Phone		Fax		Client Service Office	
	[800-745-1112]	[402-467-7335]	[PO Box 81889 / Lincoln, NE 68501]


 


	 


 


Ameritas
Life
Insurance
Corp.
 5900
O Street
/ Lincoln,
NE 68510
/ [ameritas.com]


 


	Annuitant(s):	[John Doe]
	 	[Jane Doe]
	 	 
	Owner(s):	[John Doe]
	 	[Jane Doe]
	 	 
	Policy Number:	[0123456789]


 


 


We
will
pay the
benefits
of this
policy
in accordance
with
its
terms.


 


LOOK
AT THE
APPLICATION
FORMS. 
This
policy
is issued
in consideration
of the
payment
of the
premium
and the
answers
in the
application
(see
copy attached).
 If
all
answers
are
not true
and complete,
this
policy
may
be affected,
subject
to the
'Misstatement
of Age
or Gender'
provision.


 


PLEASE
READ
THIS
POLICY
CAREFULLY.
 This
policy
is a
legal
contract
between
you
and Ameritas
Life
Insurance
Corp.


 


RIGHT TO EXAMINE THIS POLICY.  It
is important to us that you are satisfied with this policy.  You have 10 days to
review this policy after you receive it.  If this policy is a
replacement for an existing policy, you have [30] days to
review this policy after you receive it.  If during this time you are not satisfied, you may send the policy back to us or give it to our agent.  In such case, this policy will be void from the beginning.  We will refund the premium paid
including any charges and fees previously deducted, less withdrawals, adjusted by investment gains and losses, after this policy is returned.


 


AMERITAS
LIFE
INSURANCE
CORP.


 


	[	SPECIMEN	SPECIMEN	]
	   President	Secretary   


 


 


YOU
MAY
ALLOCATE
PREMIUMS
AMONG
THE SUBACCOUNTS
AND THE
FIXED
ACCOUNT. 
THE PORTION
OF YOUR
ACCUMULATION
VALUE
THAT
IS ALLOCATED
TO THE
SUBACCOUNTS
WILL
FLUCTUATE
WITH
THE INVESTMENT
EXPERIENCE
OF THE
SUBACCOUNTS.
 THERE
IS NO
MINIMUM
GUARANTEE
ON THAT
PORTION
OF YOUR
ACCUMULATION
VALUE.


 


FOR
ANY QUESTIONS
REGARDING
THIS
POLICY,
PLEASE
CONTACT
US AT
[800-745-1112].
 YOU
MAY
ALSO
CONTACT
YOUR
STATE
DEPARTMENT
OF INSURANCE
AT [DOI
#].


 


Flexible
Premium
Deferred
Variable
Annuity


With
Waiver of Surrender Charge Benefit


Monthly
Annuity Payments Starting on
Maturity
Date


Death
Benefit Payable Before Maturity
Date


Nonparticipating


 


	ICC15 6200 8-15	 	 




    	 



    	 



    

 


	TABLE OF CONTENTS


 


	POLICY SCHEDULE	3


 


	DEFINITIONS	4


 


	GENERAL PROVISIONS	5


Annual Report | Assignment | Beneficiary
Designation | Change of Beneficiary |


Change of Ownership | Claims of Creditors
| Delay of Payments | Entire Policy | Form Approval


Incontestability | Misstatement of Age
or Gender | Nonparticipating Policy


 


	PREMIUMS	7


General | Nonpayment of Premium for Two
Years| Allocating Premium


 


	INVESTMENT OPTIONS	7


Selecting Your Investments | Separate
Account | Subaccounts | Unit Value | Valuation of Assets |


Fees Charged by the Portfolios | Substitution
of Portfolios | Fixed Account Option


 


	VALUES	8


Values and Benefits | Charges and Fees
| Accumulation Value | Separate Account Value |


Fixed Account Value | Free Withdrawal
Amount | Surrender Charge | Full Surrender |


Partial Withdrawal | Waiver of Surrender
Charge


 


	TRANSFERS	11


Subaccount Transfer | Fixed Account Transfer


 


	DEATH BENEFITS	12


Death Benefit | Death of Owner | Joint
Owners | Death of Annuitant Before the Maturity Date |


Death of Beneficiary


 


	PAYMENT OF POLICY BENEFITS	13


General | Normal Settlement | Selection
of Annuity Option | Change in Annuity Option |


Change in Maturity Date | Minimum Payments
| Withdrawals | Required Proof | Basis of Values |


Current Interest


 


	ANNUITY OPTIONS	14


Life Income | Installment Payments
| Other Options


 


 


 


 


 


 


 


 


 


 


 


 


 


	 ICC15 6200 8-15	2	 




    	 



    	 



    

 


	POLICY SCHEDULE


Policy
Information


	Policy Number:	[0123456789]
	 	 
	Owner:	[John Doe]
	Owner Issue Age and Gender:	[35, Male]
	 	 
	Joint Owner:	[Jane Doe]
	Joint Owner Issue Age and Gender:	[35, Female]
	 	 
	Annuitant:	[John Doe]
	Annuitant Issue Age and Gender:	[35, Male]
	 	 
	Joint Annuitant:	[Jane Doe]
	Joint Annuitant Issue Age and Gender:	[35, Female]
	 	 
	Policy Date:	[July 1, 2016]
	 	 
	Maturity Date:	[July 1, 2076]
	 	 
	Plan:	[Nonqualified]
	 	 
	Initial Premium:	$[50,000.00]
	 	 
	Annuity Option:	Life annuity with guaranteed payments 5 years unless another option is chosen by you
	 	 
	 	 
	Fixed Account Information	 
	 	 
	Initial Declared Interest Rate:	[1.00]%, applicable for the first policy year
	 	 
	Guaranteed Minimum Interest Rate:	[1.00]%, applicable for the life of the policy
	 	 
	Nonforfeiture Interest Rate*:	[1.00]%


 


 


 


 


 


 


 


 


 


 


 


 


 


 


* This
rate applies for the life of the policy and is used in the calculation of your guaranteed minimum cash value only.  The
nonforfeiture component of this calculation reflects 87.5% of premiums and transfers allocated to the fixed account
and a $50 annual expense allowance.  See the ‘Values and Benefits’ provision of the ‘Values’ section
for details of this calculation.


	ICC15 6200 8-15	3	 




    	 



    	 



    

 


	POLICY SCHEDULE


Transfer
Information


	Free Transfers per Policy Year:	[15]
	 	 
	Transfer Fee after Free Transfer Limit:	 
	Current**	$[10] per transfer
	Maximum	$10 per transfer
	 	 
	Minimum Transfer Amount:	$[250] or the entire subaccount or fixed account value, if less
	 	 
	Maximum Transfer out of Fixed Account:	Each policy year you may make one transfer out of the fixed account.  The maximum transfer amount out of the fixed account is equal to the greatest of:
	 	 
	 	
        (1) [25]% of the fixed account value on the
        date of the transfer

        (2) the amount of any fixed account transfer
        out that occurred during the prior 13 months; and

        (3) $1,000

	 	 
	Maximum Transfer into Fixed Account:	[25]% of the separate account value as of the previous policy anniversary, per policy year
	 	 
	Minimum Subaccount Balance:	$[100]
	 	 
	Charges and Fees	 
	Mortality and Expense Risk Charge:	 
	Current**	[0.75]% annual, equivalent to [0.0020491]% daily
	Maximum	1.00% annual, equivalent to 0.0027322% daily
	 	 
	Administrative Expense Charge:	 
	Current**	[0.25]% annual, equivalent to [0.0006830]% daily
	Maximum	0.35% annual, equivalent to 0.0009562% daily
	 	 
	Policy Fee:	 
	Current**	$[40] annual
	Maximum	$50 annual
	 	 
	Premium Limitations***	 
	Maximum Annual Premium:	$[25,000], per policy year
	Maximum Total Premium:	$[1,000,000], over the life of the policy
	 	 
	Surrender Charge	 
	Completed Years Since	 
	Receipt of Premium	Surrender Charge Percentage
	 	 
	0	8%
	1	8%
	2	8%
	3	7%
	4	6%
	5	5%
	6	4%
	7 and thereafter	0%


 


Each year
after the first policy year, 10% of the accumulation value may be withdrawn without a surrender charge.


 


** Current
rates shown are applicable on the policy date.  We reserve the right to change these rates at any time; however,
they will never exceed the maximum rates shown.


*** We may
waive these limits, but waiver in one instance does not constitute waiver for additional


premiums.


 


	ICC15 6200 8-15	3A	 




    	 



    	 



    

 


This
is a
flexible
premium
deferred
variable
annuity.
 Annuity
payments
will
be paid,
subject
to the
terms
of this
policy.
 As
a variable
annuity,
this
policy
is a
security
and must
be sold
pursuant
to a
prospectus
registered
with
the
Securities
and Exchange
Commission
(SEC).  We
encourage
you to
read the
prospectus
together
with
the policy.


 


	DEFINITIONS


(Defined terms appear in italics throughout this
policy.)


 


ACCUMULATION VALUE. Means the value of the
policy before the surrender charge, if any. On the maturity date, the accumulation value will be used to determine
the annuity payments under the annuity option selected by you.


 


AGE. Means age on nearest birthday.


 


ANNUITANT. Means the person, or persons if
there are joint annuitants, whose life is used to determine the duration of any annuity payments involving life contingencies.
The annuitant is named in the application and


on the policy schedule. While the annuitant is
alive, and prior to the maturity date, you, as owner, may name a new annuitant by providing us written
notice, unless the owner is not a natural person.


 


ANNUITY PAYMENTS. Means annual, semiannual,
quarterly or monthly payments we make to you under the annuity option you select.


 


BENEFICIARY. Means a person designated by
you to receive the death benefits from this policy upon your death.


 


BUSINESS DAY. Means each day that the New
York Stock Exchange is open for trading.


 


DECLARED INTEREST RATE. Means the annual effective
interest rate used to credit interest on initial and periodic payments to the fixed account option. The initial declared
interest rate is shown on the policy schedule and is guaranteed for 12 months from the policy date. Each declared
interest rate after the initial guarantee period will be guaranteed for 12 months. The declared interest rates that
we will periodically declare will never be less than the guaranteed minimum interest rate shown on the policy schedule.


 


FIXED ACCOUNT. Means an investment account
provided by us that is part of our general account. The general account is made up of all general assets of the
Company, other than those in the separate account or other segregated accounts.


 


MATURITY DATE. Means the date on which annuity
payments will begin. The latest date is shown on the policy schedule unless an earlier date was chosen by you. The earliest
date that you may choose is three years after your policy date.


 


OWNER. Means the person, or persons if there
are joint owners, named in the application or in the latest change for which we receive written notice. The
owner may exercise policy rights, subject to any assignment and to the rights of any irrevocable beneficiary.


 


PHYSICIAN. Means a doctor of medicine or
osteopathy (other than you, your spouse, domestic partner, a member of your family, a business or professional
partner, or any person with whom you share a financial or business interest) licensed to practice medicine and surgery
in the state in which he or she practices and who is practicing within the scope of such license in the United States.


 


POLICY DATE. Means the date as shown on the
policy schedule. It is the date from which we measure policy years, policy months and policy anniversaries.


 


PREMIUM. Means the premium paid less
any applicable premium taxes.


 


PRO-RATA. Means allocating a dollar amount
among the investment options in proportion to the accumulation value in those investment options.


 


PROOF OF DEATH. Means a certified copy of
a death certificate or a certified copy of a decree of a court of competent jurisdiction as to the findings of death. We may
require a written statement by a physician who attended to the deceased and any other proof in order to investigate the
claim.


 


	ICC15 6200 8-15	4	 




    	 



    	 



    

 


QUALIFIED
INSTITUTION.
 Means
a facility
located
in the
United
States
that
is primarily
engaged in
providing
continuous,
on-going
skilled
nursing
care
and related
services
for
its residents.
 The
qualified
institution
must
be operated
pursuant
to the
laws
and regulations
of the
state
in which
it is
licensed
and be
qualified
as a
“skilled
nursing
facility”
under Medicare
or Medicaid.
 The
qualified
institution
must
maintain
daily
medical
records
of each
patient.
 The
qualified
institution’s
staff
must
be licensed,
certified,
or registered
in accordance
with
applicable
state
laws.
 A qualified
institution
does not
include:
 assisted
living
facilities,
residential
care
facilities,
facilities
primarily
engaged in
the
treatment
of mental
or nervous
disorders,
facilities
primarily
engaged in
the treatment
of alcoholism
or drug
addiction,
or rehabilitation
hospitals.


 


SEPARATE
ACCOUNT.
 Means
a separate
investment
account
established
and maintained
by us
in accordance
with
Nebraska
Revised
Statute
Section
44-402.01
and registered
in accordance
with
the Investment
Company
Act of
1940, as
amended.


 


SUBACCOUNTS.
 Means
the
divisions
within
the
separate
account
for
which
accumulation
units
are
separately
maintained.
 Each
subaccount
corresponds
to a
single
underlying
portfolio.


 


WE,
US, OUR,
COMPANY.
 Means
Ameritas
Life
Insurance
Corp.


 


WRITTEN
NOTICE.
 Means
written
information
we have
received
that
is signed
by you
and is
acceptable
to us.


 


YOU,
YOUR. 
Means
the
owner
shown
on the
policy
schedule
unless
changed.


 


 


	GENERAL PROVISIONS


 


ANNUAL REPORT. Each policy year before the
maturity date, we will send you an annual report that shows the policy activity since the last report, including
the following information:


 


(1) the beginning and end dates of the
current period;


(2) the accumulation value at the
beginning and the end of the period;


(3) amounts credited or debited to the
accumulation value during the period; and


(4) the surrender value at the end of
the period.


 


We will provide copies of the annual report
to you upon request. A reasonable fee not to exceed $50 may be charged for each annual report.


 


ASSIGNMENT. You may assign this policy.
No assignment will be binding on us unless we receive written notice. Unless you specify otherwise,
the change will take effect on the date the written notice was signed by you, subject to any actions taken
by us prior to the date we receive the written notice. We will not be responsible for the validity
or the tax consequences of any assignment. Your rights, and the rights of any beneficiary or payee, will be subject
to any assignment. We will not be liable for any payments we make or actions we take before we receive
written notice of an assignment.


 


BENEFICIARY DESIGNATION. The primary and any
contingent beneficiaries of this policy are initially named in the application. Unless the beneficiary designation
provides otherwise, any death benefits will be divided equally among beneficiaries of the same class. The contingent beneficiaries’
interests are contingent upon no primary beneficiary being alive at the time of the event giving rise to the payment
of death benefits.


 


CHANGE OF BENEFICIARY. Beneficiaries may
be changed by you by providing written notice during the annuitant's life unless an irrevocable designation
has previously been made. Unless you specify otherwise, the change will take effect on the date the written notice was
signed by you, subject to any actions taken by us prior to the date we receive the written notice.
The rights of an irrevocable beneficiary may not be changed without his or her written consent.


 


	ICC15 6200 8-15	5	 




    	 



    	 



    

 


CHANGE OF OWNERSHIP. You may change
the ownership of this policy by providing written notice. Unless you specify otherwise, the change will take effect
on the date the written notice was signed by you, subject to any actions taken by us prior to the date we
receive the written notice.


 


CLAIMS OF CREDITORS. Except as required by
law, the creditors of a payee have no right of claim against the proceeds of this policy.


 


DELAY OF PAYMENTS. We usually will
pay any amounts payable from the separate account as a result of a full surrender or a partial withdrawal within seven calendar
days after we receive written notice. We can delay such payments or any transfers of amounts between subaccounts
or into the fixed account if:


 


	(1)		the New York Stock Exchange is closed other than customary weekend and holiday closings
or trading on the New York Stock Exchange is restricted as determined by the SEC; or



	(2)		the SEC by order permits the postponement for the protection of owners; or



	(3)		an emergency exists as determined by the SEC, as a result of which disposal of securities
is not reasonably practicable, or it is not reasonably practicable to determine the value of the net assets of the separate
account.



 


Subject to obtaining prior written approval from
the insurance commissioner of our domiciliary state, we may delay the payment of a full surrender, partial withdrawal
or transfer from the fixed account for up to six months from the date we receive written notice. If we
delay payment, we will disclose to you the reason for the delay and a date which the transaction will be effective.
If the payment is delayed for 30 days or more, interest at the guaranteed minimum interest rate shown on the policy schedule will
be paid for the delay period.


 


ENTIRE POLICY. This policy, the policy schedule,
any riders, any endorsements, any amendments, and the written application, a copy of which is attached, make up the entire
policy. Any change in the policy must be approved in writing by you and signed by the President, a Vice President, the Secretary
or an Assistant Secretary of the Company. We will not be bound by the representations or promises of any other person.
Statements made in the application, in the absence of fraud, are representations and not warranties. Words that can be interpreted
as singular or plural shall mean both.


 


FORM APPROVAL.  This policy is approved
under the authority of the Interstate Insurance Product Regulation Commission (IIPRC) and is issued under the IIPRC standards.
Any provision of this policy that is in conflict with the IIPRC standards is hereby amended to conform to the IIPRC standards.


 







INCONTESTABILITY. We will not contest
a claim or the validity of this policy from the policy date.


 


MISSTATEMENT OF AGE OR GENDER. If the annuitant's
age or gender has been misstated, any amount payable will be such as would have been provided on the basis of the correct age
and gender. Any underpayments by us because of misstatement of age or gender shall be paid to the annuitant
in a single sum with interest at the guaranteed minimum interest rate shown on the policy schedule, compounded annually, from
the respective due dates of the annuity payments. Any overpayments by us because of misstatement of age or
gender shall be charged against the current and, if necessary, next succeeding annuity payments to be made by us,
with interest at the guaranteed minimum interest rate shown on the policy schedule, compounded annually, from the respective due
dates of the annuity payments.


 


NONPARTICIPATING POLICY. This policy is nonparticipating.
No dividends will be paid under this policy.


 





 


 


 


 


 


	ICC15 6200 8-15	6	 




    	 



    	 



    

 


	PREMIUMS


 


GENERAL. After your initial premium
and prior to the commencement of annuity payments, premiums may be paid at your option and may vary in
frequency and amount, subject to the limits shown on your policy schedule. All premiums are payable to the address(es)
shown on the first page of this policy, or to such other address(es) as we may designate.


 


Except for premium payments made by list billing,
electronic funds transfer or electronic means, no premium may be paid to this policy unless it is at least $100. The maximum
annual premium and the maximum total premium are shown on the policy schedule. We may waive these limits,
but waiver in one instance does not constitute waiver for additional premiums.


 


NONPAYMENT OF PREMIUM FOR TWO YEARS. If, prior
to the maturity date, no premiums are paid for two consecutive policy years, and if both:


 


(1) the total premiums
paid, less any partial withdrawals, are less than $1,000; and


(2) the accumulation
value at the end of such two-year period is less than $1,000;


 


then we may cancel the policy on the date
such two-year period ends and pay you the accumulation value less the surrender charge, if any.


 


ALLOCATING PREMIUM. On the application, you
provided instructions on how we should allocate your premiums to the investment options. These instructions are
called your premium allocation. Premium allocations must be in whole percentages and total 100%. Your initial premium
allocation is shown on the attached application. You may change your premium allocation at any time, and the change
will be effective when it is received by us.


 


 


	INVESTMENT OPTIONS


 


SELECTING YOUR INVESTMENTS. You may
allocate all or part of your premium amount to the subaccount portfolios or the fixed account option (see
the ‘Allocating Premium’ provision of the ‘Premiums’ section). Please read the policy prospectus for more
information about the separate account and the subaccount portfolios. Please read the portfolio prospectuses for
more information about the portfolios.


 


SEPARATE ACCOUNT. The separate account
is a separate investment account of ours. The assets of the separate account are our property. However,
they are not credited with earnings or charged with liabilities arising out of any other business we may conduct. No underlying
subaccount portfolio is charged with liabilities of any other underlying subaccount portfolio.


 


SUBACCOUNTS. The separate account is
divided into subaccounts. Each subaccount invests in a corresponding underlying portfolio. The accumulation value
of your policy will go up or down based on the investment performance of the subaccounts you choose.


 


UNIT VALUE. The unit value of each subaccount
reflects the investment performance of that subaccount. The unit value of each subaccount on any business
day equals the unit value of the subaccount on the previous business day multiplied by the net investment factor
for the subaccount. The net investment factor for each subaccount on any business day is determined by dividing
(A) by (B) and subtracting (C) from the result, where:


 


 


 


 


 


 


 


 


 


 


 


 


 


 


	ICC15 6200 8-15	7	 




    	 



    	 



    

 


		(A)	is the net asset value per share of that fund at the end of the business day, plus the per share amount of any dividend
or capital gain distributions paid by that fund since the previous business day, plus the per share amount of any taxes
payable by the separate account;



		(B)	is the net asset value per share of that fund at the end of the previous business day; and



(C) is the sum of
the daily mortality and expense charge and daily administrative expense charge, which will not exceed the maximum daily charges
shown on the policy schedule.


 


Because the net investment factor may be greater
than, less than, or equal to one, unit values may increase, decrease or stay the same from one business day to the next.


 


VALUATION OF ASSETS. We will determine
the value of the assets of each subaccount at the close of trading on the New York Stock Exchange on each business day.
If the New York Stock Exchange is closed (except for holidays or weekends), or trading is restricted due to an existing emergency
as defined by the SEC so that we cannot value the subaccounts, we may postpone all transactions that require
valuation of the subaccounts until valuation is possible. Any provision of the policy that specifies a business day will
be superseded by this emergency procedure.


 


FEES CHARGED BY THE PORTFOLIOS. Each underlying
portfolio charges fees separate and apart from this policy. These fees are not deducted from the accumulation value. Instead,
they are reflected in the net asset value of portfolio shares that, in turn, will affect the unit value of the subaccount.
See the policy prospectus and portfolio prospectuses for more information about these fees.


 


SUBSTITUTION OF PORTFOLIOS. We do not
control the underlying portfolios, therefore we cannot guarantee the availability of any of the portfolios. Subject to any
applicable law, we retain the right to add or change the subaccounts of the separate account, the right to
eliminate the shares of any underlying portfolio, and the right to substitute shares of another portfolio for an eliminated portfolio.
If the shares of the underlying portfolio are no longer available for investment, or if, in our judgment, investment in
a portfolio would be inappropriate in view of the purposes of the separate account, we will notify you and
receive any necessary SEC and state approvals before making such a change. Separate account underlying portfolios may be
added or eliminated when, in our sole discretion, conditions warrant a change. If a portfolio is eliminated, we will
ask you to reallocate any account value in the corresponding subaccount. If you do not reallocate this amount,
we will automatically reallocate it to a money market subaccount. If you are allocating premium to
the eliminated subaccount, we will ask you to change your premium allocation. If you do not,
we will automatically allocate any future premium allocations to the eliminated subaccount to a money market subaccount.


 


FIXED ACCOUNT OPTION. Amounts allocated to
the fixed account earn a fixed interest rate that we declare. This rate may change but will never be less than the
fixed account guaranteed minimum interest rate shown on the policy schedule. We reserve the right, at our sole
discretion, to limit or refuse premium payments and/or transfers allocated to the fixed account option if we are
crediting an interest rate less than or equal to the nonforfeiture interest rate shown on the policy schedule.


 


Premiums and transfers allocated to the fixed
account become part of our general account assets, which support our annuity and insurance obligations. The fixed
account includes all of our assets, except those assets segregated in separate accounts. We have the sole
discretion to invest the assets of the fixed account, subject to applicable law.


 


 


	VALUES


 


VALUES AND BENEFITS. Minimum benefits are
not less than the minimum benefits required by sections 7B and 7G of the Model Variable Annuity Regulation, model #250 or a successor
version. We will quote any values or benefits upon request.


 


 


 


	ICC15 6200 8-15	8	 




    	 



    	 



    

 


The guaranteed minimum cash value is equal to the
sum of the following:


 


	(1)		the separate account value less surrender charges attributable to the separate
account; and



	(2)		a value based on the minimum nonforfeiture requirements described below.



 


Prior to the maturity date, the minimum nonforfeiture
amount is equal to the net considerations paid prior to such time, as defined below, accumulated at the nonforfeiture interest
rate (shown on the policy schedule), as defined below, decreased by the sum of the following:


 


	(1)		Any prior partial withdrawals or transfers from the fixed account, accumulated
at the nonforfeiture interest rate;



	(2)		An annual expense allowance of $50, accumulated at the nonforfeiture interest rate;
and



	(3)		Any premium tax attributable to the fixed account paid by the insurer for the
policy, accumulated at the nonforfeiture interest rate.



 


The net considerations for a given policy year used
to define the minimum nonforfeiture amount shall be an amount equal to 87.5% of the gross premiums allocated to the fixed
account, or transfers into the fixed account, during that policy year.


 


The nonforfeiture interest rate used in determining
minimum nonforfeiture amounts shall be an annual rate of interest at least equal to the lesser of three percent per annum and the
following:


 


(1)
The three-month average of the (daily) five-year Constant Maturity Treasury rates for the three-month period ending one month
prior to the month in which this policy is issued, rounded to the nearest one-twentieth of one percent;


(2) Reduced by 1.25%;
and


(3) Where the resulting
interest rate is not less than one percent.


 


The resulting nonforfeiture interest rate, as determined
at issue, shall apply for the life of the policy.


 


CHARGES AND FEES. Charges and fees are deducted
from your policy. Where both current and maximum charges and fees are shown on the policy schedule, you will be charged
the current charge and current fee when your policy is issued. We reserve the right to change the current charge
and current fee at any time; however, your charges and fees will never exceed the maximum charges and fees. If we change
the current charge and/or current fee, we will provide notice as required by law. Charges and fees include:


 


(1) Mortality and
Expense Risk Charge. A daily charge that is deducted from the subaccounts only.


(2) Administrative
Expense Charge. A daily charge that is deducted from the subaccounts only.


(3) Policy Fee. An
annual fee charged on policy anniversary and full surrender that is deducted pro-rata from the fixed account and
subaccounts.


(4) Taxes. Where
imposed by law, we reserve the right to charge for state or local premium taxes. Also, if any type of tax becomes attributable
to the separate account, we reserve the right to charge for such federal, state, or local tax. A waiver of our right
to charge for taxes in one year does not represent a waiver in subsequent years. If any tax is charged to this policy, you will
be advised of the amount of such tax and its effect upon any payments made.


(5) Transfer Fee.
A fee that is conditional upon the number of transfers in a policy year. See your policy schedule for the number of free
transfers allowed in a policy year. The fee is deducted pro-rata from the fixed account and subaccounts at
the time of transfer.


(6) Surrender Charge.
A charge that may be assessed at the time of partial withdrawal or full surrender. See the ‘Surrender Charge’ provision
for additional information.


 


ACCUMULATION VALUE. The accumulation value
of your policy at any time is equal to the sum of separate account value and the fixed account value.


 


 


 


 


 


 


 


 


 


 


 


 


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SEPARATE ACCOUNT VALUE. On the policy date,
the separate account value equals the premium allocated to the separate account. On any business day
after the policy date, the separate account value is equal to the sum of the subaccount values. The value
in each subaccount on any business day equals:


 


(1) your current
number of accumulation units in that subaccount; multiplied by


(2) the current unit
value for that subaccount.


 


Your number of accumulation units in a subaccount
will increase when:


 


(1) premiums are
allocated to the subaccount; or


(2) amounts are transferred
to the subaccount from other subaccounts or the fixed account.


 


Your number of accumulation units in a subaccount
will decrease when:


 


(1) you take
partial withdrawals (including any applicable surrender charges);


(2) policy fees are
taken from the subaccount;


(3) transfer charges
are taken from the subaccount; or


(4) amounts are transferred
out of the subaccount into other subaccounts or the fixed account.


 


When transactions are made, the actual dollar amounts
are converted to accumulation units. The number of accumulation units for a transaction is found by dividing the dollar amount
of the transaction by the current unit value on the business day for that transaction. Each of the transactions listed above
will increase or decrease your accumulation units.


 


FIXED ACCOUNT VALUE. On the policy date,
the fixed account value equals the premium allocated to the fixed account. On any business day after
the policy date, the fixed account value equals:


 


(1) the fixed
account value at the end of the previous business day; plus


(2) any premiums
allocated to the fixed account since the end of the previous business day; plus


(3) any transfers
from the subaccounts to the fixed account since the end of the previous business day; minus


(4) any transfers
from the fixed account to the subaccounts since the end of the previous business day; minus


(5) any transfer
fees allocated to the fixed account since the end of the previous business day; minus


(6) any partial withdrawals
(including any applicable surrender charges) allocated to the fixed account since the end of the previous business day;
minus


(7) on the policy
anniversary, a pro-rata share of the policy fee; plus


(8) interest credited
to the fixed account since the end of the previous business day.


 


We guarantee that the fixed account value
will be credited a rate of interest at least equal to the guaranteed minimum interest rate shown on the policy schedule.


 


FREE WITHDRAWAL AMOUNT. Each year after the
first policy year, 10% of the accumulation value may be withdrawn without a surrender charge. The free withdrawal amount
is reduced by all prior free withdrawals in the policy year. Any unused portion of this free withdrawal amount cannot be carried
forward to subsequent policy years.


 


SURRENDER CHARGE. Withdrawals in excess of
the free withdrawal amount may be subject to surrender charges. Surrender charges are based on premium not yet withdrawn
and the applicable surrender charge percentage(s) shown on the policy schedule. For the purpose of calculating the total surrender
charge at the point of full surrender or partial withdrawal, amounts are assumed to be withdrawn in the following order:


 


 


 


 


 


 


 


 


 


 


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	 	(1)	any remaining
free withdrawal amount; then
		(2)	any premiums not yet withdrawn on a “first-in, first-out” basis (i.e. the oldest premium is withdrawn
before recent premium); then



		(3)	any remaining accumulation value.



 


FULL SURRENDER. You may fully surrender
this policy at any time before the maturity date for the surrender value. The surrender value is accumulation value minus
the annual policy fee and surrender charge, if any.


 


PARTIAL WITHDRAWAL. You may take a
partial withdrawal at any time before the maturity date. The accumulation value will be reduced by the amount of
the partial withdrawal, including any amount that qualified as a free withdrawal. We will pay you the amount of the
partial withdrawal minus any applicable surrender charge. Unless you direct us otherwise, the partial withdrawal
will be made pro-rata from the fixed account and subaccounts.


 


Any partial withdrawal must be at least $250. If
a partial withdrawal including any applicable surrender charge would reduce the accumulation value to less than $1,000,
we may treat the partial withdrawal request as a full surrender of the policy.


 


WAIVER OF SURRENDER
CHARGE. The surrender charge will be waived for full surrender or partial withdrawal in the event of (1) or (2) below.  You
are eligible for this benefit on the policy date.


(1) You become
confined in a qualified institution for a period of at least 30 consecutive days on or after the policy date,
subject to the following:


(a) You must
be a natural person (not a trust, corporation, or other legal entity).


(b) You must
have been an owner of this policy continuously since the policy date.


(c) You were
not confined in a qualified institution at any time during the 60-day period immediately prior to the policy date.


(d) We receive
a written notice for a full surrender or partial withdrawal, along with due proof of confinement, within 12 months following
such confinement.


(2) You are
diagnosed with a terminal illness on or after the policy date, subject to the following:


(a) You must
be a natural person (not a trust, corporation, or other legal entity).


(b) You must
have been an owner of this policy continuously since the policy date.





(c) We must
receive a written notice for a full surrender or partial withdrawal together with a certificate from your physician
stating your life expectancy and any other proof we may require.


Terminal illness is
defined as a medical condition diagnosed by your physician, resulting in a reduction of your life expectancy to
12 months or less.


 


If your policy
is terminated, either by you or us, and you are eligible for this waiver benefit at the time of termination,
then your right to this benefit will not be prejudiced and surrender charges will be waived. If the request for this waiver
is denied, you will be notified of the denial. At such time, you will be provided with the opportunity to instruct
us of your desire to either proceed with, or cancel, your full surrender or partial withdrawal.


 


 


	TRANSFERS


 


Prior to the maturity date and subject to
applicable restrictions, you may transfer amounts between currently available investment options at any time. A transfer
charge may apply, as shown on the policy schedule.


 


The transfer will take effect at the end of the business
day during which the completed transfer request is received by us. If the completed transfer request is received after
market close, the request will be effective at the end of the following business day.


 


We reserve the right to limit or prohibit
transfers without prior notice that, in the judgment of the managers of the underlying portfolios, are excessive and will have
a detrimental effect on portfolio management for the benefit of all owners.


 


We will not be liable for transfers made in
accordance with instructions of a policy owner or an authorized third-party.


 


 


 


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SUBACCOUNT TRANSFER. The minimum amount that
can be transferred out of a subaccount is shown on the policy schedule. If the remaining subaccount value would be
less than the minimum subaccount balance shown on the policy schedule, we will include that subaccount value
in the amount transferred.


 


If the subaccount value in any subaccount
falls below the minimum subaccount balance, we may transfer without charge that subaccount balance pro-rata
into your remaining investment options.


 


Subaccount transfers may be subject to additional
restrictions by the portfolio advisor.


 


 


FIXED ACCOUNT TRANSFER. See your policy
schedule for transfer limitations with respect to the fixed account. Additional restrictions may apply as discussed in the
‘Fixed Account Option’ provision of the


‘Investment Options’ section of this
policy.


 


 


	DEATH BENEFITS


 


DEATH BENEFIT. The distribution of your
death benefit will be made in accordance with the distribution requirements of the Internal Revenue Code for annuity policies
and shall supersede any provision to the contrary. If the death benefit is paid before the maturity date, the death benefit
will be the accumulation value on the date that both proof of death and direction with regard to benefit payout are
received. On or after the maturity date, the death benefit, if any, will depend on the annuity option in effect on the date
of the annuitant's death.


 


DEATH OF OWNER. If you are an owner
and die before the maturity date, the following will apply:


 


(1) If your spouse
is not the beneficiary, the death benefit will be paid to the named beneficiary:


(a) upon written
notice the death benefit may be paid under any option listed in the ‘Annuity Options’ section of this policy over
a period not exceeding the beneficiary's life expectancy. The first payment must be made no later than one year after the
date of your death; or


(b) in a single
sum. The beneficiary has the option to select to receive the death benefit any time within five years after the date of
your death unless an annuity option has been selected.


(2) If your spouse
is the beneficiary, your spouse may select, by written notice to us, one of the following options:


(a) to continue
this policy as the owner; or


(b) to receive the
death benefit under any option listed in the 'Annuity Options' section of this policy over a period not exceeding the beneficiary's
life expectancy. The first payment must be made no later than one year after the date of your death; or


(c) to receive the
death benefit in a single sum. Your spouse may select to receive the death benefit any time within five years after the
date of your death, unless an annuity option has been selected.


 


If none of these options is selected by your spouse
within 45 days after we receive proof of death, option (2)(a) above shall apply.


 


(3) If no beneficiary
is living or if no beneficiary has been named, at the date of your death, the death benefit will be paid in a
single sum to the executor or administrator of your estate within five years after the date of your death.


 


If you are an owner and die on or after
the maturity date, the remaining portion of your interest in the policy will be distributed at least as rapidly as
under the method of distribution selected as of the date of your death.


 


JOINT OWNERS. If this policy is jointly owned,
the death of the first joint owner shall be treated as the death of the owner.


 


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DEATH OF ANNUITANT BEFORE THE MATURITY DATE. If
you, the owner, are a different person from the annuitant, and the annuitant dies during your lifetime
and before the maturity date, you will be treated as the annuitant. If you are not a natural person,
and the annuitant dies before the maturity date, we will pay the death benefit to you in a single sum.
You have the option to select to receive the single sum any time within five years of the death of the annuitant.


 


DEATH OF BENEFICIARY. Unless otherwise provided,
if any beneficiary dies before, at the same time as, or within 30 days after your death, that beneficiary will
be treated as if their death occurred before yours.


 


	PAYMENT OF POLICY BENEFITS


 


GENERAL. Policy benefits under this policy
are payable as annuity payments in accordance with the ‘Basis of Values’ provision or under such other annuity
options to which we may agree.


 


NORMAL SETTLEMENT. The accumulation value
will be applied to provide annuity payments under the annuity option shown on the policy schedule if:


 


(1) the annuitant
is living on the maturity date; and


(2) an alternate
annuity option has not been selected.


 


SELECTION OF ANNUITY OPTION. You may
select any annuity option during the annuitant's life by giving written notice. We will confirm your selection
in writing. The annuitant under any annuity option must be a natural person.


 


CHANGE IN ANNUITY OPTION. At least 30 days
before the maturity date, and while the annuitant is living, you may select to change the annuity option by
giving written notice. The default annuity option is shown on the policy schedule.


 


CHANGE IN MATURITY DATE. Prior to the maturity
date, and while the annuitant is living, you may select to change the maturity date. After three years
from the policy date, you may advance the maturity date, but not to a date earlier than the date of the request,
and in no circumstances can this date be earlier than the third policy anniversary. Written notice must be received at least
30 days before the maturity date.


 


MINIMUM PAYMENTS. If a monthly, quarterly
or semiannual payment would be less than $100, we may make payments less frequently. If the annual payment would be less
than $100, we may pay the proceeds to the annuitant in a lump sum.


 


WITHDRAWALS. Proceeds applied under any annuity
option may not be surrendered or otherwise withdrawn.


 


REQUIRED PROOF. We may require proof
of age of any annuitant. We may also require proof that an annuitant is living before making a payment.


 


BASIS OF VALUES. Annuity payments are
based on the guaranteed minimum interest rate shown on the policy schedule. If you select a Life Income annuity option,
your annuity payments will further be based on the 2012 Individual Annuity Mortality Period Life Table with generational
mortality improvement in all years using Projection Scale G2, and the year of the maturity date. Annuity payments are
further based on the gender(s) of the annuitant(s), except for policies issued in states that require unisex mortality,
or in connection with employment related annuities and benefit plans not based on the gender of the annuitant(s). In these
instances, the projection and mortality rates will be 100% female for all annuitants.


 


CURRENT INTEREST. Annuity payments under
the annuity options are based on the interest rate referenced in the ‘Basis of Values’ provision, compounded annually.
Annuity payments on the maturity date will not be less than those provided by the application of the accumulation
value to a single premium immediate annuity policy at the purchase rates offered by us to the same class of annuitant.


 


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	ANNUITY OPTIONS


 


LIFE INCOME. We will make equal annual,
semiannual, quarterly or monthly annuity payments, as selected, for the life of the annuitant. The first payment
is due on the date the annuity option becomes effective.


 


(1) Life income only.
Annuity payments will be made for the annuitant's life only (or the life of the last surviving annuitant,
in the case of joint annuitants). There are no guaranteed payments. Upon the death of the last annuitant, payments
will cease.


(2) Life annuity
with installment payments. Annuity payments will be made for the annuitant’s life (or the life of the last
surviving annuitant, in the case of joint annuitant) or for a selected number of payments, whichever is longer.


(3) Life income with
installment refund. Annuity payments will be made for the annuitant's life (or the life of the last surviving annuitant,
in the case of joint annuitants) or for a period that ends when the total amount paid equals the proceeds applied under
this option, whichever is longer.


 


INSTALLMENT PAYMENTS. We will make
equal annual, semiannual, quarterly or monthly annuity payments for the number of years selected (from five to thirty years).
The first payment is due on the date the annuity option becomes effective.


 


OTHER OPTIONS. You and we may
agree to make annuity payments in another manner.


 


 


 


 


 


 


 


 


 


 


 


 


 


 


 


 


 


 


 


 


 


 


 


 


 


 


 


 


 


 


 


 


 


 


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Flexible
Premium
Deferred
Variable
Annuity


With
Waiver of Surrender Charge Benefit


Monthly
Annuity Payments Starting on
Maturity
Date


Death
Benefit Payable Before Maturity
Date


Nonparticipating






 


	ICC15 6200 8-15