Document:

Exhibit 4(g)

 EXHIBIT 4(g) 
 FORM OF POLICY RIDER 
 (RETIREMENT INCOME CHOICE 1.6) 

 XXXXXXXXXXXX 
  

			
	

	    	Home Office located at:
	    	440 Mamaroneck Avenue, Harrison, New York 10528
	    	Adm. Office located at:
	    	4333 Edgewood Road N.E. Cedar Rapids, Iowa 52499
	 A Stock Company (Hereafter called the Company, we, our or us)
	    	(319) 355-8511

 RETIREMENT INCOME CHOICE RIDER 
 This rider is issued as a part of the policy (contract) to which it is attached. 
 All provisions
of the policy that do not conflict with this rider apply to this rider. In the event of any conflict between the provisions of this rider and the provisions of the policy, the provisions of this rider shall prevail over the provisions of the policy.

 Rider Data Specification 
  

			
	 Policy Number:
	  	XXXXXXXXXXX
	 Rider Date:
	  	XXXXXXXXXX
	 Growth Rate Percentage:
	  	5.00%
		
	 Rider Fee Percentages:
	  	
	 Designated Allocation Group A:
	  	XXXXX
	 Designated Allocation Group B:
	  	XXXXX
	 Designated Allocation Group C:
	  	XXXXX
		
	 Annuitant:
	  	XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
		  	XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
	 Annuitant’s Issue Age/Sex:
	  	XX / XXXXXXXXXX

  
  

ARTICLE I 
 You may cancel
this rider on or before midnight of the thirtieth calendar day after you received it and no rider fees will be assessed. 
 This rider
provides a minimum withdrawal benefit that guarantees, upon election, a series of withdrawals from the policy equal to the Withdrawal Percentage shown in Article III applied to the withdrawal base. The withdrawal base is established for the sole
purpose of determining the minimum withdrawal benefit and is not used in calculating the cash surrender value or other guaranteed benefits. 

If you elect this rider, 100% of your policy value must be in one or more of the designated investment options. 

You can generally transfer between the designated investment options as permitted under your policy; however, you cannot make transfers as provided for
in the policy to a non-designated investment option while this rider is in force. If you wish to make a transfer to a non-designated investment option, this rider must be terminated, as described in Article IV, prior to making the transfer.

 DEFINITIONS: 
 Terms used
that are not defined in this rider shall have the same meaning as those in your policy. 
 Designated Investment Options 

Investment options authorized for use with this rider and identified by us as designated investment options. 

Excess Withdrawal 
 The excess of a gross
partial withdrawal over the rider withdrawal amount remaining prior to the withdrawal, if any. 
 Gross Partial Withdrawal 

The amount that will be deducted from your policy value as a result of each partial withdrawal. 
 Rider Anniversary 
 The anniversary of the rider date. 

Rider Fee 
 The fee charged for the
benefits under this rider. The fee will be charged on each rider quarterversary by the Company. 

  

					
	RGMB 37 0809 (IS) (NY)	  	(1	  	(Income-Single) (09/2012)

 ARTICLE I CONTINUED 
 Rider Monthiversary 
 The same day of the month as the rider date, or the next business day
if our Administrative Office or the New York Stock Exchange is closed. 
 Rider Quarter 

Each three-month period following the rider date. 
 Rider Quarterversary 
 For each rider quarter, the same day of the month as the rider date,
or the next business day if our Administrative Office or the New York Stock Exchange is closed. 
 Rider Withdrawal Amount 

The maximum amount that can be withdrawn from the policy each rider year without causing an excess withdrawal under the terms of this rider and thus
reducing the withdrawal base. This amount will change if the withdrawal base changes. 
 Rider Year 

Each twelve-month period following the rider date. 
 Valuation Period 
 The period of time from one determination of the value of a subaccount to
the next. 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. 

Withdrawal Base 
 The amount used to
calculate the rider withdrawal amount and the rider fee. This amount cannot be taken as a lump sum. 
 ARTICLE II 

RIDER FEES 
 The rider fee is deducted on
each rider quarterversary in arrears. The fee is calculated at issue and at the beginning of each rider quarter for the upcoming quarter. The rider fee percentage will not change during the first five rider years, and will only change thereafter due
to an automatic step-up. You will be notified of any increase in the rider fee percentage. A portion of this fee will also be deducted when the rider is terminated based on the number of days that have elapsed since the previous rider
quarterversary. 
 The stored fee will be adjusted for new deposits, transfers among designated investment options and excess withdrawals made
during the rider quarter. 
 Fees will be calculated and stored on the day the rider is issued and at the beginning of each rider quarter. They
will be deducted automatically from each subaccount on a pro rata basis on each rider quarterversary. The annual fee percentages for each designated allocation group are shown on page 1, in the Rider Data Specification section. 

The quarterly fee is calculated as follows: 

Multiply (1) by (2) divided by (3) multiplied by (4). 
  

	1)	Withdrawal Base; 

  

	2)	Product of each designated allocation group rider fee percentage and the applicable designated allocation group value, summed together; 

 

	3)	Total policy value; 

  

	4)	Number of days remaining in the rider quarter divided by the number of days within the applicable rider year. 

 

	Please	see the Appendix attached to this rider which illustrates how the rider fee is calculated. 

 ARTICLE III 
 GUARANTEED LIFETIME WITHDRAWAL BENEFIT 

Under this rider, we guarantee that you can receive up to the rider withdrawal amount each rider year, regardless of the policy value, (either through
withdrawals or payments, where payments are equal to the rider withdrawal amount if your policy value equals zero) until the annuitant’s death. 

  

					
	RGMB 37 0809 (IS) (NY)	  	(2	  	(Income-Single) (09/2012)

 ARTICLE III CONTINUED 
 The withdrawal percentage is determined by the attained age (age at last birthday) of the annuitant at the time of the first withdrawal of any amount from the policy value taken on or after the rider
anniversary following the annuitant’s 59th birthday. Once the withdrawal percentage is established, it may only be changed by an upgrade or automatic step-up and redetermined at that time. Upon automatic step-up, the withdrawal percentage will
be reset based on the attained age at the time of the automatic step-up. The withdrawal percentages are shown in the table below. 
  

							
	 	 	 Attained Age
	 	Withdrawal
Percentage	 	 
		 	59 - 64	 	4.0%	 	
		 	65 - 79	 	5.0%	 	
		 	80 +	 	6.0%	 	

 If the annuitant is not yet 59 on the rider date, the withdrawal percentage will be zero until the rider anniversary
following the annuitant’s 59th birthday. Withdrawals prior to age 59 1/2 will be subject to the 10% penalty tax. 
 Withdrawals will reduce
the policy value of the policy to which this rider is attached. If the policy value equals zero, you cannot make subsequent premium payments and all other policy features, benefits and guarantees are no longer available. Also, if the policy value
equals zero, you will need to request payments by selecting the amount and frequency in accordance with the policy provisions to which this rider attaches, equal to the rider withdrawal amount. Once the payment amount and frequency are established,
they cannot be changed and no additional withdrawals will be allowed. 
 We guarantee that you may withdraw up to the rider withdrawal amount
each year regardless of the policy value until the annuitant’s death. 
 Example 

Assume you are the owner and annuitant and begin taking withdrawals at age 80 and your Withdrawal Base is $100,000. Assuming a withdrawal
percentage of 6%, you could withdraw up to $6,000 each rider year for the rest of your life (assuming that you do not withdraw more than $6,000 in any one rider year). 
 Any amount you withdraw in excess of the rider withdrawal amount may impact the withdrawal base on a greater than dollar-for-dollar basis. 
 Please see the Appendix attached to this rider which illustrates the withdrawal benefit. 
 The
Guaranteed Lifetime Withdrawal Benefit can only be taken as a withdrawal benefit and it does not increase the policy value. 
 ISSUE AGE AND
SURVIVAL 
 The benefits under this rider depend on the annuitant being alive at the time of withdrawal and the amount of the benefit depends
on the attained age of the annuitant. Proof of survival and the date of birth may be required by the Company. 
 If the annuitant’s age has
been misstated, this rider’s fees and benefits will be adjusted to the amounts which would have been calculated for the correct age. However, if this rider would not have been issued had the age not been misstated, the rider is treated as if it
never existed, and any fees charged for this rider would be returned. If withdrawals under the provisions of the rider have already commenced and the misstatement caused the rider withdrawal amount to be overstated, any withdrawal in excess of the
correct rider withdrawal amount will be considered an excess withdrawal and will impact the withdrawal base and rider withdrawal amount. If overpayments occurred when the sum of the accumulated values in all the investment options was zero, the
amount of that overpayment will be deducted from one or more future payments until this amount is paid in full. 
 RIDER WITHDRAWAL AMOUNT

 The rider withdrawal amount will be equal to the greater of 1) and 2), where: 

 

	1)	is the withdrawal percentage multiplied by the withdrawal base; 

  

					
	RGMB 37 0809 (IS) (NY) (R0912)	  	(3)	  	(Income-Single) (09/2012)

	2)	is an amount equal to the minimum required distribution amount, if any. Prior to the 1st rider anniversary, this amount is based on the initial policy value on the
rider date. After this time, the minimum required distribution is calculated based on the rules established by the IRS. The minimum required distribution may only be used if all of the following are true: 

ARTICLE III CONTINUED 
  

	 	A)	the policy to which this rider is attached is a tax-qualified policy for which IRS minimum required distributions are required, 

 

	 	B)	the minimum required distributions do not start prior to the annuitant’s attained age 70 1/2, 

 

	 	C)	the minimum required distributions are based on either the Uniform Lifetime table or the Joint Life and Last Survivor Expectancy table, 

 

	 	D)	the minimum required distributions are based on age of the living annuitant. The minimum required distributions can not be based on the age of someone who is deceased,

  

	 	E)	the minimum required distributions are based only on the policy to which this rider is attached, and 

 

	 	F)	the minimum required distributions are only for the current rider year. Amounts carried over from past rider years are not considered. 

If any of the above are not true, then 2) is equal to zero and it is not available as a rider withdrawal amount. 

If you withdraw less than the rider withdrawal amount in a rider year, the unused portion cannot be carried over to the next rider year. 

WITHDRAWAL BASE 
 The withdrawal base is
used to calculate the rider withdrawal amount. On the rider date, the initial withdrawal base is equal to the policy value (less any premium enhancements if the rider is added in the first policy year). During any rider year, the withdrawal base is
increased by subsequent premium payments (not including premium enhancements, if any), and is reduced for excess withdrawals. 
 On each rider
anniversary, the withdrawal base will be set to the greatest of: 
  

	 	1)	The current withdrawal base; 

  

	 	2)	The policy value on the rider anniversary; 

  

	 	3)	The highest policy value on a rider monthiversary for the current rider year; or 

 

	 	4)	The current withdrawal base immediately prior to rider anniversary processing increased by the growth rate percentage. 

Item 3) above will be zero if there have been any excess withdrawals in the current rider year. Item 4) above will be zero after the 10th rider
anniversary or if there have been any withdrawals in the current rider year. 
 AUTOMATIC STEP-UP FEATURE 

The rider receives an automatic step-up on the rider anniversary if the withdrawal base is set equal to the policy value or the highest policy value on a
rider monthiversary. This feature does not require the termination of the existing rider. This rider will continue with the same rider date and features. The rider fee and withdrawal percentages may be changed due to an automatic step-up, but there
will be no increase in the rider fee percentage during the first five rider years. Following the fifth rider anniversary, the rider fee percentage may be increased due to an automatic step-up, but will not increase more than 0.75% from the initial
rider fee percentages shown on page 1. 
 You have the right to reject an automatic step-up within 30 days following a rider anniversary, if the
rider fee percentage increases. If you reject an automatic step-up, you must notify us in a manner which is acceptable to us, however you are eligible for future automatic step-ups. Changes as a result of the automatic step-up feature will be
reversed. Any increase in the rider fee or withdrawal percentages will also be reversed. 
 WITHDRAWAL BASE ADJUSTMENTS 

Gross partial withdrawals, taken in a rider year, less than or equal to the rider withdrawal amount will not reduce the withdrawal base. Excess
withdrawals will reduce the withdrawal base by the withdrawal base adjustment. The withdrawal base adjustment is the greater of 1) and 2), where: 
  

	1)	is the excess withdrawal amount; and 

  

					
	RGMB 37 0809 (IS) (NY)	  	(4	  	(Income-Single) (09/2012)

	2)	is the result of (A multiplied by B), divided by C, where: 

 ARTICLE III CONTINUED 
  

	 	A)	is the excess withdrawal; 

  

	 	B)	is the withdrawal base prior to the excess withdrawal amount; and 

  

	 	C)	is the policy value after the rider withdrawal amount has been withdrawn, but prior to the withdrawal of the excess withdrawal amount. 

ARTICLE IV 
 CONTINUATION

 In the case of spousal joint owners where one spouse is the annuitant, if the spouse who is not the annuitant dies and the surviving spouse is
the sole beneficiary, the surviving spouse may elect to continue the policy and rider. In the case of spousal joint owners where one spouse is the annuitant, if the spouse who is the annuitant dies, this rider will terminate. 

In the case of non-spousal joint owners where an owner who is not the annuitant dies, the surviving owner (who is also the sole designated beneficiary)
may elect to receive lifetime income payments under this rider instead of receiving any benefits applicable to the policy. The lifetime income payments must begin no later than 1 year after the owner’s death and will be equal to the rider
withdrawal amount divided by the number of payments made per year. Once the payments begin, no additional premium payments will be accepted and no additional withdrawals will be paid. 
 ANNUITIZATION 
 On the maximum annuity commencement date, as described in your policy, you
will have the option to receive lifetime income payments that are no less than your rider withdrawal amount each year. This option will also guarantee that the sum of all income payments received over time will equal or exceed the policy value on
the maximum annuity commencement date. If the annuitant should die before the sum of all income payments received equals or exceeds the policy value on the maximum annuity commencement date, the annuitant’s beneficiary will receive a final
payment equal to the difference. 
 RIDER UPGRADE 
 You may elect, in writing, to upgrade the withdrawal base to the policy value within 30 days after the fifth rider anniversary and every fifth rider anniversary thereafter, subject to the issue age
restrictions on the new rider. If an upgrade is selected, this rider will terminate and a new rider with the same features will be issued with a new rider date. The new rider will have its own growth rate percentage and rider fee percentages which
may not be the same as this rider’s percentages. Other riders with different features may be chosen, if available by the Company. 
 At the
time upgrade, the rider withdrawal amount will be recalculated based on the new withdrawal base. 
 The new rider date will be the date the
Company receives all information necessary, at our Home Office, in a written form acceptable to the Company, to process the upgrade. 

TERMINATION 
 This rider will terminate
upon the earliest of: 
  

	1)	the date the policy to which this rider is attached terminates; 

  

	2)	the date the policy to which this rider is attached is assigned or if the owner is changed without our approval; 

 

	3)	the date of the annuitant’s death; 

  

	4)	the date you elect to upgrade (as described in Article IV of this rider); 

  

	5)	the date you elect to receive annuity payments under your policy; and 

  

	6)	the date you notify us in writing of your intention to terminate this rider (this date must be within 30 days after the fifth rider anniversary and every fifth rider
anniversary thereafter). 

 Termination of the rider will result in the loss of all benefits provided by the rider. 

Signed for us at our home office. 
  

			
	

	  	

	SECRETARY	  	PRESIDENT

  

					
	RGMB 37 0809 (IS) (NY)	  	(5	  	(Income-Single) (09/2012)

 APPENDIX 
 The quarterly fee is calculated as follows: 
 Multiply (1) by (2) divided
by (3) multiplied by (4) where: 
  

	1)	Withdrawal Base 

  

	2)	Product of each designated allocation group rider fee percentage and the applicable designated allocation group value, summed together; 

 

	3)	Total policy value 

  

	4)	Number of days in the rider quarter divided by the number of days within the applicable rider year 

The fee adjustment for additional premium payments and excess withdrawals is calculated as follows: 

Multiply (1) by (2) divided by (3) multiplied by (4) where: 

 

	1)	Withdrawal base change (i.e. withdrawal base after the transaction minus the withdrawal base before the transaction) 

 

	2)	Product of each designated allocation group rider fee percentage and the applicable designated allocation group value, summed together; 

 

	3)	Total transaction amount 

  

	4)	Number of days remaining in the rider quarter divided by the number of days within the applicable rider year 

The fee adjustment for fund transfers is calculated as follows: 
 Multiply (1) by (2) divided by (3) multiplied by (4) where: 
  

	1)	Withdrawal base 

  

	2)	Product of each designated allocation group rider fee percentage and the applicable designated allocation group value, summed together; 

 

	3)	Total policy value 

  

	4)	Number of days remaining in the rider quarter divided by the number of days within the applicable rider year 

The following two examples use assumed fees and values listed in the table below. The assumed rider year is not a leap year. 

 

													
	 Designated Allocation Group
	  	Fee	 	 	Initial
Policy Value	 	  	Additional Premium
Used in Example 2	 
	 Group A
	  	 	2.50	% 	 	$	50,000	  	  	$	5,000	  
	 Group B
	  	 	2.40	% 	 	$	30,000	  	  	$	3,000	  
	 Group C
	  	 	2.30	% 	 	$	20,000	  	  	$	2,000	  

 Example 1: Calculation at rider issue for first quarter fee assuming an initial withdrawal base of $100,000.

 = 100,000 * [(50,000*0.0250) + (30,000*0.0240) + (20,000*0.0230)] / 100,000 * (91/365) 

= 100,000 * (1,250 + 720 + 460) / 100,000 * (91/365) 
 = 100,000 * 2,430/100,000 * (91/365) 
 = 2,430 * (91/365) 

= $605.84 
 Example 2:
Calculation for first quarter fee assuming initial withdrawal base from Example 1 above, plus adjustment for additional premium payment of $10,000 made with 20 days remaining in the first rider quarter (invested as shown above). The withdrawal
base change and total transaction amount equal $10,000. 
 Fee adjustment as follows: 

= 10,000 * [(5,000*0.0250) + (3,000*0.0240) + (2,000*0.0230)] / 10,000 * (20/365) 

= 10,000 * (125 + 72 + 46) / 10,000 * (20/365) 
 = 10,000 * 243/10,000 * (20/365) 
 = 243 * (20/365) 

= $13.32 
 Total fee assessed on
first rider quarterversary (assuming no further rider fee adjustments): 
 = 13.32 + 605.84 

= $619.16 

  

					
	RGMB 37 0809 (IS) (NY)	  	(A-1	  	(Income-Single) (09/2012)

 The following three examples use assumed fees and values listed in the table below. The assumed rider year
is not a leap year. 
  

																	
	 Designated Allocation Group
	  	Fee	 	 	Policy Value	 	  	Partial Withdrawal
Used in Example 4	 	  	Fund Transfer
Used in Example 5	 
	 Group A
	  	 	2.50	% 	 	$	49,000	  	  	$	-5,000	  	  	$	-5,000	  
	 Group B
	  	 	2.40	% 	 	$	29,000	  	  	$	-3,000	  	  	$	3,000	  
	 Group C
	  	 	2.30	% 	 	$	19,000	  	  	$	-2,000	  	  	$	2,000	  

 Example 3: Calculation for second quarter fee at beginning of second rider quarter, assuming withdrawal base of
$110,000 and policy value of $97,000 invested as above. 
 = 110,000 * [(49,000*0.0250) + (29,000*0.0240) + (19,000*0.0230)]
/ 97,000 * (91/365) 
 = 110,000 * (1,225 + 696 + 437) / 97,000 * (91/365) 

= 110,000 * 2,358/97,000 * (91/365) 
 = 2,674.02 * (91/365) 
 = $666.67 

Example 4: Calculation for second quarter fee assuming beginning values as in Example 3 above, plus adjustment for partial withdrawal of $10,000
taken with 40 days remaining in the second rider quarter. Assumes withdrawal percentage of 5%, policy value of $97,000 prior to the transaction and change in withdrawal base as follows: 
 Rider Withdrawal Amount (RWA) = Withdrawal Base * Withdrawal Percentage = 110,000 * .05 = $5,500 

Excess Withdrawal = Difference between assumed withdrawal amount and RWA = 10,000 - 5,500 = $4,500 

Withdrawal Base Adjustment = Max (Excess Withdrawal, Excess Withdrawal * Withdrawal Base prior to withdrawal / Policy Value after RWA has been withdrawn
but before excess withdrawal) = Max [4,500, 4,500 * 110,000 / (97,000-5,500)] = Max (4,500, 5,409.84) = $5,409.84 
 Fee adjustment as follows:

 = -5,409.84 * [(5,000*0.0250) + (3,000*0.0240) + (2,000*0.0230)] / 10,000 * (40/365) 

= -5,409.84 * (125 + 72 + 46) / 10,000 * (40/365) 
 = -5,409.84 * 243/10,000 * (40/365) 
 = -131.46 * (40/365) 

= $-14.41 
 Total fee assessed
on second rider quarterversary (assuming no further rider fee adjustments): 
 = 666.67 - 14.41 

= $652.26 
 The new Withdrawal
Base = $110,000 - $5,409.84 = $104,590.16 
 Example 5: Calculation for fund transfer occurring during second quarter with 25 days
remaining in the rider quarter, assuming beginning values as in Example 3 and withdrawal adjustment as in Example 4 above. 
 Withdrawal Base =
$104,590.16 and assumed policy value of $90,000. Fund transfer amount of $5,000 as allocated in table above. 
 Fee adjustment as follows:

 = 104,590.16 * [(-5,000*0.0250) + (3,000*0.0240) + (2,000*0.0230)] / 90,000 * (25/365) 

= 104,590.16 * (-125 + 72 + 46) / 90,000 * (25/365) 
 = 104,590.16 * -7/90,000 * (25/365) 
 = -8.13 * (25/365) 

= $-0.56 
 Total fee assessed on
second rider quarterversary (assuming no further rider fee adjustments): 
 = 652.26 - 0.56 

= $651.70 

  

					
	RGMB 37 0809 (IS) (NY)	  	(A-2	  	(Income-Single) (09/2012)

 XXXXXXXXXXXX 
  

			
	

	    	Home Office located at:
	    	440 Mamaroneck Avenue, Harrison, New York 10528
	    	Adm. Office located at:
	    	4333 Edgewood Road N.E. Cedar Rapids, Iowa 52499
	 A Stock Company (Hereafter called the Company, we, our or us)
	    	(319) 355-8511

 RETIREMENT INCOME CHOICE WITH DEATH BENEFIT RIDER 

This rider is issued as a part of the policy (contract) to which it is attached. 
 All provisions of the policy that do not conflict with this rider apply to this rider. In the event of any conflict between the provisions of this rider and the provisions of the policy, the provisions of
this rider shall prevail over the provisions of the policy. 
 Rider Data Specification 

 

			
	 Policy Number:
	  	XXXXXXXXXXX
	 Rider Date:
	  	XXXXXXXXXX
	 Growth Rate Percentage:
	  	5.00%
		
	 Rider Fee Percentages:
	  	
	 Designated Allocation Group A:
	  	XXXXX
	 Designated Allocation Group B:
	  	XXXXX
	 Designated Allocation Group C:
	  	XXXXX
		
	 Annuitant:
	  	XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
		  	XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
	 Annuitant’s Issue Age/Sex:
	  	XX / XXXXXXXXXX

  
  

ARTICLE I 
 You may cancel this
rider on or before midnight of the thirtieth calendar day after you received it and no rider fees will be assessed. 
 This rider
provides a minimum withdrawal benefit that guarantees, upon election, a series of withdrawals from the policy equal to the Withdrawal Percentage shown in Article III applied to the withdrawal base. The withdrawal base is established for the sole
purpose of determining the minimum withdrawal benefit and is not used in calculating the cash surrender value or other guaranteed benefits. 

If you elect this rider, 100% of your policy value must be in one or more of the designated investment options. 

You can generally transfer between the designated investment options as permitted under your policy; however, you cannot make transfers as provided for
in the policy to a non-designated investment option while this rider is in force. If you wish to make a transfer to a non-designated investment option, this rider must be terminated, as described in Article IV, prior to making the transfer.

 DEFINITIONS: 
 Terms used
that are not defined in this rider shall have the same meaning as those in your policy. 
 Designated Investment Options 

Investment options authorized for use with this rider and identified by us as designated investment options. 

Excess Withdrawal 
 The excess of a gross
partial withdrawal over the rider withdrawal amount remaining prior to the withdrawal, if any. 
 Gross Partial Withdrawal 

The amount that will be deducted from your policy value as a result of each partial withdrawal. 

  

					
	RGMB 37 0809 (AS) (NY)	  	( 1	  	(Income/Death-Single) (09/2012)

 ARTICLE I CONTINUED 
 Rider Anniversary 
 The anniversary of the rider date. 

Rider Fee 
 The fee charged for the
benefits under this rider. The fee will be charged on each rider quarterversary by the Company. 
 Rider Monthiversary 

The same day of the month as the rider date, or the next business day if our Administrative Office or the New York Stock Exchange is closed. 

Rider Quarter 
 Each three-month period
following the rider date. 
 Rider Quarterversary 
 For each rider quarter, the same day of the month as the rider date, or the next business day if our Administrative Office or the New York Stock Exchange is closed. 

Rider Withdrawal Amount 
 The maximum
amount that can be withdrawn from the policy each rider year without causing an excess withdrawal under the terms of this rider and thus reducing the withdrawal base. This amount will change if the withdrawal base changes. 

Rider Year 
 Each twelve-month period
following the rider date. 
 Valuation Period 
 The period of time from one determination of the value of a subaccount to the next. 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. 
 Withdrawal Base 

The amount used to calculate the rider withdrawal amount and the rider fee. This amount cannot be taken as a lump sum. 

ARTICLE II 
 RIDER FEES

 The rider fee is deducted on each rider quarterversary in arrears. The fee is calculated at issue and at the beginning of each rider quarter
for the upcoming quarter. The rider fee percentage will not change during the first five rider years, and will only change thereafter due to an automatic step-up. You will be notified of any increase in the rider fee percentage. A portion of this
fee will also be deducted when the rider is terminated based on the number of days that have elapsed since the previous rider quarterversary. 

The stored fee will be adjusted for new deposits, transfers among designated investment options and excess withdrawals made during the rider quarter.

 Fees will be calculated and stored on the day the rider is issued and at the beginning of each rider quarter. They will be deducted
automatically from each subaccount on a pro rata basis on each rider quarterversary. The annual fee percentages for each designated allocation group are shown on page 1, in the Rider Data Specification section. 

The quarterly fee is calculated as follows: 

Multiply (1) by (2) divided by (3) multiplied by (4). 
  

	1)	Withdrawal Base; 

  

	2)	Product of each designated allocation group rider fee percentage and the applicable designated allocation group value, summed together; 

 

	3)	Total policy value; 

  

	4)	Number of days remaining in the rider quarter divided by the number of days within the applicable rider year. 

 

	Please	see the Appendix attached to this rider which illustrates how the rider fee is calculated. 

  

					
	RGMB 37 0809 (AS) (NY)	  	( 2	  	(Income/Death-Single) (09/2012)

 ARTICLE III 
 GUARANTEED LIFETIME WITHDRAWAL BENEFIT 
 Under this rider, we guarantee that you can receive
up to the rider withdrawal amount each rider year, regardless of the policy value, (either through withdrawals or payments, where payments are equal to the rider withdrawal amount if your policy value equals zero) until the annuitant’s death.

 The withdrawal percentage is determined by the attained age (age at last birthday) of the annuitant at the time of the first withdrawal of
any amount from the policy value taken on or after the rider anniversary following the annuitant’s 59th birthday. Once the withdrawal percentage is established, it may only be changed by an upgrade or automatic step-up and redetermined at that
time. Upon automatic step-up, the withdrawal percentage will be reset based on the attained age at the time of automatic step-up. The withdrawal percentages are shown in the table below. 

 

							
	 	 	 Attained Age
	 	Withdrawal
Percentage	 	 
		 	59 - 64	 	4.0%	 	
		 	65 - 79	 	5.0%	 	
		 	80 +	 	6.0%	 	

 If the annuitant is not yet 59 on the rider date, the withdrawal percentage will be zero until the rider anniversary
following the annuitant’s 59th birthday. Withdrawals prior to age 59 1/2 will be subject to the 10% penalty tax. 
 Withdrawals will reduce
the policy value of the policy to which this rider is attached. If the policy value equals zero, you cannot make subsequent premium payments and all other policy features, benefits and guarantees are no longer available. Also, if the policy value
equals zero, you will need to request payments by selecting the amount and frequency in accordance with the policy provisions to which this rider attaches, equal to the rider withdrawal amount. Once the payment amount and frequency are established,
they cannot be changed and no additional withdrawals will be allowed. 
 We guarantee that you may withdraw up to the rider withdrawal amount
each year regardless of the policy value until the annuitant’s death. 
 Example 

Assume you are the owner and annuitant and begin taking withdrawals at age 80 and your Withdrawal Base is $100,000. Assuming a withdrawal
percentage of 6%, you could withdraw up to $6,000 each rider year for the rest of your life (assuming that you do not withdraw more than $6,000 in any one rider year). 
 Any amount you withdraw in excess of the rider withdrawal amount may impact the withdrawal base on a greater than dollar-for-dollar basis. 
 Please see the Appendix attached to this rider which illustrates the withdrawal benefit. 
 The
Guaranteed Lifetime Withdrawal Benefit can only be taken as a withdrawal benefit and it does not increase the policy value. 
 ISSUE AGE AND
SURVIVAL 
 The benefits under this rider depend on the annuitant being alive at the time of withdrawal and the amount of the benefit depends
on the attained age of the annuitant. Proof of survival and the date of birth may be required by the Company. 
 If the annuitant’s age has
been misstated, this rider’s fees and benefits will be adjusted to the amounts which would have been calculated for the correct age. However, if this rider would not have been issued had the age not been misstated, the rider is treated as if it
never existed, and any fees charged for this rider would be returned. If withdrawals under the provisions of the rider have already commenced and the misstatement caused the rider withdrawal amount to be overstated, any withdrawal in excess of the
correct rider withdrawal amount will be considered an excess withdrawal and will impact the withdrawal base and rider withdrawal amount. If overpayments occurred when the sum of the accumulated values in all the investment options was zero, the
amount of that overpayment will be deducted from one or more future payments until this amount is paid in full. 

  

					
	RGMB 37 0809 (AS) (NY) (R0912)	  	(3)	  	(Income/Death-Single) (09/2012)

 ARTICLE III CONTINUED 
 RIDER WITHDRAWAL AMOUNT 
 The rider withdrawal amount will be equal to the greater of 1) and
2), where: 
  

	1)	is the withdrawal percentage multiplied by the withdrawal base; 

  

	2)	is an amount equal to the minimum required distribution amount, if any. Prior to the 1st rider anniversary, this amount is based on the initial policy value on the
rider date. After this time, the minimum required distribution is calculated based on the rules established by the IRS. The minimum required distribution may only be used if all of the following are true: 

 

	 	A)	the policy to which this rider is attached is a tax-qualified policy for which IRS minimum required distributions are required, 

 

	 	B)	the minimum required distributions do not start prior to the annuitant’s attained age 70 1/2, 

 

	 	C)	the minimum required distributions are based on either the Uniform Lifetime table or the Joint Life and Last Survivor Expectancy table, 

 

	 	D)	the minimum required distributions are based on age of the living annuitant. The minimum required distributions can not be based on the age of someone who is deceased,

  

	 	E)	the minimum required distributions are based only on the policy to which this rider is attached, and 

 

	 	F)	the minimum required distributions are only for the current rider year. Amounts carried over from past rider years are not considered. 

If any of the above are not true, then 2) is equal to zero and it is not available as a rider withdrawal amount. 

If you withdraw less than the rider withdrawal amount in a rider year, the unused portion cannot be carried over to the next rider year. 

WITHDRAWAL BASE 
 The withdrawal base is
used to calculate the rider withdrawal amount. On the rider date, the initial withdrawal base is equal to the policy value (less any premium enhancements if the rider is added in the first policy year). During any rider year, the withdrawal base is
increased by subsequent premium payments (not including premium enhancements, if any), and is reduced for excess withdrawals. 
 On each rider
anniversary, the withdrawal base will be set to the greatest of: 
  

	 	1)	The current withdrawal base; 

  

	 	2)	The policy value on the rider anniversary; 

  

	 	3)	The highest policy value on a rider monthiversary for the current rider year; or 

 

	 	4)	The current withdrawal base immediately prior to rider anniversary processing increased by the growth rate percentage. 

Item 3) above will be zero if there have been any excess withdrawals in the current rider year. Item 4) above will be zero after the 10th rider
anniversary or if there have been any withdrawals in the current rider year. 
 AUTOMATIC STEP-UP FEATURE 

The rider receives an automatic step-up on the rider anniversary if the withdrawal base is set equal to the policy value or the highest policy value on a
rider monthiversary. This feature does not require the termination of the existing rider. This rider will continue with the same rider date and features. The rider fee and withdrawal percentages may be changed due to an automatic step-up, but there
will be no increase in the rider fee percentage during the first five rider years. Following the fifth rider anniversary, the rider fee percentage may be increased due to an automatic step-up, but will not increase more than 0.75% from the initial
rider fee percentages shown on page 1. 
 You have the right to reject an automatic step-up within 30 days following a rider anniversary, if the
rider fee percentage increases. If you reject an automatic step-up, you must notify us in a manner which is acceptable to us, however you are eligible for future automatic step-ups. Changes as a result of the automatic step-up feature will be
reversed. Any increase in the rider fee or withdrawal percentages will also be reversed. 

  

					
	RGMB 37 0809 (AS) (NY)	  	(4	  	(Income/Death-Single) (09/2012)

 ARTICLE III CONTINUED 
 WITHDRAWAL BASE ADJUSTMENTS 
 Gross partial withdrawals, taken in a rider year, less than or
equal to the rider withdrawal amount will not reduce the withdrawal base. Excess withdrawals will reduce the withdrawal base by the withdrawal base adjustment. The withdrawal base adjustment is the greater of 1) and 2), where: 

 

	1)	is the excess withdrawal amount; and 

  

	2)	is the result of (A multiplied by B), divided by C, where: 

  

	 	A)	is the excess withdrawal; 

  

	 	B)	is the withdrawal base prior to the excess withdrawal amount; and 

  

	 	C)	is the policy value after the rider withdrawal amount has been withdrawn, but prior to the withdrawal of the excess withdrawal amount. 

RIDER DEATH BENEFIT 
 Upon the
annuitant’s death, we will pay an additional death benefit amount equal to the excess, if any, of the rider death benefit over the greater of the base policy death benefit or the guaranteed minimum death benefit, if applicable, and this rider
will then terminate. The rider death benefit on the rider date is equal to the policy value (less any premium enhancements, if the rider is added in the first policy year). The rider death benefit after the rider date is equal to the rider death
benefit on the rider date plus any premiums (not including premium enhancements, if any) added after the rider date less any rider death benefit adjustments. 
 The rider death benefit does not reset due to the automatic step-up. 
 RIDER DEATH BENEFIT
ADJUSTMENTS 
 Cumulative gross partial withdrawals, taken in a rider year, up to the rider withdrawal amount will reduce the rider death
benefit by the same amount (dollar for dollar). Excess withdrawals will reduce the rider death benefit by the greater of: 
  

	1)	the excess withdrawal amount; and 

  

	2)	the result of (A divided by B), multiplied by C, where: 

  

	 	A)	is the excess withdrawal; 

  

	 	B)	is the policy value after the rider withdrawal amount has been withdrawn, but prior to the excess withdrawal; and 

 

	 	C)	is the rider death benefit after the rider withdrawal amount has been withdrawn, but prior to the excess withdrawal. 

ARTICLE IV 
 CONTINUATION

 In the case of spousal joint owners where one spouse is the annuitant, if the spouse who is not the annuitant dies and the surviving spouse is
the sole beneficiary, the surviving spouse may elect to continue the policy and rider. No additional death benefit will be paid under this rider at this time. In the case of spousal joint owners where one spouse is the annuitant, if the spouse who
is the annuitant dies, this rider will terminate. 
 In the case of non-spousal joint owners where an owner who is not the annuitant dies, the
surviving owner (who is also the sole designated beneficiary) may elect to receive lifetime income payments under this rider instead of receiving any benefits applicable to the policy. The lifetime income payments must begin no later than 1 year
after the owner’s death and will be equal to the rider withdrawal amount divided by the number of payments made per year. Once the payments begin, no additional premium payments will be accepted and no additional withdrawals will be paid. If
these payments are elected but the annuitant dies before the rider death benefit equals zero, the annuitant’s beneficiary will receive a death benefit equal to the rider death benefit. 
 ANNUITIZATION 
 On the maximum annuity commencement date, as described in your policy, you
will have the option to receive lifetime income payments that are no less than your rider withdrawal amount each year. This option will also guarantee that the sum of all income payments received over time will equal or exceed the greater of the
policy value or the rider death benefit on the maximum annuity commencement date. If the annuitant should die before the sum of all income payments received equals or exceeds the greater of the policy value or the rider death benefit on the maximum
annuity commencement date, the annuitant’s beneficiary will receive a final payment equal to the difference. 

  

					
	RGMB 37 0809 (AS) (NY)	  	(5	  	(Income/Death-Single) (09/2012)

 ARTICLE IV CONTINUED 
 RIDER UPGRADE 
 You may elect, in writing, to upgrade the withdrawal base to the policy
value within 30 days after the fifth rider anniversary and every fifth rider anniversary thereafter, subject to the issue age restrictions on the new rider. If an upgrade is selected, this rider will terminate and a new rider with the same features
will be issued with a new rider date. The new rider will have its own growth rate percentage and rider fee percentages which may not be the same as this rider’s percentages. Other riders with different features may be chosen, if avaiable by the
Company. 
 At the time of upgrade, the rider death benefit will also be upgraded to the policy value and the rider withdrawal amount will be
recalculated based on the new withdrawal base. 
 The new rider date will be the date the Company receives all information necessary, at our
Home Office, in a written form acceptable to the Company, to process the upgrade. 
 TERMINATION 

This rider will terminate upon the earliest of: 
  

	1)	the date the policy to which this rider is attached terminates; 

  

	2)	the date the policy to which this rider is attached is assigned or if the owner is changed without our approval; 

 

	3)	the date of the annuitant’s death; 

  

	4)	the date you elect to upgrade (as described in Article IV of this rider); 

  

	5)	the date you elect to receive annuity payments under your policy; and 

  

	6)	the date you notify us in writing of your intention to terminate this rider (this date must be within 30 days after the fifth rider anniversary and every fifth rider
anniversary thereafter). 

 Termination of the rider will result in the loss of all benefits provided by the rider. 

Signed for us at our home office. 
  

			
	

	  	

	SECRETARY	  	PRESIDENT

  

					
	RGMB 37 0809 (AS) (NY)	  	(6	  	(Income/Death-Single) (09/2012)

 APPENDIX 
 The quarterly fee is calculated as follows: 
 Multiply (1) by (2) divided
by (3) multiplied by (4) where: 
  

	1)	Withdrawal Base 

  

	2)	Product of each designated allocation group rider fee percentage and the applicable designated allocation group value, summed together; 

 

	3)	Total policy value 

  

	4)	Number of days in the rider quarter divided by the number of days within the applicable rider year 

The fee adjustment for additional premium payments and excess withdrawals is calculated as follows: 

Multiply (1) by (2) divided by (3) multiplied by (4) where: 

 

	1)	Withdrawal base change (i.e. withdrawal base after the transaction minus the withdrawal base before the transaction) 

 

	2)	Product of each designated allocation group rider fee percentage and the applicable designated allocation group value, summed together; 

 

	3)	Total transaction amount 

  

	4)	Number of days remaining in the rider quarter divided by the number of days within the applicable rider year 

The fee adjustment for fund transfers is calculated as follows: 
 Multiply (1) by (2) divided by (3) multiplied by (4) where: 
  

	1)	Withdrawal base 

  

	2)	Product of each designated allocation group rider fee percentage and the applicable designated allocation group value, summed together; 

 

	3)	Total policy value 

  

	4)	Number of days remaining in the rider quarter divided by the number of days within the applicable rider year 

The following two examples use assumed fees and values listed in the table below. The assumed rider year is not a leap year. 

 

													
	 Designated Allocation Group
	  	Fee	 	 	Initial
Policy Value	 	  	Additional Premium
Used in Example 2	 
	 Group A
	  	 	2.50	% 	 	$	50,000	  	  	$	5,000	  
	 Group B
	  	 	2.40	% 	 	$	30,000	  	  	$	3,000	  
	 Group C
	  	 	2.30	% 	 	$	20,000	  	  	$	2,000	  

 Example 1: Calculation at rider issue for first quarter fee assuming an initial withdrawal base of $100,000.

 = 100,000 * [(50,000*0.0250) + (30,000*0.0240) + (20,000*0.0230)] / 100,000 * (91/365) 

= 100,000 * (1,250 + 720 + 460) / 100,000 * (91/365) 
 = 100,000 * 2,430/100,000 * (91/365) 
 = 2,430 * (91/365) 

= $605.84 
 Example 2:
Calculation for first quarter fee assuming initial withdrawal base from Example 1 above, plus adjustment for additional premium payment of $10,000 made with 20 days remaining in the first rider quarter (invested as shown above). The withdrawal
base change and total transaction amount equal $10,000. 
 Fee adjustment as follows: 

= 10,000 * [(5,000*0.0250) + (3,000*0.0240) + (2,000*0.0230)] / 10,000 * (20/365) 

= 10,000 * (125 + 72 + 46) / 10,000 * (20/365) 
 = 10,000 * 243/10,000 * (20/365) 
 = 243 * (20/365) 

= $13.32 
 Total fee assessed on
first rider quarterversary (assuming no further rider fee adjustments): 
 = 13.32 + 605.84 

= $619.16 

  

					
	RGMB 37 0809 (AS) (NY)	  	(A-1	  	(Income/Death-Single) (09/2012)

 The following three examples use assumed fees and values listed in the table below. The assumed rider year
is not a leap year. 
  

																	
	 Designated Allocation Group
	  	Fee	 	 	Policy Value	 	  	Partial Withdrawal
Used in Example 4	 	  	Fund Transfer
Used in Example 5	 
	 Group A
	  	 	2.50	% 	 	$	49,000	  	  	$	-5,000	  	  	$	-5,000	  
	 Group B
	  	 	2.40	% 	 	$	29,000	  	  	$	-3,000	  	  	$	3,000	  
	 Group C
	  	 	2.30	% 	 	$	19,000	  	  	$	-2,000	  	  	$	2,000	  

 Example 3: Calculation for second quarter fee at beginning of second rider quarter, assuming withdrawal base of
$110,000 and policy value of $97,000 invested as above. 
 = 110,000 * [(49,000*0.0250) + (29,000*0.0240) + (19,000*0.0230)]
/ 97,000 * (91/365) 
 = 110,000 * (1,225 + 696 + 437) / 97,000 * (91/365) 

= 110,000 * 2,358/97,000 * (91/365) 
 = 2,674.02 * (91/365) 
 = $666.67 

Example 4: Calculation for second quarter fee assuming beginning values as in Example 3 above, plus adjustment for partial withdrawal of $10,000
taken with 40 days remaining in the second rider quarter. Assumes withdrawal percentage of 5%, policy value of $97,000 prior to the transaction and change in withdrawal base as follows: 
 Rider Withdrawal Amount (RWA) = Withdrawal Base * Withdrawal Percentage = 110,000 * .05 = $5,500 

Excess Withdrawal = Difference between assumed withdrawal amount and RWA = 10,000 - 5,500 = $4,500 

Withdrawal Base Adjustment = Max (Excess Withdrawal, Excess Withdrawal * Withdrawal Base prior to withdrawal / Policy Value after RWA has been withdrawn
but before excess withdrawal) = Max [4,500, 4,500 * 110,000 / (97,000-5,500)] = Max (4,500, 5,409.84) = $5,409.84 
 Fee adjustment as follows:

 = -5,409.84 * [(5,000*0.0250) + (3,000*0.0240) + (2,000*0.0230)] / 10,000 * (40/365) 

= -5,409.84 * (125 + 72 + 46) / 10,000 * (40/365) 
 = -5,409.84 * 243/10,000 * (40/365) 
 = -131.46 * (40/365) 

= $-14.41 
 Total fee assessed
on second rider quarterversary (assuming no further rider fee adjustments): 
 = 666.67 - 14.41 

= $652.26 
 The new Withdrawal
Base = $110,000 - $5,409.84 = $104,590.16 
 Example 5: Calculation for fund transfer occurring during second quarter with 25 days
remaining in the rider quarter, assuming beginning values as in Example 3 and withdrawal adjustment as in Example 4 above. 
 Withdrawal Base =
$104,590.16 and assumed policy value of $90,000. Fund transfer amount of $5,000 as allocated in table above. Fee adjustment as follows: 
 = 104,590.16* [(-5,000*0.0250) + (3,000*0.0240) + (2,000*0.0230)] / 90,000 * (25/365) 
 = 104,590.16 * (-125 + 72 + 46) / 90,000 * (25/365) 
 = 104,590.16 * -7/90,000 *
(25/365) 
 = -8.13 * (25/365) 
 = $-0.56 
 Total fee assessed on second rider quarterversary (assuming no further rider fee
adjustments): 
 = 652.26 - 0.56 
 = $651.70 

  

					
	RGMB 37 0809 (AS) (NY)	  	(A-2	  	(Income/Death-Single) (09/2012)

 XXXXXXXXXXXX 
  

			
	

	    	Home Office located at:
	    	440 Mamaroneck Avenue, Harrison, New York 10528
	    	Adm. Office located at:
	    	4333 Edgewood Road N.E. Cedar Rapids, Iowa 52499
	 A Stock Company (Hereafter called the Company, we, our or us)
	    	(319) 355-8511

 RETIREMENT INCOME CHOICE RIDER 
 This rider is issued as a part of the policy (contract) to which it is attached. 
 All provisions
of the policy that do not conflict with this rider apply to this rider. In the event of any conflict between the provisions of this rider and the provisions of the policy, the provisions of this rider shall prevail over the provisions of the policy.

 Rider Data Specification 
  

			
	 Policy Number:
	  	XXXXXXXXXXX
	 Rider Date:
	  	XXXXXXXXXX
	 Growth Rate Percentage:
	  	5.00%
		
	 Rider Fee Percentages:
	  	
	 Designated Allocation Group A:
	  	XXXXX
	 Designated Allocation Group B:
	  	XXXXX
	 Designated Allocation Group C:
	  	XXXXX
		
	 Annuitant:
	  	XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
		  	XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
	 Annuitant’s Issue Age/Sex:
	  	XX / XXXXXXXXXX
	 Annuitant’s Spouse:
	  	XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
	 Annuitant’s Spouse’s Issue Age/Sex:
	  	XX / XXXXXXXXXX

  
  

ARTICLE I 
 You may cancel
this rider on or before midnight of the thirtieth calendar day after you received it and no rider fees will be assessed. 
 This rider
provides a minimum withdrawal benefit that guarantees, upon election, a series of withdrawals from the policy equal to the Withdrawal Percentage shown in Article III applied to the withdrawal base. The withdrawal base is established for the sole
purpose of determining the minimum withdrawal benefit and is not used in calculating the cash surrender value or other guaranteed benefits. 

If you elect this rider, 100% of your policy value must be in one or more of the designated investment options. 

You can generally transfer between the designated investment options as permitted under your policy; however, you cannot make transfers as provided for
in the policy to a non-designated investment option while this rider is in force. If you wish to make a transfer to a non-designated investment option, this rider must be terminated, as described in Article IV, prior to making the transfer.

 The annuitant’s spouse as of the rider date is hereafter referred to as the annuitant’s spouse. As it pertains to the benefits of
this rider, the annuitant’s spouse cannot be changed. The annuitant’s spouse must be the sole primary beneficiary and/or a joint owner. The only living owners allowed on the policy to which this rider is attached are the annuitant and the
annuitant’s spouse. 
 DEFINITIONS: 
 Terms used that are not defined in this rider shall have the same meaning as those in your policy. 

Designated Investment Options 

Investment options authorized for use with this rider and identified by us as designated investment options. 

Excess Withdrawal 
 The excess of a gross
partial withdrawal over the rider withdrawal amount remaining prior to the withdrawal, if any. 
 Gross Partial Withdrawal 

The amount that will be deducted from your policy value as a result of each partial withdrawal 

  

					
	RGMB 37 0809 (IJ) (NY)	  	(1	  	(Income-Joint) (09/2012)

 ARTICLE I CONTINUED 
 Rider Anniversary 
 The anniversary of the rider date. 

Rider Fee 
 The fee charged for the
benefits under this rider. The fee will be charged on each rider quarterversary by the Company. 
 Rider Monthiversary 

The same day of the month as the rider date, or the next business day if our Administrative Office or the New York Stock Exchange is closed. 

Rider Quarter 
 Each three-month period
following the rider date. 
 Rider Quarterversary 
 For each rider quarter, the same day of the month as the rider date, or the next business day if our Administrative Office or the New York Stock Exchange is closed. 

Rider Withdrawal Amount 
 The maximum
amount that can be withdrawn from the policy each rider year without causing an excess withdrawal under the terms of this rider and thus reducing the withdrawal base. This amount will change if the withdrawal base changes. 

Rider Year 
 Each twelve-month period
following the rider date. 
 Valuation Period 
 The period of time from one determination of the value of a subaccount to the next. 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. 
 Withdrawal Base 

The amount used to calculate the rider withdrawal amount and the rider fee. This amount cannot be taken as a lump sum. 

ARTICLE II 
 RIDER FEES

 The rider fee is deducted on each rider quarterversary in arrears. The fee is calculated at issue and at the beginning of each rider quarter
for the upcoming quarter. The rider fee percentage will not change during the first five rider years, and will only change thereafter due to an automatic step-up. You will be notified of any increase in the rider fee percentage. A portion of this
fee will also be deducted when the rider is terminated based on the number of days that have elapsed since the previous rider quarterversary. 

The stored fee will be adjusted for new deposits, transfers among designated investment options and excess withdrawals made during the rider quarter.

 Fees will be calculated and stored on the day the rider is issued and at the beginning of each rider quarter. They will be deducted
automatically from each subaccount on a pro rata basis on each rider quarterversary. The annual fee percentages for each designated allocation group are shown on page 1, in the Rider Data Specification section. 

The quarterly fee is calculated as follows: 

Multiply (1) by (2) divided by (3) multiplied by (4). 
  

	1)	Withdrawal Base; 

  

	2)	Product of each designated allocation group rider fee percentage and the applicable designated allocation group value, summed together; 

 

	3)	Total policy value; 

  

	4)	Number of days remaining in the rider quarter divided by the number of days within the applicable rider year. 

Please see the Appendix attached to this rider which illustrates how the rider fee is calculated. 

  

					
	RGMB 37 0809 (IJ) (NY) 	  	(2	  	(Income-Joint) (09/2012)

 ARTICLE III 
 GUARANTEED LIFETIME WITHDRAWAL BENEFIT 
 Under this rider, we guarantee that you can receive
up to the rider withdrawal amount each rider year, regardless of the policy value, (either through withdrawals or payments, where payments are equal to the rider withdrawal amount if your policy value equals zero) until the annuitant’s or the
annuitant’s spouse’s death, whichever is later. 
 The withdrawal percentage is determined by the attained age (age at last birthday)
of the younger of the living spouses at the time of the first withdrawal of any amount from the policy value taken on or after the rider anniversary following the younger of the living spouse’s 59th birthday. Once the withdrawal percentage is
established, it may only be changed by an upgrade or automatic step-up and redetermined at that time. Upon automatic step-up, the withdrawal percentage will be reset based on the attained age of the younger of the living spouses at the time of the
automatic step-up. The withdrawal percentages are shown in the table below. 
  

							
	 	 	 Attained Age
	 	Withdrawal
Percentage	 	 
		 	59 - 64	 	3.5%	 	
		 	65 - 79	 	4.5%	 	
		 	80 +	 	5.5%	 	

 If the younger of the annuitant and the annuitant’s spouse is not yet 59 on the rider date, the withdrawal
percentage will be zero until the rider anniversary following the younger of the living spouse’s 59th birthday. Withdrawals prior to age 59 1/2 will be subject to the 10% penalty tax. 
 Withdrawals will reduce the policy value of the policy to which this rider is attached. If the policy value equals zero, you cannot make subsequent premium payments and all other policy features, benefits
and guarantees are no longer available. Also, if the policy value equals zero, you will need to request payments by selecting the amount and frequency in accordance with the policy provisions to which this rider attaches, equal to the rider
withdrawal amount. Once the payment amount and frequency are established, they cannot be changed and no additional withdrawals will be allowed. 

We guarantee that you may withdraw up to the rider withdrawal amount each year regardless of the policy value until the annuitant’s death.

 Example 
 Assume the younger of the annuitant and the annuitant’s spouse is 80 and withdrawals begin and your Withdrawal Base is $100,000. Assuming a withdrawal percentage of 5.5%, you could withdraw up to
$5,500 each rider year until the annuitant’s or the annuitant’s spouse’s death, which ever is later (assuming that you do not withdraw more than $5,500 in any one rider year). 
 Any amount you withdraw in excess of the rider withdrawal amount may impact the withdrawal base on a greater than dollar-for-dollar basis. 
 Please see the Appendix attached to this rider which illustrates the withdrawal benefit. 
 The
Guaranteed Lifetime Withdrawal Benefit can only be taken as a withdrawal benefit and it does not increase the policy value. 
 ISSUE AGE AND
SURVIVAL 
 The benefits under this rider depend on the annuitant or annuitant’s spouse being alive at the time of withdrawal and the
amount of the benefit depends on the attained age of the annuitant and annuitant’s spouse. Proof of survival and the date of birth may be required by the Company. 
 If the younger of the spouses’ ages has been misstated, this rider’s fees and benefits will be adjusted to the amounts which would have been calculated for the correct age. However, if this
rider would not have been issued had the age not been misstated, the rider is treated as if it never existed, and any fees charged for this rider would be returned. If withdrawals under the provisions of the rider have already commenced and the
misstatement caused the rider withdrawal amount to be overstated, any withdrawal in excess of the correct rider withdrawal amount will be considered an excess withdrawal and will impact the withdrawal base and rider withdrawal amount. If
overpayments occurred when the sum of the accumulated values in all the investment options was zero, the amount of that overpayment will be deducted from one or more future payments until this amount is paid in full. 

  

					
	RGMB 37 0809 (IJ) (NY) (R0912)	  	(3)	  	(Income-Joint) (09/2012)

 ARTICLE III CONTINUED 
 RIDER WITHDRAWAL AMOUNT 
 The rider withdrawal amount will be equal to the greater of 1) and
2), where: 
  

	1)	is the withdrawal percentage multiplied by the withdrawal base; 

  

	2)	is an amount equal to the minimum required distribution amount, if any. Prior to the 1st rider anniversary, this amount is based on the initial policy value on the
rider date. After this time, the minimum required distribution is calculated based on the rules established by the IRS. The minimum required distribution may only be used if all of the following are true: 

 

	 	A)	the policy to which this rider is attached is a tax-qualified policy for which IRS minimum required distributions are required, 

 

	 	B)	the minimum required distributions do not start prior to the annuitant’s attained age 70 1/2, 

 

	 	C)	the minimum required distributions are based on either the Uniform Lifetime table or the Joint Life and Last Survivor Expectancy table, 

 

	 	D)	the minimum required distributions are based on age of the living annuitant or the annuitant’s spouse if the annuitant is deceased. The minimum required
distributions can not be based on the age of someone who is deceased, 

  

	 	E)	the minimum required distributions are based only on the policy to which this rider is attached, and 

 

	 	F)	the minimum required distributions are only for the current rider year. Amounts carried over from past rider years are not considered. 

If any of the above are not true, then 2) is equal to zero and it is not available as a rider withdrawal amount. 

If you withdraw less than the rider withdrawal amount in a rider year, the unused portion cannot be carried over to the next rider year. 

WITHDRAWAL BASE 
 The withdrawal base is
used to calculate the rider withdrawal amount. On the rider date, the initial withdrawal base is equal to the policy value (less any premium enhancements if the rider is added in the first policy year). During any rider year, the withdrawal base is
increased by subsequent premium payments (not including premium enhancements, if any), and is reduced for excess withdrawals. 
 On each rider
anniversary, the withdrawal base will be set to the greatest of: 
  

	 	1)	The current withdrawal base; 

  

	 	2)	The policy value on the rider anniversary; 

  

	 	3)	The highest policy value on a rider monthiversary for the current rider year; or 

 

	 	4)	The current withdrawal base immediately prior to rider anniversary processing increased by the growth rate percentage. 

Item 3) above will be zero if there have been any excess withdrawals in the current rider year. Item 4) above will be zero after the 10th rider
anniversary or if there have been any withdrawals in the current rider year. 
 AUTOMATIC STEP-UP FEATURE 

The rider receives an automatic step-up on the rider anniversary if the withdrawal base is set equal to the policy value or the highest policy value on a
rider monthiversary. This feature does not require the termination of the existing rider. This rider will continue with the same rider date and features. The rider fee and withdrawal percentages may be changed due to an automatic step-up, but there
will be no increase in the rider fee percentage during the first five rider years. Following the fifth rider anniversary, the rider fee percentage may be increased due to an automatic step-up, but will not increase more than 0.75% from the initial
rider fee percentages shown on page 1. 
 You have the right to reject an automatic step-up within 30 days following a rider anniversary, if the
rider fee percentage increases. If you reject an automatic step-up, you must notify us in a manner which is acceptable to us, however you are eligible for future automatic step-ups. Changes as a result of the automatic step-up feature will be
reversed. Any increase in the rider fee or withdrawal percentages will also be reversed. 

  

					
	RGMB 37 0809 (IJ) (NY)	  	(4	  	(Income-Joint) (09/2012)

 ARTICLE III CONTINUED 
 WITHDRAWAL BASE ADJUSTMENTS 
 Gross partial withdrawals, taken in a rider year, less than or
equal to the rider withdrawal amount will not reduce the withdrawal base. Excess withdrawals will reduce the withdrawal base by the withdrawal base adjustment. The withdrawal base adjustment is the greater of 1) and 2), where: 

 

	1)	is the excess withdrawal amount; and 

  

	2)	is the result of (A multiplied by B), divided by C, where: 

  

	 	A)	is the excess withdrawal; 

  

	 	B)	is the withdrawal base prior to the excess withdrawal amount; and 

  

	 	C)	is the policy value after the rider withdrawal amount has been withdrawn, but prior to the withdrawal of the excess withdrawal amount. 

ARTICLE IV 
 CONTINUATION

 In the case of spousal joint owners where one spouse is the annuitant, if the spouse who is not the annuitant dies and the surviving spouse is
the sole beneficiary, the surviving spouse may elect to continue the policy and rider. In the case of spousal joint owners where one spouse is the annuitant, if the spouse who is the annuitant dies and the surviving spouse is the sole beneficiary,
the rider continues until the death of the surviving spouse. 
 ANNUITIZATION 
 On the maximum annuity commencement date, as described in your policy, you will have the option to receive lifetime income payments that are no less than your rider withdrawal amount each year. This
option will also guarantee that the sum of all income payments received over time will equal or exceed the policy value on the maximum annuity commencement date. If the annuitant or annuitant’s spouse should die before the sum of all income
payments received equals or exceeds the policy value on the maximum annuity commencement date, the annuitant’s beneficiary will receive a final payment equal to the difference. 
 RIDER UPGRADE 
 You may elect, in writing, to upgrade the withdrawal base to the policy
value within 30 days after the fifth rider anniversary and every fifth rider anniversary thereafter, subject to the issue age restrictions on the new rider. If an upgrade is selected, this rider will terminate and a new rider with the same features
will be issued with a new rider date. The new rider will have its own growth rate percentage and rider fee percentages which may not be the same as this rider’s percentages. Other riders with different features may be chosen, if available by
the Company. 
 At the time of upgrade the rider withdrawal amount will be recalculated based on the new withdrawal base. 

The new rider date will be the date the Company receives all information necessary, at our Home Office, in a written form acceptable to the Company, to
process the upgrade. 

  

					
	RGMB 37 0809 (IJ) (NY)	  	(5	  	(Income-Joint) (09/2012)

 ARTICLE IV CONTINUED 
 TERMINATION 
 This rider will terminate upon the earliest of: 

 

	1)	the date the policy to which this rider is attached terminates; 

  

	2)	the date the policy to which this rider is attached is assigned or if the owner is changed without our approval; 

 

	3)	the later of the annuitant’s or annuitant’s spouse’s death; 

 

	4)	the date you elect to upgrade (as described in Article IV of this rider); 

  

	5)	the date you elect to receive annuity payments under your policy; and 

  

	6)	the date you notify us in writing of your intention to terminate this rider (this date must be within 30 days after the fifth rider anniversary and every fifth rider
anniversary thereafter). 

 Termination of the rider will result in the loss of all benefits provided by the rider. 

Signed for us at our home office. 
  

			
	

	  	

	SECRETARY	  	PRESIDENT

  

					
	RGMB 37 0809 (IJ) (NY)	  	(6	  	(Income-Joint) (09/2012)

 APPENDIX 
 The quarterly fee is calculated as follows: 
 Multiply (1) by (2) divided
by (3) multiplied by (4) where: 
  

	1)	Withdrawal Base 

  

	2)	Product of each designated allocation group rider fee percentage and the applicable designated allocation group value, summed together; 

 

	3)	Total policy value 

  

	4)	Number of days in the rider quarter divided by the number of days within the applicable rider year 

The fee adjustment for additional premium payments and excess withdrawals is calculated as follows: Multiply (1) by (2) divided by
(3) multiplied by (4) where: 
  

	1)	Withdrawal base change (i.e. withdrawal base after the transaction minus the withdrawal base before the transaction) 

 

	2)	Product of each designated allocation group rider fee percentage and the applicable designated allocation group value, summed together; 

 

	3)	Total transaction amount 

  

	4)	Number of days remaining in the rider quarter divided by the number of days within the applicable rider year 

The fee adjustment for fund transfers is calculated as follows: Multiply (1) by (2) divided by (3) multiplied by (4) where:

  

	1)	Withdrawal base 

  

	2)	Product of each designated allocation group rider fee percentage and the applicable designated allocation group value, summed together; 

 

	3)	Total policy value 

  

	4)	Number of days remaining in the rider quarter divided by the number of days within the applicable rider year 

The following two examples use assumed fees and values listed in the table below. The assumed rider year is not a leap year. 

 

													
	 Designated Allocation Group
	  	Fee	 	 	Initial
Policy Value	 	  	Additional Premium
Used in Example 2	 
	 Group A
	  	 	2.50	% 	 	$	50,000	  	  	$	5,000	  
	 Group B
	  	 	2.40	% 	 	$	30,000	  	  	$	3,000	  
	 Group C
	  	 	2.30	% 	 	$	20,000	  	  	$	2,000	  

 Example 1: Calculation at rider issue for first quarter fee assuming an initial withdrawal base of $100,000.

 = 100,000 * [(50,000*0.0250) + (30,000*0.0240) + (20,000*0.0230)] / 100,000 * (91/365) 

= 100,000 * (1,250 + 720 + 460) / 100,000 * (91/365) 
 = 100,000 * 2,430/100,000 * (91/365) 
 = 2,430 * (91/365) 

= $605.84 
 Example 2:
Calculation for first quarter fee assuming initial withdrawal base from Example 1 above, plus adjustment for additional premium payment of $10,000 made with 20 days remaining in the first rider quarter (invested as shown above). The withdrawal
base change and total transaction amount equal $10,000. 
 Fee adjustment as follows: 

= 10,000 * [(5,000*0.0250) + (3,000*0.0240) + (2,000*0.0230)] / 10,000 * (20/365) 

= 10,000 * (125 + 72 + 46) / 10,000 * (20/365) 
 = 10,000 * 243/10,000 * (20/365) 
 = 243 * (20/365) 

= $13.32 
 Total fee assessed on
first rider quarterversary (assuming no further rider fee adjustments): 
 = 13.32 + 605.84 

= $619.16 

  

					
	RGMB 37 0809 (IJ) (NY)	  	(A-1	  	(Income-Joint) (09/2012)

 The following three examples use assumed fees and values listed in the table below. The assumed rider year
is not a leap year. 
  

																	
	 Designated Allocation Group
	  	Fee	 	 	Policy Value	 	  	Partial Withdrawal
Used in Example 4	 	  	Fund Transfer
Used in Example 5	 
	 Group A
	  	 	2.50	% 	 	$	49,000	  	  	$	-5,000	  	  	$	-5,000	  
	 Group B
	  	 	2.40	% 	 	$	29,000	  	  	$	-3,000	  	  	$	3,000	  
	 Group C
	  	 	2.30	% 	 	$	19,000	  	  	$	-2,000	  	  	$	2,000	  

 Example 3: Calculation for second quarter fee at beginning of second rider quarter, assuming withdrawal base of
$110,000 and policy value of $97,000 invested as above. 
 = 110,000 * [(49,000*0.0250) + (29,000*0.0240) + (19,000*0.0230)]
/ 97,000 * (91/365) 
 = 110,000 * (1,225 + 696 + 437) / 97,000 * (91/365) 

= 110,000 * 2,358/97,000 * (91/365) 
 = 2,674.02 * (91/365) 
 = $666.67 

Example 4: Calculation for second quarter fee assuming beginning values as in Example 3 above, plus adjustment for partial withdrawal of $10,000
taken with 40 days remaining in the second rider quarter. Assumes withdrawal percentage of 4.5%, policy value of $97,000 prior to the transaction and change in withdrawal base as follows: 
 Rider Withdrawal Amount (RWA) = Withdrawal Base * Withdrawal Percentage = 110,000 * .045 = $4,950 

Excess Withdrawal = Difference between assumed withdrawal amount and RWA = 10,000 - 4,950 = $5,050 

Withdrawal Base Adjustment = Max (Excess Withdrawal, Excess Withdrawal * Withdrawal Base prior to withdrawal / Policy Value after RWA has been withdrawn
but before excess withdrawal) = Max [5,050, 5,050 * 110,000 / (97,000-4,950)] = Max (5,050, 6,034.76) = $6,034.76 
 Fee adjustment as follows:

 = -6,034.76 * [(5,000*0.0250) + (3,000*0.0240) + (2,000*0.0230)] / 10,000 * (40/365) 

= -6,034.76 * (125 + 72 + 46) / 10,000 * (40/365) 
 = -6,034.76 * 243/10,000 * (40/365) 
 = -146.64 * (40/365) 

= $-16.07 
 Total fee assessed
on second rider quarterversary (assuming no further rider fee adjustments): 
 = 666.67 - 16.07 

= $650.60 
 The new Withdrawal
Base = $110,000 - $6,034.76 = $103,965.24 
 Example 5: Calculation for fund transfer occurring during second quarter with 25 days
remaining in the rider quarter, assuming beginning values as in Example 3 and withdrawal adjustment as in Example 4 above. 
 Withdrawal Base =
$103,965.24 and assumed policy value of $90,000. Fund transfer amount of $5,000 as allocated in table above. Fee adjustment as follows: 
 = 103,965.24 * [(-5,000*0.0250) + (3,000*0.0240) + (2,000*0.0230)] / 90,000 * (25/365) 
 = 103,965.24* (-125 + 72 + 46) / 90,000 * (25/365) 
 = 103,965.24 * -7/90,000 *
(25/365) 
 = -8.09 * (25/365) 
 = $-0.55 
 Total fee assessed on second rider quarterversary (assuming no further rider fee
adjustments): 
 = 650.60 - 0.55 
 = $650.05 

  

					
	RGMB 37 0809 (IJ) (NY)	  	(A-2	  	(Income-Joint) (09/2012)

			
	 XXXXXXXXXXXX
  
	    	 
	

	    	Home Office located at:
	    	440 Mamaroneck Avenue, Harrison, New York 10528
	    	Adm. Office located at:
	    	4333 Edgewood Road N.E. Cedar Rapids, Iowa 52499
	 A Stock Company (Hereafter called the Company, we, our or us)
	    	(319) 355-8511

 RETIREMENT INCOME CHOICE WITH DEATH BENEFIT RIDER 

This rider is issued as a part of the policy (contract) to which it is attached. 
 All provisions of the policy that do not conflict with this rider apply to this rider. In the event of any conflict between the provisions of this rider and the provisions of the policy, the provisions of
this rider shall prevail over the provisions of the policy. 
 Rider Data Specification 

 

			
	 Policy Number:
	  	XXXXXXXXXXX
	 Rider Date:
	  	XXXXXXXXXX
	 Growth Rate Percentage:
	  	5.00%
		
	 Rider Fee Percentages:
	  	
	 Designated Allocation Group A:
	  	XXXXX
	 Designated Allocation Group B:
	  	XXXXX
	 Designated Allocation Group C:
	  	XXXXX
		
	 Annuitant:
	  	XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
		  	XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
	 Annuitant’s Issue Age/Sex:
	  	XX / XXXXXXXXXX
	 Annuitant’s Spouse:
	  	XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
	 Annuitant’s Spouse’s Issue Age/Sex:
	  	XX / XXXXXXXXXX

  
  

ARTICLE I 
 You may cancel
this rider on or before midnight of the thirtieth calendar day after you received it and no rider fees will be assessed. 
 This rider
provides a minimum withdrawal benefit that guarantees, upon election, a series of withdrawals from the policy equal to the Withdrawal Percentage shown in Article III applied to the withdrawal base. The withdrawal base is established for the sole
purpose of determining the minimum withdrawal benefit and is not used in calculating the cash surrender value or other guaranteed benefits. 

If you elect this rider, 100% of your policy value must be in one or more of the designated investment options. 

You can generally transfer between the designated investment options as permitted under your policy; however, you cannot make transfers as provided for
in the policy to a non-designated investment option while this rider is in force. If you wish to make a transfer to a non-designated investment option, this rider must be terminated, as described in Article IV, prior to making the transfer.

 The annuitant’s spouse as of the rider date is hereafter referred to as the annuitant’s spouse. As it pertains to the benefits of
this rider, the annuitant’s spouse cannot be changed. The annuitant’s spouse must be the sole primary beneficiary and/or a joint owner. The only living owners allowed on the policy to which this rider is attached are the annuitant and the
annuitant’s spouse. 
 DEFINITIONS: 
 Terms used that are not defined in this rider shall have the same meaning as those in your policy. 

Designated Investment Options 

Investment options authorized for use with this rider and identified by us as designated investment options. 

Excess Withdrawal 
 The excess of a gross
partial withdrawal over the rider withdrawal amount remaining prior to the withdrawal, if any. 
 Gross Partial Withdrawal 

The amount that will be deducted from your policy value as a result of each partial withdrawal. 

  

					
	RGMB 37 0809 (AJ) (NY) 	  	(1	  	(Income/Death-Joint) (09/2012)

 ARTICLE I CONTINUED 
 Rider Anniversary 
 The anniversary of the rider date. 

Rider Fee 
 The fee charged for the
benefits under this rider. The fee will be charged on each rider quarterversary by the Company. 
 Rider Monthiversary 

The same day of the month as the rider date, or the next business day if our Administrative Office or the New York Stock Exchange is closed. 

Rider Quarter 
 Each three-month period
following the rider date. 
 Rider Quarterversary 
 For each rider quarter, the same day of the month as the rider date, or the next business day if our Administrative Office or the New York Stock Exchange is closed. 

Rider Withdrawal Amount 
 The maximum
amount that can be withdrawn from the policy each rider year without causing an excess withdrawal under the terms of this rider and thus reducing the withdrawal base. This amount will change if the withdrawal base changes. 

Rider Year 
 Each twelve-month period
following the rider date. 
 Valuation Period 
 The period of time from one determination of the value of a subaccount to the next. 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. 
 Withdrawal Base 

The amount used to calculate the rider withdrawal amount and the rider fee. This amount cannot be taken as a lump sum. 

ARTICLE II 
 RIDER FEES

 The rider fee is deducted on each rider quarterversary in arrears. The fee is calculated at issue and at the beginning of each rider quarter
for the upcoming quarter. The rider fee percentage will not change during the first five rider years, and will only change thereafter due to an automatic step-up. You will be notified of any increase in the rider fee percentage. A portion of this
fee will also be deducted when the rider is terminated based on the number of days that have elapsed since the previous rider quarterversary. 

The stored fee will be adjusted for new deposits, transfers among designated investment options and excess withdrawals made during the rider quarter.

 Fees will be calculated and stored on the day the rider is issued and at the beginning of each rider quarter. They will be deducted
automatically from each subaccount on a pro rata basis on each rider quarterversary. The annual fee percentages for each designated allocation group are shown on page 1, in the Rider Data Specification section. 

The quarterly fee is calculated as follows: 

Multiply (1) by (2) divided by (3) multiplied by (4). 
  

	1)	Withdrawal Base; 

  

	2)	Product of each designated allocation group rider fee percentage and the applicable designated allocation group value, summed together; 

 

	3)	Total policy value; 

  

	4)	Number of days remaining in the rider quarter divided by the number of days within the applicable rider year. 

Please see the Appendix attached to this rider which illustrates how the rider fee is calculated. 

  

					
	RGMB 37 0809 (AJ) (NY) 	  	(2	  	(Income/Death-Joint) (09/2012)

 ARTICLE III 
 GUARANTEED LIFETIME WITHDRAWAL BENEFIT 
 Under this rider, we guarantee that you can receive
up to the rider withdrawal amount each rider year, regardless of the policy value, (either through withdrawals or payments, where payments are equal to the rider withdrawal amount if your policy value equals zero) until the annuitant’s or the
annuitant’s spouse’s death, whichever is later. 
 The withdrawal percentage is determined by the attained age (age at last birthday)
of the younger of the living spouses at the time of the first withdrawal of any amount from the policy value taken on or after the rider anniversary following the younger of the living spouse’s 59th birthday. Once the withdrawal percentage is
established, it may only be changed by an upgrade or automatic step-up and redetermined at that time. Upon automatic step-up, the withdrawal percentages will be reset based on the attained age of the younger of the living spouses at the time of the
automatic step-up. The withdrawal percentages are shown in the table below. 
  

							
	 	 	 Attained Age
	 	Withdrawal
Percentage	 	 
		 	59 - 64	 	3.5%	 	
		 	65 - 79	 	4.5%	 	
		 	80 +	 	5.5%	 	

 If the younger of the annuitant and the annuitant’s spouse is not yet 59 on the rider date, the withdrawal
percentage will be zero until the rider anniversary following the younger of the living spouse’s 59th birthday. Withdrawals prior to age 59 1/2 will be subject to the 10% penalty tax. 
 Withdrawals will reduce the policy value of the policy to which this rider is attached. If the policy value equals zero, you cannot make subsequent premium payments and all other policy features, benefits
and guarantees are no longer available. Also, if the policy value equals zero, you will need to request payments by selecting the amount and frequency in accordance with the policy provisions to which this rider attaches, equal to the rider
withdrawal amount. Once the payment amount and frequency are established, they cannot be changed and no additional withdrawals will be allowed. 

We guarantee that you may withdraw up to the rider withdrawal amount each year regardless of the policy value until the annuitant’s death.

 Example 
 Assume the younger of the annuitant and the annuitant’s spouse is 80 and withdrawals begin and your Withdrawal Base is 
 $100,000. Assuming a withdrawal percentage of 5.5%, you could withdraw up to $5,500 each rider year until the annuitant’s or the annuitant’s spouse’s death, which ever is later (assuming
that you do not withdraw more than $5,500 in any one rider year). 
 Any amount you withdraw in excess of the rider withdrawal amount may impact
the withdrawal base on a greater than dollar-for-dollar basis. 
 Please see the Appendix attached to this rider which illustrates the
withdrawal benefit. 
 The Guaranteed Lifetime Withdrawal Benefit can only be taken as a withdrawal benefit and it does not increase the policy
value. 
 ISSUE AGE AND SURVIVAL 

The benefits under this rider depend on the annuitant or annuitant’s spouse being alive at the time of withdrawal and the amount of the benefit
depends on the attained age of the annuitant and annuitant’s spouse. Proof of survival and the date of birth may be required by the Company. 
 If the younger of the spouses’ ages has been misstated, this rider’s fees and benefits will be adjusted to the amounts which would have been calculated for the correct age. However, if this
rider would not have been issued had the age not been misstated, the rider is treated as if it never existed, and any fees charged for this rider would be returned. If withdrawals under the provisions of the rider have already commenced and the
misstatement caused the rider withdrawal amount to be overstated, any withdrawal in excess of the correct rider withdrawal amount will be considered an excess withdrawal and will impact the withdrawal base and rider withdrawal amount. If
overpayments occurred when the sum of the accumulated values in all the investment options was zero, the amount of that overpayment will be deducted from one or more future payments until this amount is paid in full. 

  

					
	RGMB 37 0809 (AJ) (NY) (R0912)	  	(3)	  	(Income/Death-Joint) (09/2012)

 ARTICLE III CONTINUED 
 RIDER WITHDRAWAL AMOUNT 
 The rider withdrawal amount will be equal to the greater of 1) and
2), where: 
  

	1)	is the withdrawal percentage multiplied by the withdrawal base; 

  

	2)	is an amount equal to the minimum required distribution amount, if any. Prior to the 1st rider anniversary, this amount is based on the initial policy value on the
rider date. After this time, the minimum required distribution is calculated based on the rules established by the IRS. The minimum required distribution may only be used if all of the following are true: 

 

	 	A)	the policy to which this rider is attached is a tax-qualified policy for which IRS minimum required distributions are required, 

 

	 	B)	the minimum required distributions do not start prior to the annuitant’s attained age 70 1/2, 

 

	 	C)	the minimum required distributions are based on either the Uniform Lifetime table or the Joint Life and Last Survivor Expectancy table, 

 

	 	D)	the minimum required distributions are based on age of the living annuitant or the annuitant’s spouse if the annuitant is deceased. The minimum required
distributions can not be based on the age of someone who is deceased, 

  

	 	E)	the minimum required distributions are based only on the policy to which this rider is attached, and 

 

	 	F)	the minimum required distributions are only for the current rider year. Amounts carried over from past rider years are not considered. 

If any of the above are not true, then 2) is equal to zero and it is not available as a rider withdrawal amount. 

If you withdraw less than the rider withdrawal amount in a rider year, the unused portion cannot be carried over to the next rider year. 

WITHDRAWAL BASE 
 The withdrawal base is
used to calculate the rider withdrawal amount. On the rider date, the initial withdrawal base is equal to the policy value (less any premium enhancements if the rider is added in the first policy year). During any rider year, the withdrawal base is
increased by subsequent premium payments (not including premium enhancements, if any), and is reduced for excess withdrawals. 
 On each rider
anniversary, the withdrawal base will be set to the greatest of: 
  

	 	1)	The current withdrawal base; 

  

	 	2)	The policy value on the rider anniversary; 

  

	 	3)	The highest policy value on a rider monthiversary for the current rider year; or 

 

	 	4)	The current withdrawal base immediately prior to rider anniversary processing increased by the growth rate percentage. 

Item 3) above will be zero if there have been any excess withdrawals in the current rider year. Item 4) above will be zero after the 10th rider
anniversary or if there have been any withdrawals in the current rider year. 

  

					
	RGMB 37 0809 (AJ) (NY)	  	(4	  	(Income/Death-Joint) (09/2012)

 ARTICLE III CONTINUED 
 AUTOMATIC STEP-UP FEATURE 
 The rider receives an automatic step-up on the rider anniversary
if the withdrawal base is set equal to the policy value or the highest policy value on a rider monthiversary. This feature does not require the termination of the existing rider. This rider will continue with the same rider date and features. The
rider fee and withdrawal percentages may be changed due to an automatic step-up, but there will be no increase in the rider fee percentage during the first five rider years. Following the fifth rider anniversary, the rider fee percentage may be
increased due to an automatic step-up, but will not increase more than 0.75% from the initial rider fee percentages shown on page 1. 
 You have
the right to reject an automatic step-up within 30 days following a rider anniversary, if the rider fee percentage increases. If you reject an automatic step-up, you must notify us in a manner which is acceptable to us, however you are eligible for
future automatic step-ups. Changes as a result of the automatic step-up feature will be reversed. Any increase in the rider fee or withdrawal percentages will also be reversed. 
 WITHDRAWAL BASE ADJUSTMENTS 
 Gross partial withdrawals, taken in a rider year, less than or
equal to the rider withdrawal amount will not reduce the withdrawal base. Excess withdrawals will reduce the withdrawal base by the withdrawal base adjustment. The withdrawal base adjustment is the greater of 1) and 2), where: 

 

	1)	is the excess withdrawal amount; and 

  

	2)	is the result of (A multiplied by B), divided by C, where: 

  

	 	A)	is the excess withdrawal; 

  

	 	B)	is the withdrawal base prior to the excess withdrawal amount; and 

  

	 	C)	is the policy value after the rider withdrawal amount has been withdrawn, but prior to the withdrawal of the excess withdrawal amount. 

RIDER DEATH BENEFIT 
 Upon the later of
the annuitant or the annuitant’s spouse’s death, we will pay an additional death benefit amount equal to the excess, if any, of the rider death benefit over the greater of the base policy death benefit or the guaranteed minimum death
benefit, if applicable, and this rider will then terminate. The rider death benefit on the rider date is equal to the policy value (less any premium enhancements, if the rider is added in the first policy year). The rider death benefit after the
rider date is equal to the rider death benefit on the rider date plus any premiums (not including premium enhancements, if any) added after the rider date less any rider death benefit adjustments. 

The rider death benefit does not reset due to the automatic step-up. 
 RIDER DEATH BENEFIT ADJUSTMENTS 
 Cumulative gross partial withdrawals, taken in a rider
year, up to the rider withdrawal amount will reduce the rider death benefit by the same amount (dollar for dollar). Excess withdrawals will reduce the rider death benefit by the greater of: 

 

	1)	the excess withdrawal amount; and 

  

	2)	the result of (A divided by B), multiplied by C, where: 

  

	 	A)	is the excess withdrawal; 

  

	 	B)	is the policy value after the rider withdrawal amount has been withdrawn, but prior to the excess withdrawal; and 

 

	 	C)	is the rider death benefit after the rider withdrawal amount has been withdrawn, but prior to the excess withdrawal. 

  

					
	RGMB 37 0809 (AJ) (NY)	  	(5	  	(Income/Death-Joint) (09/2012)

 ARTICLE IV 
 CONTINUATION 
 In the case of spousal joint owners where one spouse is the annuitant, if the
spouse who is not the annuitant dies and the surviving spouse is the sole beneficiary, the surviving spouse may elect to continue the policy and rider. No additional death benefit will be paid under this rider at this time. In the case of spousal
joint owners where one spouse is the annuitant, if the spouse who is the annuitant dies and the surviving spouse is the sole beneficiary, the rider continues until the death of the surviving spouse. 

ANNUITIZATION 
 On the maximum annuity
commencement date, as described in your policy, you will have the option to receive lifetime income payments that are no less than your rider withdrawal amount each year. This option will also guarantee that the sum of all income payments received
over time will equal or exceed the greater of the policy value or the rider death benefit on the maximum annuity commencement date. If the annuitant or annuitant’s spouse should die before the sum of all income payments received equals or
exceeds the greater of the policy value or the rider death benefit on the maximum annuity commencement date, the annuitant’s beneficiary will receive a final payment equal to the difference. 

RIDER UPGRADE 
 You may elect, in
writing, to upgrade the withdrawal base to the policy value within 30 days after the fifth rider anniversary and every fifth rider anniversary thereafter, subject to the issue age restrictions on the new rider. If an upgrade is selected, this rider
will terminate and a new rider with the same features will be issued with a new rider date. The new rider will have its own growth rate percentage and rider fee percentages which may not be the same as this rider’s percentages. Other riders
with different features may be chosen, if available by the Company. 
 At the time of upgrade, the rider death benefit will also be upgraded to
the policy value and the rider withdrawal amount will be recalculated based on the new withdrawal base. 
 The new rider date will be the date
the Company receives all information necessary, at our Home Office, in a written form acceptable to the Company, to process the upgrade. 

TERMINATION 
 This rider will terminate
upon the earliest of: 
  

	1)	the date the policy to which this rider is attached terminates; 

  

	2)	the date the policy to which this rider is attached is assigned or if the owner is changed without our approval; 

 

	3)	the later of the annuitant’s or annuitant’s spouse’s death; 

 

	4)	the date you elect to upgrade (as described in Article IV of this rider); 

  

	5)	the date you elect to receive annuity payments under your policy; and 

  

	6)	the date you notify us in writing of your intention to terminate this rider (this date must be within 30 days after the fifth rider anniversary and every fifth rider
anniversary thereafter). 

 Termination of the rider will result in the loss of all benefits provided by the rider. 

Signed for us at our home office. 
  

			
	

	  	

	SECRETARY	  	PRESIDENT

  

					
	RGMB 37 0809 (AJ) (NY)	  	(6	  	(Income/Death-Joint) (09/2012)

 APPENDIX 
 The quarterly fee is calculated as follows: 
 Multiply (1) by (2) divided
by (3) multiplied by (4) where: 
  

	1)	Withdrawal Base 

  

	2)	Product of each designated allocation group rider fee percentage and the applicable designated allocation group value, summed together; 

 

	3)	Total policy value 

  

	4)	Number of days in the rider quarter divided by the number of days within the applicable rider year 

The fee adjustment for additional premium payments and excess withdrawals is calculated as follows: 

Multiply (1) by (2) divided by (3) multiplied by (4) where: 

 

	1)	Withdrawal base change (i.e. withdrawal base after the transaction minus the withdrawal base before the transaction) 

 

	2)	Product of each designated allocation group rider fee percentage and the applicable designated allocation group value, summed together; 

 

	3)	Total transaction amount 

  

	4)	Number of days remaining in the rider quarter divided by the number of days within the applicable rider year 

The fee adjustment for fund transfers is calculated as follows: Multiply (1) by (2) divided by (3) multiplied by (4) where:

  

	1)	Withdrawal base 

  

	2)	Product of each designated allocation group rider fee percentage and the applicable designated allocation group value, summed together; 

 

	3)	Total policy value 

  

	4)	Number of days remaining in the rider quarter divided by the number of days within the applicable rider year 

The following two examples use assumed fees and values listed in the table below. The assumed rider year is not a leap year. 

 

													
	 Designated Allocation Group
	  	Fee	 	 	Initial
Policy Value	 	  	Additional Premium
Used in Example 2	 
	 Group A
	  	 	2.50	% 	 	$	50,000	  	  	$	5,000	  
	 Group B
	  	 	2.40	% 	 	$	30,000	  	  	$	3,000	  
	 Group C
	  	 	2.30	% 	 	$	20,000	  	  	$	2,000	  

 Example 1: Calculation at rider issue for first quarter fee assuming an initial withdrawal base of $100,000.

 = 100,000 * [(50,000*0.0250) + (30,000*0.0240) + (20,000*0.0230)] / 100,000 * (91/365) 

= 100,000 * (1,250 + 720 + 460) / 100,000 * (91/365) 
 = 100,000 * 2,430/100,000 * (91/365) 
 = 2,430 * (91/365) 

= $605.84 
 Example 2:
Calculation for first quarter fee assuming initial withdrawal base from Example 1 above, plus adjustment for additional premium payment of $10,000 made with 20 days remaining in the first rider quarter (invested as shown above). The withdrawal
base change and total transaction amount equal $10,000. 
 Fee adjustment as follows: 

= 10,000 * [(5,000*0.0250) + (3,000*0.0240) + (2,000*0.0230)] / 10,000 * (20/365) 

= 10,000 * (125 + 72 + 46) / 10,000 * (20/365) 
 = 10,000 * 243/10,000 * (20/365) 
 = 243 * (20/365) 

= $13.32 
 Total fee assessed on
first rider quarterversary (assuming no further rider fee adjustments): 
 = 13.32 + 605.84 

= $619.16 

  

					
	RGMB 37 0809 (AJ) (NY)	  	(A-1	  	(Income/Death-Joint) (09/2012)

 The following three examples use assumed fees and values listed in the table below. The assumed rider year
is not a leap year. 
  

																	
	 Designated Allocation Group
	  	Fee	 	 	Policy Value	 	  	Partial Withdrawal
Used in Example 4	 	  	Fund Transfer
Used in Example 5	 
	 Group A
	  	 	2.50	% 	 	$	49,000	  	  	$	-5,000	  	  	$	-5,000	  
	 Group B
	  	 	2.40	% 	 	$	29,000	  	  	$	-3,000	  	  	$	3,000	  
	 Group C
	  	 	2.30	% 	 	$	19,000	  	  	$	-2,000	  	  	$	2,000	  

 Example 3: Calculation for second quarter fee at beginning of second rider quarter, assuming withdrawal base of
$110,000 and policy value of $97,000 invested as above. 
 = 110,000 * [(49,000*0.0250) + (29,000*0.0240) + (19,000*0.0230)]
/ 97,000 * (91/365) 
 = 110,000 * (1,225 + 696 + 437) / 97,000 * (91/365) 

= 110,000 * 2,358/97,000 * (91/365) 
 = 2,674.02 * (91/365) 
 = $666.67 

Example 4: Calculation for second quarter fee assuming beginning values as in Example 3 above, plus adjustment for partial withdrawal of $10,000
taken with 40 days remaining in the second rider quarter. Assumes withdrawal percentage of 4.5%, policy value of $97,000 prior to the transaction and change in withdrawal base as follows: 
 Rider Withdrawal Amount (RWA) = Withdrawal Base * Withdrawal Percentage = 110,000 * .045 = $4,950 

Excess Withdrawal = Difference between assumed withdrawal amount and RWA = 10,000 - 4,950 = $5,050 

Withdrawal Base Adjustment = Max (Excess Withdrawal, Excess Withdrawal * Withdrawal Base prior to withdrawal / Policy Value after RWA has been withdrawn
but before excess withdrawal) = Max [5,050, 5,050 * 110,000 / (97,000-4,950)] = Max (5,050, 6,034.76) = $6,034.76 
 Fee adjustment as follows:

 = -6,034.76 * [(5,000*0.0250) + (3,000*0.0240) + (2,000*0.0230)] / 10,000 * (40/365) 

= -6,034.76 * (125 + 72 + 46) / 10,000 * (40/365) 
 = -6,034.76 * 243/10,000 * (40/365) 
 = -146.64 * (40/365) 

= $-16.07 
 Total fee assessed
on second rider quarterversary (assuming no further rider fee adjustments): 
 = 666.67 - 16.07 

= $650.60 
 The new Withdrawal
Base = $110,000 - $6,034.76 = $103,965.24 
 Example 5: Calculation for fund transfer occurring during second quarter with 25 days
remaining in the rider quarter, assuming beginning values as in Example 3 and withdrawal adjustment as in Example 4 above. 
 Withdrawal Base =
$103,965.24 and assumed policy value of $90,000. Fund transfer amount of $5,000 as allocated in table above. 
 Fee adjustment as follows:

 = 103,965.24 * [(-5,000*0.0250) + (3,000*0.0240) + (2,000*0.0230)] / 90,000 * (25/365) 

= 103,965.24 * (-125 + 72 + 46) / 90,000 * (25/365) 
 = 103,965.24 * -7/90,000 * (25/365) 
 = -8.09 * (25/365) 

= $-0.55 
 Total fee assessed on
second rider quarterversary (assuming no further rider fee adjustments): 
 = 650.60 - 0.55 

= $650.05 

  

					
	RGMB 37 0809 (AJ) (NY)	  	(A-2	  	(Income/Death-Joint) (09/2012)Exhibit 4(a)

 EXHIBIT 4(a) 
 FORM OF POLICY 

			
	 

	  	 Home Office located at:
 440 Mamaroneck Avenue, Harrison, New York 10528
 Adm. Office located at:

4333 Edgewood Road N.E. Cedar Rapids, Iowa 52499
 (319) 355-8511
 www.transamericaannuities.com

	  
		  

 READ YOUR POLICY CAREFULLY 

This policy is a legal contract between the Owner and Transamerica Financial Life Insurance Company issued in consideration of the
payment of an initial premium. This annuity policy is delivered in, and is governed by the laws of, the State of New York. 

The value held in the Separate Account may increase or decrease in value. Policy Value and benefits based on Separate Account assets
are not guaranteed and will decrease and increase with investment experience. 
 We agree to provide annuity payments, to
pay withdrawal benefits, and to pay Surrender benefits or death proceeds in accordance with this policy, as applicable. 
 This
policy permits the accumulation of funds on a tax-deferred basis and provides a periodic annuity payment for the life of the Annuitant or for a certain period of time, or a combination of both. Payments start on the Annuity Commencement Date.

 The smallest annual rate of investment return that would have to be earned on the assets of the Separate Account so that the
dollar amount of variable Annuity Payments will not decrease is 3.45%. 
 Prior to the Annuity Commencement Date, a daily
charge, corresponding to an annual charge of no more than 2.50% for the death benefit option, is applied by the Company to the assets of the Separate Account. The corresponding annual charge after the Annuity Commencement Date is no more than 2.50%
regardless of the death benefit option elected prior to the Annuity Commencement Date. 
 RIGHT TO CANCEL 

You may cancel this policy by delivering or mailing a written notice in Good Order to us or Your registered representative. You must
return the policy to us before close of business on the 10th 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. We will return the Fixed
Account premium and the Policy Value of the Separate Account, including any fees and charges, within 10 days afer we receive notice of cancellation and the returned policy. 
 If this policy is a replacement of another annuity or life insurance policy, the Right to Cancel period is extended to 60 days. 
 Signed for us at our home office. 
  

							
		  	

 	  	

 	  	
		  	SECRETARY	  	PRESIDENT	  	

 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 And Will Increase Or Decrease In Value Based Upon Investment 

Experience (See Sections 7 and 10) 
 Non-Participating 
 THE FIXED ACCOUNT AND THE DOLLAR COST AVERAGING FIXED
ACCOUNT OPTIONS MAY NOT BE 
 AVAILABLE ON THE ISSUE DATE. PLEASE CHECK SECTION 2 - DATA PAGE TO DETERMINE WHETHER THE
ACCOUNTS ARE AVAILABLE. AFTER THE POLICY DATE WE RESERVE THE RIGHT TO (I) REFUSE PREMIUM PAYMENTS TO THE FIXED ACCOUNT, AND (II) PROHIBIT TRANSFERS TO THE FIXED 
 ACCOUNT 

  

			
	NIC12 VA(2)0513(NY)	  	Page 1

 TABLE OF CONTENTS 

 

					
		
	 Definitions
	  	 	3	  
		
	 Policy Data Pages
	  	 	5	  
		
	 General Provisions
	  	 	6	  
		
	 Premium Payments
	  	 	9	  
		
	 Cash Value and Withdrawals
	  	 	10	  
		
	 Policy Value
	  	 	11	  
		
	 Separate Account
	  	 	11	  
		
	 Transfers
	  	 	13	  
		
	 Death Proceeds
	  	 	15	  
		
	 Income Options
	  	 	17	  
		
	 Fixed Account
	  	 	20	  
		
	 Income Option Tables
	  	 	21	  

  

			
	NIC12 VA(2)0513(NY)	  	Page 2

 SECTION 1 – DEFINITIONS 

Annuitant – The person on whose life any annuity payments involving life contingencies will be based. 

Annuity Commencement Date – The date an income option has been selected, all necessary paperwork is in Good Order, and the
Company has issued a supplementary contract. In no event can this date be earlier than the first Policy Anniversary, or later than the last day of the month following the month in which the Annuitant attains age 99. You may elect an Annuity
Commencement Date at any time by giving the Company 30 days written notice. If You do not elect an Annuity Commencement Date prior to the last available Annuity Commencement Date, annuity payments will begin as outlined in Section 10.

 Cash Value – The amount as defined in Section 5 that is available for Surrender. 

Commissioner - The primary Insurance Regulator for the State in which this policy has been issued. 

DCA Source Account - The Money Market Subaccount and/or other Subaccount(s) as identified by the Company and the DCA Fixed Account
Option, if offered, which are permitted to be used in conjunction with Dollar Cost Averaging. 
 Decedent - The deceased
Annuitant or Owner. 
 Earnings – An amount equal to the Policy Value at the time a withdrawal or Surrender is made,
minus the sum of all Premium Payments, reduced by all prior withdrawals deemed to have been from premium, if any. 
 Fixed
Account Guaranteed Minimum Effective Annual Interest Rate – If the Fixed Account is offered, the minimum guaranteed credited rate used to determine the Fixed Account portion of Your Policy Value prior to the Annuity Commencement Date. This
rate will apply for the life of the policy and is shown in Section 2 - Policy Data. 
 Good Order – The receipt
by the Company, at our Administrative Office, of all information, documentation, instructions and/or Premium Payment deemed necessary by the Company, in its sole discretion, to issue the policy or execute any transaction pursuant to the terms of the
policy. 
 Guaranteed Period Option or GPO – An Investment Option offered within the Fixed Account which credits a
guaranteed interest rate for a specified period of time. 
 Investment Options – Any of the Subaccounts of the
Separate Account and any of the options of the Fixed Account, if offered. 
 Market Day – Any day and for so long as
the New York Stock Exchange is open for business. 

  

			
	NIC12 VA(2)0513(NY)	  	Page 3

 Owner – The person who may exercise all rights and privileges under the policy.

 Policy Anniversary – The anniversary of the Policy Date for each year the policy remains in force. If a certain
date does not exist in a given month, the first day of the following month will be used. 
 Policy Date – The date,
shown in Section 2 - Policy Data, on which this policy becomes effective. 
 Policy Value – The amount
described in Section 6, which represents the value of Your Investment Options. 
 Policy Year – The 12-month
period following the Policy Date shown in Section 2 - Policy Data. The first Policy Year starts on the Policy Date. Each subsequent Policy Year starts on the anniversary of the Policy Date. 

Premium Payment – An amount paid to us by or on behalf of an Owner, as consideration for the benefits provided under this
policy. 
 Separate Account – The separate investment account(s) established by us, under the Investment Company Act
of 1940, as amended (the “1940 Act”), to which Premium Payments under the policy may be allocated. 
 Subaccount
– A division within the Separate Account, the assets of which are invested in a specified underlying fund portfolio. 

Surrender – A full withdrawal of Cash Value and termination of this policy. 

Valuation Period - The period of time from one determination of the value of each Subaccount to the next. Such determinations are
made when the values of the assets and liabilities of each Subaccount are calculated. This is generally the close of business on each Market Day. 
 You, Your – The Owner of this policy. Unless otherwise specified, the Annuitant and the Owner shall be the same person. If a joint Owner is named, reference to “You” or
“Your” in this policy will apply to both the Owner and any joint Owner. If the Owner is a trust and the trust allows any person(s) other than the trustee to exercise ownership rights under the policy, then such person(s) must be named as
the Annuitant, as applicable. The Owner, while living, controls all rights and benefits under the policy. 

  

			
	NIC12 VA(2)0513(NY)	  	Page 4

 SECTION 2 – POLICY DATA 

Policy Information 
  

			
	 	 
	Policy Number:	  	12345
	 	 
	Policy Date:	  	May 1, 2013
	 	 
	Income Tax Status of the Policy:	  	Non-Qualified
	 	 
	Initial Premium Payment:	  	$5,000.00
	 	 
	 Last
Available Annuity
 Commencement Date:
	  	May 31, 2077
	 	 
	Death Benefit Option:	  	Policy Value

Annuitant(s) Information 
  

			
	 	 
	Annuitant(s):	  	John Doe
	 	 
	Primary Annuitant’s Issue 
Age/Sex:	  	35/Male

Owner(s) Information 
  

			
	 	 
	Owner(s):	  	John Doe
	 	 
	Primary Owner’s Issue
Age/Sex:	  	35/Male

Rate Information for Fixed Account, if offered 
  

			
	Fixed Account Guaranteed Minimum Effective Annual Interest Rate:*	  	
1.00%  - THE COMPANY IS NOT CURRENTLY OFFERING A FIXED ACCOUNT OPTION.

 *This rate applies for the life of the policy. 
 After the Policy Date, we reserve the right to (I) refuse Premium Payments to the Fixed Account and (II) prohibit transfers to the Fixed Account. 

The credited interest rate for the Dollar Cost Averaging Fixed Account will never be less than the Fixed Account Guaranteed Minimum Annual Interest Rate
shown above. 

  

			
	NIC12 PD(2)0513(NY-IE)	  	Page 5(a)

 SECTION 2 – POLICY DATA (continued) 

Minimum Premium Payments 
  

			
	 	 
	Minimum Initial Premium
Payment:	  	 Non-Qualified - $5,000

Qualified $ 1,000

	 	 
	Minimum Subsequent Premium
Payment:	  	$50

Maximum Premium Payments (without prior Company Approval) 

 

					
	 	 	 
	  	  	Issue Age 0-80*	  	Issue Age 81+*
	 Total during the 1st Policy Year:

 
	  	 $1,000,000

 
	  	
$500,000
  

	  
 Total during
each Policy Year After 1st Policy Anniversary:
	  	  
 Non-qualified - $25,000
 Qualified - Lesser of $60,000 or IRS Contribution limit
	  	  

Non-qualified - $25,000
 Qualified - Lesser of
$60,000 or IRS Contribution limit

	  
 Cumulative
Maximum Premiums - Life of Policy:
	  	$1,000,000	  	$500,000

 * Issue Age is the greater of the Owner(s)’ or Annuitant(s)’ age. 

Mortality and Expense Risk Fee and Administrative Charge 

 

			
	  

Before the Annuity Commencement Date:

 
	  	
0.45%
  

	  
 After the
Annuity Commencement Date:
  
	  	
0.45%
  

 Withdrawal/Surrender Charges 
 At anytime, you may withdraw or Surrender the Policy Value without surrender charges. 
 The
amount paid on Surrender will never be less than the Cash Value described in Section 5. 

  

			
	NIC12 PD(2)0513(NY-IE)	  	Page 5(b)

 SECTION 2 – POLICY DATA (continued) 

Service Charge 
  

			
	 	 
	  

Service Charge at the Time of Issue:  

 
	  	  
 $35
  

	 	 
	  

Maximum Annual Service Charge:
  
	  	  
 $50
  

 The Company may waive some or all of Your service charge each year based on Your Policy Value, Premium
Payments made or active participation in specific online or e-delivery service programs at the time a service charge is assessed. 

1.  If Your Policy Value or sum of Premium Payments minus all withdrawals equals or exceeds: 

$50,000       =     up to a $35 fee waiver 

$250,000     =     up to a $50 fee waiver 

2.  Enrollment in specific online or e-delivery service programs may result in up to a $15 fee waiver. 

Transfer Minimums and Charges Before the Annuity Commencement Date 

 

			
	 	 
	  

Transfers Allowed Without
 Charges in
any One Policy Year:  
  
	  	 12

 

	 	 
	  

Charges After Allowable
 Transfers in
any One Policy Year:      
  
	  	 $10

 

	 	 
	  

Minimum Transfer
 Amount from a
Subaccount:
  
	  	 $500 or the entire Subaccount Policy
Value, if less
  

	 	 
	  

Minimum Transfer
 Amount from a
GPO:
  
	  	 $50

 

	 
	 Dollar Cost Averaging (DCA)

 

	 	 
	  

DCA Source Account

Minimum:
  
	  	$3,000
	 	 
	  

Minimum Amount
 of each
Transfer:
  
	  	$500
	 	 
	  

Minimum Time
 DCA can be
Scheduled:
  
	  	6 months
	 	 
	  

Maximum Time
 DCA can be
Scheduled:
  
	  	24 months

  

			
	NIC12 PD(2)0513(NY-IE)	  	Page 5(c)

 SECTION 2 – POLICY DATA (continued) 

 

 Fund Facilitation Fee 
 A Fund Facilitation Fee may be charged in addition to any policy fees and charges, and will be used in the calculation of net investment factor as described in Section 7 of the policy. The Fund
Facilitation Fee will only be charged when money is allocated to one of the Subaccounts listed with a Fund Facilitation Fee. The Fund Facilitation Fee is an annualized percentage taken from the daily net asset values of a fund share held in that
Subaccount. 
 We may update Fund Facilitation Fee funds and charge up to the maximum of 0.30% for Subaccounts made available
subsequent to the Policy Date. The Subaccount(s) as of Your Policy Date which include this fee are listed below with the current fee noted after the Subaccount name. 
 Initial Investment Options: 
  

			
	 Fixed Account(s) :
  

The Company is not currently offering a Fixed Account option.
  

1 Year Fixed Guaranteed Period
 3 Year Fixed
Guaranteed Period
 5 Year Fixed Guaranteed Period
 7 Year Fixed Guaranteed Period
  

Subaccounts :
 TA AEGON Money
Market
 TA AEGON High Yield Bond
 TA
AEGON Tactical Vanguard ETF - Balanced
 TA AEGON Tactical Vanguard ETF - Conservative
 TA AEGON Tactical Vanguard ETF - Growth
 TA AEGON U.S. Government Securities

TA AllianceBernstein Dynamic Allocation
 TA Asset
Allocation - Conservative
 TA Asset Allocation - Growth
 TA Asset Allocation - Moderate
 TA Asset Allocation - Moderate Growth

TA Barrow Hanley Dividend Focused
 TA BlackRock
Global Allocation
 TA BlackRock Tactical Allocation
 TA BNP Paribas Large Cap Growth
 TA Clarion Global Real Estate Securities

TA Hanlon Income
 TA International Moderate
Growth
	  	 TA Janus Balanced
 TA Jennison
Growth
 TA JPMorgan Core Bond
 TA
JPMorgan Enhanced Index
 TA JPMorgan Mid Cap Value
 TA JPMorgan Tactical Allocation
 TA Legg Mason Dynamic Allocation - Balanced

TA Legg Mason Dynamic Allocation - Growth
 TA
Market Participation Strategy
 TA MFS International Equity
 TA Morgan Stanley Mid-Cap Growth
 TA Multi-Managed Balanced

TA PIMCO Real Return TIPS
 TA PIMCO Tactical -
Balanced
 TA PIMCO Tactical - Conservative
 TA PIMCO Tactical - Growth
 TA PIMCO Total Return

TA Systematic Small/Mid Cap Value
 TA T. Rowe
Price Small Cap
 TA TS&W International Equity
 TA Vanguard ETF - Aggressive Growth
 TA Vanguard ETF - Balanced

TA Vanguard ETF - Conservative
 TA Vanguard ETF -
Growth
 TA WMC Diversified Growth

  

			
	NIC12 PD(2)0513(NY-IE)	  	Page 5(d)

 SECTION 3 – GENERAL PROVISIONS 

The Contract 
 The entire
contract consists of this policy, the Policy Data page, endorsements or riders, if any, and the application signed by You, a copy of which is attached hereto. If any portion of this policy or rider attached hereto shall be found to be invalid,
unenforceable or illegal, the remainder shall not in any way be affected or impaired thereby, but shall have the same force and effect as if the invalid, unenforceable or illegal portion had not been inserted. All statements in the application made
by or under the authority of the applicant are representations and not warranties. Nothing is incorporated by reference, unless a copy is endorsed upon or attached to the policy. Nothing in the policy or any attached endorsements or riders thereto
invalidates or impairs any right granted to the Owner by New York law or this policy. 
 Modification of Policy

 No change in this policy is valid unless made in writing by us and approved by one of our authorized officers. 

Tax Qualification and Change of Law 
 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, retroactively or prospectively, to reflect any amendment or 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. Any such amendment will be filed with and approved by the Department of Financial Services prior to use. We will send You a copy in the event of
any such amendment. If You refuse such an amendment, You must provide written notice to us, and Your refusal may result in adverse tax consequences. We reserve the right to amend this policy or riders attached to, as necessary to comply with
specific direction provided by our state or federal regulators, through change of law, rule, regulation, bulletin, regulatory directives or agreements. If any change deminishes Your rights or benefits under this policy, Your written consent is
required. 
 Non-Participating 
 This policy will not share in our profits. 
 Age or Sex Corrections

 We may require proof of the Annuitant’s or Owner’s age and/or sex before any payments associated with the death
benefit or any rider(s) attached to this policy are made. If the age and/or sex of the Annuitant or Owner is incorrectly stated, we will base any such payment associated with the death benefit and/or rider benefit proceeds on the Annuitant’s or
Owner’s correct age and/or sex. If required by law to ignore differences in the sex of the Annuitant, the annuity payments will be determined using the unisex factors in Section 12. 

We may require proof of the Annuitant’s age and/or sex before starting annuity payments. If the age and/or sex (or both) of the
Annuitant is incorrectly stated, we will correct the amount payable based upon the Annuitant’s correct age and/or sex, if applicable. Any underpayment made by us will be paid with the next payment. Any overpayment by us will be deducted from
future payments. Any underpayment or overpayment will include annual interest at a rate of 1% per year, from the date of the underpayment or overpayment to the date of the adjustment. 

Incontestability 
 This policy shall be incontestable from the Policy Date. 
 Involuntary Cashout

 If, at anytime, Your Policy Value is below $2,000, and there have been no Premium Payments made to the policy within the
last three Policy Years, we reserve the right to pay the full Policy Value and terminate the policy. 

  

			
	NIC12 VA(2)0513(NY)	  	Page 6

 Evidence of Survival 
 We have the right to require reasonable and satisfactory evidence that a person is alive if a payment is based on that person being alive. 
 Rights of Owner 
 The Owner may, while the Annuitant is living: 

	 	a.	Assign this policy; 

	 	b.	Surrender the policy to us; 

	 	c.	Amend or modify the policy with our consent; 

	 	d.	Receive annuity payments or name a payee to receive the payments; and 

	 	e.	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 or irrevocable beneficiary, and of the spouse in a community or
marital property state. Unless we have been notified of a community or marital property interest in this policy, we will rely on our good faith belief that no such interest exists and will assume no responsibility for inquiry. 

Change of Ownership 
 In the case of a non-tax-qualified annuity, You can change the Owner of this policy from Yourself to a new Owner. You must send written notification, to our Administrative Office, which contains all
necessary information to make the change. Any Owner change made, unless otherwise specified by the Owner, shall take effect on the date the notification is signed by the Owner, when received in Good Order, subject to any payments made or actions
taken by us prior to receipt of the notification. No change will apply to any payment we made before the written notice was received. 
 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. A change in
Ownership due to death is outlined further in Section 9. 
 Assignment 

In the case of a non-tax-qualified annuity, this policy may be assigned. You must send written notification, to our Administrative Office,
which contains all necessary information to make the change. Any assignment made, unless otherwise specified by the Owner, shall take effect on the date the notification is signed by the Owner, when received in Good Order, subject to any payments
made or actions taken by us prior to receipt of the notification. 
 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 does not change the benefit or amount of the policy. 

This policy may be applied for and issued to qualify as a tax-qualified annuity under certain sections of the Internal Revenue Code
(IRC). Ownership of this policy is then restricted so it will comply with provisions of the IRC. 
 Assignment of this policy
may result in adverse tax consequences. 
 Beneficiary 

Amounts payable upon death in accordance with Section 9, may be payable to the designated beneficiary or beneficiaries. Such
beneficiary(ies) must be named and may be changed without beneficiary consent (unless irrevocably designated or required by law) by notifying us in writing, on a form acceptable to us. Unless otherwise specified by You, the change will take effect
upon the date You sign it, whether or not You are living when we receive it, subject to any payments made or actions taken by the Company prior to receipt of this notice. The notice must have been postmarked (or show other evidence of delivery that
is acceptable to us) on or before the Decedent’s date of death. Your most recent beneficiary change notice will replace any prior beneficiary designations. No change will apply to any payment we made before the written notice was received by
us. If an irrevocable beneficiary dies, You may designate a new beneficiary. 
 You may elect the method of payment for each
named beneficiary, subject to our then current rules, prior to the date of death of the Decedent. When no such election is made as to a specific beneficiary, such beneficiary must elect the method of payment within 60 days of the date we receive all
required documentation, in Good Order, to pay the amount payable to that beneficiary. 

  

			
	NIC12 VA(2)0513(NY)	  	Page 7

 If there is more than one beneficiary at any level (primary or contingent), and You failed
to specify their interest, they will share equally. 
  

	 	a.	General Distribution Rules 

 Unless You have provided other specific instructions to us, amounts payable upon death will be paid in accordance with Section 9 and as outlined below: 

	 	 1.	 If a primary beneficiary is alive at the time of Decedent’s death, and there is no surviving Owner, payment will be made to the primary
beneficiary; 

	 	 2.	 If a primary beneficiary dies before the Decedent and there are additional living primary beneficiaries, the deceased primary beneficiary’s
interest will be shared proportionately with all living primary beneficiaries; 

	 	 3.	 When all primary beneficiaries die before the Decedent’s death, payment will be made to the living contingent beneficiary(ies), if any;

	 	 4.	 If a contingent beneficiary dies before the Decedent and there are additional living contingent beneficiaries, the deceased contingent
beneficiary’s interest will be shared proportionately with all living contingent beneficiaries; 

	 	 5.	 In the event no primary or contingent beneficiaries have been named and/or all have died before the Decedent, the Owner’s estate will become
the beneficiary; 

	 	 6.	 If a primary or contingent beneficiary dies after the Decedent’s death, but prior to death proceeds being payable to the beneficiary, payment
will be made to the beneficiary’s estate. 

  

	 	b.	Other Specific Instructions 

 You may provide specific instructions to the Company which direct that upon the death of a beneficiary, that their interest pass to a specific contingent beneficiary(ies) or per stirpes. 

	 	 1.	 Per Stirpes: If You provide instructions that a specific primary or contingent beneficiary’s share be passed per stirpes, we will pay that
beneficiary’s share to their identifiable lineal descendants who are living at the time of Decedent’s death. 

	 	 2.	 Specific Contingent: If You provide instructions that a specific primary or contingent beneficiary’s share be passed to a specified contingent
beneficiary(ies), we will pay that specific beneficiary’s share to those identifiable specific contingent beneficiaries who are living (or in existence) at the time of Decedent’s death. 

A deceased beneficiary share will be distributed as outlined under General Distributions Rules above. 

Protection of Proceeds 
 Unless You so direct by filing written notice with us, no beneficiary may assign any payments under this policy before the same 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 

Payment of any amount due from the Separate Account for a Surrender, withdrawal or death proceeds will generally occur within seven days
from the date we receive in Good Order all required information. We may defer payments or transfers from the Separate Account if: 

	 	 a.	 The New York Stock Exchange is closed other than for usual weekends or holidays or trading on the Exchange is otherwise restricted;

	 	 b.	 An emergency exists as defined by the Securities and Exchange Commission (SEC) or the SEC requires that trading be restricted; or

	 	 c.	 The SEC permits a delay for the protection of Owners. 

 We may defer payment of any transfers, withdrawals or Surrender proceeds from the Fixed Account, if offered, for up to 6 months from the date we receive Your request. If the Owner or 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 10 days or more. We will pay interest on that amount from the date
of receipt to the date of payment, at a current interest rate determined by the Company’s Board of Directors. 
 If we
delay payment of any transactions as noted above, we will disclose to You the specified date on which the above transactions will be effective and the reason for the delay. 

  

			
	NIC12 VA(2)0513(NY)	  	Page 8

 Reports to Owner 
 We will give You a report at least once each Policy Year, and may provide it more often. This report will show the start date and end date for the current period and include the following information:

	 	a.	The amounts credited or debited to the Policy Value during the current report period; 

	 	b.	The Policy Value at start and end date of the current report period; 

	 	c.	The number and value of the accumulation units held in each Separate Account; 

	 	d.	The Cash Value at start and end date of the current report period; 

	 	e.	The death benefit at the end of the current report period; 

	 	f.	The dollar amount in the Fixed Account, if any. 

 A report as described above will be mailed to Your last known address as shown in our records. The information provided will be as of a date not more than four months prior to the date of the mailing. We
will provide copies of the report available to You upon request at no additional cost. 
 SECTION 4 – PREMIUM PAYMENTS

 Payment of Premiums 
 Premium Payments may be made any time while this policy is in force and prior to the Annuity Commencement Date, subject to the minimums and maximums as specified in Section 2 – Policy Data. We
may prohibit Premium Payments and/or transfers to the Fixed Account options described in Section 11 if the yield on investments at such time is not sufficient to support the statutory minimum interest rate guarantee and other company expenses.
We will provide 30 days advance written notice of this decision. We will also provide timely written notification to You once any such prohibition of premiums to the Fixed Account is no longer in effect. 

Premium Payment Date 

The Premium Payment date is the date the Premium Payment is credited to the policy. The initial Premium Payment will be credited to the
policy within two Market Days after the Market Day we receive it and Your complete policy information in Good Order. Subsequent Premium Payments will be credited to the policy as of the Market Day the Premium Payment and required information are
received in Good Order. 
 Allocation of Premium Payments 
 Premium Payments may be applied to various Investment Options, which we make available. For each Premium Payment, You must indicate what percentage to allocate to various Investment Options. For
additional Premium Payments, allocations will be what is currently indicated by You. Each percentage may be either zero or any whole number; however, the allocation among all Investment Options must total 100%. 

Change of Allocation 

You may change allocations for additional Premium Payments by providing us instructions. The allocation change will apply to Premium
Payments received on or after the date we receive the allocation change in Good Order. We will allocate subsequent Premium Payments the same way, unless You request a different allocation. 
 Premium Taxes 
 The insurance laws of the State of New York as of 2012 do
not allow the imposition of premium taxes on annuity considerations. Therefore, wherever reference is made in this annuity policy to the deduction of premium taxes, such deductions will not be made while the Owner is a resident of the State of New
York, unless subsequent changes in New York’s insurance laws provide otherwise. The amount of any applicable premium tax imposed on amounts relating to this annuity policy may be deducted from this annuity policy. For purposes of this annuity
policy, premium taxes include retaliatory taxes or similar taxes. 

  

			
	NIC12 VA(2)0513(NY)	  	Page 9

 SECTION 5 – CASH VALUE AND WITHDRAWALS 

A. Cash Value 
 On or
before the Annuity Commencement Date, You may make withdrawals or Surrender the Cash Value. The Cash Value is equal to the Policy Value. Information on the current amount of Your Cash Value is available upon request. We must receive Your withdrawal
or Surrender request, in Good Order, before the Annuity Commencement Date. 
 There is no Cash Value once an income option has
been selected, all necessary instructions are received in Good Order, and the Company has issued a supplementary contract. 
 B. Withdrawals
and Surrenders 
 You may, on or before the Annuity Commencement Date, withdraw all (Surrender) or a portion (withdrawal) of
the amount available under this policy, provided we receive Your request, in Good Order, while this policy is in effect and before the Annuity Commencement Date. The minimum withdrawal is $500, with the exception of systematic payouts and required
minimum distributions. 
 You may specify that the withdrawal be taken from one or more specific Investment Options or pro rata
from all Investment Options. If You do not specify the Investment Option from which the withdrawal is to be made, the withdrawal will be taken pro rata from all Investment Options relative to the value in each Investment Option. 

Withdrawals will reduce the amount of the death proceeds. Withdrawals and Surrenders will normally be effective as of the end of the
Market Day the request is received in Good Order. 
 The gross withdrawal is the total amount which will be deducted from Your
Policy Value as a result of each withdrawal. The gross withdrawal equals the requested withdrawal. 
 Systematic Payout Option

 A Systematic Payout Option (SPO) is a series of pre-scheduled withdrawals. Beginning in the first Policy Year, a SPO is
available on a monthly, quarterly, semi-annual or annual basis. At the time a SPO is made, each such payout must be at least $50. Monthly and quarterly SPO’s must be sent through electronic funds transfer directly to a checking, savings or
other similar financial account. You may stop SPO payouts at any time with a 30 day written notice sent to our Administrative Office. 

Required Minimum Distribution 
 For tax-qualified plans and policies, withdrawals taken to satisfy required minimum distribution requirements under Section 401(a)(9) of the Internal Revenue Code (IRC) are available. The amount
available from this policy with respect to the required minimum distribution is based solely on this policy. 
 Minimum Values

 Benefits available under this policy, including any paid up annuity values, Cash Values, or death benefits, are not less
than those required by the insurance laws of the state of New York. Minimum benefits will be increased to reflect any guaranteed additional amounts credited to the policy and will be decreased by prior withdrawals. 

  

			
	NIC12 VA(2)0513(NY)	  	Page 10

 SECTION 6 – POLICY VALUE 

Policy Value 
 On or
before the Annuity Commencement Date, the Policy Value is equal to Your: 

	 	a.	Premium Payment(s); minus 

	 	b.	Gross withdrawals; plus 

	 	c.	Interest credited to the Fixed Account (if any); plus 

	 	d.	 Accumulated gains including the deduction of the mortality and expense risk fee and administrative charge, in the Separate Account; minus

	 	e.	 Accumulated losses including the deduction of the mortality and expense risk fee and administrative charge, in the Separate Account; minus

	 	f.	Service charges, rider fees, premium taxes, and transfer fees if any. 

 Service Charge 
 On each Policy Anniversary prior to the Annuity
Commencement Date and at the time of Surrender, we may deduct an annual service charge as set forth in Section 2 - Policy Data. The service charge will be deducted from each Subaccount in proportion to the portion of Policy Value (prior to such
charge) in each Subaccount. In no event will the service charge exceed 2% of the Policy Value or the maximum, as shown in Section 2 - Policy Data, on the Policy Anniversary or at the time of Surrender. 

SECTION 7 – SEPARATE ACCOUNT 
 Separate Account 
 We have established and will maintain one or more
Separate Account(s), under the laws of the state of New York. 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 put 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 portfolio(s), or in the case of a managed Separate Account, direct
investments in stocks or other securities as permitted by law. Fund shares refer to shares of underlying mutual funds or pro-rata ownership of the assets held in a Subaccount of a managed Separate Account. Fund shares are purchased, redeemed and
valued on behalf of the Separate Account. 
 The Separate Account is divided into Subaccounts. Each Subaccount invests
exclusively in shares of one of the portfolios of an underlying fund. We reserve the right to add or remove any Subaccount of the Separate Account. You will be notified in writing of any changes to the Subaccounts. 

The Separate Account meets the definition of a “Separate Account” under rule 0-l(e)(l) of the Investment Company Act of 1940
(the “1940 Act”). 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 the Valuation Period, which we establish in good faith. In order to determine the value of an asset on a day that is not a Market Day, the Company will use the value of that asset as of the end of the next Market Day on which trading
takes place. 
 The Company will determine the value of the reserves for assets in the Separate Account at the end of each
Market Day. In order to determine the value of reserves for assets on a day that is not a Market Day, the Company will use the value of that asset as of the end of the prior Market Day on which trading took place. 

We also reserve the right (with prior authorization from the Superintendent) 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 are transferred. 

  

			
	NIC12 VA(2)0513(NY)	  	Page 11

 We also reserve the right, when permitted by law and with any required approval from the
Superintendent, 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 Separate Accounts; 

	 	e.	Create new Separate Accounts; 

	 	f.	 Add new Separate Accounts 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 mutual fund. 

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 New York 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, both before and after the Annuity Commencement Date,
to compensate for changes in mortality and expenses not anticipated by the mortality and administration charges guaranteed in the policy. Expenses and mortality results will not adversely affect the dollar amounts of variable benefits or other
variable contractual payments or values. The mortality and expense risk fee and the administrative charge is specified in Section 2 - Policy Data. 
 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 Market Day to Market Day reflecting the investment experience of the Subaccount. 

Premium Payments allocated to and any amounts transferred 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 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 withdrawal or transfer date. 
 The value of an accumulation unit on any Market Day is determined by multiplying the value of that unit at the end of the immediately preceding Valuation Period by the net investment factor for the
Valuation Period. 

  

			
	NIC12 VA(2)0513(NY)	  	Page 12

 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 taxes reserved for, 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. This factor is less than
or equal to, on an annual basis, the percentage shown in Section 2 - Policy Data, 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. 
 SECTION 8 – TRANSFERS 
 A. TRANSFERS BEFORE THE ANNUITY COMMENCEMENT DATE

 Prior to the Annuity Commencement Date, You may transfer the value of the accumulation units from one Investment Option to
another within certain limitations. 
 Transfers of interest credited in the GPO’s 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 is subject to transfer minimums and charges as set forth in Section 2 - Policy Data. 

You may choose which GPO to transfer to or from; however, any GPO elected may not extend beyond the last available Annuity Commencement
Date shown in Section 2 - Policy Data. 
 Transfers of Policy Value from the Separate Account are subject to a minimum and
charges as set forth in Section 2 - Policy Data. If the remaining Subaccount Policy Value is less than the minimum transfer amount, as shown in Section 2 - Policy Data, we reserve the right to include that amount as part of the transfer.
Transfers among multiple Investment Options will be treated as one transfer in determining the number of transfers that have occurred. 
 If You want to transfer the value of the variable units You must provide written notification with the following information provided: 

	 	1.	The Investment Option from which the transfer is to be made; 

	 	2.	The amount of the transfer; and 

	 	3.	The Investment Option(s) to receive the transferred amount. 

 The policy was not designed for the use of market timers or frequent or disruptive traders. Such transfers may be harmful to the underlying fund portfolios and increase transaction costs. We have
developed policies and procedures with respect to market timing and disruptive trading (which vary for certain Subaccounts at the request of the corresponding underlying fund portfolios). 

  

			
	NIC12 VA(2)0513(NY)	  	Page 13

 We employ various means in an attempt to detect market timing and disruptive trading.
However, despite our monitoring, we may not be able to detect nor halt all harmful trading. If we determine You are engaged in market timing or disruptive trading, we may take one or more actions in an attempt to halt such trading. Your ability to
make transfers is subject to modification or restriction if we determine, in our sole discretion, that Your exercise of the transfer privilege may disadvantage or potentially harm the rights or interests of other Owners (or others having an interest
in the variable insurance products). Transfer restrictions may take the form of loss of expedited transfer privilege. We consider transfers by fax, overnight mail, or the Internet to be “expedited” transfers. This means that we would
accept only an original signature transmitted to us only by U.S. mail. We may also restrict the transfer privileges of others acting on Your behalf, including Your registered representative or an asset allocation or investment advisory service.

 We reserve the right to reject any Premium Payments or transfer requests from any person without prior notice, if, in our
judgment: 

	 	1.	 The payment or transfer, or series of transfers, would have a negative impact on an underlying fund portfolio’s operations; or

	 	2.	 If an underlying fund portfolio would reject or has rejected our purchase order or has instructed us not to allow that purchase or transfer; or

	 	3.	Because of a history of market timing or disruptive trading. 

 Dollar Cost Averaging 
 Prior to the Annuity Commencement Date, You may
enroll in Dollar Cost Averaging (DCA) by instructing us to automatically make periodic transfers of Policy Value from a DCA Source Account without waiting for further instructions from You. A DCA program will begin once we have received, in Good
Order, all necessary information and the minimum required amount. 
 You must provide us with the following information to initiate DCA:

	 	1.	 The date on which the transfers are to begin. Your request will normally be effective the day after the effective date of the policy. If a certain
date does not exist in a given month, the first day of the following month will be used; 

	 	2.	 The DCA Source Account from which the transfers are to be made. To begin dollar cost averaging, the value of the DCA Source Account is subject to
minimums as described in Section 2 - Policy Data; 

	 	3.	 The amount and frequency of the transfers. You may choose monthly or quarterly transfers. The amount of each transfer is subject to minimums as
described in Section 2 - Policy Data; and 

	 	4.	 The Investment Option(s) to receive the transferred amounts. You may choose one or more Investment Options. If You select more than one Investment
Option, Your request must specify how the transferred amounts are to be allocated among these Investments Options and cannot include Your DCA Source Account. 

 Transfers must be scheduled for a minimum or maximum length of time as specified in Section 2 - Policy Data. DCA 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 DCA program will result in higher Policy Values or will otherwise be successful. 

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. Any amounts in the DCA Source
Account or Fixed Account, if offered, are ignored for the purposes of Asset Rebalancing. Rebalancing can be started, stopped or changed at any time. Rebalancing will cease as soon as we receive a request for any transfer. 

B. TRANSFERS AFTER THE ANNUITY COMMENCEMENT DATE 
 After the Annuity Commencement Date, You may transfer the value of the variable annuity units from one Subaccount to another within the Separate Account or to the Fixed Account, if offered. If You want to
transfer the value of the variable units You must provide written notification with the following information provided: 

	 	1.	The Investment Option from which the transfer is to be made; 

	 	2.	The amount of the transfer; and 

	 	3.	The Investment Option(s) to receive the transferred amount. 

  

			
	NIC12 VA(2)0513(NY)	  	Page 14

 The minimum amount which may be transferred is the lesser of the variable annuity units that
produce $10 monthly income or the variable annuity units that produce the entire monthly income 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. We reserve the right to limit transfers between the Subaccounts or to the Fixed Accounts to once per Policy Year. 

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

 SECTION 9 - DEATH PROCEEDS 
 A. DEATH PRIOR TO THE ANNUITY COMMENCEMENT DATE 
 The amount payable upon
death will be determined and made payable upon receipt, in Good Order, of satisfactory proof of death, written directions from each eligible recipient regarding how they wish to receive the amount payable, and any other documents, forms and
information that we need (collectively referred to as “due proof of death”). Not withstanding the foregoing, we may confer with a variety of resources and/or other affiliates in order to ascertain or verify whether the Annuitant or any
other relevant life is or may have become deceased during the term of this policy. Any such activities or efforts by us in no manner abrogate, waive or otherwise diminish Your continued obligation to provide us with timely notice in writing of due
proof of death in Good Order. 
 The amount of the death benefit payable will be the greater of: 

	 	1.	 The Policy Value on the date we receive due proof of death and an election of method of settlement; 

	 	2.	 The Guaranteed Minimum Death Benefit (GMDB), if any, on the date of death, plus any additional Premium Payments received, less any gross withdrawals
from the date of death to the date of payment of death proceeds. 

 The Owner(s) may elect the method of
payment of death proceeds for each named beneficiary, subject to our then current rules, prior to the date of the applicable Decedent’s death. When no such election is made as to a specific beneficiary, such beneficiary must elect the method of
payment within 60 days of the date we receive all required documentation, in Good Order, to pay the death proceeds to that beneficiary. If no election is made as to the method of payment by the beneficiary, we will distribute the proceeds in a lump
sum. 
 Guaranteed Minimum Death Benefit 
 If elected, the GMDB rider will establish a minimum death benefit payable under the policy. Your election, if any, is shown in Section 2 - Policy Data. You may not change Your election after the
policy is issued. 
 Death of Annuitant Prior To The Annuity Commencement Date 

A death benefit will be payable if the Annuitant dies prior to the Annuity Commencement Date. 

 

	 	1.	Non-Natural Owner(s) 

 For purposes of determining who receives the death benefit for a policy owned by a non-natural Owner, we will apply the rules for Individual Owner(s) as provided below in 2(a) or (b). 

 

	 	2.	Individual Owner(s) 

	 	(a)	Surviving Owner 

If there is a surviving Owner(s) when the Annuitant dies, the surviving Owner(s) will receive the death benefit (i.e.,
the surviving Owner(s) takes the place of any beneficiary designation). 
  

	 	(b)	No surviving Owner 

 If there is no surviving Owner, the death benefit is payable to the named beneficiary(ies). If no beneficiary(ies) are named, the death benefit will be payable to the Owner’s estate. 

  

			
	NIC12 VA(2)0513(NY)	  	Page 15

 Death of Owner Prior To The Annuity Commencement Date 

If the Owner is not the Annuitant and the Owner dies before the Annuitant, under certain circumstances, an amount equal to the Policy
Value, as of the date we receive due proof of death, will be paid. 
 If You are not also the Annuitant and in the event of
simultaneous deaths of both You and the Annuitant, the death proceeds will be calculated under the Death of Annuitant provisions. 
  

	 	1.	Non-Natural Owner(s) 

 If the policy is owned by a trust using the grantor’s social security number as its taxpayer identification number, the death of the grantor will be treated as the death of the Owner. 

If there is a change in the Annuitant, such change will be treated as the death of the non-natural Owner and we will pay
an amount equal to the Policy Value as of the day we receive, in Good Order, the request to change the Annuitant. 
  

	 	2.	Individual Owner(s) 

 If You die while the Annuitant is living, the Policy Value will be paid to the first among the following who is living or in existence: 

	 	a.	The surviving Owner(s); 

	 	b.	Primary beneficiary(ies); 

	 	c.	Contingent beneficiary(ies); or 

	 	d.	Deceased Owner’s estate. 

  

	 	3.	Joint Owner(s) 

 If there is a joint Owner, the Policy Value will be payable upon the death of the first Owner, unless the surviving joint Owner is the spouse. 
 Non-Spouse Individual Beneficiary: 
 If the beneficiary is an individual who
is not eligible to continue the policy as noted below, the amount payable must be distributed by the end of 5 years after the date of Decedent’s death, or payments must begin no later than one year after the date of Decedent’s death and
must be made for a period certain or for the beneficiary’s lifetime, so long as the period certain does not exceed the beneficiary’s life expectancy. 
 If the beneficiary is not a natural person, the death proceeds must be distributed by the end of 5 years after the date of Decedent’s death. 
 Spousal Beneficiary 
 A spousal beneficiary, who is the sole beneficiary,
may elect to continue this policy as Owner rather than receiving the amount payable when they are the deceased Owner’s surviving spouse. 
 If the surviving spouse does not elect to continue the policy, the amount payable must be distributed by the end of 5 years after the date of the Decedent’s death, or payments must begin no later
than one year after the Decedent’s death and must be made for a period certain or for the beneficiary’s lifetime, so long as the period certain does not exceed the beneficiary’s life expectancy. 

If a death benefit is payable and 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. This is a one-time only Policy Value adjustment applied at the time the policy is continued. The spousal continuation election is only available once per policy. 

B. DEATH ON OR AFTER THE ANNUITY COMMENCEMENT DATE 
 In the event of a death after the Annuity Commencement Date, the amount payable will depend on the income 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 will be distributed to the beneficiary(ies) at least as rapidly as under the method of distribution being used as of the date of that death.

  

			
	NIC12 VA(2)0513(NY)	  	Page 16

 C. ADDITIONAL TAX INFORMATION 

In any event, the death proceeds will be paid in accordance with Section 72(s) of the IRC. For purposes of applying the non-natural
Owner death rules of Section 72(s)(6), we will apply the Annuitant death rules set forth earlier in this section. 
 These
distribution rules do not apply to an annuity provided under a plan described in Section 401(a), 403(a), 403(b), 408 or 408A of the IRC or to an annuity that is a qualified funding asset as defined in Code Section 130(d) of the IRC.

 SECTION 10 – INCOME OPTIONS 
 A. GENERAL PAYMENT PROVISIONS 
 Payment 

You may use the Policy Value on the Annuity Commencement Date. If the policy is in force on the last available Annuity Commencement Date,
we will make annuity payments to the payee under Option 2(b), with 10 years certain, or if elected, under one or more of the other options described in this section, or any other method of payment if we agree. However, the option(s) elected must
provide for lifetime income or income for a period of at least 120 months. Payments will be made at 1, 3, 6 or 12 month intervals. We reserve the right to avoid making payments of less than $20.00. If any income settlement option with a period
certain provides for installment payments of the same amount at some ages for different periods certain, the Company will deem an election to have been made for the longest period certain which could have been elected for such age and amount.

 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 placed under one or more of the options described in this section. 

Betterment of Rates 
 The
amounts shown in the tables on pages 21(a) and 21(b) are the guaranteed amounts. Current amounts offered to individuals of the same class may be obtained from us. Fixed annuity payments at the time of their commencement will not be less than those
which would be provided by the application of the Policy Value to purchase any single consideration immediate annuity contract (as described in Section 4223 (a)(1)(E) of the New York Insurance Law) offered by the Company at the time to the same
class of Annuitant. 
 Adjusted Age 
 Payments under Options 2 and 4 and the first payment under Options 2-V and 4-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 2025
	  	Actual Age
	 2025 - 2032
	  	Actual Age minus 1
	 2033 - 2040
	  	Actual Age minus 2
	 2041 - 2048
	  	Actual Age minus 3
	 2049 - 2055
	  	Actual Age minus 4
	 After 2055
	  	Actual Age minus 5

 Election of Optional Method of Payment 
 You may elect, in a 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 policy proceeds
on the Annuity Commencement Date is to be applied to provide each type of payment. You must also specify which Subaccounts to allocate policy proceeds. 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 of the Separate Account. 
 Qualified Plans
and Policies 
 Certain income options may not be available or may be limited for qualified plans and qualified policies in
order to ensure compliance with the IRC. 

  

			
	NIC12 VA(2)0513(NY)	  	Page 17

 Proof of Age 
 We may require proof of the age of any person who has an annuity purchased under Options 2, 2-V, 4 and 4-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. 

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 option. The contract will name the payee(s) and will describe the payment schedule. 
 B. FIXED INCOME OPTIONS 

Guaranteed Income Options 

The fixed income option is determined by multiplying each $1,000 of policy proceeds allocated to a fixed income option by the amounts
shown in Section 12 for the option You select. Options 1 and 3 are based on a guaranteed interest rate of 0.25%. Options 2 and 4 are based on a guaranteed interest rate of 0.25% and the “Annuity 2000” (male, female and unisex if
required by law) mortality table projected for improvement using projection scale G (70% of female scale G factors were used, while 30% of the male scale factors were used). The rates were projected dynamically using an assumed Annuity Commencement
Date of 2020. The “Annuity 2000” mortality rates are adjusted based on improvements in mortality to more appropriately reflect increased longevity. 
 Option 1 – Income for a Specified Period 
 We will make level payments
only for the fixed period You choose. Payments should not exceed the Annuitant’s life expectancy. In the event of the death of the person receiving payments prior to the end of the fixed period elected, payments will be continued to that
person’s beneficiary. No funds will remain at the end of the specified period. 
 Option 2 – Life Income 

You may choose between: 

	 	a.	Life Only – We will make level payments only during the Annuitant’s lifetime;* or 

	 	b.	Life 10 Years Period Certain – We will make level payments for the longer of: 

	 	1.	The Annuitant’s lifetime; or 

	 	2.	10 years, or 

  

	 	c.	Guaranteed Return of policy proceeds – We will make level payments for the longer of: 

	 	1.	The Annuitant’s lifetime; or 

	 	2.	Until the total dollar amount of payments made to You equals the amount applied to this option. 

*Option 2(a) is not available for adjusted ages greater than 85. 
 Option 3 – Income of a Specified Amount 
 Payments are made for any
specified amount until the amount applied to this option, with interest, is exhausted. Payments should not exceed the Annuitant’s life expectancy. This will be a series of level payments followed by a smaller final payment. In the event of the
death of the person receiving payments prior to the time policy proceeds with interest are exhausted, payments will be continued to that person’s beneficiary. 
 Option 4 – Joint and Survivor Annuity 
 You may choose between: 

	 	a.	Life Only – We will make level payments only during the Annuitants’ lifetimes;** or 

	 	b.	Life and 10 Years Period Certain – We will make level payments for the longer of: 

	 	1.	The Annuitant’s lifetime and a joint Annuitant of Your selection; or 

	 	2.	10 years. 

 **Option 4(a) is not
available for adjusted ages greater than 85. 

  

			
	NIC12 VA(2)0513(NY)	  	Page 18

 Current Income Options 
 The amounts shown in the tables in Section 12 are the guaranteed amounts. Payments at the time of their commencement will not be less than those that would be provided by the application of the
policy proceeds to purchase a single premium immediate annuity policy at purchase rates offered by the Company at the time to the same class of Annuitants. 
 C. VARIABLE INCOME OPTIONS 
 Variable Annuity Units 

The policy proceeds You tell us to apply to a variable income option will be used 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
Market Day is equal to “a” x “b” x “c”, where: 

	 	“a”	 Is the variable annuity unit value for that Subaccount on the immediately preceding Market 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 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 taxes reserved for, 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 after the Annuity Commencement Date. This factor is less than
or equal to, on an annual basis, the percentage shown in Section 2 - Policy Data, of the daily net asset value of a fund share held in that Subaccount. 

 Determination of the First Variable Payment 
 The amount of the first
variable payment is determined by multiplying $1,000 of policy proceeds allocated to a variable income option by the amounts shown in Section 13 for the variable option You select. The tables are based on a 3% Effective Annual Assumed
Investment Return and the “Annuity 2000” (male, female and unisex if required by law) mortality table projected for improvement using projection scale G (70% of female scale G factors were used, while 30% of the male scale factors were
used). The rates were projected dynamically using an assumed Annuity Commencement Date of 2020. The “Annuity 2000” mortality rates are adjusted based on improvements in mortality to more appropriately reflect increased longevity.

 Option 2-V – Life Income 

You may choose between: 

	 	a.	Life Only – Payments will be made during the lifetime of the Annuitant;* or 

	 	b.	 Life and 10 Years Period Certain – Payments will be made for the longer of the Annuitant’s lifetime or ten years. In the event of the
death of the person receiving payments prior to the end of the guarantee period for which the election was made, payments will be continued to that person’s beneficiary. 

*Option 2-V(a) is not available for adjusted age(s) greater than 85. 
 Option 4-V – Joint and Survivor Annuity 
 Life Only -
Payments are made 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. Option 4-V is not available for adjusted ages greater than 85. 

  

			
	NIC12 VA(2)0513(NY)	  	Page 19

 Determination of Subsequent Variable Payments 

The amount of each variable annuity payment after the first 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 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. 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 such Subaccount on the Annuity
Commencement Date. 
 Once Annuity Payments begin, neither expenses actually incurred other than taxes on the investment return,
nor mortality actually experienced by the Company, shall adversely affect the dollar amount of Variable Annuity Payements to any Annuitant for whom such payments have commenced. 

The smallest annual rate of investment return that would have to be earned on the assets of the Separate Account so that the dollar
amount of variable income payments will not decrease is shown on the first page of this policy. 
 SECTION 11 – FIXED
ACCOUNT 
 We may make available a Fixed Account as an Investment Option. The Fixed Account, if offered, may be comprised of
one or more options shown below. Premium Payments applied to and any amount transferred to the Fixed Account will be credited interest based on a fixed rate. The interest rates we set will be credited for increments of at least one year measured
from each Premium Payment or transfer date. If the Fixed Account is available, these rates will never be less than the Fixed Account Guaranteed Minimum Effective Annual Interest Rate shown in Section 2 – Policy Data. After the Policy Date,
we reserve the right at our sole discretion, to limit or refuse Premium Payments and/or transfers allocated to any of the Fixed Account options. We will provide 30 days advance written notice of this decision. We will also provide timely written
notification to You once any such prohibition of premium payments and/or transfers is no longer in effect. 
 Guaranteed Period Options

 We may offer optional Guaranteed Period Options, into which Premium Payments may be paid or amounts transferred. The
current interest rate we set for Policy Value allocated to each Guaranteed Period Option (GPO) is guaranteed until the end of that guaranteed period. 
 We will notify You before the end of the GPO. You may elect to have the Policy Value in the GPO transferred to any Investment Option, including any GPO we then make available. However, any GPO elected may
not extend beyond the last available Annuity Commencement Date. If we do not receive instructions from You in Good Order before the end of the GPO regarding how the Policy Value in that GPO is to be allocated, we will allocate the Policy Value in
that GPO to the Money Market Subaccount available in Your policy. 
 When funds are withdrawn or transferred from a GPO, the
Policy Value associated with the oldest Premium Payment is considered to be withdrawn or transferred first. If the amount withdrawn or transferred exceeds the Policy Value associated with the oldest premium, the Policy Value associated with the next
oldest Premium Payment is considered to be withdrawn or transferred next, and so on until the Policy Value associated with the most recent premium is considered to be withdrawn or transferred (this is a First-In, First-Out, or FIFO, basis).

 Dollar Cost Averaging Fixed Account Option 
 We may offer a Dollar Cost Averaging (DCA) Fixed Account Option (a “DCA Source Account”) separate from the Guaranteed Period Options. This option will have a one-year interest rate guarantee.
The current interest rate we credit may vary on different portions of the DCA Fixed Account. The credited interest rate will never be less than the Fixed Account Guaranteed Minimum Effective Annual Interest Rate shown in Section 2 - Policy
Data. The DCA Fixed Account Option will only be available under a Dollar Cost Averaging program as described in Section 8. 

  

			
	NIC12 VA(2)0513(NY)	  	Page 20

 SECTION 12 – GUARANTEED FIXED INCOME OPTION TABLES 

The amounts shown in these tables are the guaranteed amounts for each $1,000 of the policy proceeds. 

Higher current amounts may be available at the time of settlement. 

 

																							
	Option 1	 	  	 	Option 2(a)	 	Option 2(b)	 	Option 2(c)
	 Number

of Years

Payable
	 	
Amount of

Monthly

Installment
	 	  	 	 Monthly Installment For
 Life No Period Certain
	 	 Monthly Installment For
 Life 10 Years Certain
	 	 Monthly Installment For
 Life Guaranteed Return of

Policy Proceeds

	  	 	  	 	Age*	 	Male	 	Female	 	Unisex	 	Male	 	Female	 	Unisex	 	Male	 	Female	 	Unisex
	 	 	 	 	50    	 	$2.22    	 	$2.00    	 	$2.07    	 	    $2.21    	 	$2.00    	 	$2.06    	 	    $1.85    	 	$1.74    	 	$1.78    
	 	 	 	 	51    	 	2.27    	 	2.05    	 	2.12    	 	2.26    	 	2.05    	 	2.11    	 	1.89    	 	1.78    	 	1.80    
	 	 	 	 	52    	 	2.33    	 	2.10    	 	2.17    	 	2.32    	 	2.10    	 	2.17    	 	1.91    	 	1.80    	 	1.84    
	 	 	 	 	53    	 	2.40    	 	2.15    	 	2.23    	 	2.39    	 	2.15    	 	2.22    	 	1.95    	 	1.84    	 	1.88    
	 	 	 	 	54    	 	2.46    	 	2.21    	 	2.29    	 	2.45    	 	2.21    	 	2.28    	 	1.99    	 	1.88    	 	1.91    
	 	 	 	 	55    	 	2.54    	 	2.27    	 	2.35    	 	2.52    	 	2.26    	 	2.34    	 	2.03    	 	1.91    	 	1.95    
	 	 	 	 	56    	 	2.61    	 	2.33    	 	2.42    	 	2.59    	 	2.33    	 	2.41    	 	2.07    	 	1.95    	 	1.99    
	 	 	 	 	57    	 	2.69    	 	2.40    	 	2.49    	 	2.67    	 	2.39    	 	2.48    	 	2.13    	 	1.99    	 	2.03    
	 	 	 	 	58    	 	2.77    	 	2.47    	 	2.56    	 	2.75    	 	2.46    	 	2.55    	 	2.17    	 	2.03    	 	2.07    
	
10    
	 	8.44    	 	59    	 	2.86    	 	2.54    	 	2.64    	 	2.83    	 	2.53    	 	2.62    	 	2.21    	 	2.07    	 	2.13    
	
11    
	 	7.68    	 	60    	 	2.95    	 	2.62    	 	2.72    	 	2.92    	 	2.61    	 	2.70    	 	2.26    	 	2.13    	 	2.17    
	
12    
	 	7.05    	 	61    	 	3.05    	 	2.70    	 	2.81    	 	3.02    	 	2.69    	 	2.79    	 	2.32    	 	2.17    	 	2.21    
	
13    
	 	6.51    	 	62    	 	3.16    	 	2.79    	 	2.90    	 	3.11    	 	2.77    	 	2.88    	 	2.38    	 	2.22    	 	2.26    
	
14    
	 	6.06    	 	63    	 	3.27    	 	2.88    	 	3.00    	 	3.22    	 	2.86    	 	2.97    	 	2.44    	 	2.28    	 	2.33    
	
15    
	 	5.66    	 	64    	 	3.39    	 	2.98    	 	3.10    	 	3.33    	 	2.95    	 	3.07    	 	2.49    	 	2.34    	 	2.39    
	
16    
	 	5.31    	 	65    	 	3.51    	 	3.09    	 	3.21    	 	3.45    	 	3.05    	 	3.17    	 	2.55    	 	2.39    	 	2.43    
	
17    
	 	5.01    	 	66    	 	3.65    	 	3.20    	 	3.33    	 	3.57    	 	3.16    	 	3.28    	 	2.61    	 	2.44    	 	2.49    
	
18    
	 	4.73    	 	67    	 	3.79    	 	3.32    	 	3.46    	 	3.70    	 	3.27    	 	3.40    	 	2.69    	 	2.50    	 	2.55    
	
19    
	 	4.49    	 	68    	 	3.95    	 	3.44    	 	3.59    	 	3.83    	 	3.39    	 	3.53    	 	2.75    	 	2.57    	 	2.64    
	
20    
	 	4.27    	 	69    	 	4.11    	 	3.58    	 	3.74    	 	3.97    	 	3.52    	 	3.66    	 	2.82    	 	2.64    	 	2.69    
	 	 	 	 	70    	 	4.29    	 	3.73    	 	3.89    	 	4.12    	 	3.65    	 	3.79    	 	2.90    	 	2.72    	 	2.77    
	 	 	 	 	71    	 	4.47    	 	3.89    	 	4.06    	 	4.27    	 	3.80    	 	3.94    	 	3.00    	 	2.79    	 	2.84    
	 	 	 	 	72    	 	4.67    	 	4.06    	 	4.24    	 	4.43    	 	3.95    	 	4.09    	 	3.08    	 	2.86    	 	2.93    
	 	 	 	 	73    	 	4.88    	 	4.24    	 	4.43    	 	4.59    	 	4.11    	 	4.25    	 	3.15    	 	2.94    	 	3.02    
	 	 	 	 	74    	 	5.10    	 	4.44    	 	4.64    	 	4.76    	 	4.27    	 	4.42    	 	3.25    	 	3.06    	 	3.12    
	 	 	 	 	75    	 	5.34    	 	4.65    	 	4.86    	 	4.94    	 	4.45    	 	4.60    	 	3.35    	 	3.13    	 	3.20    
	 	 	 	 	76    	 	5.60    	 	4.88    	 	5.09    	 	5.12    	 	4.63    	 	4.78    	 	3.46    	 	3.21    	 	3.30    
	 	 	 	 	77    	 	5.88    	 	5.13    	 	5.35    	 	5.31    	 	4.82    	 	4.97    	 	3.60    	 	3.35    	 	3.41    
	 	 	 	 	78    	 	6.17    	 	5.40    	 	5.63    	 	5.50    	 	5.02    	 	5.17    	 	3.66    	 	3.44    	 	3.51    
	 	 	 	 	79    	 	6.49    	 	5.69    	 	5.92    	 	5.69    	 	5.22    	 	5.37    	 	3.81    	 	3.53    	 	3.62    
	 	 	 	 	80    	 	6.82    	 	6.00    	 	6.24    	 	5.88    	 	5.43    	 	5.57    	 	3.89    	 	3.68    	 	3.74    
	 	 	 	 	81    	 	7.19    	 	6.34    	 	6.59    	 	6.08    	 	5.65    	 	5.78    	 	4.06    	 	3.81    	 	3.87    
	 	 	 	 	82    	 	7.58    	 	6.70    	 	6.96    	 	6.27    	 	5.86    	 	5.99    	 	4.20    	 	3.89    	 	4.00    
	 	 	 	 	83    	 	7.99    	 	7.10    	 	7.36    	 	6.46    	 	6.08    	 	6.20    	 	4.34    	 	4.09    	 	4.16    
	 	 	 	 	84    	 	8.44    	 	7.53    	 	7.80    	 	6.65    	 	6.29    	 	6.40    	 	4.50    	 	4.23    	 	4.32    
	 	 	 	 	85    	 	8.92    	 	7.99    	 	8.27    	 	6.83    	 	6.49    	 	6.60    	 	4.70    	 	4.40    	 	4.49    
	 	 	 	 	86    	 		 		 	 	 	7.00    	 	6.69    	 	6.79    	 	4.89    	 	4.54    	 	4.74    
	 	 	 	 	87    	 		 		 	 	 	7.17    	 	6.88    	 	6.97    	 	5.11    	 	4.71    	 	4.84    
	 	 	 	 	88    	 		 		 	 	 	7.32    	 	7.06    	 	7.14    	 	5.28    	 	4.90    	 	5.08    
	 	 	 	 	89    	 		 		 	 	 	7.47    	 	7.23    	 	7.31    	 	5.53    	 	5.19    	 	5.27    
	 	 	 	 	90    	 		 		 	 	 	7.60    	 	7.39    	 	7.46    	 	5.73    	 	5.39    	 	5.48    
	 	 	 	 	91    	 		 		 	 	 	7.73    	 	7.53    	 	7.59    	 	5.88    	 	5.63    	 	5.79    
	 	 	 	 	92    	 		 		 	 	 	7.84    	 	7.66    	 	7.72    	 	6.17    	 	5.78    	 	5.97    
	 	 	 	 	93    	 		 		 	 	 	7.95    	 	7.79    	 	7.84    	 	6.44    	 	6.02    	 	6.17    
	 	 	 	 	94    	 		 		 	 	 	8.04    	 	7.90    	 	7.94    	 	6.79    	 	6.46    	 	6.52    
	 	 	 	 	95    	 		 		 	 	 	8.12    	 	8.00    	 	8.04    	 	7.13    	 	6.73    	 	6.83    
	 	 	 	 	96    	 		 		 	 	 	8.20    	 	8.09    	 	8.13    	 	7.40    	 	6.89    	 	7.17    
	 	 	 	 	97    	 		 		 	 	 	8.26    	 	8.17    	 	8.20    	 	7.91    	 	7.53    	 	7.66    
	 	 	 	 	98    	 		 		 	 	 	8.31    	 	8.24    	 	8.27    	 	8.19    	 	7.84    	 	7.75    
	 	 	 	 	99    	 	 	 	 	 	 	 	8.35    	 	8.30    	 	8.32    	 	8.82    	 	8.18    	 	8.57    

  

	*	Adjusted Age as defined in Section 10.A. 

 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 10). 

  

			
	NIC12 VA(2)0513(NY)	  	Page 21(a)

 Option 4(a) 
 Monthly Installment For Joint and Survivor 
  

															
	
Adjusted Age

of
 Male

Annuitant*
	  	  

Adjusted Age of Female Annuitant*

	  	
15 Years
Less Than
 Male
	  	
12 Years
Less Than
 Male
	  	
9 Years
Less Than
 Male
	  	
6 Years

Less Than

Male
	  	
3 Years

Less Than

Male
	  	
Same As

Male
	  	 3 Years
 More Than

Male

	
50    
	  	$1.45    	  	$1.51    	  	$1.58    	  	$1.66    	  	$1.73    	  	$1.80    	  	$1.87    
	
55    
	  	1.58    	  	1.66    	  	1.75    	  	1.84    	  	1.93    	  	2.02    	  	2.10    
	
60    
	  	1.75    	  	1.85    	  	1.95    	  	2.07    	  	2.18    	  	2.29    	  	2.41    
	
65    
	  	1.95    	  	2.08    	  	2.21    	  	2.36    	  	2.51    	  	2.66    	  	2.81    
	
70    
	  	2.21    	  	2.37    	  	2.55    	  	2.74    	  	2.94    	  	3.15    	  	3.35    
	
75    
	  	2.54    	  	2.76    	  	3.00    	  	3.26    	  	3.54    	  	3.83    	  	4.11    
	
80    
	  	2.99    	  	3.29    	  	3.62    	  	3.99    	  	4.39    	  	4.79    	  	5.18    
	 85    
	  	3.60    	  	4.02    	  	4.50    	  	5.03    	  	5.59    	  	6.17    	  	6.71    

 Monthly Installment For Unisex Joint and Survivor 

 

															
	
Adjusted Age

of

First

Annuitant*
	  	  

Adjusted Age of Joint Annuitant*

	  	
15 Years

Less Than

First
	  	
12 Years

Less Than

First
	  	 9
Years
 Less Than
 First
	  	
6 Years

Less Than

First
	  	
3 Years

Less Than

First
	  	
Same As

First
	  	 3 Years
More Than
 First

	
50    
	  	$1.47    	  	$1.53    	  	$1.60    	  	$1.66    	  	$1.72    	  	$1.78    	  	$1.84    
	
55    
	  	1.61    	  	1.68    	  	1.76    	  	1.84    	  	1.92    	  	2.00    	  	2.06    
	
60    
	  	1.78    	  	1.87    	  	1.97    	  	2.07    	  	2.17    	  	2.27    	  	2.36    
	
65    
	  	1.99    	  	2.11    	  	2.24    	  	2.37    	  	2.50    	  	2.62    	  	2.74    
	
70    
	  	2.26    	  	2.41    	  	2.58    	  	2.76    	  	2.93    	  	3.11    	  	3.27    
	
75    
	  	2.60    	  	2.81    	  	3.04    	  	3.28    	  	3.53    	  	3.77    	  	4.00    
	
80    
	  	3.07    	  	3.36    	  	3.68    	  	4.02    	  	4.37    	  	4.71    	  	5.04    
	 85    
	  	3.71    	  	4.12    	  	4.58    	  	5.07    	  	5.57    	  	6.07    	  	6.54    

 Option 4(b) 
 Monthly Installment For Joint and Survivor (Life with 10 year Certain) 
  

															
	
Adjusted Age

of
 Male

Annuitant*
	  	  

Adjusted Age of Female Annuitant*

	  	
15 Years
 Less
Than
 Male
	  	
12 Years
 Less
Than
 Male
	  	 9
Years
 Less Than
 Male
	  	 6
Years
 Less Than
 Male
	  	 3
Years
 Less Than
 Male
	  	
Same As

Male
	  	 3 Years
 More Than

Male

	
50    
	  	$1.45    	  	$1.51    	  	$1.58    	  	$1.66    	  	$1.73    	  	$1.80    	  	$1.87    
	
55    
	  	1.58    	  	1.66    	  	1.75    	  	1.84    	  	1.93    	  	2.02    	  	2.10    
	
60    
	  	1.75    	  	1.85    	  	1.95    	  	2.07    	  	2.18    	  	2.29    	  	2.41    
	
65    
	  	1.95    	  	2.08    	  	2.21    	  	2.36    	  	2.51    	  	2.66    	  	2.80    
	
70    
	  	2.21    	  	2.37    	  	2.55    	  	2.74    	  	2.94    	  	3.14    	  	3.34    
	
75    
	  	2.54    	  	2.76    	  	3.00    	  	3.25    	  	3.53    	  	3.80    	  	4.07    
	
80    
	  	2.98    	  	3.27    	  	3.60    	  	3.95    	  	4.32    	  	4.68    	  	5.02    
	 85    
	  	3.58    	  	3.97    	  	4.41    	  	4.88    	  	5.34    	  	5.76    	  	6.11    

 Monthly Installment For Unisex Joint and Survivor (Life with 10 year Certain) 

 

															
	
Adjusted Age

of

First

Annuitant*
	  	  

Adjusted Age of Joint Annuitant*

	  	
15 Years

Less Than

First
	  	
12 Years

Less Than

First
	  	
9 Years
 Less
Than
 First
	  	
6 Years
Less Than
 First
	  	
3 Years

Less Than

First
	  	
Same As

First
	  	 3 Years
 More Than

First

	
50    
	  	$1.47    	  	$1.53    	  	$1.60    	  	$1.66    	  	$1.72    	  	$1.78    	  	$1.84    
	
55    
	  	1.61    	  	1.68    	  	1.76    	  	1.84    	  	1.92    	  	2.00    	  	2.06    
	
60    
	  	1.78    	  	1.87    	  	1.97    	  	2.07    	  	2.17    	  	2.27    	  	2.36    
	
65    
	  	1.99    	  	2.11    	  	2.24    	  	2.37    	  	2.50    	  	2.62    	  	2.74    
	
70    
	  	2.25    	  	2.41    	  	2.58    	  	2.75    	  	2.93    	  	3.10    	  	3.26    
	
75    
	  	2.60    	  	2.81    	  	3.04    	  	3.27    	  	3.52    	  	3.75    	  	3.96    
	
80    
	  	3.06    	  	3.35    	  	3.66    	  	3.98    	  	4.31    	  	4.62    	  	4.90    
	 85    
	  	3.68    	  	4.06    	  	4.48    	  	4.91    	  	5.33    	  	5.70    	  	6.00    

 * Adjusted Age as defined in Section 10.A. 
 Dollar amounts of monthly, quarterly, semi-annual and annual installments and for gender combinations 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 10). 

  

			
	NIC12 VA(2)0513(NY)	  	Page 21(b)

 SECTION 13 – VARIABLE INCOME OPTION TABLES 

BASED ON ASSUMED INVESTMENT RETURN 
 The amounts shown in these tables are the initial payment amounts based on a 3.0% Assumed Investment Return for each 
 $1,000 of the policy proceeds. 
  

													
	  	  	Option 2-V(a)	  	Option
2-V(b)
	  	  	 Monthly Installment For
 Life No Period Certain
	  	 Monthly Installment For
 Life 10 Years Certain

	Age*	  	Male	  	Female	  	Unisex	  	Male	  	Female	  	Unisex
	
50    
	  	        $3.70    	  	$3.47	  	$3.54	  	        $3.68    	  	$3.47	  	$3.53
	
51    
	  	3.76    	  	3.52	  	3.59	  	3.74    	  	3.51	  	3.58
	
52    
	  	3.82    	  	3.57	  	3.65	  	3.80    	  	3.56	  	3.63
	
53    
	  	3.88    	  	3.62	  	3.70	  	3.86    	  	3.61	  	3.69
	
54    
	  	3.95    	  	3.68	  	3.76	  	3.92    	  	3.66	  	3.74
	
55    
	  	4.02    	  	3.73	  	3.82	  	3.99    	  	3.72	  	3.80
	
56    
	  	4.09    	  	3.80	  	3.89	  	4.06    	  	3.78	  	3.87
	
57    
	  	4.17    	  	3.86	  	3.96	  	4.13    	  	3.84	  	3.93
	
58    
	  	4.25    	  	3.93	  	4.03	  	4.21    	  	3.91	  	4.00
	
59    
	  	4.34    	  	4.00	  	4.11	  	4.30    	  	3.98	  	4.08
	
60    
	  	4.44    	  	4.08	  	4.19	  	4.38    	  	4.05	  	4.15
	
61    
	  	4.54    	  	4.16	  	4.28	  	4.48    	  	4.13	  	4.24
	
62    
	  	4.65    	  	4.25	  	4.37	  	4.57    	  	4.21	  	4.32
	
63    
	  	4.76    	  	4.34	  	4.47	  	4.68    	  	4.30	  	4.42
	
64    
	  	4.89    	  	4.44	  	4.58	  	4.79    	  	4.39	  	4.51
	
65    
	  	5.02    	  	4.55	  	4.69	  	4.90    	  	4.49	  	4.62
	
66    
	  	5.16    	  	4.66	  	4.81	  	5.02    	  	4.60	  	4.73
	
67    
	  	5.31    	  	4.78	  	4.94	  	5.15    	  	4.71	  	4.84
	
68    
	  	5.47    	  	4.91	  	5.08	  	5.28    	  	4.83	  	4.97
	
69    
	  	5.64    	  	5.05	  	5.23	  	5.42    	  	4.95	  	5.10
	
70    
	  	5.82    	  	5.21	  	5.39	  	5.56    	  	5.09	  	5.23
	
71    
	  	6.01    	  	5.37	  	5.56	  	5.71    	  	5.23	  	5.38
	
72    
	  	6.22    	  	5.55	  	5.75	  	5.86    	  	5.37	  	5.53
	
73    
	  	6.44    	  	5.74	  	5.95	  	6.02    	  	5.53	  	5.68
	
74    
	  	6.67    	  	5.94	  	6.16	  	6.19    	  	5.70	  	5.85
	
75    
	  	6.92    	  	6.17	  	6.39	  	6.36    	  	5.87	  	6.02
	
76    
	  	7.18    	  	6.40	  	6.64	  	6.53    	  	6.05	  	6.20
	
77    
	  	7.47    	  	6.66	  	6.90	  	6.71    	  	6.23	  	6.38
	
78    
	  	7.77    	  	6.94	  	7.19	  	6.89    	  	6.42	  	6.57
	
79    
	  	8.10    	  	7.24	  	7.49	  	7.07    	  	6.62	  	6.76
	
80    
	  	8.45    	  	7.56	  	7.83	  	7.25    	  	6.82	  	6.96
	
81    
	  	8.82    	  	7.92	  	8.19	  	7.44    	  	7.02	  	7.15
	
82    
	  	9.23    	  	8.30	  	8.57	  	7.62    	  	7.23	  	7.35
	
83    
	  	9.66    	  	8.71	  	8.99	  	7.79    	  	7.43	  	7.54
	
84    
	  	10.12    	  	9.16	  	9.44	  	7.96    	  	7.63	  	7.73
	
85    
	  	10.61    	  	9.64	  	9.93	  	8.13    	  	7.82	  	7.92
	
86    
	  		  		  	 	  	8.29    	  	8.00	  	8.09
	
87    
	  		  		  	 	  	8.44    	  	8.18	  	8.26
	
88    
	  		  		  	 	  	8.58    	  	8.34	  	8.42
	
89    
	  		  		  	 	  	8.71    	  	8.50	  	8.57
	
90    
	  		  		  	 	  	8.84    	  	8.64	  	8.70
	
91    
	  		  		  	 	  	8.95    	  	8.77	  	8.83
	
92    
	  		  		  	 	  	9.06    	  	8.89	  	8.95
	
93    
	  		  		  	 	  	9.15    	  	9.01	  	9.06
	
94    
	  		  		  	 	  	9.24    	  	9.11	  	9.15
	
95    
	  		  		  	 	  	9.32    	  	9.20	  	9.24
	
96    
	  		  		  	 	  	9.39    	  	9.29	  	9.32
	
97    
	  		  		  	 	  	9.45    	  	9.36	  	9.39
	
98    
	  		  		  	 	  	9.49    	  	9.43	  	9.45
	 99    
	  	 	  	 	  	 	  	9.53    	  	9.48	  	9.50

 *Adjusted Age as defined in Section 10.A. 
 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 10). 

  

			
	NIC12 VA(2)0513(NY)	  	Page 21(c)

 Option 4-V 
 Monthly Installment For Joint and Survivor 
  

															
	
Adjusted Age

of
 Male

Annuitant*
	  	Adjusted Age of Female
Annuitant*
	  	
15 Years

Less Than

Male
	  	
12 Years

Less Than

Male
	  	
9 Years

Less Than

Male
	  	
6 Years

Less Than

Male
	  	
3 Years

Less Than

Male
	  	
Same As

Male
	  	 3 Years
 More Than

Male

	
50    
	  	$2.96    	  	$3.01    	  	$3.06    	  	$3.12    	  	$3.18    	  	$3.24    	  	$3.31    
	
55    
	  	3.07    	  	3.14    	  	3.21    	  	3.28    	  	3.36    	  	3.44    	  	3.52    
	
60    
	  	3.21    	  	3.30    	  	3.39    	  	3.49    	  	3.59    	  	3.70    	  	3.81    
	
65    
	  	3.40    	  	3.51    	  	3.64    	  	3.77    	  	3.91    	  	4.05    	  	4.20    
	
70    
	  	3.64    	  	3.79    	  	3.96    	  	4.14    	  	4.34    	  	4.54    	  	4.74    
	
75    
	  	3.97    	  	4.17    	  	4.41    	  	4.66    	  	4.93    	  	5.22    	  	5.50    
	
80    
	  	4.41    	  	4.70    	  	5.03    	  	5.39    	  	5.79    	  	6.19    	  	6.60    
	
85    
	  	5.03    	  	5.45    	  	5.92    	  	6.45    	  	7.02    	  	7.59    	  	8.15    
	 	  	 	  	 	  	 	  	 	  	 	  	 	  	 

 Monthly Installment For Unisex Joint and Survivor 

 

															
	 Adjusted Age

of

First

Annuitant*
	  	Adjusted Age of Joint
Annuitant*
	  	
15 Years

Less Than

First
	  	
12 Years

Less Than

First
	  	
9 Years

Less Than

First
	  	
6 Years
Less Than
 First
	  	
3 Years
Less Than
 First
	  	
Same As

First
	  	 3 Years
More Than
 First

	
50    
	  	$2.97    	  	$3.02    	  	$3.07    	  	$3.12    	  	$3.18    	  	$3.23    	  	$3.28    
	
55    
	  	3.09    	  	3.15    	  	3.22    	  	3.29    	  	3.35    	  	3.42    	  	3.48    
	
60    
	  	3.24    	  	3.32    	  	3.41    	  	3.49    	  	3.58    	  	3.67    	  	3.76    
	
65    
	  	3.43    	  	3.54    	  	3.65    	  	3.77    	  	3.89    	  	4.02    	  	4.13    
	
70    
	  	3.68    	  	3.83    	  	3.98    	  	4.15    	  	4.32    	  	4.49    	  	4.65    
	
75    
	  	4.02    	  	4.22    	  	4.44    	  	4.67    	  	4.92    	  	5.16    	  	5.39    
	
80    
	  	4.49    	  	4.77    	  	5.08    	  	5.42    	  	5.76    	  	6.11    	  	6.45    
	
85    
	  	5.14    	  	5.54    	  	6.00    	  	6.48    	  	6.99    	  	7.50    	  	7.97    
	 	  	 	  	 	  	 	  	 	  	 	  	 	  	 

 *Adjusted Age as defined in Section 10.A. 
 Dollar amounts of monthly, quarterly, semi-annual, and annual installments and for gender combinations 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 10). 
  

  

			
	NIC12 VA(2)0513(NY)	  	Page 21(d)

  
  

 
  
  

This page left intentionally blank 

			
	

	  	 Home Office located at:

440 Mamaroneck Avenue, Harrison, New York 10528

Adm. Office located at:
 4333 Edgewood Road
N.E. Cedar Rapids, Iowa 52499
 (319) 355-8511
 www.transamericaannuities.com

  

  

			
	NIC12 VA(2)0513(NY)	  	Page 24

Source: [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00215-of-00352.parquet"}, [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00215-of-00352.parquet"}]]