.63        6.46       6.52
 73       8.12      7.58      7.74      7.45      7.17      7.25      6.78        6.62       6.66
 74       8.39      7.83      8.00      7.61      7.34      7.42      6.94        6.78       6.83
 75       8.68      8.11      8.28      7.78      7.52      7.60      7.11        6.95       7.00
 76       8.99      8.40      8.58      7.95      7.71      7.78      7.29        7.13       7.18
 77       9.32      8.72      8.90      8.12      7.90      7.97      7.47        7.33       7.36
 78       9.68      9.07      9.25      8.29      8.09      8.16      7.68        7.52       7.57
 79      10.06      9.45      9.63      8.47      8.29      8.34      7.88        7.74       7.79
 80      10.47      9.85     10.04      8.64      8.48      8.53      8.11        7.98       8.01
 81      10.91     10.30     10.48      8.80      8.67      8.71      8.34        8.23       8.26
 82      11.38     10.78     10.96      8.97      8.86      8.89      8.60        8.48       8.53
 83      11.88     11.30     11.47      9.12      9.04      9.06      8.84        8.75       8.77
 84      12.42     11.87     12.03      9.27      9.21      9.23      9.09        9.01       9.05
 85      12.99     12.48     12.63      9.41      9.37      9.38      9.35        9.31       9.32
 86                                     9.54      9.51      9.52
 87                                     9.67      9.65      9.65
 88                                     9.78      9.77      9.77
 89                                     9.89      9.88      9.88
 90                                     9.98      9.98      9.98
 91                                    10.07     10.07     10.07
 92                                    10.15     10.15     10.15
 93                                    10.22     10.22     10.22
 94                                    10.28     10.28     10.28
 95                                    10.34     10.33     10.33
 96                                    10.38     10.38     10.38
 97                                    10.42     10.42     10.42
 98                                    10.45     10.45     10.45
-------------------------------------------------------------------------------------------------
<FN>
<F1>
*Adjusted Age as defined in Section 11.A.

<F2>
**The discount factor per day which corresponds to the Assumed Investment Return
of [5.0%] is [.99986634.]
</FN>
</TABLE>

Dollar amounts of monthly, quarterly, semi-annual, and annual installments not
shown in the above tables will be calculated on the same basis as those shown
and may be obtained from the Company (if the option is available based on
Adjusted Age as described in Section 11).

H1343                                Page 22

<PAGE>

<TABLE>
<CAPTION>
                                Variable Income Option 5-V(a)
                       Monthly installment For Joint and Full Survivor
--------------------------------------------------------------------------------------------
 Adjusted                             Adjusted Age of Female Annuitant*
   Age       -------------------------------------------------------------------------------
   of        15 Years    12 Years     9 Years     6 Years     3 Years               3 Years
  Male       Less Than   Less Than   Less Than   Less Than   Less Than   Same As   More Than
Annuitant*     Male        Male        Male        Male        Male        Male      Male
--------------------------------------------------------------------------------------------
<S>          <C>         <C>         <C>         <C>         <C>         <C>       <C>
    50       $    4.37   $    4.42   $    4.46   $    4.51   $    4.56   $  4.62   $    4.67
    55            4.48        4.54        4.60        4.67        4.74      4.81        4.88
    60            4.62        4.70        4.79        4.88        4.98      5.08        5.18
    65            4.81        4.92        5.04        5.17        5.31      5.46        5.61
    70            5.07        5.23        5.40        5.59        5.79      6.00        6.22
    75            5.43        5.65        5.90        6.18        6.48      6.79        7.11
    80            5.94        6.26        6.63        7.04        7.49      7.95        8.40
    85            6.67        7.15        7.70        8.31        8.97      9.63       10.26
--------------------------------------------------------------------------------------------
</TABLE>

<TABLE>
<CAPTION>
                   Monthly Installment For Unisex Joint and Full Survivor
--------------------------------------------------------------------------------------------
 Adjusted                             Adjusted Age of Joint Annuitant*
   Age       -------------------------------------------------------------------------------
   of        15 Years    12 Years     9 Years     6 Years     3 Years               3 Years
  First      Less Than   Less Than   Less Than   Less Than   Less Than   Same As   More Than
Annuitant*     First       First       First       First       First      First      First
--------------------------------------------------------------------------------------------
<S>          <C>         <C>         <C>         <C>         <C>         <C>       <C>
    50       $    4.38   $    4.42   $    4.47   $    4.51   $    4.56   $  4.61   $    4.66
    55            4.48        4.54        4.60        4.67        4.73      4.80        4.87
    60            4.63        4.70        4.79        4.88        4.97      5.07        5.16
    65            4.82        4.93        5.05        5.17        5.30      5.44        5.57
    70            5.09        5.24        5.41        5.59        5.78      5.97        6.16
    75            5.46        5.68        5.93        6.19        6.47      6.75        7.03
    80            5.99        6.31        6.67        7.07        7.48      7.90        8.30
    85            6.75        7.23        7.76        8.35        8.97      9.59       10.17
--------------------------------------------------------------------------------------------
*Adjusted Age as Defined in Section 11.A
--------------------------------------------------------------------------------------------
</TABLE>

<TABLE>
<CAPTION>
                                Variable Income Option 5-V(b)
       Monthly Installment For Joint and Full Survivor (Life with Emergency Cash (SM))
--------------------------------------------------------------------------------------------
 Adjusted                             Adjusted Age of Female Annuitant*
   Age       -------------------------------------------------------------------------------
   of        15 Years    12 Years     9 Years     6 Years     3 Years               3 Years
  Male       Less Than   Less Than   Less Than   Less Than   Less Than   Same As   More Than
Annuitant*     First       First       First       First       First      First      First
--------------------------------------------------------------------------------------------
<S>          <C>         <C>         <C>         <C>         <C>         <C>       <C>
    50       $    4.34   $    4.38    $   4.42   $    4.47   $    4.51   $  4.57   $    4.61
    55            4.43        4.48        4.54        4.60        4.67      4.74        4.79
    60            4.55        4.62        4.70        4.78        4.88      4.97        5.05
    65            4.71        4.80        4.91        5.03        5.16      5.30        5.41
    70            4.92        5.05        5.21        5.38        5.56      5.76        5.91
    75            5.21        5.40        5.61        5.86        6.12      6.40        6.61
    80            5.61        5.88        6.19        6.53        6.90      7.29        7.56
    85            6.16        6.54        6.98        7.46        7.95      8.41        8.76
--------------------------------------------------------------------------------------------
</TABLE>

<TABLE>
<CAPTION>
   Monthly Installment For Unisex Joint and Full Survivor (Life with Emergency Cash (SM))
--------------------------------------------------------------------------------------------
 Adjusted                             Adjusted Age of Joint Annuitant*
   Age       -------------------------------------------------------------------------------
   of        15 Years    12 Years     9 Years     6 Years     3 Years               3 Years
  First      Less Than   Less Than   Less Than   Less Than   Less Than   Same As   More Than
Annuitant*     First       First       First       First       First      First      First
--------------------------------------------------------------------------------------------
<S>          <C>         <C>         <C>         <C>         <C>         <C>       <C>
    50       $    4.34   $    4.38   $    4.42   $    4.47   $    4.51   $  4.56   $    4.60
    55            4.43        4.48        4.54        4.60        4.67      4.73        4.78
    60            4.55        4.62        4.70        4.78        4.87      4.96        5.03
    65            4.71        4.81        4.92        5.03        5.16      5.29        5.38
    70            4.93        5.07        5.22        5.38        5.56      5.74        5.87
    75            5.23        5.42        5.63        5.87        6.12      6.38        6.56
    80            5.64        5.91        6.21        6.55        6.90      7.26        7.51
    85            6.21        6.58        7.02        7.48        7.97      8.41        8.74
--------------------------------------------------------------------------------------------
*Adjusted Age as defined in Section 11.A
--------------------------------------------------------------------------------------------
</TABLE>

Dollar amounts of monthly, quarterly, semi-annual, and annual installments not
shown in the above tables will be calculated on the same basis as those shown
and may be obtained from the Company (if the option is available based on
Adjusted Age as described in Section 11).

J1343                                Page 23

<PAGE>


                   WESTERN RESERVE LIFE ASSURANCE CO. OF OHIO

                           Home Office: Columbus, Ohio


                             Administrative Office:
                                  P.O. Box 5068
                         Clearwater, Florida 33758-5068


                                      INDEX

                                                                            Page
Accumulation Units .......................................................    11
Adjusted Age .............................................................    16
Adjusted Policy Value ....................................................     6
Age or Sex Corrections ...................................................     4
Annuity Commencement Date ................................................     4
Assignment ...............................................................     4
Beneficiary ..............................................................     5
Cash Value ...............................................................     7
Contract .................................................................     4
Death Proceeds ...........................................................    14
Definitions ..............................................................     2
Dollar Cost Averaging Option .............................................    13
Evidence of Survival .....................................................     4
Excess Interest Adjustment ...............................................     6
Fixed Account ............................................................    12
Guaranteed Minimum Death Benefit .........................................    14
Guaranteed Period Options ................................................    12
Income Options ...........................................................    16
Income Option Tables .....................................................    21
Incontestability .........................................................     4
Modification of Policy ...................................................     4
Non-participating ........................................................     4
Option to Change Annuity Commencement Date ...............................     4
Partial Withdrawals ......................................................     9
Payee ....................................................................    16
Payment of Premiums ......................................................     5
Policy Data Page .........................................................     3
Policy Value .............................................................     6
Proof of Age .............................................................    16
Protection of Proceeds ...................................................     5
Right to Cancel ..........................................................     1
Rights of Owner ..........................................................     4
Separate Account .........................................................    10
Service Charge ...........................................................     6
Settlement ...............................................................     4
Surrender Charges ........................................................     7
Transfers ................................................................    13


                   FLEXIBLE PREMIUM DEFERRED VARIABLE ANNUITY
                   INCOME PAYABLE AT ANNUITY COMMENCEMENT DATE
            BENEFITS BASED ON THE PERFORMANCE OF THE SEPARATE ACCOUNT
                       ARE VARIABLE AND ARE NOT GUARANTEED
                  AS TO DOLLAR AMOUNT (SEE SECTIONS 7 AND 11C)
                                NON-PARTICIPATING

Y1063