Document:

Specimen Certificate

 Exhibit 4.2 
  

					
	 C
	  	

	  	SHARES
			
	 	  	HORNBECK OFFSHORE SERVICES, INC.	  	 
	THIS CERTIFICATE IS TRANSFERABLE IN NEW YORK, NY OR RIDGEFIELD PARK, NJ	  	 	  	SEE REVERSE FOR CERTAIN DEFINITIONS AND LEGENDS
	 	  	INCORPORATED UNDER THE LAWS OF THE STATE OF DELAWARE	  	 
	 	  	 	  	CUSIP 440543 10 6

  
  
  
  
  
  
  
 FULLY
PAID AND NON-ASSESSABLE SHARES OF THE COMMON STOCK, $.01 PAR VALUE PER SHARE, OF 
  
  
 HORNBECK OFFSHORE SERVICES, INC. 
  
 a corporation organized under the laws of the State of Delaware, transferable on the books of the Corporation by the holder hereof in person or by duly authorized attorney upon
surrender of this Certificate properly endorsed. This Certificate and shares represented hereby are subject to all the terms, conditions and limitations of the certificate of incorporation and the by-laws of the Corporation and amendments thereto,
copies of which are on file with the Corporation and the Transfer Agent, to all of which the holder, by acceptance hereof, assents. 
  
 WITNESS the facsimile seal of the Corporation and facsimile signatures of its duly authorized officers. 
  

					
	Dated:	  	 	  	 
	 	  	[HORNBECK OFFSHORE SERVICES, INC. SEAL]	  	 
			
	 	  	 	  	 
	VICE PRESIDENT, CHIEF FINANCIAL OFFICER AND ASSISTANT SECRETARY	  	 	  	PRESIDENT AND CHIEF EXECUTIVE OFFICER
		
	 COUNTERSIGNED AND REGISTERED:
     MELLON INVESTOR SERVICES LLC
                                        
 TRANSFER AGENT AND REGISTRAR
  
 BY
                                        
                  AUTHORIZED SIGNATURE
	  	 

  
 RESTRICTIONS ON
TRANSFERABILITY 
  
 Article Twelve of the Corporation’s Certificate
of Incorporation provides that any transfer of shares of Common Stock of the Corporation, or any interest therein, to an “Alien” (as defined in such Article) which would result in the percentage of outstanding shares owned or controlled by
Aliens being in excess of a specified percentage will be void and ineffective. The Corporation will furnish a copy of said Article Twelve to the holder of this certificate without charge upon written request to the Corporation at its principal place
of business or registered office. 
  
 In no event will the shares
represented by this certificate be transferred upon the books of the Corporation unless the certificate of citizenship (on the reverse side hereof) or a counterpart thereof is properly completed. 
  

 HORNBECK OFFSHORE SERVICES, INC. 
  
 THE CORPORATION IS AUTHORIZED TO ISSUE SHARES OF TWO CLASSES, COMMON STOCK AND PREFERRED STOCK. THE CORPORATION WILL FURNISH WITHOUT
CHARGE TO EACH SHAREHOLDER WHO SO REQUESTS A STATEMENT OF THE POWERS, DESIGNATIONS, PREFERENCES AND RELATIVE, PARTICIPATING, OPTIONAL OR OTHER SPECIAL RIGHTS OF EACH CLASS OF STOCK OR SERIES THEREOF AND THE QUALIFICATIONS, LIMITATIONS OR
RESTRICTIONS OF SUCH PREFERENCES AND/OR RIGHTS. 
  
 RIGHTS AGREEMENT

  
 This certificate also evidences and entitles the holder hereof to
certain rights as set forth in a Rights Agreement between Hornbeck Offshore Services, Inc. (the “Corporation”) and Mellon Investor Services LLC (the “Rights Agent”), dated as of June 18, 2003, as it may from time to time be
supplemented or amended (the “Rights Agreement”), the terms of which are incorporated herein by reference and a copy of which is on file at the Company’s principal executive offices. Under certain circumstances, as set forth in the
Rights Agreement, such Rights may be redeemed, may be exchanged, may expire or may be evidenced by separate certificates and will no longer be evidenced by this certificate. The Company will mail to the registered holder of this certificate a copy
of the Rights Agreement without charge after receipt of a written request therefor. As described in the Rights Agreement, Rights issued to any Person who becomes an Acquiring Person (as defined in the Rights Agreement) whether currently held by or
on behalf of such Person or by any subsequent holder will become null and void and may not be transferred to any Person. 
  
  
 CERTIFICATE OF CITIZENSHIP OF TRANSFEREE 
  
 Hornbeck Offshore Services, Inc. 
  
 The undersigned hereby certifies to Hornbeck Offshore Services, Inc. that: 
  

					
	 The undersigned
	 	 ̈ IS	  	 ̈ IS NOT an “Alien”.
	 The undersigned
	 	 ̈ DOES	  	  ̈ DOES NOT hold his shares of Common Stock of the Corporation, or any of them, for or on behalf of an “Alien”.

  
 NOTE: If a
portion of such shares are held for or on behalf of an “Alien”, complete the following: 
  
              shares ARE NOT held for or on behalf of an “Alien”.             
shares ARE held for or on behalf of an “Alien”. 
  
 The undersigned hereby agrees
that, on request of the Corporation, the undersigned will furnish proof in support of this certification. 
  

									
					
	Date:	 	                                      
                                        
                 	 	 	 	Sign here:	 	                                      
                                        
                 
					
	 	 	 	 	 	 	Signature(s) of Owner(s)	 	                                      
                                        
                 
	 	 	 	 	 	 	(If the owner is a corporation or a fiduciary, the title of the person signing on behalf of the owner must be stated)

  
 Definition of an
“Alien”: (1) any person (including an individual, a partnership, a corporation, a limited liability company or an association) who is not a United States citizen within the meaning of Section 2 of the Shipping Act of 1916, as amended or as
it may hereafter be amended; (2) any foreign government of the representative thereof; (3) any corporation, the chief executive officer by any title or chairman of the board of directors of which is an Alien, or of which more than a minority of its
directors necessary to constitute a quorum are Aliens; (4) any corporation organized under the laws of any foreign government; (5) any corporation of which 25% or greater interest is owned beneficially or of record, or may be voted by an Alien or
Aliens, or which by any other means whatsoever is controlled by or in which control is permitted to be exercised by an Alien or Aliens; (6) any partnership, limited liability company or association which is controlled by an Alien or Aliens or; (7)
any person (including an individual, partnership, corporation, limited liability company or association) who acts as a representative of or fiduciary for any person described in clauses (1) through (6) above. 
  
 NOTICE: This certificate constitutes a basis for the Corporation’s
representation to the United States Government that the share owner is a citizen within the meaning of the Shipping Act of 1916, as amended, and the Merchant Marine Act of 1936, as amended. Any person making a statement herein which he knows to be
false may be proceeded against under Title 18 United States Code Section 1001 which section provides for a fine or up to five years imprisonment or both. 
  
 The following abbreviations, when used in the inscription on the face of this certificate, shall be construed as though they were written out in full according to
applicable laws or regulations: 
  

											
	 TEN COM
	 	—	 	as tenants in common	  	 	 	UNIF GIFT MIN ACT  —	 	                 Custodian
                            
	 TEN ENT
	 	—	 	as tenants by the entireties	  	 	 	 	 	     (Cust)                            (Minor)

	 JT TEN
	 	—	 	as joint tenants with right of survivorship and not as tenants in common	  	 	 	 	 	 under Uniform Gifts to Minors
 Act
                                        
        
                     (State)

  
 Additional abbreviations may also
be used though not in the above list. 
  
 For Value Received,
                                     hereby sell, assign and
transfer unto 
  
 PLEASE INSERT SOCIAL SECURITY OR OTHER 
         IDENTIFYING NUMBER OF ASSIGNEE 
  
                                       
                                        
         
  
                                       
                                        
                                        
                                        
                                        
                    
 (PLEASE PRINT OR TYPEWRITE NAME
AND ADDRESS, INCLUDING POSTAL ZIP CODE, OF ASSIGNEE) 
  
                                       
                                        
                                        
                                        
                                        
                    
  
                                       
                                        
                                        
                                        
                                        
                    
  
                                       
                                        
                                        
                                        
                                        
         Shares 
 of the Stock represented by the within Certificate, and do hereby irrevocably constitute and appoint

  
                                       
                                        
                                        
                                        
                                        
                    
 Attorney to transfer the said stock on the
books of the within named Company with full power of substitution in the premises. 
  

									
					
	Dated	 	                                      
                                        
                 	 	 	 	 	 	 
	 	 	 	 	 	 	X	 	                                      
                                        
                 
	 	 	 	 	 	 	 	 	(Signature)
	 	 	 NOTICE:
 THE SIGNATURE(S) TO THIS
ASSIGNMENT MUST CORRESPOND WITH THE NAME(S) AS WRITTEN UPON THE FACE OF THE CERTIFICATE IN EVERY PARTICULAR, WITHOUT ALTERATION OR ENLARGEMENT OR ANY CHANGE WHATEVER.
	 	 	 	X	 	                                      
                                        
                 
	 	 	 	 	 	 	 	 	(Signature)

  

									
				
	 	 	 	 	 	 	                                       
                                        
                         
 THE
SIGNATURE(S) SHOULD BE GUARANTEED BY AN ELIGIBLE GUARANTOR INSTITUTION (BANKS, STOCKBROKERS, SAVINGS AND LOAN ASSOCIATIONS AND CREDIT UNIONS WITH MEMBERSHIP IN AN APPROVED SIGNATURE GUARANTEE MEDALLION PROGRAM), PURSUANT TO S.E.C. RULE
17Ad-15.
                                       
                                        
                         

	 	 	 	 	 	 	 SIGNATURE(S) GUARANTEED BY:<PAGE>

                                                                    Exhibit 10.1

================================================================================

    The Northwestern Mutual Life Insurance Company agrees to pay the benefits
         provided in this contract, subject to its terms and conditions.
                Signed at Milwaukee, Wisconsin on the Issue Date.

                /s/ Edward J. Zore         /s/ Robert J. Berdan
                --------------------       --------------------
                President and CEO          Secretary

                  FLEXIBLE PAYMENT VARIABLE ANNUITY - ACCOUNT A

  Net Purchase Payments accumulated in a Separate Account, assets of which are
  invested in shares of one or more mutual funds, or Guaranteed Interest Fund.

               Contract benefits payable in one sum or as variable
                          or guaranteed monthly income.
             Variable Payment Plan benefits described in Section 11.

                                 Participating.

AMOUNTS ALLOCATED TO THE SEPARATE ACCOUNT DIVISIONS AND VARIABLE PAYMENTS
PROVIDED BY THIS CONTRACT ARE NOT GUARANTEED AS TO FIXED DOLLAR AMOUNT BUT ARE
VARIABLE AND MAY INCREASE OR DECREASE TO REFLECT THE INVESTMENT EXPERIENCE OF
THE SEPARATE ACCOUNT.

Right To Return Contract. Please read this contract carefully. The Owner may
return the contract for any reason within ten days after receiving it. Return of
the contract is effective on the date written notice of the return is delivered,
mailed or sent by telegram to either The Northwestern Mutual Life Insurance
Company, 720 East Wisconsin Avenue, Milwaukee, Wisconsin 53202 or the agent who
sold the contract. If returned, the contract will be cancelled and the Company
will refund the sum of (a) the difference between the Purchase Payments paid and
the amounts, if any, allocated to the Separate Account plus (b) the value of the
Accumulation Units of the Separate Account on the effective date of return.

RR.V.A.(0803)

--------------------------------------------------------------------------------
                                                  [LOGO] Northwestern Mutual(TM)
--------------------------------------------------------------------------------

                           CONTRACT NUMBER     00 000 000

                           PRIMARY ANNUITANT   John J Doe

                           ISSUE DATE          July 31, 2003

RR.V.A.FR.(0803)

                                                               SEX NEUTRAL FRONT

<PAGE>

                                TABLE OF CONTENTS

CONTRACT INFORMATION, INVESTMENT ACCOUNTS

CHARGES AND FEES

MINIMUM PURCHASE PAYMENTS, ACCUMULATION VALUE, PAYMENT PLANS

SECTION 1. GENERAL TERMS AND DEFINITIONS

SECTION 2. SEPARATE ACCOUNT

     .    Separate Account
     .    Accumulation Units
     .    Net Investment Factor
     .    Substitution and Change

SECTION 3. GUARANTEED INTEREST FUND

     .    Guaranteed Interest Fund
     .    Accumulation Value
     .    Transfer Restrictions
     .    Maximum Guaranteed Interest Fund Accumulation Value
     .    Table of Guaranteed Values

SECTION 4. PURCHASE PAYMENTS, TRANSFERS, WITHDRAWALS

     .    Payment of Purchase Payments
     .    Application of Purchase Payments
     .    Selection of Investment Account for Purchase Payments
     .    Transfer of Accumulation Value
     .    Withdrawals and Full Surrender
     .    Effective Date

SECTION 5. BENEFITS

     .    Maturity Benefit
     .    Death Benefit if Annuitant is an Owner
     .    Death Benefit if Annuitant is not an Owner

SECTION 6. BENEFICIARIES AND CONTINGENT ANNUITANTS

     .    Naming and Changing of Beneficiaries
     .    Succession in Interest of Beneficiaries
     .    Trustee as Beneficiary
     .    General
     .    Naming and Changing a Contingent Annuitant

SECTION 7. CHARGES AND FEES

     .    Sales Load and Premium Taxes
     .    Contract Fee

SECTION 8. OWNERSHIP

     .    The Owner
     .    Transfer of Ownership
     .    Naming and Changing a Successor Owner
     .    Collateral Assignment
     .    Reports to Owners
     .    Transferability Restrictions

RR.V.A.FR.(0803)

<PAGE>

SECTION 9. THE CONTRACT

     .    Guarantees
     .    Valuation of Separate Account Assets
     .    Determination of Separate Account Values
     .    Deferment of Benefit Payments
     .    Dividends
     .    Incontestability
     .    Misstatements
     .    Entire Contract; Changes
     .    Termination of Contract

SECTION 10. PAYMENT OF CONTRACT BENEFITS

     .    Payment of Benefits
     .    Death Benefit
     .    Effective Date for Payment Plan
     .    Payment Plan Elections

SECTION 11. PAYMENT PLANS

     .    Description of Payment Plans
     .    Allocation of Benefits
     .    Annuity Units under Variable Payment Plans
     .    Payments under Variable Payment Plans
     .    Transfers Involving Variable Payment Plans
     .    Withdrawal under Payment Plans
     .    Naming and Changing of Beneficiaries under Payment Plans
     .    Succession in Interest of Beneficiaries under Payment Plans
     .    Payment Plan Rates

ADDITIONAL BENEFITS (if any)

APPLICATION

                                  ENDORSEMENTS
                to be made only by the Company at the Home Office

RR.V.A.FR.(0803)

<PAGE>

                              CONTRACT INFORMATION

CONTRACT NUMBER          00 000 000

PLAN                     Flexible Payment Variable Annuity

ADDITIONAL BENEFITS      Enhanced Death Benefit

TAX REPORTING CATEGORY   Pension Annuity

PRIMARY ANNUITANT        John J. Doe
AGE AND SEX              35 Male
OWNER                    John J. Doe, the Annuitant

ISSUE DATE               July 31, 2003
CONTRACT ANNIVERSARY     July 31, 2004 and each July 31
                         thereafter

MATURITY DATE            July 31, 2053

DIRECT BENEFICIARY       Jane K. Doe, Wife of the Annuitant

                               INVESTMENT ACCOUNTS

On the Issue Date, Purchase Payments and contract values may be allocated among
the following Investment Accounts. Available Separate Account Divisions are
subject to change. See Section 2.1.

 Divisions of Separate Account A:
     Select Bond Division
     Franklin Templeton International Equity Division
     Money Market Division
     Balanced Division
     Index 500 Stock Division
     Aggressive Growth Stock Division
     High Yield Bond Division
     Growth Stock Division
     Large Cap Core Stock Division
     Index 400 Stock Division
     Small Cap Growth Stock Division
     Russell Multi-Style Equity Division
     Russell Aggressive Equity Division
     Russell Non-US Division
     Russell Real Estate Securities Division
     Russell Core Bond Division
     Asset Allocation Division
     International Growth Stock Division
     T. Rowe Price Small Cap Value Division
     Capital Guardian Domestic Equity Division
     AllianceBernstein Mid Cap Value Division
     Janus Capital Appreciation Division
     T. Rowe Price Equity Income Division
     Fidelity VIP Mid Cap Division

 Guaranteed Accounts:
     Guaranteed Interest Fund

RR.V.A.FR.(0803)                    Page 3                             (GTY.1.5)

<PAGE>

                                                    CONTRACT NUMBER   00 000 000

                                CHARGES AND FEES

DEDUCTION FROM PURCHASE PAYMENTS:
     SALES LOAD (See Section 7.1]

     Total Purchase Payments           Amount Deducted
     Paid Under the Contract        From Purchase Payment
          First        $100,000              4.5%
          Next         $400,000              2.0%
          Balance over $500,000              1.0%

     PREMIUM TAX (See Section 7.1):
          For the first Contract Year, Premium Taxes are not deducted from
          Purchase Payments. After the first Contract Year, the Company may
          deduct Premium Taxes from Purchase Payments received or benefits paid.

ANNUAL MORTALITY AND EXPENSE RISK CHARGE (See Section 2.3):
     0.50% at Issue; 0.75% Maximum

ANNUAL CONTRACT FEE (See Section 7.2):
     $30 charged on the contract anniversary. The contract fee will be waived if
     the Accumulation Value of the contract equals or exceeds $25,000 on the
     contract anniversary.

ENHANCED DEATH BENEFIT CHARGE:
     0.10% of the Enhanced Death Benefit on each contract anniversary.

TRANSFER FEE (See Sections 4.4 and 11.5):
     $25 beginning with the thirteenth transfer in any Contract Year.

          MINIMUM PURCHASE PAYMENTS, ACCUMULATION VALUE, PAYMENT PLANS

MINIMUM PURCHASE PAYMENT (See Section 4.1): $25

MINIMUM ACCUMULATION VALUE (See Sections 5.2 and 9.9): $2,000

MINIMUM PAYMENT UNDER PAYMENT PLAN (See Sections 9.9 and 10.1): $50
Monthly Income.

                            GUARANTEED INTEREST FUND

GUARANTEED ANNUAL EFFECTIVE INTEREST RATE (See Section 3.2): 1.5%

MAXIMUM GUARANTEED INTEREST FUND ACCUMULATION VALUE (See Section 3.4): $100,000

RR.V.A.FR.(0803)                    Page 4                             (GTY.1.5)

<PAGE>

                                                    CONTRACT NUMBER   00 000 000

              GUARANTEED INTEREST FUND - TABLE OF GUARANTEED VALUES

The table shows minimum guaranteed values and assumes a $10,000 Purchase Payment
made at the time of issue followed by subsequent $100 Purchase Payments made
annually thereafter on each contract anniversary. The values are based on the
assumption that 100% of all Net Purchase Payments are allocated to, and remain
in, the Guaranteed Interest Fund.

 End of
Contract             Accumulation    Cash
  Year     July 31      Value        Value
--------   -------   ------------   -------
      1      2003       $ 9,693     $ 9,693
      2      2004         9,905       9,905
      3      2005        10,120      10,120
      4      2006        10,338      10,338
      5      2007        10,560      10,560

      6      2008        10,784      10,784
      7      2009        11,013      11,013
      8      2010        11,244      11,244
      9      2011        11,480      11,480
     10      2012        11,718      11,718

     11      2013        11,960      11,960
     12      2014        12,206      12,206
     13      2015        12,456      12,456
     14      2016        12,709      12,709
     15      2017        12,966      12,966

     16      2018        13,227      13,227
     17      2019        13,492      13,492
     18      2020        13,761      13,761
     19      2021        14,034      14,034
     20      2022        14,311      14,311

 Age 60      2027        15,760      15,760
 Age 65      2032        17,320      17,320
 Age 70      2037        19,001      19,001

This table is based on the guaranteed annual effective interest rate of 1.5%.
Higher declared rates of interest will increase values. Values shown at the end
of contract years do not reflect any Purchase Payments paid on that contract
anniversary. The actual guaranteed values may differ from those shown above,
depending on the amount and frequency of Purchase Payments.

                                    Page 4A                            (GTY.1.5)

<PAGE>

                    SECTION 1. GENERAL TERMS AND DEFINITIONS

ACCUMULATION UNIT. A unit of measure used to determine the value of the interest
of this contract in the Separate Account prior to the date on which amounts are
placed under a payment plan.

ACCUMULATION VALUE. The Accumulation Value of a Separate Account Division is the
total value of all Accumulation Units in that Division. The Accumulation Value
of the Guaranteed Interest Fund is the sum of amounts applied to the fund, plus
credited interest, less amounts withdrawn or transferred from the fund. The
Accumulation Value of the contract is the sum of the Accumulation Values of all
Investment Accounts.

ANNUITANT. The Primary Annuitant and, upon the death of the Primary Annuitant,
the Contingent Annuitant.

ANNUITY UNIT. A unit of measure used to determine the amount of variable
payments under a variable payment plan and the value of the interest of a
variable payment plan in the Separate Account.

BENEFICIARIES. The term "Beneficiaries" as used in this contract includes direct
beneficiaries, contingent beneficiaries and further payees.

COMPANY. The Northwestern Mutual Life Insurance Company.

CONTINGENT ANNUITANT. The person who becomes the Annuitant upon the death of an
Annuitant.

CONTRACT FEE. An annual charge for administration expenses made on each contract
anniversary prior to the Maturity Date.

CONTRACT YEAR. The first Contract Year is the period of time ending on the first
contract anniversary. Subsequent Contract Years are the annual periods between
contract anniversaries.

DIVISION. A component of the Separate Account to which the Owner may allocate
Net Purchase Payments and contract values.

GUARANTEED INTEREST FUND. The portion of the contract that is credited with a
guaranteed interest rate and which is held as part of the general assets of the
Company.

HOME OFFICE. The office of The Northwestern Mutual Life Insurance Company
located at 720 East Wisconsin Avenue, Milwaukee, WI 53202.

INVESTMENT ACCOUNT. The Guaranteed Interest Fund and Separate Account Divisions
available for allocation of Net Purchase Payments and contract values. The
available Investment Accounts are listed on page 3.

ISSUE DATE. The date this contract is issued and becomes effective.

MATURITY DATE. The date upon which contract benefits will become payable. If the
contract is continued in force under the Optional Maturity Date provision, the
Optional Maturity Date will become the Maturity Date.

NET PURCHASE PAYMENT. A Purchase Payment less all applicable deductions.
Deductions may include the Sales Load and a Premium Tax.

OPTIONAL MATURITY DATE. The contract anniversary nearest the Annuitant's 90th
birthday. Upon reaching the Maturity Date shown on page 3, the Owner may elect
to continue the contract in force until this Optional Maturity Date.

OWNER. The person possessing the ownership rights stated in this contract.

RP.V.A.FR.(0803)                       5

<PAGE>

PORTFOLIOS. Mutual funds or portfolios of mutual funds in which the assets of
the Separate Account are invested.

PREMIUM TAX. A tax imposed by a governmental entity when Purchase Payments are
received or benefits are paid.

PRIMARY ANNUITANT. The person upon whose life this contract is initially issued.

PURCHASE PAYMENT. A payment made by or on behalf of the Owner with respect to
this contract.

SALES LOAD. A deduction made from Purchase Payments received.

SEPARATE ACCOUNT. NML Variable Annuity Account A. The Separate Account consists
of assets set aside by the Company, the investment performance of which is kept
separate from that of the general assets and all other separate account assets
of the Company.

SUCCESSOR OWNER. The person designated to become the Owner upon the death of the
Owner, provided the Owner was not the Annuitant at the time of the Owner's
death.

TRANSFER FEE. A deduction that is made from the amount transferred between
Investment Accounts.

VALUATION DATE. Any day on which the assets of the Separate Account are valued.
Assets are valued as of the close of trading on the New York Stock Exchange for
each day the Exchange is open.

                           SECTION 2. SEPARATE ACCOUNT

2.1  SEPARATE ACCOUNT

     The Separate Account (NML Variable Annuity Account A) has been established
by the Company. The Separate Account consists of assets set aside by the
Company, the investment performance of which is kept separate from that of the
general assets and all other separate account assets of the Company. The assets
of the Separate Account will not be charged with liabilities arising out of any
other business the Company may conduct. Interests in the Separate Account are
represented by Accumulation Units and Annuity Units, described in Sections 2.2
and 11.3, respectively.

     The Separate Account is comprised of the Divisions listed on page 3. The
assets allocated to these Divisions are invested in shares of the corresponding
Portfolios. Shares of the Portfolios are purchased for the Separate Account at
their net asset value.

     The Company reserves the right to eliminate or add additional Divisions and
Portfolios.

2.2  ACCUMULATION UNITS

     The interest of this contract in the Separate Account, prior to the date on
which amounts become payable under a payment plan, is represented by
Accumulation Units. The dollar value of Accumulation Units for each Division
will increase or decrease to reflect the investment experience of the Division.
The value of an Accumulation Unit on any Valuation Date is the product of:

     .    the value on the immediately preceding Valuation Date; and

     .    the Net Investment Factor for the period from the immediately
          preceding Valuation Date up to and including the current Valuation
          Date (the current period).

RP.V.A.FR.(0803)                       6

<PAGE>

2.3  NET INVESTMENT FACTOR

     For each Division of the Separate Account the Net Investment Factor for the
current period is one plus the net investment rate for that Division. The net
investment rate for the current period is equal to the gross investment rate for
the Division reduced on each Valuation Date by a Mortality and Expense Risk
Charge. The charge for these risks on the Issue Date is shown on page 4. The
Company may increase or decrease the charge after the Issue Date, but the
Company may not increase the charges to exceed the maximum charges shown on page
4.

The gross investment rate for the current period for each Division is equal to
a. divided by b. where:

     a.   is:

          .    the investment income of the Division for the current period;
               plus

          .    capital gains for the period, whether realized or unrealized, on
               the assets of the Division; less

          .    capital losses for the period, whether realized or unrealized, on
               the assets of the Division; less

          .    deduction for any tax liability paid or reserved for by the
               Company resulting from the maintenance or operation of the
               Division; and less

          .    any reasonable expenses paid or reserved for by the Company which
               result from a substitution of other securities for shares of the
               Portfolio(s) as set forth in Section 2.4; and

     b.   is the value of the assets in the Division on the immediately
          preceding Valuation Date.

     The gross investment rate may be positive or negative. The deduction for
any tax liability may be charged proportionately against those contracts to
which the liability is attributable by a reduction in the gross investment rate
for those contracts.

2.4  SUBSTITUTION AND CHANGE

     Pursuant to the authority of the Board of Trustees of the Company:

     .    the assets of the Division may be invested in securities other than
          shares of the Portfolio(s) as a substitute for those shares already
          purchased or as the securities to be purchased in the future; and

     .    the provisions of the contracts may be modified to comply with any
          other applicable federal or state laws.

     In the event of a substitution or change, the Company may make appropriate
endorsement on this and other contracts having an interest in the Separate
Account and take other actions as may be necessary to effect the substitution or
change. Any such substitution or change will be subject to any required approval
of the Commissioner of Insurance for the state of Wisconsin, and filing with the
state in which this contract is issued.

RP.V.A.FR.(0803)                       7

<PAGE>

                       SECTION 3. GUARANTEED INTEREST FUND

3.1  GUARANTEED INTEREST FUND

     Net Purchase Payments (see Section 4.2) and amounts transferred from other
Investment Accounts under this contract (see Section 4.4) may be applied to the
Guaranteed Interest Fund. Contract benefits placed under a variable payment plan
may not be applied to the Guaranteed Interest Fund. Amounts applied to the
Guaranteed Interest Fund become part of the general assets of the Company.

3.2  ACCUMULATION VALUE

     The Accumulation Value of the Guaranteed Interest Fund is the sum of the
amounts applied to it, plus credited interest, less any amounts withdrawn or
transferred from the fund. Interest begins to accrue on the effective date of
the Purchase Payment or transfer (see Section 4.6).

     Interest will be credited at an annual effective interest rate of not less
than the guaranteed annual effective interest rate stated on page 4. A higher
rate may be declared by the Company from time to time for a period set by the
Company.

3.3  TRANSFER RESTRICTIONS

     Transfers of Accumulation Value from the Guaranteed Interest Fund will not
be allowed for a period of 365 days following the most recent transfer of
Accumulation Value from the Guaranteed Interest Fund.

     The maximum amount of the Accumulation Value that may be transferred from
the Guaranteed Interest Fund in one transfer is limited to the greater of:

     .    25% of the Accumulation Value of the Guaranteed Interest Fund on the
          last contract anniversary preceding the transfer; and

     .    the amount of the most recent transfer from the Guaranteed Interest
          Fund.

However, in no event will this maximum transfer amount be less than $1,000 or
greater than $50,000.

     Transfers of Accumulation Value into the Guaranteed Interest Fund will not
be allowed for a period of 90 days following the most recent transfer of
Accumulation Value from the Guaranteed Interest Fund.

3.4  MAXIMUM GUARANTEED INTEREST FUND ACCUMULATION VALUE

     The Accumulation Value of the Guaranteed Interest Fund may not exceed the
maximum Guaranteed Interest Fund accumulation value shown on page 4 without
prior consent of the Company, except when the maximum is exceeded because of
interest accruing to the Guaranteed Interest Fund.

3.5  TABLE OF GUARANTEED VALUES

     Accumulation and cash values are shown on page 4A. The values are based on
the assumptions stated on page 4A and are for the end of the contract years
shown. Values for contract years not shown are calculated on the same basis as
those shown on page 4A. Guaranteed values are at least as great as those
required by the state in which this contract is delivered.

RP.V.A.FR.(0803)                       8

<PAGE>

              SECTION 4. PURCHASE PAYMENTS, TRANSFERS, WITHDRAWALS

4.1  PAYMENT OF PURCHASE PAYMENTS

     All Purchase Payments are payable at the Home Office or to an authorized
agent. A receipt signed by an officer of the Company will be furnished on
request.

     Purchase Payments may be made at any time prior to the death of an Owner
and prior to the Maturity Date. Purchase Payments may be made after the death of
an Owner only if the new Owner of the contract is the surviving spouse of the
deceased Owner. The Owner may vary the amount of Purchase Payments, but no
Purchase Payment may be less than the Minimum Purchase Payment shown on page 4.
Total Purchase Payments may not exceed $5,000,000 without the consent of the
Company.

     The Company will not accept any Purchase Payment under Section 4 unless it
is a contribution under a pension or profit sharing plan which meets the
requirements of Section 401 of the Internal Revenue Code of 1954, as amended, or
the requirements for deduction of the employer's contribution under Section
404(a)(2) of such code.

4.2  APPLICATION OF PURCHASE PAYMENTS

     Each Purchase Payment, net of the Sales Load and Premium Taxes, will be
applied to one or more Investment Accounts. Net Purchase Payments applied to the
Guaranteed Interest Fund will accrue interest from the effective date of the
Purchase Payment. Net Purchase Payments applied to the Separate Account will
provide Accumulation Units in one or more Divisions. Accumulation Units are
credited as of the effective date of the Net Purchase Payment.

     The number of Accumulation Units will be determined by dividing the Net
Purchase Payment by the value of an Accumulation Unit on the effective date.
This number of Accumulation Units will not be changed by any subsequent change
in the dollar value of Accumulation Units.

4.3  SELECTION OF INVESTMENT ACCOUNT FOR PURCHASE PAYMENTS

     The Owner may change the allocation of Net Purchase Payments among the
Investment Accounts by written notice to the Company. Net Purchase Payments
received at the Home Office on or after the date on which notice is received
will be applied to the designated Investment Accounts on the basis of the new
allocation.

4.4  TRANSFER OF ACCUMULATION VALUE

     Before the Maturity Date the Owner may, on request satisfactory to the
Company, transfer amounts from one Investment Account to another, subject to the
transfer restrictions described in Section 3.3.

     For transfers among the Separate Account Divisions, the number of
Accumulation Units to be applied or deducted will be adjusted to reflect the
respective value of the Accumulation Units in each of the Divisions on the date
the transfer is effective.

     For transfers from the Guaranteed Interest Fund, amounts closest to
expiration of an interest rate guarantee will be removed first. In the event
that two amounts are equally close to expiration, the one which was applied to
the Guaranteed Interest Fund earlier will be removed first.

     A Transfer Fee may be deducted from the amount transferred. The maximum
amount of the Transfer Fee is shown on page 4. The minimum amount that may be
transferred is the lesser of $100 or the entire Accumulation Value of the
Investment Account from which the transfer is being made.

     A transfer request is subject to limitation or modification if the Company
determines that the transfer would be to the disadvantage of other contract
owners with interests in the Separate Account Divisions or if required by
applicable laws or regulations. The limitation or modification may be applied to
transfers to and/or from the Separate Account Divisions and could include but
not be limited to:

     .    the requirement of a minimum time period between each transfer;

     .    limiting the dollar amount that may be transferred between or among
          the Separate Account Divisions in any one day;

     .    requiring that a transfer request be submitted in a particular form
          and/or by a specific process.

     The Company reserves the right to modify or eliminate any transfer request
process (including without limitation transfer requests via the Internet, via
facsimile, or by telephone) for some or all contract owners as the Company deems
appropriate.

RP.V.A.FR.(0803)                       9

<PAGE>

4.5  WITHDRAWALS AND FULL SURRENDER

     Before the Maturity Date the Owner may, on request satisfactory to the
Company, withdraw all or a portion of the Accumulation Value of the contract.
The Company may require that the Minimum Accumulation Value shown on page 4
remain after a partial withdrawal. Withdrawal of the entire value of the
contract constitutes a full surrender, and receipt of the contract at the Home
Office will terminate this contract. Receipt of the contract may be waived by
the Company.

     The cash value of the amount withdrawn will be the Accumulation Value
withdrawn determined as of the date the withdrawal is effective.

     The term "withdrawal amounts" as used in this contract includes amounts
paid as full surrenders and withdrawals of a portion of the Accumulation Value
of the contract.

     For withdrawals from the Guaranteed Interest Fund, amounts closest to
expiration of an interest rate guarantee will be removed first. In the event
that two amounts are equally close to expiration, the one which was applied to
the Guaranteed Interest Fund earlier will be removed first.

4.6  EFFECTIVE DATE

     The effective date of a Purchase Payment, transfer, or withdrawal is the
Valuation Date on which the Purchase Payment or the request for transfer or
withdrawal is received at the Home Office. However, the Purchase Payment,
transfer, or withdrawal will be effective on the following Valuation Date if the
Purchase Payment, request for transfer or withdrawal is received at the Home
Office either:

     .    on a Valuation Date after the close of trading on the New York Stock
          Exchange; or

     .    on a day on which the New York Stock Exchange is closed.

                               SECTION 5. BENEFITS

5.1  MATURITY BENEFIT

Maturity Options. If the Annuitant is living on the Maturity Date shown on page
3, and that Maturity Date is earlier than the contract anniversary nearest the
Annuitant's 90th birthday, the Owner may elect between the following maturity
options:

     .    payment of a monthly income under a payment plan chosen by the Owner;
          or

     .    deferral of the maturity benefit and continuation of this contract to
          the Optional Maturity Date. The contract will continue under this
          option if a written election for this purpose is received by the
          Company or if on the Maturity Date shown on page 3, the Owner has not
          chosen a payment plan.

If the Annuitant is living on the Maturity Date and that Maturity Date is on or
after the contract anniversary nearest the Annuitant's 90th birthday, the
Company will pay a monthly income under a payment form chosen by the Owner.

Payment of Maturity Benefit. The amount of the monthly income paid as the
maturity benefit will depend on the payment plan chosen (see Section 11) and the
maturity value. The maturity value of this contract will be the Accumulation
Value of the contract on the effective date of the maturity benefit. The
maturity benefit will be effective on the Maturity Date. However, if the New
York Stock Exchange is closed on the Maturity Date, the effective date will be
the Valuation Date next preceding the Maturity Date.

If no payment form is chosen at the time a monthly income becomes payable,
payments will be made under the variable payment form of Life Income Plan
(Option C), with installments certain for ten years, as described in Section
11.1.

RP.V.A.FR.(0803)                       10

<PAGE>

Optional Maturity Date. The Optional Maturity Date is the contract anniversary
nearest the Annuitant's 90th birthday. If the contract is continued to the
Optional Maturity Date, all contract rights of the Owner will continue in effect
to the Optional Maturity Date. The Optional Maturity Date will become the
Maturity Date for all other purposes of this contract.

5.2  DEATH BENEFIT IF ANNUITANT IS AN OWNER

     If the Annuitant is an Owner, the beneficiary becomes entitled to the Death
Benefit upon receipt at the Home Office of satisfactory proof of the death of
the Annuitant before the Maturity Date. The Death Benefit will be the
Accumulation Value of the contract determined on the effective date. The
effective date is the date on which proof of death is received at the Home
Office. However, the effective date will be the next following Valuation Date if
the proof of death is received at the Home Office either:

     .    on a Valuation Date after the close of trading on the New York Stock
          Exchange; or

     .    on a day on which the New York Stock Exchange is closed.

     If the beneficiary becomes entitled to the Death Benefit due to the death
of the Primary Annuitant prior to the Primary Annuitant's 75th birthday, the
Death Benefit will not be less than:

     .    total Net Purchase Payments paid under the contract; less

     .    an adjustment for every withdrawal made under Section 4.5. The
          adjustment for each withdrawal equals (a) times (b), where:

          (a)  = the amount withdrawn from the Accumulation Value divided by the
               Accumulation Value immediately before the withdrawal; and

          (b)  = total Net Purchase Payments paid under the contract prior to
               the withdrawal less all adjustments for prior withdrawals.

     As of the effective date, the Accumulation Value of the contract will be
set at an amount equal to the Death Benefit. Unless a payment plan was elected
by the Owner, the beneficiary automatically becomes the Owner and Annuitant of
the contract. However, if the beneficiary is not a natural person and no payment
plan was elected by the Owner, the beneficiary may select a natural person to be
the Annuitant. If a natural person is not selected to be the Annuitant within 60
days of the date on which proof of death of the Annuitant is received at the
Home Office, the Accumulation Value will be distributed to the beneficiary.

     If a beneficiary becomes entitled to the Death Benefit in an amount less
than the Minimum Accumulation Value shown on page 4, the Accumulation Value will
be distributed to the beneficiary.

     The cash value of any amount distributed will be the Accumulation Value
withdrawn as of the date of withdrawal as determined in Section 4.6.

5.3  DEATH BENEFIT IF ANNUITANT IS NOT AN OWNER

     If the Annuitant is not an Owner, upon the death of the Annuitant the
contract continues with the Contingent Annuitant (Section 6.5) as the new
Annuitant. The Death Benefit will be the Accumulation Value of the contract
determined on the effective date. The effective date is the date on which proof
of death is received at the Home Office. However, the effective date will be the
next following Valuation Date if the proof of death is received at the Home
Office either:

     .    on a Valuation Date after the close of trading on the New York Stock
          Exchange; or

     .    on a day on which the New York Stock Exchange is closed.

     If the Primary Annuitant dies prior to the Primary Annuitant's 75th
birthday, the Death Benefit will not be less than:

     .    total Net Purchase Payments paid under the contract; less

     .    an adjustment for every withdrawal made under Section 4.5. The
          adjustment for each withdrawal equals (a) times (b), where:

          (a)  = the amount withdrawn from the Accumulation Value divided by the
               Accumulation Value immediately before the withdrawal; and

          (b)  = total Net Purchase Payments paid under the contract prior to
               the withdrawal less all adjustments for prior withdrawals.

     As of the effective date, the Accumulation Value of the contract will be
set at an amount equal to the Death Benefit.

RP.V.A.FR.(0803)                       11

<PAGE>

               SECTION 6. BENEFICIARIES AND CONTINGENT ANNUITANTS

6.1  NAMING AND CHANGING OF BENEFICIARIES

For Maturity Benefits or Withdrawals by Owner. The Owner may name and change the
beneficiaries of maturity benefits or withdrawal amounts before the Maturity
Date. If no beneficiary is named by the Owner, the Owner will be the direct
beneficiary.

For Death Benefits by Owner. The Owner may name and change the beneficiaries of
the Death Benefits while the Annuitant is living. If no such beneficiary is
named by the Owner, the Owner or the Owner's estate will be the direct
beneficiary.

For Maturity or Death Benefits or Withdrawal Amounts by Spouse (Marital
Deduction Provision).

     .    Power to Appoint. The spouse of the Annuitant will have the power
          alone and in all events to appoint all amounts payable to the spouse
          under the contract if:

          a.   just before the Annuitant's death, the Annuitant was the Owner;
               and

          b.   the spouse is a direct beneficiary; and

          c.   the spouse survives the Annuitant.

     .    To Whom Spouse Can Appoint. Under this power, the spouse can appoint:

          a.   to the estate of the spouse; or

          b.   to any other person.

     .    Effect of Exercise. As to the amounts appointed, the exercise of this
          power will:

          a.   revoke any other designation of beneficiaries;

          b.   revoke any election of payment plan as it applies to them; and

          c.   cause any provision to the contrary in Section 6 or 10 of this
               contract to be of no effect.

Effective Date. A naming or changing of a beneficiary will be effective on
receipt at the Home Office of a written request that is acceptable to the
Company. The request will then take effect as of the date that it was signed.
The Company is not responsible for any payment or other action that is taken by
it before the receipt of the request. The Company may require that the contract
be sent to it to be endorsed to show the naming or change.

6.2  SUCCESSION IN INTEREST OF BENEFICIARIES

     The rights and benefits that a beneficiary becomes entitled to under the
contract are shared equally among all surviving direct beneficiaries, if any,
otherwise equally among all surviving contingent beneficiaries, if any,
otherwise to the Owner or the Owner's Estate.

6.3  TRUSTEE AS BENEFICIARY

     If a trustee is named as a beneficiary and no qualified trustee makes claim
to the proceeds, or to the present value of any unpaid payments under a payment
plan, within one year after payment becomes due to the trustee, or if
satisfactory evidence is furnished to the Company within that year showing that
no trustee can qualify to receive payment, payment will be made as though the
trustee had not been named.

     The Company will be fully discharged of liability for any action taken by
the trustee and for all amounts paid to, or at the direction of, the trustee and
will have no obligation as to the use of the amounts. In all dealings with the
trustee the Company will be fully protected against the claims of every other
person. The Company will not be charged with notice of a change of trustee
unless written evidence of the change is received at the Home Office.

6.4  GENERAL

Transfer of Ownership. A transfer of ownership of itself will not change the
interest of a beneficiary.

Claims of Creditors. So far as allowed by law, no amount payable under this
contract will be subject to the claims of creditors of a beneficiary.

RP.V.A.FR.(0803)                       12

<PAGE>

6.5  NAMING AND CHANGING A CONTINGENT ANNUITANT

     The Owner may name and change a Contingent Annuitant while the Annuitant is
living.

     If the Annuitant was not the Owner immediately prior to the Annuitant's
death, the Owner may name and change a Contingent Annuitant during the first 60
days after the date on which proof of death of the Annuitant is received at the
Home Office. A change made during this 60 days cannot be revoked. If no one is
named as Contingent Annuitant by the end of the 60 day time period, the Company
will pay the Accumulation Value to the Owner. The cash value of any amount
distributed will be the Accumulation Value withdrawn as of the date of
withdrawal as determined in Section 4.6.

     A naming or changing of a Contingent Annuitant will be effective on receipt
at the Home Office of a written request that is acceptable to the Company.

                           SECTION 7. CHARGES AND FEES

7.1  SALES LOAD AND PREMIUM TAXES

     The Company will deduct the Sales Load shown on page 4 from Purchase
Payments received. The Company may also deduct Premium Taxes incurred from
Purchase Payments received.

7.2  CONTRACT FEE

     On each contract anniversary prior to the Maturity Date, a Contract Fee
will be charged for administrative expenses. The amount of the Contract Fee is
shown on page 4. The Contract Fee will be deducted from the Investment Accounts
in proportion to the Accumulation Value of the Investment Accounts.

     The Contract Fee deducted from the Guaranteed Interest Fund will not exceed
the sum of:

     .    10% of the gross purchase payments applied to the Guaranteed Interest
          Fund during the contract year; and

     .    interest in excess of the guaranteed annual effective interest rate
          shown on page 4 credited to the Guaranteed Interest Fund during the
          contract year.

     The effective date of the Contract Fee will be the contract anniversary.
However, if the New York Stock Exchange is closed on the contract anniversary,
the effective date will be the next following Valuation Date.

RP.V.A.FR.(0803)                       13

<PAGE>

                              SECTION 8. OWNERSHIP

8.1  THE OWNER

     The Owner is named on page 3. All contract rights may be exercised by the
Owner, the Owner's successor, or the Owner's transferee without the consent of
any beneficiary.

     If the contract has more than one Owner, contract rights may be exercised
only by authorization of all Owners. Upon the death of an Owner, ownership
rights of all Owners terminate if the deceased Owner was the Annuitant.

8.2  TRANSFER OF OWNERSHIP

     The Owner may transfer the ownership of this contract. Written proof of
transfer satisfactory to the Company must be received at its Home Office. The
transfer will then take effect as of the date it was signed. The Company may
require that the contract be sent to it for endorsement to show the transfer.
The Company will not be responsible to a transferee Owner for any payment or
other action taken by the Company before receipt of the proof of transfer at its
Home Office.

8.3  NAMING AND CHANGING A SUCCESSOR OWNER

     An Owner may name and change a Successor Owner. Naming or changing a
Successor Owner will be effective on receipt at the Home Office of a written
request for such change that is acceptable to the Company. A Successor Owner
succeeds to the interests of an Owner only if the Owner was not the Annuitant at
the time of the Owner's death.

8.4  COLLATERAL ASSIGNMENT

     The Owner may assign this contract as collateral security. The Company is
not responsible for the validity or effect of a collateral assignment. The
Company will not be responsible to an assignee for any payment or other action
taken by the Company before receipt of the assignment in writing at its Home
Office.

     The interest of any beneficiary will be subject to any collateral
assignment made either before or after the beneficiary is named.

     A collateral assignee is not an Owner. A collateral assignment is not a
transfer of ownership. Ownership can be transferred only by complying with
Section 8.2.

8.5  REPORTS TO OWNERS

     At least once each Contract Year, the Company will also send to the Owner
or payee a statement of the Accumulation Values of the Investment Accounts, the
number of units credited to the contract, the dollar value of a unit as of a
date not more than two months previous to the date of mailing, and a statement
of the investments held by the Separate Account.

8.6  TRANSFERABILITY RESTRICTIONS

     Notwithstanding any other provisions of this contract, the Owner may not:

     .    change the ownership of the contract; or

     .    sell the contract, or assign or pledge the contract as collateral for
          a loan or as security for the performance of an obligation or for any
          other purpose, to any person other than the Company.

     These restrictions will not apply if the Owner is:

     .    the trustee of an employee trust that is qualified under the Internal
          Revenue Code; or

     .    the custodian of a custodial account treated as an employee trust that
          is qualified under the Internal Revenue Code.

     The restrictions do not preclude the employer under a nontrusteed plan from
transferring ownership of this contract to the Annuitant or to the employer or
trustee under another plan or trust when required by the plan.

RP.V.A.FR.(0803)                       14

<PAGE>

                             SECTION 9. THE CONTRACT

9.1  GUARANTEES

     The Company guarantees that mortality and expense results will not
adversely affect the amount of variable payments.

9.2  VALUATION OF SEPARATE ACCOUNT ASSETS

     The value of the shares of each Portfolio held in the Separate Account on
each Valuation Date will be the redemption value of the shares on that date. If
the right to redeem shares of a Portfolio has been suspended, or payment of the
redemption value has been postponed, the shares held in the Separate Account
(and Annuity Units) may be valued at fair value as determined in good faith by
the Board of Trustees of the Company for the sole purpose of computing annuity
payments.

9.3  DETERMINATION OF SEPARATE ACCOUNT VALUES

     The method of determination by the Company of the Net Investment Factor,
and the number and value of Accumulation Units and Annuity Units, will be
conclusive upon the Owner, any assignee, the Annuitant, and any beneficiary.

9.4  DEFERMENT OF BENEFIT PAYMENTS

Separate Account Divisions. The Company reserves the right to defer
determination of the contract values of the Separate Account portion of this
contract, or the payment of benefits under a variable payment plan, until after
the end of any period during which the right to redeem shares of a Portfolio is
suspended, or payment of the redemption value is postponed. Any deferment would
be in accordance with the provisions of the Investment Company Act of 1940 by
reason of closing of, or restriction of trading on, the New York Stock Exchange,
or other emergency, or as otherwise permitted by the Act. In addition, the
Company reserves the right to defer payment of contract values until seven days
after the end of any deferment in the determination of contract values.

Guaranteed Interest Fund. The Company may defer paying contract values of the
Guaranteed Interest Fund for up to six months from the effective date of the
withdrawal or full surrender. If payment is deferred for 30 days or more,
interest will be paid on the withdrawal amounts at an annual effective interest
rate in accordance with the laws of the state in which this contract is
delivered.

9.5  DIVIDENDS

     This contract will share in the divisible surplus of the Company, except
while payments are being made under a variable payment plan. This surplus will
be determined each year, and the dividend, if any, will be credited on the
contract anniversary. Any dividend credited prior to the Maturity Date will be
applied on the effective date as a Net Purchase Payment unless the Owner elects
to have the dividend paid in cash. The effective date of the dividend will be
the contract anniversary. However, if the New York Stock Exchange is closed on
the contract anniversary, the effective date will be the next following
Valuation Date.

     Since this policy is not expected to contribute to divisible surplus, it is
not expected that any dividends will be paid.

9.6  INCONTESTABILITY

     The Company will not contest this contract after it has been in force
during the lifetime of the Annuitant for two years from the Issue Date. This
Issue Date is shown on page 3.

RP.V.A.FR.(0803)                       15

<PAGE>

9.7  MISSTATEMENTS

     If the age of the Annuitant has been misstated, the amount payable will be
 the amount which the Purchase Payments paid would have purchased at the correct
 age. If any amounts have been overpaid by the Company due to a misstatement of
 age, the amount of the overpayment may be deducted from payments to be made by
 the Company. If any amounts have been underpaid by the Company due to a
 misstatement of age, the amount of the underpayment will be paid.

9.8  ENTIRE CONTRACT; CHANGES

     This contract with any amendments and additional benefits and the attached
application is the entire contract. Statements in the application are
representations and not warranties. A change in the contract is valid only if it
is approved by an officer of the Company. The Company may require that the
contract be sent to it for endorsement to show a change. No agent has the
authority to change the contract or to waive any of its terms.

     All payments by the Company under this contract are payable at its Home
Office.

     Assets of the Separate Account are owned by the Company and the Company is
not a trustee with respect thereto. The Company may from time to time adjust the
amount of assets contained in the Separate Account, by periodic withdrawals or
additions, to reflect the contract deductions and the Company's reserves for
this and other similar contracts.

     This contract is subject to the laws of the state in which it is delivered.
All benefits are at least as great as those required by that state.

9.9  TERMINATION OF CONTRACT

     The Company may terminate the contract and pay the Owner the Accumulation
Value of the contract and be released of any further obligation if:

     .    prior to the Maturity Date no Purchase Payments have been received
          under the contract for a period of two full years and each of the
          following is less than the Minimum Accumulation Value shown on page 4:

          a.   the Accumulation Value of the contract; and

          b.   total Purchase Payments paid under the contract, less any amounts
               withdrawn under Section 4.5; or

     .    on the Maturity Date the Accumulation Value of the contract is less
          than the Minimum Accumulation Value shown on page 4 or would provide
          an initial monthly income which is less than the minimum payment
          amount shown on page 4.

                    SECTION 10. PAYMENT OF CONTRACT BENEFITS

10.1 PAYMENT OF BENEFITS

     All or part of the contract benefits may be paid under one or more of the
following:

     .    a variable payment plan;

     .    a fixed payment plan; or

     .    in cash.

     The provisions and rates for variable and fixed payment plans are described
in Section 11. Contract benefits may not be placed under a payment plan unless
the plan would provide to each beneficiary an initial monthly income of at least
the minimum payment amount shown on page 4.

10.2 DEATH BENEFIT

     A beneficiary entitled to the Death Benefit upon the death of an Annuitant
may elect to receive the Accumulation Value under a payment plan or in cash
provided no payment plan was elected by the Owner. The cash value of any amount
distributed will be the Accumulation Value withdrawn as of the date of
withdrawal as determined in Section 4.6.

RP.V.A.FR.(0803)                       16

<PAGE>

10.3 EFFECTIVE DATE FOR PAYMENT PLAN

     A payment plan that is elected for maturity benefits will take effect on
the Maturity Date.

     If the Annuitant is an Owner, a payment plan that is elected by the Owner
for the Death Benefit will take effect on the date proof of death of the
Annuitant is received at the Home Office.

     In all other cases, a payment plan that is elected will take effect:

     .    on the date the election is received at the Home Office; or

     .    on a later date, if requested.

10.4 PAYMENT PLAN ELECTIONS

For Death Benefits by Owner. The Owner may elect payment plans for death
benefits while the Annuitant is living.

For Maturity Benefits or Withdrawal Amounts. The Owner may elect payment plans
for maturity benefits or withdrawal amounts.

Transfer Between Payment Plans. A beneficiary who is receiving payment under a
payment plan which includes the right to withdraw may transfer the amount
withdrawable to any other payment plan that is available.

                            SECTION 11. PAYMENT PLANS

11.1 DESCRIPTION OF PAYMENT PLANS

Installment Income For Specified Period (Option B)

     The Company will make monthly installment income payments providing for
payment of benefits over a specified period of 10 to 30 years during the first
five contract years and over a specified period of 5 to 30 years beginning with
the sixth contract year.

Life Income Plans

     .    Single Life Income (Option C). The Company will make monthly payments
          for the selected certain period, if any, and thereafter during the
          remaining lifetime of the individual upon whose life income payments
          depend. The selections available are: (a) no certain period; or (b) a
          certain period of 10 or 20 years.

     .    Joint and Survivor Life Income (Option E). The Company will make
          monthly payments for a 10-year certain period and thereafter during
          the joint lifetime of the two individuals upon whose lives income
          payments depend and continuing during the remaining lifetime of the
          survivor.

     .    Other Selections. The Company may offer other selections under the
          Life Income Plans.

     .    Limitations. A direct or contingent beneficiary who is a natural
          person may be paid under a Life Income Plan only if the payments
          depend on that beneficiary's life. A corporation may be paid under a
          Life Income Plan only if the payments depend on the life of the
          Annuitant or, after the death of the Annuitant, on the life of the
          Annuitant's spouse or dependent.

     These payment plans are available on either a fixed or variable basis.
Under a fixed payment plan the payment remains level. Under a variable payment
plan the payment will increase or decrease as described in Section 11.4.

11.2 ALLOCATION OF BENEFITS

     Upon election of a variable payment plan, the Owner or direct or contingent
beneficiary may select the allocation of variable benefits among the Divisions.

     If no selection is made, the allocation of benefits will be as follows:

     .    for amounts in the Separate Account Divisions, benefits will be
          allocated in proportion to the Accumulation Value of each Division on
          the effective date of the variable payment plan; and

     .    for amounts in the Guaranteed Interest Fund, benefits will be
          allocated 100% to the Money Market Division.

RP.V.A.FR.(0803)                       17

<PAGE>

11.3 ANNUITY UNITS UNDER VARIABLE PAYMENT PLANS

     The interest of this contract in the Separate Account after the effective
date of a variable payment plan is represented by Annuity Units.

     The dollar value of Annuity Units for each Division will increase or
decrease to reflect the investment experience of the Division. The value of an
Annuity Unit on any Valuation Date is the product of:

     .    the Annuity Unit value on the immediately preceding Valuation Date;

     .    the Net Investment Factor for the period from the immediately
          preceding Valuation Date up to and including the current Valuation
          Date (the current period); and

     .    the Daily Adjustment Factor of .99990575 raised to a power equal to
          the number of days in the current period to reflect the Assumed
          Investment Rate of 3 1/2% used in calculating the monthly payment
          rate.

11.4 PAYMENTS UNDER VARIABLE PAYMENT PLANS

First Payment. The first payment under a variable payment plan will be due as of
the effective date of the payment plan.

The amount of the first payment is the sum of payments from each Division, each
determined by multiplying the benefits allocated to the Division under the
variable payment plan by the applicable monthly variable payment rate per $1,000
of benefits.

Number of Annuity Units. The number of Annuity Units in each Division under a
variable payment plan is determined by dividing the amount of the first payment
payable from the Division by the Annuity Unit value for the Division at the
close of business on the effective date of the variable payment plan. The number
of Annuity Units will not be changed by any subsequent change in the dollar
value of Annuity Units.

Subsequent Variable Payments. The amount of each subsequent payment from each
Division under a variable payment plan will increase or decrease in accord with
the increase or decrease in the value of an Annuity Unit which reflects the
investment experience of that Division of the Separate Account.

The amount of subsequent variable payments is the sum of payments from each
Division, each determined by multiplying the fixed number of Annuity Units for
the Division by the value of an Annuity Unit for the Division on:

     .    the fifth Valuation Date prior to the payment due date if the payment
          due date is a Valuation Date; or

     .    the sixth Valuation Date prior to the payment due date if the payment
          due date is not a Valuation Date.

11.5 TRANSFERS INVOLVING VARIABLE PAYMENT PLANS

     A beneficiary receiving payments under a variable payment plan may transfer
Annuity Units from one Division to another. The number of Annuity Units in each
Division will be adjusted to reflect the respective value of the Annuity Units
in the Divisions on the date the transfer is effective.

     A Transfer Fee may be deducted from the amount transferred. The amount of
the Transfer Fee is shown on page 4. Transfers from the Money Market Division
may be made at any time. No transfer from the other Divisions may be made within
90 days of the effective date of a variable payment plan or within 90 days from
the effective date of the last transfer.

     A beneficiary receiving payments under a variable payment plan may transfer
from an Installment Income Plan (Option B) to either form of the Life Income
Plan (Option C or E). Other transfers may be permitted subject to conditions set
by the Company.

     A transfer will be effective on the Valuation Date on which a satisfactory
transfer request is received in the Home Office, or a later date if requested.
However, the transfer will be effective on the following Valuation Date if the
request is received at the Home Office either:

     .    on a Valuation Date after the close of trading on the New York Stock
          Exchange; or

     .    on a day on which the New York Stock Exchange is closed.

RP.V.A.FR.(0803)                       18

<PAGE>

11.6 WITHDRAWAL UNDER PAYMENT PLANS

     Withdrawal of the present value of any unpaid income payments may be
elected at any time by the beneficiary, except that withdrawal may not be
elected under a Life Income Plan (Option C or E) until the death of all
individuals upon whose lives income payments depend.

     The withdrawal value under the Installment Income Plan (Option B) will be
the present value of any unpaid payments. The withdrawal value under a Life
Income Plan (Option C or E) will be the present value of any unpaid payments for
the certain period.

     For a fixed payment plan, the present value of any unpaid income payments
will be based on the rate of interest used to determine the amount of the
payments. For a variable payment plan, the present value of any unpaid income
payments will be based on interest at the Assumed Investment Rate used in
calculating the amount of the variable payments. The amount of variable payments
used in calculating the present value of unpaid payments will be determined by
multiplying the number of Annuity Units by the value of an Annuity Unit on the
effective date of withdrawal.

     A withdrawal will be effective on the Valuation Date on which the request
is received in the Home Office. However, the withdrawal will be effective on the
following Valuation Date if the request is received at the Home Office either:

     .    on a Valuation Date after the close of trading on the New York Stock
          Exchange; or

     .    on a day on which the New York Stock Exchange is closed.

11.7 NAMING AND CHANGING OF BENEFICIARIES UNDER PAYMENT PLANS

For Payment Plans Elected By Owner. If the Owner of the contract elected a
payment plan, a direct beneficiary may name and change the contingent
beneficiaries and further payees of the direct beneficiary's share of the
benefits only if:

     .    the direct beneficiary was the Owner of the contract; or

     .    no contingent beneficiary or further payee of that share is living.

For Payment Plans Elected By Direct Beneficiary. If the direct beneficiary
elected the payment plan, the direct beneficiary may name and change the
contingent beneficiaries and further payees of the direct beneficiary's share of
the benefits.

11.8 SUCCESSION IN INTEREST OF BENEFICIARIES UNDER PAYMENT PLANS

Direct Beneficiary. Amounts payable under a payment plan will be payable to the
direct beneficiary.

Contingent Beneficiaries. At the death of the direct beneficiary, the present
value of any unpaid payments under a payment plan, will be payable in equal
shares to the contingent beneficiaries who survive and receive payment. If a
contingent beneficiary dies before receiving all or part of the contingent
beneficiary's full share, the unpaid portion will be payable in equal shares to
the other contingent beneficiaries who survive and receive payment.

Further Payees. At the death of all direct and contingent beneficiaries, the
present value of any unpaid payments under a payment plan, will be paid in one
sum:

     .    in equal shares to the further payees who survive and receive payment;
          or

     .    if no further payees survive and receive payment, to the estate of the
          last to die of all beneficiaries.

RP.V.A.FR.(0803)                       19

<PAGE>

11.9 PAYMENT PLAN RATES

Payment Rate Tables. The guaranteed monthly payment rates for both a fixed
payment plan and the first payment under a variable payment plan are shown in
the Payment Rate Tables. The tables show rates for the Installment Income Plan
for a Specified Period (Option B) and Life Income Plans (Options C and E). Life
Income Plan (Option C or E) rates are based on the adjusted age of any
individual upon whose life payments depend. The adjusted age is:

     .    the age on the birthday that is nearest to the date on which the
          payment plan takes effect; plus

     .    the age adjustment shown below for the number of Contract Years that
          have elapsed from the Issue Date to the date that the payment plan
          takes effect. A part of a Contract Year is counted as a full year.

-----------------------------------------
CONTRACT     AGE      CONTRACT      AGE
 YEARS     ADJUST-     YEARS      ADJUST-
ELAPSED     MENT      ELPASED      MENT
-----------------------------------------
 1 to 8       0       33 to 40      -4
 9 to 16     -1       41 to 48      -5
17 to 24     -2      49 or more     -6
25 to 32     -3
-----------------------------------------

Current Fixed Payment Plan Rates

     .    Installment Income for Specified Period (Option B). The Company may
          offer fixed payment plan rates higher than those guaranteed in this
          contract with conditions on withdrawal.

     .    Life Income Plans (Option C or E). Payments will be based on rates
          declared by the Company that will not be less than the rates
          guaranteed in this contract. The declared rates will provide at least
          as much income as would the Company's rates, on the date that the
          payment plan takes effect, for a single premium immediate annuity
          contract.

Alternate Variable Rate Basis. The Company may from time to time publish higher
initial rates for variable payment plans under this contract. These higher rates
will not be available to increase payments under payment plans already in
effect.

When a variable payment plan is effective on an alternate rate basis, the Daily
Adjustment Factor described in Section 11.3 will be determined based on the
Assumed Investment Rate used in calculating the alternate payment rate.

RP.V.A.FR.(0803)                       20

<PAGE>

                               PAYMENT RATE TABLES

                   Monthly Income Payments Per $1,000 Benefits

                    First Payment Under Variable Payment Plan

INSTALLMENT INCOME PLANS (OPTION B)
---------------------------------------------------------------
   PERIOD       MONTHLY   PERIOD    MONTHLY   PERIOD    MONTHLY
   (YEARS)      PAYMENT   (YEARS)   PAYMENT   (YEARS)   PAYMENT
---------------------------------------------------------------
  Years 1-4                 11       $9.09       21      $5.56
Not Available               12        8.46       22       5.39
                            13        7.94       23       5.24
                            14        7.49       24       5.09
      5          18.12      15        7.10       25       4.96

      6          15.35      16        6.76       26       4.84
      7          13.38      17        6.47       27       4.73
      8          11.90      18        6.20       28       4.63
      9          10.75      19        5.97       29       4.53
     10           9.83      20        5.75       30       4.45
---------------------------------------------------------------

                         Guaranteed Fixed Payment Plans

INSTALLMENT INCOME PLANS (OPTION B)
---------------------------------------------------------
PERIOD    MONTHLY   PERIOD    MONTHLY   PERIOD    MONTHLY
(YEARS)   PAYMENT   (YEARS)   PAYMENT   (YEARS)   PAYMENT
---------------------------------------------------------
   1      $84.09      11       $8.42       21      $4.85
   2       42.46      12        7.80       22       4.67
   3       28.59      13        7.26       23       4.51
   4       21.65      14        6.81       24       4.36
   5       17.49      15        6.42       25       4.22

   6       14.72      16        6.07       26       4.10
   7       12.74      17        5.77       27       3.98
   8       11.25      18        5.50       28       3.87
   9       10.10      19        5.26       29       3.77
  10        9.18      20        5.04       30       3.68
---------------------------------------------------------

RP.V.A.FR.(0803)                       21

<PAGE>

                               PAYMENT RATE TABLES

                   Monthly Income Payments Per $1,000 Benefits

      Guaranteed Fixed Payment or First Payment Under Variable Payment Plan

LIFE INCOME PLAN (OPTION C)
------------------------------------
    SINGLE LIFE MONTHLY PAYMENTS
------------------------------------
               CHOSEN PERIOD (YEARS)
  ADJUSTED    ----------------------
    AGE*       ZERO      10     20
------------------------------------
    55        $ 4.11   $4.09   $4.01
    56          4.18    4.15    4.07
    57          4.25    4.22    4.13
    58          4.33    4.29    4.18
    59          4.40    4.36    4.24

    60          4.49    4.45    4.30
    61          4.58    4.53    4.37
    62          4.68    4.61    4.43
    63          4.77    4.71    4.50
    64          4.89    4.81    4.57

    65          5.01    4.92    4.64
    66          5.13    5.03    4.72
    67          5.26    5.15    4.78
    68          5.41    5.27    4.85
    69          5.57    5.40    4.93

    70          5.74    5.55    5.00
    71          5.92    5.69    5.07
    72          6.12    5.84    5.13
    73          6.33    6.00    5.20
    74          6.55    6.17    5.26

    75          6.79    6.35    5.32
    76          7.06    6.53    5.37
    77          7.34    6.72    5.41
    78          7.65    6.90    5.46
    79          7.98    7.10    5.50

    80          8.34    7.30    5.53
    81          8.73    7.49    5.56
    82          9.15    7.68    5.59
    83          9.60    7.88    5.61
    84         10.09    8.07    5.62

85 and over    10.61    8.24    5.63
------------------------------------

LIFE INCOME PLAN (OPTION E)
-------------------------------------------------------------------------
              JOINT AND SURVIVOR MONTHLY PAYMENTS (with 10 years certain)
-------------------------------------------------------------------------
OLDER LIFE                     YOUNGER LIFE ADJUSTED AGE*
 ADJUSTED     -----------------------------------------------------------
   AGE*        55      60      65      70      75      80     85 and over
-------------------------------------------------------------------------

    55        $3.75
    60         3.83   $4.02
    65         3.90    4.13   $4.39
    70         3.94    4.22    4.54   $4.89
    75         3.98    4.28    4.65    5.10   $5.59
    80         4.00    4.32    4.73    5.24    5.86   $6.51
85 and over    4.01    4.34    4.77    5.34    6.04    6.84      $7.58

-------------------------------------------------------------------------
* See Section 11.9

The amount of the payment for any other combination of ages will be furnished by
the Company on request.

The maximum initial monthly income per $1,000 will be $7.58.

Monthly payment rates are based on an Assumed Investment Rate of 3 1/2% and the
1983 Table a with Projection Scale G.

RP.V.A.FR.(0803)                       22

<PAGE>

================================================================================

It is recommended that you ...

read your contract.

notify your Northwestern Mutual agent or the Company at 720 East Wisconsin
Avenue, Milwaukee, WI 53202, of an address change.

call your Northwestern Mutual agent for information--particularly on a
suggestion to terminate or exchange this contract for another contract or plan.

Election Of Trustees

The members of The Northwestern Mutual Life Insurance Company are its
policyholders of insurance policies and deferred annuity contracts. The members
exercise control through a Board of Trustees. Elections to the Board are held
each year at the annual meeting of members. Members are entitled to vote in
person or by proxy.

                  FLEXIBLE PAYMENT VARIABLE ANNUITY - ACCOUNT A

AMOUNTS ALLOCATED TO THE SEPARATE ACCOUNT DIVISIONS AND VARIABLE PAYMENTS
PROVIDED BY THIS CONTRACT ARE NOT GUARANTEED AS TO FIXED DOLLAR AMOUNT BUT ARE
VARIABLE AND MAY INCREASE OR DECREASE TO REFLECT THE INVESTMENT EXPERIENCE OF
THE SEPARATE ACCOUNT.

RP.V.A.(0803)

--------------------------------------------------------------------------------
                                                  [LOGO] Northwestern Mutual(TM)
--------------------------------------------------------------------------------

<PAGE>

                                  Exhibit 10.3

                               PAYMENT RATE TABLES

                   Monthly Income Payments Per $1000 Benefits

      Guaranteed Fixed Payment or First Payment Under Variable Payment Plan

LIFE INCOME PLAN (OPTION C)
---------------------------------------------------------------------------
                       SINGLE LIFE MONTHLY PAYMENTS
---------------------------------------------------------------------------
   MALE        CHOSEN PERIOD (YEARS)      FEMALE      CHOSEN PERIOD (YEARS)
 ADJUSTED     ----------------------     ADJUSTED    ----------------------
   AGE*        ZERO      10     20         AGE*       ZERO      10      20
---------------------------------------------------------------------------
    55        $ 4.41   $4.36   $4.23       55        $ 4.04   $4.02   $3.96
    56          4.49    4.44    4.29       56          4.10    4.08    4.01
    57          4.58    4.52    4.35       57          4.17    4.14    4.07
    58          4.67    4.60    4.41       58          4.24    4.21    4.12
    59          4.77    4.69    4.47       59          4.31    4.28    4.18

    60          4.87    4.79    4.54       60          4.39    4.36    4.24
    61          4.98    4.89    4.60       61          4.48    4.44    4.31
    62          5.10    4.99    4.67       62          4.57    4.52    4.37
    63          5.23    5.11    4.74       63          4.66    4.61    4.44
    64          5.36    5.22    4.81       64          4.77    4.71    4.51

    65          5.51    5.35    4.87       65          4.88    4.81    4.58
    66          5.67    5.47    4.94       66          5.00    4.92    4.66
    67          5.84    5.61    5.00       67          5.12    5.03    4.73
    68          6.02    5.75    5.07       68          5.26    5.15    4.80
    69          6.21    5.89    5.13       69          5.41    5.28    4.88

    70          6.41    6.05    5.19       70          5.57    5.42    4.95
    71          6.63    6.20    5.25       71          5.74    5.56    5.02
    72          6.86    6.36    5.30       72          5.93    5.71    5.09
    73          7.11    6.53    5.35       73          6.13    5.87    5.16
    74          7.37    6.70    5.39       74          6.34    6.04    5.23

    75          7.65    6.87    5.44       75          6.58    6.22    5.29
    76          7.96    7.05    5.47       76          6.83    6.40    5.34
    77          8.28    7.23    5.51       77          7.11    6.59    5.39
    78          8.63    7.40    5.54       78          7.40    6.78    5.44
    79          9.01    7.58    5.56       79          7.72    6.98    5.48

    80          9.41    7.76    5.59       80          8.07    7.18    5.52
    81          9.84    7.93    5.61       81          8.45    7.38    5.55
    82         10.30    8.10    5.62       82          8.86    7.58    5.58
    83         10.79    8.27    5.63       83          9.30    7.78    5.60
    84         11.31    8.42    5.64       84          9.78    7.98    5.62

85 and over    11.87    8.57    5.65   85 and over    10.30    8.16    5.63
---------------------------------------------------------------------------

LIFE INCOME PLAN (OPTION E)
-------------------------------------------------------------------------
              JOINT AND SURVIVOR MONTHLY PAYMENTS (with 10 years certain)
-------------------------------------------------------------------------
   MALE                            FEMALE ADJUSTED AGE*
 ADJUSTED     -----------------------------------------------------------
   AGE*        55      60       65      70      75      80    85 and over
-------------------------------------------------------------------------

    55        $3.75   $3.89   $4.02   $4.14   $4.23   $4.29      $4.33
    60         3.83    4.02    4.21    4.39    4.54    4.65       4.73
    65         3.90    4.13    4.39    4.65    4.89    5.09       5.22
    70         3.94    4.22    4.54    4.89    5.26    5.58       5.81
    75         3.98    4.28    4.65    5.10    5.59    6.07       6.45
    80         4.00    4.32    4.73    5.24    5.86    6.51       7.07
85 and over    4.01    4.34    4.77    5.34    6.04    6.84       7.58
-------------------------------------------------------------------------
* See Section 11.9

The amount of the payment for any other combination of ages will be furnished by
the Company on request.

The maximum initial monthly income per $1,000 will be $7.58.

Monthly payment rates are based on an Assumed Investment Rate of 3 1/2% and the
1983 Table a with Projection Scale G.

RR.V.A.FR.(0803)                       22

SEX DISTINCT

<PAGE>

                                  Exhibit 10.4

                             ENHANCED DEATH BENEFIT

     As of the Issue Date, this amendment is made part of this annuity contract
issued by The Northwestern Mutual Life Insurance Company. In the case of a
conflict with any provisions in the contract, the provisions of this amendment
will control.

Section 5.2 and Section 5.3 are amended in their entirety to read as follows:

Section 5.2 DEATH BENEFIT IF PRIMARY ANNUITANT IS AN OWNER

     If the Primary Annuitant is an Owner, the beneficiary becomes entitled to
the Death Benefit upon receipt at the Home Office of satisfactory proof of the
death of the Primary Annuitant before the Maturity Date. The Death Benefit will
be the greater of:

     .    the Accumulation Value of the contract on the effective date; or

     .    the Enhanced Death Benefit.

     As of the effective date, the Accumulation Value of the contract will be
set at an amount equal to the Death Benefit. Unless a payment plan was elected
by the Owner, the beneficiary becomes the Owner and Annuitant of the contract.
However, if the beneficiary is not a natural person and no payment plan was
elected by the Owner, the beneficiary may select a natural person to be the
Annuitant. If a natural person is not selected to be the Annuitant within 60
days of the date on which proof of death of the Annuitant is received at the
Home Office, the Accumulation Value will be distributed to the beneficiary.

     If a beneficiary becomes entitled to the Death Benefit in an amount less
than the Minimum Accumulation Value shown on page 4, the Accumulation Value will
be distributed to the beneficiary.

     The cash value of any amount distributed will be the Accumulation Value
withdrawn as of the date of withdrawal as determined in Section 4.6.

Enhanced Death Benefit. Prior to the first contract anniversary, the Enhanced
Death Benefit will equal the total Purchase Payments paid under the contract
less an adjustment for every withdrawal made under Section 4.5.

     On the first contract anniversary and on each subsequent contract
anniversary prior to the Primary Annuitant's 80th birthday, the Enhanced Death
Benefit will equal the greater of:

     .    the Accumulation Value of the contract on that contract anniversary;
          or

     .    the Enhanced Death Benefit on the most recent Valuation Date prior to
          that contract anniversary.

     On any other Valuation Date prior to the Primary Annuitant's 80th birthday,
the Enhanced Death Benefit will be equal to the Enhanced Death Benefit on the
most recent contract anniversary, increased by any Purchase Payments paid since
that contract anniversary and decreased by an adjustment for every withdrawal
made under Section 4.5 since that contract anniversary.

     On any Valuation Date on or after the Primary Annuitant's 80th birthday,
the Enhanced Death Benefit will equal the Enhanced Death Benefit on the contract
anniversary immediately prior to the Primary Annuitant's 80th birthday increased
by any Purchase Payments paid since that contract anniversary and decreased by
an adjustment for every withdrawal made under Section 4.5 since that contract
anniversary.

     The adjustment for each withdrawal made under Section 4.5 will be (a) times
(b), where:

          (a)  = the amount withdrawn from the Accumulation Value divided by the
               Accumulation Value immediately prior to the withdrawal; and

          (b)  = the Enhanced Death Benefit immediately prior to the withdrawal.

Enhanced Death Benefit Charge. On each contract anniversary while this amendment
is in effect, a charge for the Enhanced Death Benefit will be deducted from the
Investment Accounts in proportion to the Accumulation Value of the Investment
Accounts. The charge is shown on page 4.

Effective Date. The effective date is the date on which proof of death is
received at the Home Office. However, the effective date will be the next
following Valuation Date if the proof of death is received at the home office
either:

VA.EDB.(0803)

<PAGE>

     .    on a Valuation Date after the close of trading on the New York Stock
          Exchange; or

     .    on a day on which the New York Stock Exchange is closed.

Termination of Enhanced Death Benefit. This amendment will remain in effect
until Maturity unless the Owner requests that it be removed, the contract
terminates, or the Primary Annuitant dies. Once the amendment is removed, it
cannot be added again. The provisions of Section 5.2 in the contract are
applicable if this amendment terminates.

Section 5.3 DEATH BENEFIT IF PRIMARY ANNUITANT IS NOT AN OWNER

     If the Primary Annuitant is not an Owner, upon the death of the Primary
Annuitant, the contract continues with the Contingent Annuitant (Section 6.5) as
the new Annuitant. The Death Benefit will be the greater of:

     .    the Accumulation Value of the contract on the effective date; or

     .    the Enhanced Death Benefit.

     As of the effective date, the Accumulation Value of the contract will be
set at an amount equal to the Death Benefit.

Enhanced Death Benefit. Prior to the first contract anniversary, the Enhanced
Death Benefit will equal the total Purchase Payments paid under the contract
less an adjustment for every withdrawal made under Section 4.5.

     On the first contract anniversary and on each subsequent contract
anniversary prior to the Primary Annuitant's 80th birthday, the Enhanced Death
Benefit will equal the greater of:

     .    the Accumulation Value of the contract on that contract anniversary;
          or

     .    the Enhanced Death Benefit on the most recent Valuation Date prior to
          that contract anniversary.

     On any other Valuation Date prior to the Primary Annuitant's 80th birthday,
the Enhanced Death Benefit will be equal to the Enhanced Death Benefit on the
most recent contract anniversary, increased by any Purchase Payments paid since
that contract anniversary and decreased by an adjustment for every withdrawal
made under Section 4.5 since that contract anniversary.

     On any Valuation Date on or after the Primary Annuitant's 80th birthday,
the Enhanced Death Benefit will equal the Enhanced Death Benefit on the contract
anniversary immediately prior to the Primary Annuitant's 80th birthday increased
by any Purchase Payments paid since that contract anniversary and decreased by
an adjustment for every withdrawal made under Section 4.5 since that contract
anniversary.

     The adjustment for each withdrawal made under Section 4.5 will be (a) times
(b), where:

          (a)  = the amount withdrawn from the Accumulation Value divided by the
               Accumulation Value immediately prior to the withdrawal; and

          (b)  = the Enhanced Death Benefit immediately prior to the withdrawal.

Enhanced Death Benefit Charge. On each contract anniversary while this amendment
is in effect, a charge for the Enhanced Death Benefit will be deducted from the
Investment Accounts in proportion to the Accumulation Value of the Investment
Accounts. The charge is shown on page 4.

Effective Date. The effective date is the date on which proof of death is
received at the Home Office. However, the effective date will be the next
following Valuation Date if the proof of death is received at the Home Office
either:

     .    on a Valuation Date after the close of trading on the New York Stock
          Exchange; or

     .    on a day on which the New York Stock Exchange is closed.

Termination of Enhanced Death Benefit. This amendment will remain in effect
until Maturity unless the Owner requests that it be removed, the contract
terminates, or the Primary Annuitant dies. Once the amendment is removed, it
cannot be added again. The provisions of Section 5.3 in the contract are
applicable if this amendment terminates.

                                                    /s/ Robert J. Berdan
                                                    ----------------------------
                                                              Secretary
                                                    THE NORTHWESTERN MUTUAL LIFE
                                                          INSURANCE COMPANY

VA.EDB.(0803)

<PAGE>

                                  Exhibit 10.6

                        APPLICATION FOR DEFERRED ANNUITY

                 THE NORTHWESTERN MUTUAL LIFE INSURANCE COMPANY
              720 East Wisconsin Avenue, Milwaukee, Wisconsin 53202

<TABLE>
<S>                                                                                            <C>
                                                                                               Contract Number

                                                                                               ---------------------------

1.   OTHER POLICIES

     Has a Northwestern Mutual Policy ever been issued on the annuitant's life?

     [ ] Yes, the last policy number is:            [X] No
                                         ----------

2.   ANNUITANT

          Name: First, MI, Last                                                         Sex     Birthdate: (MM/DD/YYYY)
          John J. Doe                                                                    M      03-15-1965

          Residence Address (If mailing address is different, provide both addresses.)
          1234 Main St.

          City, State, Zip                                                              Country, if other than US
          Milwaukee, WI 53202
                                                                                        ----------------------------------

          Taxpayer ID Number                                                            Home Phone Number
          ###-##-####                                                                   (414) 555-5678

          US Citizen? [X] Yes [ ] No If no, what country?
                                     (Provide copy, both sides, of green card)          E-mail Address
                                                                                        john.j.Doe@mainst.com
          ----------------------------------------------------------------------

3.   MARKET

     Select one:

     [ ] Non-Tax Qualified
     [ ] 457 Deferred Compensation Plan                 Owner must be indicated.
          [ ] Government   [ ] Non-profit               Proceed to section 4.

     [ ] Traditional IRA                                If the annuitant is a minor,
     [ ] Roth IRA                                       proceed to section 4; otherwise
     [ ] SIMPLE IRA                                     the annuitant is the owner,
     [ ] Simplified Employee Pension Plan IRA (SEP)     proceed to section 5.

     [ ] 403(b) TDA - Employee Salary Reduction Only
     [ ] 403(b) TDA - Employer Matching or Non-elective Contributions Included     The annuitant is the owner.
     [ ] 401(g) Non-Transferable Annuity                                           Proceed to section 5.

     [X] Pension & Profit Sharing:

         Trust Number                    Taxpayer ID Number
            000123                                              The owner and beneficiary
                                      ---------------------     are the trustees of the plan.
                                                                Proceed to section 6.
         Name of Owner - Trustees of

         --------------------------------------------------
</TABLE>

90-1900(0203)                                           90-1900-50(0203)(Page 1)
                                                                (Rev. 1003) - FE

<PAGE>

4.   OWNER

     A minor owner limits future contract actions.

<TABLE>
<S>                                    <C>                                                 <C>
     Select one:

     [X] Annuitant        Proceed to   [ ] UGMA/UTMA - custodian is owner for the benefit of minor   Enter
     [ ] See attachment   section 5.   [ ] Corporation or Trust                                      information
                                       [ ] Other                                                     below.

          Name: First, MI, Last / Corporation / Trust                                      Sex     Birthdate: (MM/DD/YYYY)

          ----------------------------------------------------------------------------------------------------------------

          Residence Address or street address of business for non-natural owners. (If mailing address is different,
          provide both addresses.)

          ----------------------------------------------------------------------------------------------------------------

          City, State, Zip                                                                 Country, if other than US

          ----------------------------------------------------------------------------------------------------------------

          Relationship to Annuitant            Taxpayer ID Number                          Home Phone Number
                                                                                           (    )
          ----------------------------------------------------------------------------------------------------------------

          Date of Trust                        Name of Trustees

          ----------------------------------------------------------------------------------------------------------------

          US Citizen? [ ] Yes [ ] No           If no, what country?
                                               (Provide copy, both sides, of green card)   E-mail Address

          ----------------------------------------------------------------------------------------------------------------

     Additional Owner: (If more than two owners, provide additional information below on a separate sheet)

          Name: First, MI, Last                                                            Sex     Birthdate: (MM/DD/YYYY)

          ----------------------------------------------------------------------------------------------------------------

          Residence Address or street address of business for non-natural owners. (If mailing address is different,
          provide both addresses.)

          ----------------------------------------------------------------------------------------------------------------

          City, State, Zip                                                                 Country, if other than US

          ----------------------------------------------------------------------------------------------------------------

          Relationship to Annuitant            Taxpayer ID Number                          Home Phone Number
                                                                                           (    )
          ----------------------------------------------------------------------------------------------------------------

          US Citizen? [ ] Yes [ ] No           If no, what country?
                                               (Provide copy, both sides, of green card)   E-mail Address

          ----------------------------------------------------------------------------------------------------------------

     Successor Owner:

     Do not name a successor owner if the owner and the annuitant are the same person.

          Successor Owner Name                                                             Birthdate: (MM/DD/YYYY)

          ----------------------------------------------------------------------------------------------------------------

          Relationship to Annuitant                                                        Taxpayer ID Number

          ----------------------------------------------------------------------------------------------------------------
</TABLE>

                                                                              FE
90-1900(0203)                                           90-1900-50(0203)(Page 2)

<PAGE>

5.   BENEFICIARY (upon the death of the Annuitant)

     Cannot be annuitant unless "Estate of Annuitant" named.

     [ ] See attachment - Proceed to section 6.

     Direct Beneficiary:   [ ] Owner   [ ] Other - Enter information below:

<TABLE>
<S>                                            <C>                                         <C>                        <C>
          Name                                 Taxpayer ID Number                          Relationship               %

          ---------------------------------------------------------------------------------------------------------------

          Name                                 Taxpayer ID Number                          Relationship               %

          ---------------------------------------------------------------------------------------------------------------

     Contingent Beneficiary:

          Name                                 Taxpayer ID Number                          Relationship               %

          ---------------------------------------------------------------------------------------------------------------

          Name                                 Taxpayer ID Number                          Relationship               %

          ---------------------------------------------------------------------------------------------------------------
</TABLE>

     [ ] And all (other) children, including legally adopted children, of the
         Annuitant as additional Contingent Beneficiaries.

6.   REPLACEMENT

     As a result of this purchase, will the values or benefits of any other life
     insurance policy or annuity contract, on any life, be affected in any way?
     [ ] Yes [X] No

     Note to Agent: Values or benefits are affected if any question on the
     Definition of Replacement Supplement could be answered "yes".

     Will this annuity:

     A. Replace Northwestern Mutual Life [ ] Yes [X] No

     B. Replace other companies?         [ ] Yes [X] No

     C. Result in 1035 exchange?         [ ] Yes [X] No

7.   PLAN

     Select one:

     [X] Variable Annuity - Proceed to section V1.

     [ ] Fixed Annuity - Single Premium Retirement Annuity - Proceed to section
         F1.

                                                                              FE
90-1900(0203)                                           90-1900-50(0203)(Page 3)

<PAGE>

VARIABLE ANNUITY SECTION

V1.  TYPE

     [ ] Back-End Design - Minimum initial purchase payment for non-tax
         qualified market $5,000.

     [X] Front-End Design - Minimum initial purchase payment $10,000.

     The front-end design may provide better long term financial value than the
     back end design. Factors to consider in making a decision include the
     expected holding period of the annuity as well as anticipated liquidity
     needs.

V2.  OPTIONAL ENHANCED DEATH BENEFIT

     [ ] I elect the enhanced death benefit rider.

     There is an additional charge. Available to age 65. If this rider is not
     elected, the standard death benefit will apply. See prospectus for more
     information.

V3.  PAYMENT ALLOCATION AND OPTIONS

A.   PAYMENT ALLOCATION

     You must indicate payment allocations. Use whole percentages. Total must
     equal 100%.

     Funds

       %
       5     Select Bond

       5     Franklin Templeton International Equity

       5     Money Market

       5     Balanced

       5     Index 500 Stock

       5     Aggressive Growth Stock

       5     High Yield Bond

       5     Growth Stock

       5     Large Cap Core Stock

       5     Index 400 Stock

       5     Small Cap Growth Stock

       5     Russell Multi-Style Equity

       5     Russell Aggressive Equity

       5     Russell Non-US

       5     Russell Real Estate Securities

       5     Russell Core Bond

       5     Asset Allocation

       5     International Growth Stock

       5     T. Rowe Price Small Cap Value

       5     Cap Guardian Domestic Equity

       5     AllianceBernstein Mid Cap Value

       5     Janus Capital Appreciation

       5     T. Rowe Price Equity Income

       5     Fidelity VIP Mid Cap Portfolio

                                   Fixed Fund
                                   %
                                   20 Guaranteed Interest

                                   Fund availability subject to state approval.

                                                                              FE
90-1900(0203)                                           90-1900-50(0203)(Page 4)

<PAGE>

V3.  PAYMENT ALLOCATION AND OPTIONS (continued)

B.   OPTIONS

     You may select one of the following options:

     [ ]  Automatic Dollar-Cost Averaging

                              Amount
               I authorize $           to be transferred from the Money Market
                            ----------
               Fund:

               [ ] Monthly   [ ] Quarterly

               to the following funds:

               Funds

                 %
                     Select Bond
               -----
                     Franklin Templeton International Equity
               -----
                     Balanced
               -----
                     Index 500 Stock
               -----
                     Aggressive Growth Stock
               -----
                     High Yield Bond
               -----
                     Growth Stock
               -----
                     Large Cap Core Stock
               -----
                     Index 400 Stock
               -----
                     Small Cap Growth Stock
               -----
                     Russell Multi-Style Equity
               -----
                     Russell Aggressive Equity
               -----
                     Russell Non-US
               -----
                     Russell Real Estate Securities
               -----
                     Russell Core Bond
               -----
                     Asset Allocation
               -----
                     International Growth Stock
               -----
                     T. Rowe Price Small Cap Value
               -----
                     Cap Guardian Domestic Equity
               -----
                     AllianceBernstein Mid Cap Value
               -----
                     Janus Capital Appreciation
               -----
                     T. Rowe Price Equity Income
               -----
                     Fidelity VIP Mid Cap Portfolio
               -----

                             Fixed Fund
                               %
                                  Guaranteed Interest
                             -----
                             Fund availability subject to state approval.

     [ ]  Portfolio Re-Balancing

          Minimum contract value $10,000. Re-balancing transfers are not made to
          or from the Guaranteed Interest Fund. If you elected Guaranteed
          Interest Fund as a Payment Allocation (section V3A.), you must submit
          a Transfer & Allocate Investment Funds form (90-1854).

          I authorize re-balancing transfers to be made according to the elected
          Payment Allocations:

          [ ] Monthly         [ ] Quarterly

          [ ] Semi-Annually   [ ] Annually

                                                                              FE
90-1900(0203)                                           90-1900-50(0203)(Page 5)

<PAGE>

V4.  INITIAL PAYMENT

     METHOD OF PAYMENT

     Select one:

                               Amount
          [X] Check attached $10,000.00

                                                      Estimated Amount
          [ ] Check coming from another institution $
                                                     -----------------

          [ ] Electronic Funds Transfer (ISA/EFT) - Complete section V5.

          [ ] Multiple Contract Bill (MCB) - Required for SIMPLE IRAs. Complete
              section V5.

     IRA INFORMATION

     This section must be completed if an IRA market was selected in Section 3.
     Caution: Accurate selection is needed to assure correct tax reporting. For
     advice, consult your tax professional. Select all that apply:

          [ ] New Contributions

               .    For Roth and Traditional IRAs, enter the applicable Current
                    and Prior Tax Year(s) and the respective amount(s).

               .    For SEP and SIMPLE IRAs, always enter the current calendar
                    year as the "Current Tax Year" and the amount of the new
                    contribution as the "Current Tax Year Amount".

                         Current Tax Year       Amount
                                             $
                        ------------------    ----------
                          Prior Tax Year        Amount
                                             $
                        ------------------    ----------

          [ ] Direct Transfer - Check must be made payable as follows:
                                "Northwestern Mutual Life FBO [Name of Contract
                                Owner]."

                                Indicate the market the money is coming from.
                                Select one:

                                [ ] TDA
                                [ ] Pension/Profit Sharing/401k/Defined Benefit
                                [ ] Traditional IRA
                                [ ] Roth IRA
                                [ ] SEP
                                [ ] SIMPLE IRA - The owner has been a
                                                 participant in the employer's
                                    SIMPLE plan for: [ ] Two years or less
                                                     [ ] More than two years

          [ ]60-Day Rollover - Personal check from owner or check endorsed to
                               Northwestern Mutual Life.

                               Only if applicable, also select one:

                               [ ] Traditional IRA to Roth IRA

                               [ ] SIMPLE IRA to Traditional IRA - The owner
                                                                   has been a
                                                                   participant
                                                                   in the
                                                                   employer's
                                   SIMPLE plan for: [ ] Two years or less
                                                    [ ] More than two years

                                                                              FE
90-1900(0203)                                           90-1900-50(0203)(Page 6)

<PAGE>

V5.  SCHEDULED PAYMENTS

     You may select either ISA/EFT or MCB.                        ISA Number

     [ ]  Electronic Funds Transfer (ISA/EFT)                -------------------

          You must attach a voided check.

          Select one:

          [ ] Monthly         [ ] Quarterly

          [ ] Semi-Annually   [ ] Annually

          Attach Voided Check

              Amount               Date of First Draft (MM/DD/YYYY)
           $
            -------------------------------------------------------

            Bank Transit Number    Checking/Savings Account Number

            -------------------------------------------------------

          [ ] Checking             Bank Name

          [ ] Savings             ---------------------------------

          Bank Account Owner - Select one

          [ ] Annuitant       [ ] Other - Enter information below:

          Name: First, MI, Last                   Sex   Birthdate: (MM/DD/YYYY)

          ----------------------------------------------------------------------

          Residence Address                       City, State, Zip

          ----------------------------------------------------------------------

          Taxpayer ID Number                      Daytime Telephone Number
                                                  (     )
          ----------------------------------------------------------------------

          Signature below is authorization to the depository institution
          specified above to pay and charge named account with electronic funds
          transfers, or other form of pre-authorized check or withdrawal order
          transfers, initiated by the Northwestern Mutual Life Insurance Company
          to its own order. This authorization will remain in effect until
          revoked in writing.

                         X
                         -------------------------------
                         Signature of Bank Account Owner

     [ ]  Multiple Contract Bill (MCB)

            Amount      MCB Number    MCB Payer Name
          $
          ----------------------------------------------------------------------

                                                                              FE
90-1900(0203)                                           90-1900-50(0203)(Page 7)

<PAGE>

SIGNATURES - VARIABLE ANNUITY

The Annuitant consents to this application.

Each person signing this application declares that the answers and statements
made in this application are correctly recorded, complete and true to the best
of his or her knowledge and belief.

IT IS UNDERSTOOD AND AGREED THAT:

If the Owner is a Trustee or successor Trustee under a tax qualified plan or the
employer under a tax qualified non-trusteed plan, Northwestern Mutual Life will
be fully discharged of liability for any action taken by the Owner in the
exercise of any contract right and for all amounts paid to, or at the direction
of, the Owner and will have no obligation as to the use of the amounts. In all
dealings with the Owner, Northwestern Mutual Life will be fully protected
against the claims of every other person.

The first purchase payment will be credited on the valuation date coincident
with or next following the date both the application and the purchase payment
are received at the Home Office.

Receipt of purchase payments at a payment facility designated by Northwestern
Mutual Life will be considered the same as receipt at the Home Office.

If a Tax Qualified Employee Plan, an IRA or TDA is applied for, the Applicant
and/or Annuitant have received and reviewed the appropriate ERISA, IRA or TDA
disclosure statements.

Back-end design Variable Annuity contracts have provisions for the assessment of
withdrawal charges on withdrawals.

No agent is authorized to make or alter contracts or to waive the rights or
requirements of Northwestern Mutual Life.

I acknowledge receipt of the Prospectus or Offering Circular and Report and I
understand that all payments and values provided by this contract, when based on
the investment experience of a separate account, are variable and are not
guaranteed as to amount.

As part of required anti-money laundering programs, information has been
requested in this application, and may otherwise be requested from me, for
purposes of identity verification.

X /s/ John J. Doe                            X
-------------------------------------------  -----------------------------------
Signature of Applicant                       Signature of Annuitant
(Indicate relationship below if applicable)  (if other than Applicant)

[ ] Trustee  [ ] Employer

                                             X /s/ Norm W. Weston
                                             -----------------------------------
                                             Signature of Licensed Agent

Date (MM/DD/YYYY)   Signed at: City            County      State
08-31-03            Milwaukee                  Milwaukee   WI

                                                                              FE
90-1900(0203)                                           90-1900-50(0203)(Page 8)

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