Document:

EXHIBIT 4(C)

 EXHIBIT (4)(c) 

FORM OF POLICY RIDER (RIC 1.5) 

			
	
 

  
	  	 Home Office located at:

	  	 440 Mamaroneck Avenue, Harrison, New York 10528

	  	 Adm. Office located at:

	  	 4333 Edgewood Road N.E. Cedar Rapids, Iowa 52499

	 A Stock Company (Hereafter called the Company, we, our or us)
	  	 (319) 355-8511

RETIREMENT INCOME CHOICE® 1.5 RIDER 
 This rider is issued as a part of the policy (contract) to which it is attached. 

All provisions of the policy that do not conflict with this rider apply to this rider. In the event of any conflict between the
provisions of this rider and the provisions of the policy, the provisions of this rider shall prevail over the provisions of the policy. 
 Rider Data Specification 
  

											
	 Policy Number:
	 		  		 	12345	 		 	
	 Rider Date:
	 		  		 	03/01/201	 		 	
	 Growth Rate Percentage:
	 		  		 	5.00%	 		 	
						
	 Initial Rider Fee Percentages:
	 		  		 		 		 	
	 Designated Allocation Model A:
	 		  		 	1.40%	 		 	
	 Designated Allocation Model B:
	 		  		 	1.00%	 		 	
	 Designated Allocation Model C:
	 		  		 	0.45%	 		 	
						
	 Annuitant:
	 		  		 	John Doe	 		 	
						
	 Annuitant’s Issue Age/Sex:
	 		  		 	65    /    Male	 		 	

  
  

ARTICLE I 

You may cancel this rider on or before midnight of the thirtieth calendar day after you received it and no rider fees will be
assessed. 
 This rider provides a minimum withdrawal benefit that guarantees, upon election, a series of withdrawals
from the policy equal to the Withdrawal Percentage shown in Article III applied to the withdrawal base. The withdrawal base is established for the sole purpose of determining the minimum withdrawal benefit and is not used in calculating the cash
surrender value or other guaranteed benefits. 
 If you elect this rider, 100% of your policy value must be invested in one
of the designated allocation models, designated for use with this rider. 
 You can generally transfer between the designated
allocation models as permitted under your policy; however, you cannot allocate policy value to a subaccount outside of the designated allocation models while this rider is in force. If the designated allocation model in which your policy value is
allocated is no longer available, you will be required to reallocate 100% of your policy value from that allocation model to a different designated allocation model in order to keep the guarantees of this rider. Failure to reallocate to a different
designated allocation model will result in termination of this rider, as described in Article IV. Also, if you wish to transfer any of your policy value to a subaccount option outside of the designated allocation models, you must terminate this
rider prior to making the transfer. 
 The Company will automatically rebalance amounts among subaccounts within the designated
allocation models to maintain the allocations of the policy value among the required subaccounts. Rebalancing will occur on a monthly basis. Failure to be enrolled in monthly asset rebalancing can result in termination of this rider. You will be
given 30 days written notice and the opportunity to re-enroll in asset rebalancing before termination. The dollar cost averaging option is not available with this rider. 
 DEFINITIONS: 
 Terms used that are not defined in this rider shall have the same meaning as
those in your policy. 
 Designated Allocation Models 
 Asset allocation models authorized for use with this rider and identified by us as designated allocation models. 
 Excess Withdrawal 
 The excess of a gross partial withdrawal over the rider withdrawal
amount remaining prior to the withdrawal, if any. 

  

					
	RGMB 42 0511 (IS)(NY)	  	(1)	  	(Income-Single)

 ARTICLE I CONTINUED 
 Gross Partial Withdrawal 
 The amount that will be deducted from your policy value as a
result of each partial withdrawal. 
 Rider Anniversary 
 The anniversary of the rider date. 
 Rider Fee 

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

Rider Monthiversary 

The same calendar day of the month as the rider date, or the next business day if our Administrative Office or the New York Stock
Exchange is closed. If a certain date does not exist in a given month, the first day of the following month will he used. 
 Rider Quarter

 Each three-month period beginning on the rider date. 
 Rider Quarterversary 
 The same calendar day of each rider quarter as the
rider date, or the next business day if our Administrative Office or the New York Stock Exchange is closed. If a certain date does not exist in a given month, the first day of the following month will be used. 

Rider Withdrawal Amount 

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

Each twelve-month period following the rider date. 
 Withdrawal Base 
 The amount used to calculate the rider withdrawal amount
and the rider fee. This amount has no cash value and cannot be taken as a lump sum. 
 ARTICLE II 

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

Multiply (1) by (2) by (3). 
  

	1)	 Withdrawal Base; 

  

	2)	 Designated allocation model rider fee percentage (based upon the designated allocation model chosen at the time of the quarterly fee calculation):

  

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

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

  

					
	RGMB 42 0511 (IS)(NY)	  	(2)	  	(Income-Single)

 ARTICLE III 
 GUARANTEED LIFETIME WITHDRAWAL BENEFIT 
 Under this rider, we guarantee
that you can receive up to the rider withdrawal amount each rider year. regardless of the policy value, (first as withdrawals from your policy value and, if necessary, as payments from us) until the annuitant’s death. 

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

			
	 Attained Age
	  	 Withdrawal

Percentage

		
	 59 - 64
	  	4.0%
	 65 - 74
	  	5.0%
	 75 +
	  	6.0%

 If the annuitant is
not yet 59 on the rider date, the withdrawal percentage will be zero until the rider anniversary following the annuitant’s 59th birthday. Withdrawals prior to age 59 1/2 may be subject to the 10% penalty tax. 

Withdrawals will reduce the policy value of the policy to which this rider is attached. If the policy value equals zero, you cannot make
subsequent premium payments and all other policy features, benefits and guarantees are no longer available. Also, if the policy value equals zero, you will need to request payments by selecting the amount and frequency in accordance with the policy
provisions to which this rider attaches, equal to the rider withdrawal amount. Once the payment amount and frequency are established, they cannot be changed and no additional withdrawals will be allowed. 

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

 Example 

Assume you are the owner and annuitant and begin taking withdrawals at age 59 and your Withdrawal Base is $100,000. Assuming a withdrawal
percentage of 4%, you could withdraw up to $4,000 each rider year for the rest of your life (assuming that you do not withdraw more than $4,000 in any one rider year). 
 Any amount you withdraw in excess of the rider withdrawal amount may impact the withdrawal base on a greater than dollar-for-dollar basis. 

The Guaranteed Lifetime Withdrawal Benefit can only be taken as a withdrawal benefit and it does not increase the policy value.

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

  

					
	RGMB 42 0511 (IS)(NY)	  	(3)	  	(Income-Single)

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

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

 

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

 

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

  

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

 

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

  

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

  

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

 

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

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

 If you withdraw less than the rider withdrawal amount in a rider year, the unused portion cannot be carried over to the next
rider year. 
 WITHDRAWAL BASE 
 The withdrawal base is used to calculate the rider withdrawal amount. On the rider date, the initial withdrawal base is equal to the policy value (less any premium enhancements if the rider is added in
the first policy year). During any rider year, the withdrawal base is increased by subsequent premium payments (not including premium enhancements, if any), and is reduced for excess withdrawals. 

On each rider anniversary, the withdrawal base will be set to the greatest of: 

 

	 	1)	 The current withdrawal base; 

  

	 	2)	 The policy value on the rider anniversary; 

  

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

 

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

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

 The rider receives an automatic step-up on the rider anniversary if the withdrawal base is set equal to the policy value
or the highest policy value on a rider monthiversary. This feature does not require the termination of the existing rider. This rider will continue with the same rider date and features. The rider fee may change and the withdrawal percentage may
increase due to an automatic step-up. Beginning with the first rider anniversary, the rider fee percentage may be increased if there is an automatic step-up, but will not increase more than 0.75% from the initial rider fee percentages shown on page
1. 
 You have the right to reject an automatic step-up within 30 days following a rider anniversary, if the rider fee
percentage increases. If you reject an automatic step-up, you must notify us a manner which is acceptable to us, however you are eligible for future automatic step-ups. Changes as a result of the automatic step-up feature will be reversed. Any
increase in the rider fee or withdrawal percentages will also be reversed. 

  

					
	RGMB 42 0511 (IS)(NY)	  	(4)	  	(Income-Single)

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

  

	1)	 is the excess withdrawal amount; and 

  

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

 

	 	A)	 is the excess withdrawal; 

  

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

 

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

 ARTICLE IV 
 CONTINUATION 
 In the case of spousal joint owners where one spouse is the
annuitant, if the spouse who is not the annuitant dies and the surviving spouse is the sole beneficiary, the rider continues. In the case of spousal joint owners where one spouse is the annuitant, if the spouse who is the annuitant dies, this rider
will terminate. 
 In the case of non-spousal joint owners where an owner who is not the annuitant dies, the surviving owner
(who is also the sole designated beneficiary) may elect to receive lifetime income payments under this rider instead of receiving any benefits applicable to the policy. The lifetime income payments must begin no later than 1 year after the
owner’s death and will be equal to the rider withdrawal amount divided by the number of payments made per year. Once the payments begin, no additional premium payments will be accepted and no additional withdrawals will be allowed. 

ANNUITIZATION 
 On the
maximum annuity commencement date, as described in your policy, you will have the option to receive lifetime income payments that are no less than your rider withdrawal amount each year. 
 TERMINATION 
 This rider will terminate upon the earliest of: 

 

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

 

	2)	 the date of the annuitant’s death; 

  

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

 

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

  

	5)	 the date any of your policy value is not invested in one of the designated allocation models. 

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

Signed for us at our home office. 
  

			
	
 

	  	

 

		
	 SECRETARY
	  	PRESIDENT

  

					
	RGMB 42 0511 (IS)(NY)	  	(5)	  	(Income-Single)

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

	1)	 Withdrawal Base 

  

	2)	 Designated allocation model rider fee percentage (based upon the designated allocation model chosen at the time of the quarterly fee calculation)

  

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

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

Multiply (1) by (2) by (3) where: 
  

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

 

	2)	 Designated allocation model rider fee percentage (based upon the designated allocation model chosen at the time of the transaction)

  

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

The fee adjustment for a change between Designated Allocation Models is calculated as follows: 
 Multiply (1) by (2) by (3) where: 
  

	1)	 Withdrawal base 

  

	2)	 Designated allocation model fee percentage after the change minus designated allocation model fee percentage prior to the change

  

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

The following progressive examples assume an annualized rider fee percentage of 1.40%. The assumed rider year is not a leap year.

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

= 100,000 * 0.0140 * (91/365) 
 = 1,400 * (91/365) 
 = $349.04 

Example 2: Calculation for first quarter fee assuming initial withdrawal base from Example 1 above, plus adjustment for additional
premium payment of $10,000 made with 20 days remaining in the first rider quarter. The withdrawal base change equals $10,000. 
 Fee adjustment
as follows: 
 = 10,000 * 0.0140 * (20/365) 

= 140 * (20/365) 
 = $7.67 
 Total fee assessed on first rider quarterversary (assuming no further rider fee
adjustments): 
 = 7,67 + 349.04 

= $356.71 

  

					
	RGMB 42 0511 (IS)(NY)	  	(A-1)	  	(Income-Single)

 Example 3: Calculation for second quarter rider fee at beginning of second rider
quarter, assuming withdrawal base of $110,000. 
 = 110,000 0.0140 * (91/365) 

= 1,540 * (91/365) 
 = $383.95 
 Example 4: Calculation for second quarter fee from Example 3
above, plus adjustment for partial withdrawal of $10,000 taken with 40 days remaining in the second rider quarter. Assumes withdrawal percentage of 5%, policy value of $97,000 prior to the transaction and pre-transaction withdrawal base of $110,000.
Change in withdrawal base calculated as follows: 
 Rider Withdrawal Amount (RWA) = Withdrawal Base * Withdrawal Percentage = 110,000 * .05 =
$5,500 
 Excess Withdrawal = Difference between assumed withdrawal amount and RWA = 10,000 - 5,500 = $4,500 

Withdrawal Base Adjustment Max = (Excess Withdrawal, Excess Withdrawal * Withdrawal Base prior to withdrawal / Policy Value after RWA has
been withdrawn but before excess withdrawal) = Max [4,500, 4,500 * 110,000 / (97,000-5,500) = Max (4,500, 5,409.84) = $5,409.84 
 Fee
adjustment as follows: 
 = -5,409.84 * 0.0140 * (40/365) 

= -75.74 * (40/365) 
 =$-8.30 
 Total fee assessed on second rider quarterversary (assuming no further rider fee
adjustments): 
 = 383.95 - 8.30 

= $375.65 
 The
new Withdrawal Base = $110,000 - $5,409.84 = $104,590.16 
 Example 5: Calculation for third quarter fee assuming
election to change from designated allocation model A to designated allocation model B with 40 days remaining in the rider quarter. The assumed rider year is not a leap year. Assumed withdrawal base of $104,590.16 and policy value of $95,000
transferred to the following investment allocations: 
  

									
	 Designated Allocation Model
	    	Fee	 	    	Fund Transfer	 
	 A
	    	 	1.40	% 	    	$	-95,000	  
	 B
	    	 	1.00	% 	    	$	95,000	  
	 C
	    	 	0.45	% 	    	$	0.00	  

 Rider fee calculation at beginning of
rider quarter: 
 =104,590.16 * 0.0140 * (91/365) 

= 1,464.26 * (91/365) 
 = $365.06 
 Fee adjustment as follows: 

=104,590.16 * (0.010 - 0.0140) * (40/365) 

= 104,590.16 * (-0.004) * (40/365) 

= -418.36 * (40/365) 
 = $-45.85 
 Total fee assessed on third rider quarterversary (assuming no further rider fee
adjustments): 
 = 365.06 - 45.85 

= $319.21 

  

					
	RGMB 42 0511 (IS)(NY)	  	(A-2)	  	(Income-Single)

			
	
 

  
	  	 Home Office located at:

	  	 440 Mamaroneck Avenue, Harrison, New York 10528

	  	 Adm. Office located at:

	  	 4333 Edgewood Road N.E. Cedar Rapids, Iowa 52499

	 A Stock Company (Hereafter called the Company, we, our or us)
	  	 (319) 355-8511

RETIREMENT INCOME CHOICE® 1.5 RIDER 
 This rider is issued as a part of the policy (contract) to which it is attached. 

All provisions of the policy that do not conflict with this rider apply to this rider. In the event of any conflict between the
provisions of this rider and the provisions of the policy, the provisions of this rider shall prevail over the provisions of the policy. 
 Rider Data Specification 
  

											
	 Policy Number:
	 		  		 	12345	  		  	
	 Rider Date:
	 		  		 	03/01/2011	  		  	
	 Growth Rate Percentage:
	 		  		 	5.00%	  		  	
						
	 Initial Rider Fee Percentages:
	 		  		 		  		  	
	 Designated Allocation Model A:
	 		  		 	1.40%	  		  	
	 Designated Allocation Model B:
	 		  		 	1.00%	  		  	
	 Designated Allocation Model C:
	 		  		 	0.45%	  		  	
						
	 Annuitant:
	 		  		 	John Doe	  		  	
						
	 Annuitant’s Issue Age/Sex:
	 		  		 	65    /    Male	  		  	
	 Annuitant’s Spouse:
	 		  		 	Jane Doe	  		  	
	 Annuitant’s Spouse’s Issue Age/Sex:
	 		  		 	65    /    Female	  		  	

  
  

ARTICLE I 

You may cancel this rider on or before midnight of the thirtieth calendar day after you received it and no rider fees will be
assessed. 
 This rider provides a minimum withdrawal benefit that guarantees, upon election, a series of withdrawals
from the policy equal to the Withdrawal Percentage shown in Article III applied to the withdrawal base. The withdrawal base is established for the sole purpose of determining the minimum withdrawal benefit and is not used in calculating the cash
surrender value or other guaranteed benefits. 
 If you elect this rider, 100% of your policy value must be invested in one
of the designated allocation models, designated for use with this rider. 
 You can generally transfer between the designated
allocation models as permitted under your policy; however, you cannot allocate policy value to a subaccount outside of the designated allocation models while this rider is in force. If the designated allocation model in which your policy value is
allocated is no longer available, you will be required to reallocate 100% of your policy value from that allocation model to a different designated allocation model in order to keep the guarantees of this rider. Failure to reallocate to a different
designated allocation model will result in termination of this rider, as described in Article IV. Also, if you wish to transfer any of your policy value to a subaccount option outside of the designated allocation models, you must terminate this
rider prior to making the transfer. 
 The Company will automatically rebalance amounts among subaccounts within the designated
allocation models to maintain the allocations of the policy value among the required subaccounts. Rebalancing will occur on a monthly basis. Failure to be enrolled in monthly asset rebalancing can result in termination of this rider. You will be
given 30 days written notice and the opportunity to re-enroll in asset rebalancing before termination. The dollar cost averaging option is not available with this rider. 
 The annuitant’s spouse as of the rider date is hereafter referred to as the annuitant’s spouse. As it pertains to the benefits of this rider, the annuitant’s spouse cannot be changed. The
annuitant’s spouse must be the sole primary beneficiary and/or a joint owner. The only living owners allowed on the policy to which this rider is attached are the annuitant and the annuitant’s spouse. 

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

  

					
	RGMB 42 0511 (IJ)(NY)	  	(1)	  	(Income-Joint)

 ARTICLE I CONTINUED 
 Designated Allocation Models 
 Asset allocation models authorized for use with this rider
and identified by us as designated allocation models. 
 Excess Withdrawal 
 The excess of a gross partial withdrawal over the rider withdrawal amount remaining prior to the withdrawal, if any. 
 Gross Partial Withdrawal 
 The amount that will be deducted from your policy value as a
result of each partial withdrawal. 
 Rider Anniversary 
 The anniversary of the rider date. 
 Rider Fee 

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

Rider Monthiversary 

The same calendar day of the month as the rider date, or the next business day if our Administrative Office or the New York Stock
Exchange is closed. If a certain date does not exist in a given month, the first day of the following month will be used. 
 Rider Quarter

 Each three-month period beginning on the rider date. 
 Rider Quarterversary 
 The same calendar day of each rider quarter as the
rider day, or the next business day if our Administrative Office or the New York Stock Exchange is closed. If a certain date does not exist in a given month, the first day of the following month will be used. 

Rider Withdrawal Amount 

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

Each twelve-month period following the rider date. 
 Withdrawal Base 
 The amount used to calculate the rider withdrawal amount
and the rider fee. This amount has no cash value and cannot be taken as a lump sum. 
 ARTICLE II 

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

Multiply (1) by (2) by (3). 
  

	1)	 Withdrawal base: 

  

	2)	 Designated allocation model rider fee percentage (based upon the designated allocation model chosen at the time of the quarterly fee calculation):

  

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

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

  

					
	RGMB 42 0511 (IJ)(NY)	  	(2)	  	(Income-Joint)

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

			
	 Attained Age
	  	 Withdrawal

Percentage

		
	 59 - 64
	  	3.5%
	 65 - 74
	  	4.5%
	 75 +
	  	5.5%

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

Assume the younger of the annuitant and the annuitant’s spouse is 59 and withdrawals begin and your Withdrawal Base
is $100,000. Assuming a withdrawal percentage of 3.5%, you could withdraw up to $3,500 each rider year until the annuitant’s or the annuitant’s spouse’s death, which ever is later (assuming that you do not withdraw more than $3,500 in
any one rider year). 
 Any amount you withdraw in excess of the rider withdrawal amount may impact the withdrawal base on a
greater than dollar-for-dollar basis. 
 The Guaranteed Lifetime Withdrawal Benefit can only be taken as a withdrawal benefit
and it does not increase the policy value. 
 ISSUE AGE AND SURVIVAL 

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

  

					
	RGMB 42 0511 (IJ)(NY)	  	(3)	  	(Income-Joint)

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

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

 

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

 

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

  

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

 

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

  

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

  

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

 

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

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

 If you withdraw less than the rider withdrawal amount in a rider year, the unused portion cannot be carried over to the next
rider year. 
 WITHDRAWAL BASE 
 The withdrawal base is used to calculate the rider withdrawal amount. On the rider date, the initial withdrawal base is equal to the policy value (less any premium enhancements if the rider is added in
the first policy year). During any rider year, the withdrawal base is increased by subsequent premium payments (not including premium enhancements, if any), and is reduced for excess withdrawals. 

On each rider anniversary, the withdrawal base will be set to the greatest of: 

 

	 	1)	 The current withdrawal base; 

  

	 	2)	 The policy value on the rider anniversary; 

  

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

 

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

Item 3) above will be zero if there have been any excess withdrawals in the current rider year. Item 4) above will be zero
after the l0th rider anniversary or if there have been any withdrawals in the current rider year. 
 AUTOMATIC STEP-UP FEATURE

 The rider receives an automatic step-up on the rider anniversary if the withdrawal base is set equal to the policy value
or the highest policy value on a rider monthiversary. This feature does not require the termination of the existing rider. This rider will continue with the same rider date and features. The rider fee may change and the withdrawal percentage may
increase due to an automatic step-up. Beginning with the first rider anniversary, the rider fee percentage may be increased if there is an automatic step-up, but will not increase more than 0.75% from the initial rider fee percentages shown on page
1. 
 You have the right to reject an automatic step-up within 30 days following a rider anniversary, if the rider fee
percentage increases. If you reject an automatic step-up, you must notify us in a manner which is acceptable to us, however you are eligible for future automatic step-ups. Changes as a result of the automatic step-up feature will be reversed. Any
increase in the rider fee or withdrawal percentages will also be reversed. 

  

					
	RGMB 42 0511 (IJ)(NY)	  	(4)	  	(Income-Joint)

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

  

	1)	 is the excess withdrawal amount; and 

  

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

 

	 	A)	 is the excess withdrawal; 

  

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

 

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

 ARTICLE IV 
 CONTINUATION 
 In the case of spousal joint owners where one spouse is the
annuitant, if the spouse who is not the annuitant dies and the surviving spouse is the sole beneficiary, the rider continues. In the case of spousal joint owners where one spouse is the annuitant, if the spouse who is the annuitant dies and the
surviving spouse is the sole beneficiary, the rider continues if the policy to which this rider is attached is continued until the death of the surviving spouse. 
 ANNUITIZATION 
 On the maximum annuity commencement date, as described in
your policy, you will have the option to receive lifetime income payments that are no less than your rider withdrawal amount each year. 

TERMINATION 
 This rider will terminate
upon the earliest of: 
  

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

 

	2)	 the later of the annuitant’s or annuitants spouse’s death; 

 

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

 

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

  

	5)	 the date any of your policy value is not invested in one of the designated allocation models. 

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

Signed for us at our home office. 
  

			
	
 

  
	  	

 
  

	 SECRETARY
	  	PRESIDENT

  

					
	RGMB 42 0511 (IJ)(NY)	  	(5)	  	(Income-Joint)

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

	1)	 Withdrawal Base 

  

	2)	 Designated allocation model rider fee percentage (based upon the designated allocation model chosen at the time of the quarterly fee calculation)

  

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

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

Multiply (1) by (2) by (3) where: 
  

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

 

	2)	 Designated allocation model rider fee percentage (based upon the designated allocation model chosen at the time of the transaction)

  

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

The fee adjustment for a change between Designated Allocation Models is calculated as follows: 
 Multiply (1) by (2) by (3) where: 
  

	1)	 Withdrawal base 

  

	2)	 Designated allocation model fee percentage after the change minus designated allocation model fee percentage prior to the change

  

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

The following progressive examples assume an annualized rider fee percentage of 1.40%. The assumed rider year is not a leap year.

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

= 100,000 * 0.0140 * (91/365) 
 = 1,400 * (91/365) 
 = $349.04 

Example 2: Calculation for first quarter fee assuming initial withdrawal base from Example 1 above, plus adjustment for additional
premium payment of $10,000 made with 20 days remaining in the first rider quarter. The withdrawal base change equals $10,000. 
 Fee adjustment
as follows: 
 = 10,000 * 0.0140 * (20/365) 

= 140 * (20/365) 
 = $7.67 
 Total fee assessed on first rider quarterversary (assuming no further rider fee
adjustments): 
 = 7.67 + 349.04 

= $356.71 

  

					
	RGMB 42 0511 (IJ)(NY)	  	(A-1)	  	(Income-Joint)

 Example 3: Calculation for second quarter rider fee at beginning of second rider
quarter, assuming withdrawal base of $110,000. 
 = 110,000*0.0140 * (91/365) 

= 1,540 * (91/365) 
 = $383.95 
 Example 4: Calculation for second quarter fee from Example 3
above, plus adjustment for partial withdrawal of $10,000 taken with 40 days remaining in the second rider quarter. Assumes withdrawal percentage of 5%, policy value of $97,000 prior to the transaction and pre-transaction withdrawal base of $110,000.
Change in withdrawal base calculated as follows: 
 Rider Withdrawal Amount (RWA) = Withdrawal Base * Withdrawal Percentage = 110,000 * .05 =
$5,500 
 Excess Withdrawal = Difference between assumed withdrawal amount and RWA = 10,000 - 5,500 = $4,500 

Withdrawal Base Adjustment = Max (Excess Withdrawal, Excess Withdrawal * Withdrawal Base prior to withdrawal / Policy Value after RWA has
been withdrawn but before excess withdrawal) = Max [4,500, 4,500 * 110,000 / (97,000-5,500)] = Max (4,500, 5,409.84) = $5,409.84 
 Fee
adjustment as follows: 
 = -5,409.84 * 0.0140 * (40/365) 

= -75.74 * (40/365) 
 =$-8.30 
 Total fee assessed on second rider quarterversary (assuming no further rider fee
adjustments): 
 = 383.95 - 8.30 

= $375.65 
 The
new Withdrawal Base = $110,000 - $5,409.84 = $104,590.16 
 Example 5: Calculation for third quarter fee assuming
election to change from designated allocation model A to designated allocation model B with 40 days remaining in the rider quarter. The assumed rider year is not a leap year. Assumed withdrawal base of $104,590.16 and policy value of $95,000
transferred to the following investment allocations: 
  

									
	 Designated Allocation Model
	  	Fee	 	 	Fund Transfer	 
	 A
	  	 	1.40	% 	 	$	-95,000	  
	 B
	  	 	1.00	% 	 	$	95,000	  
	 C
	  	 	0.45	% 	 	$	0.00	  

 Rider fee calculation at beginning of
rider quarter: 
 = 104,590.16 * 0.0140 * (91/365) 

= 1,464.26 * (91/365) 
 = $365.06 
 Fee adjustment as follows: 

=104,590.16 * (0.010 - 0.0140) * (40/365) 

= 104,590.16 * (-0.004) * (40/365) 

= -418.36 * (40/365) 
 = $-45.85 
 Total fee assessed on third rider quarterversary (assuming no further rider fee
adjustments): 
 = 365.06 - 45.85 

= $319.21 

  

					
	RGMB 42 0511 (IJ)(NY)	  	(A-2)	  	(Income-Joint)EXHIBIT 4(A)

 EXHIBIT (4)(a)
 FORM OF POLICY 

			
	
 

  
 Policy Number: 12345
	  	 Home Office located at:
 440
Mamaroneck Avenue, Harrison, New York 10528
 Adm. Office located at:
 4333 Edgewood Road N.E. Cedar Rapids, Iowa 52499
 (319) 355-8511

This is a legal contract between the Owner and Transamerica Financial Life Insurance Company, a Stock Company (Hereafter called the Company, we, our
or us.) The Company will provide annuity and other benefits as set out in this annuity policy, subject to its provisions. This annuity policy is delivered in, and is governed by the laws of. the State of New York. 

 

 WE AGREE 

 

	 	•	 	 To provide annuity payments as set forth in Section 10 of this policy; 

 

	 	•	 	 To pay withdrawal benefits in accordance with Section 5 of this policy; 

 

	 	•	 	 To pay death proceeds in accordance with Section 9 of this policy. 

 This contract permits the accumulation of funds on a tax—deferred basis and provides a periodic annuity payment for the life of the Annuitant or for a certain period of time, or a combination of
both, Payments start on the Annuity Commencement Date. 
 The smallest annual rate of investment return that would have to be earned on the
assets of the Separate Account so that the dollar amount of variable Annuity Payments will not decrease is 6.50%. 
 Prior to the Annuity
Commencement Date, a daily charge corresponding to an annual charge of no more than 1.85% for the Policy Value death benefit option (2.05% for the Return of Premium death benefit option and 2.25% for the Annual Step-Up death benefit option), is
applied by the Company to the assets of the Separate Account. The corresponding annual charge after the Annuity Commencement Date is no more than 1.50% regardless of death benefit option elected prior to the Annuity Commencement Date. The amounts
applicable to this policy are shown on the Policy Data page. In addition, a maximum annual Service Charge of $35 is assessed (prior to the Annuity Commencement Date only) on each Policy Anniversary. However, the Service Charge will not be deducted
on a Policy 

 Anniversary if, (1) the sum of all premium payments less the sum of all Withdrawals taken equals or
exceeds $50,000; or (2) the Policy Value equals or exceeds $50,000. 
 See the “Service Charge” provision in Section 4 and
the “Charges and Deductions” provision in Section 6 of this contract for more details This contract is issued in consideration of the application and payment of the initial premium as provided. This contract may be applied for and
issued to qualify as a tax-qualified annuity under the applicable sections of the Internal Revenue Code. 
 20 DAY RIGHT TO
CANCEL 
 You may cancel this policy by delivering or mailing a written notice to us or Your agent You must return the policy before
midnight of the twentieth day after the day You receive it Notice given by mail and return of the policy by mail are effective upon being mailed, properly addressed and postage prepaid. We will return the Fixed Account premium and the Policy Value
of the Separate Account including any fees and charges, within 10 days after we receive notice of cancellation and the returned policy. 
 If
this policy is a replacement of another policy, the Right to Cancel period is extended to 60 days and we will return the Fixed Account premium and the Policy Value of the Separate Account, including any fees and charges, for this policy within 10
days after we receive notice of cancellation and the returned policy. 

 

 

 Signed for us at our home office. 

 

									
		 	

	 		 	

	 	
		 	SECRETARY	 		 	PRESIDENT	 	

 This policy is a legal contract between the Owner and the Company. 

READ YOUR POLICY CAREFULLY. 
 Flexible Premium Deferred Variable Annuity 
 Income Payable At Annuity Commencement
Date 
 Benefits Based On The Performance Of The Separate Account Are Variable And Are Not 

Guaranteed As To Dollar Amount And Will Increase Or Decrease In Value Based Upon 

Investment Experience (See Sections 6 and IOC) 
 Non-Participating 
 AFTER THE POLICY DATE, WE RESERVE THE RIGHT TO (I) REFUSE
PREMIUM PAYMENTS TO 
 THE FIXED ACCOUNT, AND (II) PROHIBIT TRANSFERS TO THE FIXED ACCOUNT 

  

					
	AV1396 101 179 1003	  		  	

 SECTION 1 – DEFINITIONS 
  

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

ANNUITY COMMENCEMENT DATE - The Date the Annuitant will begin receiving payments from this policy. You may change the Annuity Commencement Date at
any time by giving us 30 days written notice. In no event can this date be later than the last day of the month following the month in which the Annuitant attains age 95. The Annuity Commencement Date may not be scheduled at issue to be earlier than
the first day of the calendar month coinciding with or next following the first Policy Anniversary. 
 CASH VALUE - Amount defined in
Section 5 that is available for partial or full Surrenders. 
 CUMULATIVE EARNINGS - An amount equal to the Policy Value at the time
a lump sum payout or systematic payout option payout is made, minus the sum of all premium payments reduced by all prior partial Withdrawals deemed to have been from premium, if any. 
 DISTRIBUTION - A Withdrawal or disbursement of funds from the Policy Value or Cash Value. Policy Value and Cash Value will be reduced by any Distribution. 

EARNINGS - The gains, if any, in the Policy Value. 
 FIXED ACCOUNT GUARANTEED MINIMUM EFFECTIVE ANNUAL INTEREST RATE - The minimum guaranteed credited rate used to determine the Fixed Account portion of Your Policy Value prior to the Annuity
Commencement Date. This rate will apply for the life of the policy and is shown on the Policy Data page. 
 GAINS - Cumulative Earnings,
if any, in the Policy Value. 
 HOSPITAL - An institution which 1) is operated pursuant to the laws of the jurisdiction in which it is
located, 2) operates primarily for the care and treatment of sick and injured persons on an inpatient basis, 3) provides 24-hour nursing service by or under the supervision of registered graduate professional nurses, 4) is supervised by a staff of
one or more licensed physicians, and 5) has medical, surgical and diagnostic facilities or access to such facilities. 
 INCOME OPTIONS -
Options through which the distribution of the Policy Value can be directed. 
 INVESTMENT OPTIONS - The one-year Guaranteed Period Option
of the Fixed Account the Dollar Cost Averaging Fixed Account Option, and any of the Subaccounts of the Separate Account 
 NURSING CARE -
Care prescribed by a physician and performed or supervised by a registered graduate nurse. Such care includes nursing and rehabilitation services available 24 hours.

 NURSING FACILITY - A facility which 1) is operated pursuant to the laws of the jurisdiction in which
it is located, 2) provides care prescribed by a physician and performed or supervised by a registered graduate nurse on a 24 hour basis, or provides care designed essentially to help a person with the activities of daily living that require the
continuous attention of trained medical or paramedical personnel, and 3) is not other than incidentally, a hospital, a retirement home, a rest home, a community living center or a place mainly for the treatment of alcoholism, mental illness, or drug
abuse. 
 PAYEE - The person to whom annuity payments will be made. 
 POLICY ANNIVERSARY - The anniversary of the Policy Date for each year the policy remains in force. 
 POLICY DATE - The date shown on the Policy Data page of this policy and the date on which this policy becomes effective. 
 POLICY VALUE - Amount defined in Section 4, that can be used to fund one of the Income Options. 
 POLICY YEAR - The 12-month period following the Policy Date shown on the Policy Data page. The first Policy Year starts on the Policy Date. Each subsequent year starts on the anniversary of the
Policy Data 
 SEPARATE ACCOUNT - The separate investment account(s) established by us, as described in Section 6. The investment
performance of the Separate Account is independent of the performance of the general assets of the Company. 
 SUBACCOUNT - A division of
the Separate Account which invests in shares of one Portfolio. The investment performance of each Subaccount is directly linked to the investment performance of the corresponding Portfolio, as described in Section 6. SURRENDER - A partial or
full Withdrawal of funds from the Policy Value or Cash Value. 
 WITHDRAWAL - A distribution of funds from the Policy Value or Cash
Value. 
 YOU, YOUR - The Owner of this policy. Unless otherwise specified on the Policy Data page. the Annuitant and the Owner shall be
one and the same person. If the Owner is a trust and the trust allows any person(s) other than the trustee to exercise ownership rights under the policy, then such person(s) must be named as the Annuitant, as applicable. The Owner, while living,
controls all rights and benefits under the policy. 

 

  

					
	AV1396 101 179 1003	  	Page 2	  	AVB1396

 SECTION 2 – POLICY DATA 
  
  

									
	POLICY NUMBER:	  	12345	  		  	ANNUITANT:	  	John Doe
					
	INITIAL PREMIUM PAYMENT:	  	$5.000.00	  		  	ISSUE AGE/SEX:	  	35 / Male
					
	POLICY DATE:	  	February 1, 2011	  		  	OWNER(S):	  	John Doe
					
	ANNUITY COMMENCEMENT DATE:	  	March 31, 2071	  		  		  	
		  		  		  	DEATH BENEFIT OPTION:	  	Policy Value
	BENEFICIARY:	  	Jane Doe	  		  		  	

 Initial Effective Annual Interest Rate Credited to the Fixed Account 1.50% 

Fixed Account Guaranteed Minimum Effective Annual Interest Rate:* 1.50% 
  

	*	This interest rate applies for the life of the policy. 

 After the policy date, we reserve the right to (l) refuse premium payments to the Fixed Account and (II) prohibit transfers to the Fixed Account. 
 The credited interest rate for the Dollar Cost Averaging Fixed Account will never be less than the Fixed Account Guaranteed Minimum Annual Interest Rate shown above. 

The minimum initial premium payment is $5,000 for nonqualified and $1,000 for qualified. 
 The maximum total premium payments which we will accept without prior approval is $1,000,000 for issue ages 0-80, $500,000 for issue ages 81 and older. 

Before the Annuity Commencement Date: 

Service Charge: Annual charge equal to the lesser of 2% of the Policy Value or $35. 

Mortality and Expense Risk Fee and Administrative Charge: 0.45% 
 After the Annuity Commencement Date: 
 Mortality and Expense Risk Fee and
Administrative Charge: 0.45% 

  

					
	AV1396 101 179 IOO3SP (PV) (R)	  	Page 3	  	

 SECTION 3 – PREMIUM PAYMENTS 

 

 

 PAYMENT OF PREMIUMS 
 Premium payments may be made any time while this policy is in force before the Annuity Commencement Date. You may start or stop, increase or decrease, or skip any premium payments. We reserve the right to
prohibit premium payments to the Fixed Account options described in Section 7 after the Policy Date. We will provide 30 days advance written notice of this decision. We will also provide timely written notification to You once any such
prohibition of premiums to the Fixed Account is no longer in effect 
 MAXIMUM AND MINIMUM PREMIUM PAYMENT 

The premium payments may not be more than the amount permitted by law if this is a tax - qualified annuity. The minimum initial premium payment is $5,000.
If this policy is being used as a tax – qualified annuity, the minimum initial premium is $1,000, except that no minimum initial premium payment will be required for 403(b) annuities The minimum subsequent premium payment we will accept is $50.
The maximum total premium payments which we will accept without prior Company approval is $1,000,000 for issue ages 0 -80, $500,000 for issue ages 81 and older 
 If premium payments are discontinued, the Policy Value at the cessation of premium payments will be held by us and the Fixed Account portion of the policy will continue to be credited with at least the
Fixed Account Guaranteed Minimum Effective Annual Interest Rate provided in this policy. We may declare a higher rate in advance, Any portion of the Policy Value that is allocated to the Subaccounts of the Separate Account at the time premium
payments are discontinued, will remain in those Subaccounts unless You transfer the value to another Subaccount or to the Fixed Account

 The values in the Subaccounts will change from business day to business day reflecting the investment
experience of the Subaccount On the Annuity Commencement Date we will distribute the Policy Value under one of the Income Options. 
 PREMIUM
PAYMENT DATE 
 The premium payment date is the date on which the premium payment is credited to the policy. The initial premium payment less
any applicable premium taxes will be credited to the policy within two business days of receipt of the premium payment and the information needed. Subsequent additional premium payments will be credited to the policy as of the business day the
premium payment and required information are received A business day is any day that the New York Stock Exchange is open for trading. 

ALLOCATION OF PREMIUM PAYMENTS 
 Premium
payments may be applied to various Investment Options, which we make available. For each premium payment, You must indicate what percentage to allocate to various Investment Options. Each percent may be either zero or any whole number; however, the
allocation among all accounts must total 100%. 
 CHANGE OF ALLOCATION 
 You may change the allocation of premium payments to various Investment Options by providing us notice containing the facts that we need. Premium payments received after the date on which we receive Your
notice will be applied on the basis of the new allocation. 
 PREMIUM TAXES 
 The insurance laws of the State of New York as of 2011 do not allow the imposition of premium taxes on annuity considerations. Therefore, wherever reference is made in this annuity policy to the deduction
of premium taxes, such deductions will not be made while the Owner is a resident of the State of New York, unless subsequent changes in New York’s insurance laws provide otherwise. The amount of any applicable premium tax imposed on amounts
relating to this annuity policy may be deducted from this annuity policy. For purposes of this annuity policy, premium taxes include retaliatory taxes or similar taxes.

 

  
 SECTION 4 –
POLICY VALUE 

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

	(a)	premium payments; minus 

  

	(b)	Gross Partial Withdrawals (as defined in Section 5); plus 

  

	(c)	interest credited to the Fixed Account (see Section 7); plus 

  

	(d)	accumulated gains, including the deduction of the Mortality and Expense Risk Fee and Administrative Charge, in the Separate Account (see Section 6); minus

 

  

	(e)	accumulated losses including the deduction of the Mortality and Expense Risk Fee and Administrative Charge, in the Separate Account (see Section 6); minus

  

	(f)	service charges, premium taxes, rider fees and transfer fees, if any. 

 You may use the Policy Value on the Annuity Commencement Date to provide income under the General Payment Provisions in Section 10. 
 SERVICE CHARGE 
 On each Policy Anniversary during any Policy Year before the Annuity
Commencement Date, we reserve the right to assess a Service Charge up to $35 for policy administration expenses. 

 

  

  

					
	AV1396 101 179 1003	  	Page 4	  	M1667R

 SECTION 4 – CONTINUED 

 

 
 The Service Charge will be deducted from each Subaccount in proportion to the portion of Policy Value
(prior to such charge) in each Subaccount In no event will the Service Charge exceed 2% of the Policy Value on the Policy Anniversary.

 The Service Charge will not be deducted on a Policy Anniversary if, (1) the sum of all premium
payments less the sum of all Withdrawals taken equals or exceeds $50,000; or (2) the Policy Value equals or exceeds $50,000.

 

  
 SECTION 5 –
CASH VALUE AND PARTIAL WITHDRAWALS 

 CASH VALUE 
 On or before the Annuity Commencement Date, the Cash Value is equal to the Policy Value. Information on the current amount of Your policy’s Cash Value is available upon request The Cash Value may be
partially withdrawn or will be paid in the event of a full Surrender of the policy. We must receive Your written partial Withdrawal or Surrender request before the Annuity Commencement Date. 
 There is no Cash Value once Annuity payments have begun. 
 MINIMUM VALUES 

Benefits available under this policy, including any paid up annuity Cash Value or death benefits that may be available, are not less than those required
by the insurance laws of the State of New York. Such benefits will be increased as interest is credited to the policy as described in the Fixed Account or increased/decreased by Separate Account gains/losses. 

PARTIAL WITHDRAWALS 
 We may delay
payment of the Cash Value from the Fixed Account for up to 6 months after we receive the request If payment of the Partial Withdrawal or full Surrender is not made within 10 business days of our receipt of the request, we will pay interest on that
amount from the date of receipt of the request to the date of payment as described in the Deferment provision in Section 11. If the Owner dies after we receive the request but before the request is processed, the request will be processed
before the death proceeds are determined 
 The Gross Partial Withdrawal is the total amount which will be deducted from Your Policy Value as a
result of each Partial Withdrawal. The Gross Partial Withdrawal equals the requested Partial Withdrawal. 
 If no premium payments have been
made for three Policy Years and any Partial Withdrawal reduces the Policy Value below $2,000, we reserve the right to pay the full Policy Value and terminate the policy. 
  

 For interest crediting purposes only, the oldest premium payment is considered to be withdrawn first, then
the interest associated with that premium payment If the amount withdrawn exceeds this amount the next oldest premium payment and its associated interest is considered to be withdrawn, and so on until the most recent premium payment and its
associated interest is considered to be withdrawn (i.e. Partial Withdrawals are made on a First-In, First-Out or FIFO basis). 
 Amounts also
may be withdrawn under one of the options as described below. 
 LUMP SUM 
 Beginning in the first Policy Year, partial withdrawals are available as lump sum distributions in one or more withdrawals during a policy year. 
 The minimum withdrawal is $500. 
 SYSTEMATIC PAYOUT OPTION 

Beginning in the first Policy Year, a Systematic Payout Option (SPO) is available on a monthly, quarterly, semi-annual or annual basis At the time a SPO
payout is made, such payout must be at least $50 and may not exceed the greater of A or B, divided by the number of payouts made per year (e.g. 12 for monthly). 
  

	A	is the Cumulative Earnings, if any, in the Policy Value; and 

  

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

 Monthly and quarterly payouts must be sent through electronic funds transfer directly to a checking or savings account You may start or stop SPO payouts at any time; however, 30 days written notice is
required to stop SPO payouts. 
 Once You have elected a SPO, You must wait a minimum time before the first SPO payment 1 month for monthly, 3
months for quarterly, 6 months for semi-annual, or 12 months for annual. Lf a Lump Sum or Partial Withdrawal distribution is taken in the same Policy Year when SPO payments are being taken, and the total Withdrawal would exceed the greater of A or B
above in that Policy Year, the SPO will be stopped. 

 

  

  

					
	AV1396 101 179 1003	  	Page 5	  	U1667R

 SECTION 5 - CONTINUED 
  

 
 MINIMUM REQUIRED DISTRIBUTION 
 For tax-qualified plans, Partial Withdrawals taken to satisfy minimum distribution requirements under Section 401 (a)(9) of the Internal Revenue Code (IRC) are available. The amount available from
this annuity with respect to the minimum distribution requirements is based solely on this policy. 
 Systematic minimum distributions must be
at least $50 or a lump sum Distribution is available if minimum required distributions are less than $50. 
 NURSING CARE AND TERMINAL
CONDITION WITHDRAWAL OPTION 
 Beginning in the first Policy Year, if the Owner or Owners spouse (Annuitant or Annuitant’s spouse if the
Owner is not a natural person) has been 1) confined in a hospital or nursing facility for 30 consecutive days or 2) diagnosed as having a terminal condition and the confinement begins or diagnosis is made on or after the Policy Date, You may elect
to withdraw all or a portion of the Policy Value. The minimum Withdrawal under this option is $1000. This option is available even during the Policy Years other partial Withdrawal options were exercised prior to nursing care.

 For nursing care, we must receive each Withdrawal request and proof of eligibility with each request no
later than 90 days following the date that confinement has ceased, unless it can be shown that it was not reasonably possible to provide the notice and proof within the above time period and that the notice and proof were given as soon as reasonably
possible. However, in no event, except the absence of legal capacity, shall the notice and proof be provided later than one year following the date that confinement has ceased. Proof of confinement may be a physician’s statement or a statement
from a hospital or nursing facility administrator. 
 For a terminal condition, we must receive each Withdrawal request and the applicable proof
of eligibility no later than one year following diagnosis of the terminal condition. Proof of a terminal condition is required only with the initial Withdrawal request and must be furnished by the Owner’s, Owner’s spouse’s,
Annuitants, or Annuitant’s spouse’s physician, as applicable. 

 

  
 SECTION 6 -
SEPARATE ACCOUNT 

 

 SEPARATE ACCOUNT 
 We have established and will maintain one or more Separate Account(s), under the laws of the state of New York. Any realized or unrealized income, net gains and losses from the assets of the Separate
Account are credited to or charged against it without regard to our other income, gains or losses, Assets are put in the Separate Account for this policy, as well as for other variable annuity policies Any Separate Account may invest assets in
shares of one or more mutual fund portfolios, or in the case of a managed Separate Account direct investments in stocks or other securities as permitted by law. Fund shares refer to shares of underlying mutual funds or prorata ownership of the
assets held in a Subaccount of a managed Separate Account Fund shares are purchased, redeemed and valued on behalf of the Separate Account. 

The Separate Account is divided into Subaccounts. Each Subaccount invests exclusively in shares of one of the portfolios of an underlying fund. We
reserve the right to add or remove any Subaccount of the Separate Account.

 The Separate Account meets the definition of a “Separate Account” under rule 0-1(e)(1) of the
Investment Company Act of 1940 (the “1940 Act’). The assets of the Separate Account are our property. These assets will equal or exceed the reserves and other contract liabilities of the Separate Account. These assets will not be
chargeable with liabilities arising out of any other business we conduct We reserve the right, subject to regulations governing the Separate Account to transfer assets of a Subaccount, in excess of the reserves and other contract liabilities with
respect to that Subaccount, to another Subaccount or to our General Account. 
 We will determine the fair market value of the assets of the
Separate Account in accordance with a method of valuation, which we establish in good faith. Valuation Period means the period of time from one determination of the value of each Subaccount to the next. Such determinations are made when the value of
the assets and liabilities of each Subaccount is calculated This is generally the close of business on each day on which the New York Stock Exchange is open. In order to determine the value of an asset on a day that is not a Business Day, the
Company will use the value of that asset as of the end of the next Business Day on which trading takes place. 

 

  

  

					
	AV1396 101 179 1003	  	Page 6	  	V1545R

 SECTION 6 - CONTINUED 

 

 
 The Company will determine the value of the reserves for assets in the Separate Account at the end of each
Business Day. In order to determine the value of reserves for assets on a day that is not a Business Day, the Company will use the value of that asset as of the end of the prior Business Day on which trading took place. 

We also reserve the right (with prior authorization from the Superintendent) to transfer assets of the Separate Account which we determine to be
associated with the class of policies to which this policy belongs, to another Separate Account. If this type of transfer is made, the term Separate Account’, as used in the policy, shall then mean the Separate Account to which the assets were
transferred. 
 We also reserve the right when permitted by law to: 

 

	(a)	deregister the Separate Account under the Investment Company Act of 1940; 

  

	(b)	manage the Separate Account under the direction of a committee at any time; 

 

	(c)	restrict or eliminate any voting rights of policy Owners or other persons who have voting rights as to the Separate Account; 

 

	(d)	combine the Separate Account with one or more other Separate Accounts; 

  

	(e)	create new Separate Accounts; 

  

	(f)	add new Subaccounts to or remove existing Subaccounts from the Separate Account, or combine Subaccounts; and 

 

	(g)	add new underlying mutual funds, remove existing mutual funds, or substitute a new fund for an existing fund. 

The Net Asset Value of a fund share is the per-share value calculated by the mutual fund or, in the case of a managed Separate Account, by the Company.
The Net Asset Value is computed by adding the value of the Subaccounts investments, cash and other assets, subtracting its liabilities, and then dividing by the number of shares outstanding. Net Asset Values of fund shares reflect investment
advisory fees and other expenses incurred in managing a mutual fund or a managed Separate Account. 
 CHANGE IN INVESTMENT OBJECTIVE OR
POLICY OF A MUTUAL FUND 
 If required by law or regulation, an investment policy of the Separate Account will only be changed if approved by
the appropriate insurance official of the state of New York or deemed approved in accordance with such law or regulation. If so required, the process for obtaining such approval is filed with the insurance official of the state or district in which
this policy is delivered. 

 CHARGES AND DEDUCTIONS 
 The Mortality and Expense Risk Fee and Administrative Charge is deducted both before and after the Annuity Commencement Date to compensate for changes in mortality and expenses not anticipated by the
mortality and administration charges guaranteed in the policy. Neither expenses actually incurred, other than taxes on the investment return, nor mortality actually experienced, shall adversely affect the dollar amount of variable benefits under the
policy. 
 The Service Charge is deducted prior to the Annuity Commencement Date only. 
 If the Mortality and Expense Risk Fee and Administrative Charge is more than sufficient the Company will retain the balance as profit or may reduce this fee in the future. 

ACCUMULATION UNITS 
 The Policy Value in
the Separate Account before the Annuity Commencement Date is represented by accumulation units. The dollar value of accumulation units for each Subaccount will change from business day to business day reflecting the investment experience of the
Subaccount. 
 Premium Payments allocated to and any amounts transferred to the Subaccounts will be applied to provide accumulation units in
those Subaccounts. The number of accumulation units purchased in a Subaccount will be determined by dividing the amount allocated to or transferred to that Subaccount, by the value of an accumulation unit for that Subaccount on the premium payment
or transfer date. 
 The number of accumulation units withdrawn or transferred from the Subaccounts will be determined by dividing the amount
withdrawn or transferred by the value of an accumulation unit for that Subaccount on the Withdrawal or transfer date. 
 The value of an
accumulation unit on any business day is determined by multiplying the value of that unit at the end of the immediately preceding valuation period by the net investment factor for the valuation period. 

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

 

  

  

					
	AV1396 101 179 1003	  	Page 7	  	VB1545R

 SECTION 6 - CONTINUED 
  

 

	(a)	is the result of: 

  

	 	(1)	the net asset value of a fund share held in that Subaccount determined as of the end of the current valuation period; plus 

 

	 	(2)	the per share amount of any dividend or capital gain Distributions made by the fund for shares held in that Subaccount if the ex-dividend date occurs during the
valuation period; plus or minus 

  

	 	(3)	a per share credit or charge for any taxes reserved for, which we determine to have resulted from the investment operations of that Subaccount.

	(b)	is the net asset value of a fund share held in that Subaccount determined as of the end of the immediately preceding valuation period. 

 

	(c)	is a factor representing the Mortality and Expense Risk Fee and Administrative Charge before the Annuity Commencement Date. This factor is less than or equal to, on an
annual basis, the percentage shown on the Policy Data Page of the daily net asset value of a fund share held in that Subaccount 

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

 

  
 SECTION 7 - FIXED
ACCOUNT 

 

 FIXED ACCOUNT 
 The Fixed Account is comprised of a one-year Guaranteed Period Option and the Dollar Cost Averaging Fixed Option that we may choose to offer. Premium payments applied to and any amounts transferred to the
Fixed Account will reflect a fixed interest rate. The interest rates we set will be credited for increments of at least one year measured from each premium payment or transfer date. These rates will never be less than the Fixed Account Guaranteed
Minimum Effective Annual Interest Rate shown on the Policy Data page. 
 After the policy date, we reserve the right to prohibit premium
payments and/or transfers allocated to the Fixed Account described in this section. We will provide 30 days advance written notice of this decision. We will also provide timely written notification to You once any such prohibition of premium
payments and/or transfers is no longer in effect 
 Even if we are prohibiting premium payments or transfers to the Fixed Account funds will
still roll into a new one-year Guaranteed Period Option at the end of the expiring option’s guaranteed period 
 GUARANTEED PERIOD
OPTION 
 We will offer the one–year Guaranteed Period Option. The current interest rate we set for funds entering a Guaranteed Period
Option (GPO) is guaranteed until the end of that option’s Guaranteed Period. At that time, the premium payment made or amount transferred into the GPO, less any Withdrawals or transfers from that GPO, plus accrued interest will be rolled into a
new one–year GPO or may be transferred to any Subaccount(s) within the Separate Account(s). 
 You may choose the Investment Option(s) You
want the funds transferred into by giving us a written notice within 30 days before the end of the expiring option’s Guaranteed Period. However, any Guaranteed Period elected may not extend beyond the maximum Annuity Commencement Date defined
in Section 11. 

 In the absence of such election, the funds will be rolled into a new one-year GPO, You will be mailed a
notice of completion of any rollover with the new interest rate applicable. The new GPO will be deemed as accepted if we do not receive a written rejection within 30 days from the postmark date of the completion notice. 

When funds are withdrawn or transferred from the one year GPO, the Policy Value associated with the oldest premium payment or rollover is considered to
be withdrawn/transferred first If the amount withdrawn/transferred exceeds the Policy Value associated with the oldest premium, the Policy Value associated with the next oldest premium payment or rollover is considered to be withdrawn/transferred
next and so on until the Policy Value associated with the most recent premium payment or rollover is considered to be withdrawn/transferred (this is a “First-In, First-Out” or FIFO basis). 

DOLLAR COST AVERAGING FIXED ACCOUNT OPTION 
 We may offer a Dollar Cost Averaging one-year (DCA) Fixed Account Option separate from the Guaranteed Period Option. This option will have a one-year interest rate guarantee. The current interest rate we
set for the DCA Fixed Account may differ from the rates credited on the one-year GPO in the Fixed Account In addition, the current interest rate we credit may vary on different portions of the DCA Fixed Account The credited interest rate will never
be less than the Fixed Account Guaranteed Minimum Effective Annual Interest Rate shown on Page 3. The DCA Fixed Account Option will only be available under a Dollar Cost Averaging program as described in Section 8.

 

  

					
	AV1396 101 179 1003	  	Page 8	  	L11 41R

 SECTION 8 - TRANSFERS 
  

 

	A.	TRANSFERS BEFORE THE ANNUITY COMMENCEMENT DATE 

 Prior to the Annuity Commencement Date, You may transfer the value of the accumulation units from one Investment Option to another by providing us notice containing the facts that we need. 

Transfers of interest credited in the one-year GPO to other Investment Options are allowed on a “First-In, First-Out” basis. Such transfers may
be made monthly, quarterly, semi-annually, or annually. Each such transfer must be at least $50, 
 Transfers of Policy Value from the Separate
Account are subject to a minimum of $500 or the entire Subaccount Policy Value, if less. However, if the remaining Subaccount Policy Value is less than $500, we reserve the right to include that amount as part of the transfer. 

We reserve the right to limit transfers to no more than 12 in any one Policy Year. Any transfers in excess of 12 per Policy Year may be charged a $1
0 per transfer fee. Transfers among multiple Investment Options will be treated as one transfer in determining the number of transfers that have occurred We also reserve the right to prohibit transfers to the Fixed Account We may prohibit premium
payments and/or transfers if the yield on investments at such time is not sufficient to support the statutory minimum interest rate guarantee and other company expenses If we are prohibiting transfers to the Fixed Account we will provide 30 days
advance written notice of this decision. You must indicate which Investment Option(s) to transfer the funds to while such prohibition is in effect We will also provide timely written notification to You once any such prohibition of transfers is no
longer in effect 
 The policy was not designed for professional market timing organizations or other persons that use programmed, large, or
frequent transfers. The use of such transfers may be disruptive to an underlying portfolio. We reserve the right to reject any transfer request from any person in the interest of overall fund management or, if, in our judgment an underlying fund
would be unable to invest effectively in accordance with its investment objectives and policies or would otherwise be potentially adversely affected or if an underlying fund would reject our purchase order. We also reserve the right to revoke Your
fax and electronic transfer privileges at any time without revoking all owners’ fax and electronic transfer privileges. 
 DOLLAR COST
AVERAGING OPTION 
 Prior to the Annuity Commencement Date, You may instruct us to automatically transfer a specified amount from the Money
Market Subaccount, U.S. Government Securities 

 Subaccount, or out of the Dollar Cost Averaging (DCA) Fixed Account Option to any other Subaccount(s) of
the Separate Account The automatic transfers can occur monthly or quarterly. 
 Transfers will continue until the elected Subaccount or DCA
Fixed Account value is depleted. The amount transferred each time must be at least $500. All transfers from the DCA account will be the same amount as the initial transfer. Changes to the Subaccounts to which these transfers are allocated are not
restricted. Transfers must be scheduled for at least 6, but not more than 24 months or for at least 4, but not more than 8 quarters each time the Dollar Cost Averaging program is started or restarted following termination of the program for any
reason. 
 Dollar Cost Averaging results in the purchase of more accumulation units when the value of the accumulation unit is low, and fewer
accumulation units when the value of the accumulation unit is high. However, there is no guarantee that the Dollar Cost Averaging program will result in higher Policy Values. 
 Dollar Cost Averaging may be discontinued before its scheduled completion by sending written notice to us While Dollar Cost Averaging is in effect Asset Rebalancing is not available. If Dollar Cost
Averaging is discontinued prior to the end of the scheduled period, all remaining funds in the Dollar Cost Averaging Fixed Account will be transferred at that time. Unless we are notified otherwise, the funds remaining in the Dollar Cost Averaging
Fixed Account will be transferred to the Subaccounts in the percentages currently indicated. 
 ASSET REBALANCING 

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

 

  

					
	AV1396 101 179 1003	  	Page 9	  	LB1141R

 SECTION 8 - CONTINUED 
  

 

	B.	TRANSFERS AFTER THE ANNUITY COMMENCEMENT DATE 

 After the Annuity Commencement Date, You may transfer the value of the variable annuity units from one Subaccount to another within the Separate Account or to the Fixed Account. If You want to transfer
the value of the variable annuity units, You must provide a signed notice, containing the facts that we need. We reserve the right to limit transfers between the Subaccounts or to the Fixed Accounts to once per Policy Year.

 The minimum amount which may be transferred is the lesser of $10 monthly income or the entire monthly
income of the variable annuity units in the Subaccount from which the transfer is being made. If the monthly income of the remaining units in a Subaccount is less than $10, we have the right to include the value of those variable annuity units as
part of the transfer 
 After the Annuity Commencement Date, no transfers may be made from the Fixed Account to any other Investment Options.

 

  
 SECTION 9 - DEATH
PROCEEDS 

 

  

	A.	DEATH PROCEEDS PRIOR TO ANNUITY COMMENCEMENT DATE 

 The amount of death proceeds will be the greater of (a) or (b) where: 
  

	(a)	is the Policy Value on the date we receive due proof of death and an election of a method of settlement and; 

 

	(b)	is the Guaranteed Minimum Death Benefit (GMDB), if any, plus any additional premium payments received, (less any Gross Partial Withdrawals) from the date of death to
the date of payment of death proceeds. 

 For purposes of this policy, due proof of death means: 

 

	(a)	a certified copy of the death certificate; or 

  

	(b)	a certified copy of a decree of a court of competent jurisdiction as to a finding of death; and 

 

	(c)	any other proof or other documents required by us. 

 If You have not selected a payment option by the date of death, the beneficiary may make such election within one year of the date we receive due proof of the Owner’s or Annuitant’s death as
described in C below. The beneficiary may elect to receive the death proceeds as a lump sum payment or may use the death proceeds to provide any of the annuity Income Options described in Section 10. 

We will pay interest on death proceeds from the date of death to the date of payment at an annual interest rate of 1.5%, or the guaranteed annual rate
used for calculating settlement options, whichever is greater. 
 B. GUARANTEED MINIMUM DEATH BENEFIT 

The amount of the Guaranteed Minimum Death Benefit (GMDB) is based on the death benefit option shown on the Policy Data Page. You may not change the GMDB
option after the policy is issued. 

 Annual Step-Up Death Benefit 
 This GMDB is equal to: 
  

	(a)	the step-up value as described below; plus 

  

	(b)	any premium payments subsequent to the previous determination point; minus 

 

	(c)	any Adjusted Partial Withdrawals subsequent to the previous determination point. 

 On the Policy Date, the step-up value is the Policy Value. On each Policy Anniversary (referred to as the determination points) prior to the earlier of the date of death of the Annuitant or the
Annuitant’s 81st birthday, a comparison is made between (a) and (b), where (a) is the Policy Value at this point in time and (b) is the previous step-up value, plus premium payments minus Adjusted Partial Withdrawals (as
described below) made since the previous determination point The larger of (a) and (b) becomes the new step-up value. This step-up process stops at the earlier of the date of death of the Annuitant or the Annuitant’s 81st birthday.
The then current step-up value becomes the final step-up value. 
 Return of Premium Death Benefit 

This GMDB is equal to the total premiums paid for this policy, less any Adjusted Partial Withdrawals (as described below), as of the date of death.

 Adjusted Partial Withdrawal 

A partial Withdrawal taken as provided in Section 5 will reduce the Guaranteed Minimum Death Benefit by an amount referred to as the
“Adjusted Partial Withdrawal”. The Adjusted Partial Withdrawal may be a different amount than the Gross Partial Withdrawal described in Section 5. If at the time of the partial Withdrawal, the Policy Value is greater than the GMDB, the
Adjusted Partial Withdrawal will equal the Gross Partial Withdrawal. 

 

  

					
	AV1396 101 179 1003	  	Page 10	  	D568R

 SECTION 9 - CONTINUED 
  

 

 The Adjusted Partial Withdrawal formula is APW = GPW times (DP/PV) where: 

 

	APW=	Adjusted Partial Withdrawal 

	GPW=	Gross Partial Withdrawal 

	DP=	Death Proceeds prior to the Withdrawal 

 (equal to the greater of PV and GMDB) 

	PV=	Policy Value prior to the Withdrawal 

	GMDB=	Guaranteed Minimum Death Benefit prior to the Withdrawal 

  

	C.	DEATH PRIOR TO ANNUITY COMMENCEMENT DATE 

Payment of death proceeds depends upon the relationships between the Owner, Annuitant, and beneficiary as outlined below. 

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

 

	I.	Annuitant Death 

 When
we have due proof that the Annuitant died before the Annuity Commencement Date, we will provide the death proceeds to the beneficiary. Interest upon the death proceeds will be computed daily at the rate set forth in Section 9, A, above from the
date of death to the date of payment and will be considered part of the total sum paid. If no beneficiary is designated, the Owner or Owner’s estate will become the beneficiary. 

 

	 	a)	When the beneficiary is the deceased Annuitant’s surviving spouse. The beneficiary may elect to continue this policy as Owner and Annuitant rather than
receiving the death proceeds. If the policy is continued, an amount equal to the excess, if any, of the Guaranteed Minimum Death Benefit (if any) over the Policy Value will then be added to the Policy Value pro rata according to the amount of Policy
Value in each Investment Option at that time. This is a one-time only Policy Value adjustment applied at the time the policy is continued, and the Guaranteed Minimum Death Benefit previously selected will continue on as applicable. If no election is
received from the spouse following the Annuitant’s death, the policy will be continued with the surviving spouse as the Owner and Annuitant 

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

 

	 	b)	When the beneficiary is an individual who is not the deceased Annuitant’s surviving spouse. The death proceeds must be distributed:

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

 

	 	(2)	payments must begin no later than one year after the deceased Annuitant’s death and must be made for a period certain or for this beneficiary’s lifetime, so
long as any period certain does not exceed this beneficiary’s life expectancy (as defined by the Internal Revenue Code and regulations adopted under that Code). Election of this option must be made at least 60 days prior to the one year
anniversary of the Annuitant’s death. 

  

	 	c)	When the beneficiary is not a natural person. The death proceeds may be paid in a lump sum or must be distributed within 5 years after the Annuitant’s
death. 

 In 1035 exchanges where there are joint Annuitants, the death proceeds will only be payable upon the death of the
surviving Annuitant, subject to the distribution rules described in section II. 
  

	II.	Owner Death 

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

	 	a)	surviving Owner; 

  

	 	b)	primary beneficiary; 

  

	 	c)	contingent beneficiary; or 

  

	 	d)	deceased Owner’s estate. 

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

 

	 	a)	If the sole successor Owner is the deceased Owner’s opposite-sex spouse. We will continue this policy with the successor Owner as the new Owner. If no distribution
option is elected by the deceased Owner’s same-sex spouse, the Policy Value will be distributed according to b) below. 

  

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

 

  

					
	AV1396 101 179 1003	  	Page 11	  	DB568R

 SECTION 9 - CONTINUED 
  

 

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

 

	 	(2)	payments must begin no later than one year after the deceased Owner’s death and must be made for a period certain or for the successor Owner’s lifetime, so
long as any period certain does not exceed the successor Owner’s life expectancy (as defined by the Internal Revenue Code and regulations adopted under that Code). Election of this option must be made at least 60 days prior to the one year
anniversary of the deceased Owner’s death. 

  

	c)	If the successor Owner is not a natural person, the Policy Value may be paid in a lump sum, or must be distributed within 5 years after the Owner’s death.

 

	D.	DEATH ON OR AFTER THE ANNUITY COMMENCEMENT DATE 

 The death proceeds on or after the Annuity Commencement Date depend on the payment option selected. If any Owner dies on or after the Annuity Commencement Date, but before the entire interest in the
policy is distributed, the remaining portion of such interest in the policy will be distributed to the Owner’s beneficiary at least as rapidly as under the method of distribution being used as of the date of that Owner’s death. 

 

	E.	AN OWNER IS NOT AN INDIVIDUAL 

 In the
case of a non tax-qualified annuity, if any Owner or beneficial Owner is not an individual, then for purposes of Section 72(s) of the Internal Revenue Code’s mandatory distribution provisions in subsection C or D above, (1) the
primary Annuitant will be treated as the Owner of the policy, and (2) if there is any change in the primary Annuitant, such a change will be treated as the death of the Owner.

 

  
 SECTION 10 -
ANNUITY PAYMENTS 

 

  

	A.	GENERAL PAYMENT PROVISIONS 

  

	Payment	

 If this policy is in force on the
Annuity Commencement Date, we will use the Fixed Account portion and/or the Separate Account portion of the Policy Value to make annuity payments to the Annuitant under Option 2 and/or 3-V, respectively, with 10 years certain, or if elected, under
one or more of the other options described in this section. However, the option(s) elected must provide for lifetime income or income for a period of at least 60 months. You will become the Annuitant at the Annuity Commencement Date. Payments will
be made at 1, 3, 6 or 12-month intervals. We reserve the right to change the frequency of payments to avoid making payments of less than $20.00. 
 Before the Annuity Commencement Date, if the death proceeds become payable or if You Surrender this policy, we will pay any proceeds in one sum, or if elected, all or part of these proceeds may be placed
under one or more of the options described in this section. If we agree, the proceeds may be placed under some other method of payment instead. 

Betterment of Rates 
 The amounts shown
in the tables on page 16-17 are the guaranteed amounts. Current amounts offered to individuals of the same class may be obtained from us. Fixed annuity payments at the time of their commencement will not be less than those which would be provided by
the application of the Policy Value to purchase any single consideration immediate annuity contract (as described in Section 4223 (a)(1)(E) of the New York Insurance Law) offered by the Company at the time to the same class of Annuitant.

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

					
	 Annuity
 Commencement Date
	  	Adjusted Age	 
	 2011 - 2019
	  	 	Actual Age minus 1	  
	 2020 - 2026
	  	 	Actual Age minus 2	  
	 2027 - 2033
	  	 	Actual Age minus 3	  
	 2034 - 2040
	  	 	Actual Age minus 4	  
	 After 2040
	  	 	Actual Age minus 5	  

 Election of Optional Method of
Payment Before the Annuity Commencement Date You can elect or change an Income Option. You may elect in a notice You sign which gives us the facts that we need, annuity payments that may be either variable, fixed, or a combination of both. If You
elect a combination, You must also tell us what part of the policy proceeds on the Annuity Commencement Date are to be applied to provide each type of payment (You must also specify which Subaccounts,) The amount of a combined payment will be the
sum of the variable and fixed payments. Payments under a variable Income Option will reflect the investment performance of the selected Subaccount of the Separate Account

 

  

  

					
	AV1396 101 179 1003	  	Page 12	  	S1254R

 SECTION 10 - CONTINUED 
  

 

 Payee 
 Unless You specify otherwise, the Payee shall be the Annuitant, or the beneficiary as defined in the Beneficiary provision in Section 11. 
 Proof of Age 
 We may require proof of the age of any person who has an annuity purchased
under Options 2, 3-V, 4 and 5-V of this section before we make the first payment 
 Minimum Proceeds 

If the Policy Value on the Annuity Commencement Date is less than $2,000, we reserve the right to pay the Policy Value as a lump sum instead of applying
it to an income option. 
 Premium Tax 
 The Insurance laws of the State of New York as of 2011 do not allow the imposition of premium taxes on the amount applied to a settlement option. Therefore, such deductions will not be made while the
Owner is a resident of the State of New York, unless subsequent changes in New York’s insurance laws provide otherwise. However, if the Owner becomes a non-resident of New York or if New York changes its insurance laws to allow the imposition
of premium taxes on the amount applied to a settlement option, we will deduct the applicable premium tax before applying the proceeds. 

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

	B.	FIXED INCOME OPTIONS 

 Guaranteed
Income Options 
 The fixed income option is determined by multiplying each $1,000 of policy proceeds allocated to a fixed income option by
the amounts shown on pages 16 and 17 for the option You select Options 1 and 3 are based on a guaranteed interest rate of 1.5%. Options 2 and 4 are based on a guaranteed interest rate of 1.5% and the “Annuity 2000” male, female mortality
table projected for improvement using projection scale G (50% of the female scale G factors were used, while 100% of the male scale G factors were used). The rates were projected dynamically using an assumed Annuity Commencement date of 2005. The
“Annuity 2000” mortality rates are adjusted based on improvements in mortality since 2000 to more appropriately reflect increased longevity. This is accomplished using a set of improvement factors referred to as projection scale C.

 Option 1 - Income for a Specified Period 
 We will make level payments only for the fixed period You choose. The duration of the payments may not exceed the Annuitant’s life expectancy, (as defined by the Internal Revenue Code and regulations
adopted under that code) nor be for a period of time that is less than 60 months. In the event of the death of the person receiving payments prior to the end of the fixed period elected, payments will be continued to that person’s beneficiary.

 

  

  

					
	AV1386 101 179 1003	  	Page 13	  	SB1254R

 SECTION 10 - CONTINUED 
  

 

 Option 2 - Life Income - You may choose between: 

 

	1.	No Period Certain - We will make level payments only during the Annuitants lifetime. 

 

	2.	10 Years Certain - We will make level payments for the longer of the Annuitants lifetime or ten years In the event of the death of the person receiving payments prior
to the end of the fixed period elected, payments will be continued to that person’s beneficiary. 

  

	3.	Guaranteed Return of Policy Proceeds - We will make level payments for the longer of the Annuitant’s lifetime or until the total dollar amount of payments we made
to You equals the amount applied to this option. 

 Option 2(1) is not available for Adjusted Age(s) greater than 85. 

If any life income settlement option with a period certain provides for installment payments of the same amount at some ages for different periods
certain, the Company will deem the election to have been made for the longest period certain which could have been elected for such age and amount 
 Option 3 - Income of a Specified Amount Payments are made for any specified amount until the amount applied to this option, with interest is exhausted This will be a series of level payments followed by a
smaller final payment. In the event of the death of the person receiving payments prior to the time proceeds with interest are exhausted, payments will be continued to that person’s beneficiary. 

Option 4 - Joint and Survivor Annuity 

Payments are made during the joint lifetime of the Payee and a joint Payee of Your selection. Payments will be made as long as either person is living.

 Option 4 is not available for Adjusted Age(s) greater than 85. 
 Current Income Options 
 The amounts shown in the tables on pages 16 and 1 7 are the
guaranteed amounts. Current amounts offered to individuals of the same class may be obtained from us Any rates not shown in the Tables contained in this annuity policy and which are available will be provided by the Company upon request.

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

	(a)	is the variable annuity unit value for that Subaccount on the immediately preceding business day; 

 

	(b)	is the net investment factor for that Subaccount for the Valuation Period; and 

 

	(c)	is the Assumed Investment Return adjustment factor for the Valuation Period. 

 The Assumed Investment Return adjustment factor for the valuation period is the product of discount factors of .99986634 per day to recognize the 5.0% effective annual Assumed Investment Return.

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

	(a)	is the net result of: 

  

	 	(1)	the net asset value of a fund share held in that Subaccount determined as of the end of the current valuation period; plus 

 

	 	(2)	the per share amount of any dividend or capital gain Distributions made by the fund for shares held in that Subaccount if the ex-dividend date occurs during the
Valuation Period; plus or minus 

  

	 	(3)	a per share credit or charge for any taxes reserved for, which we determine to have resulted from the investment operations of the Subaccount 

 

	(b)	is the net asset value of a fund share held in that Subaccount determined as of the end of the immediately preceding Valuation Period. 

 

	(c)	is a factor representing the Mortality and Expense Risk Fee and Administrative Charge applicable after the Annuity Commencement Date. This factor is less than or equal
to, on an annual basis, the percentage shown on the Policy Data Page of the daily net asset value of a fund share held in the Separate Account for that Subaccount.

 

  

					
	AV1396 101 179 1003	  	Page 14	  	C937R

 SECTION 10 – CONTINUED 

 

 

 Determination of the First Variable Payment 
 The amount of the first variable payment is determined by multiplying each $1,000 of policy proceeds allocated to a variable income option by the amounts shown on pages 18 and 19 for the variable option
You select The tables are based on a 5% effective annual Assumed Investment Return and the “Annuity 2000” male, and female mortality table projected for improvement using projection scale G (50% of the female scale G factors were used,
while 100% of the male scale G factors were used). The rates were projected dynamically using an assumed Annuity Commencement date of 2005. The “Annuity 2000” mortality rates are adjusted based on improvements in mortality since 2000 to
more appropriately reflect increased longevity. This is accomplished using a set of improvement factors referred to as projection scale G. 

Option 3–V – Life Income - You may choose between: 
  

	1.	No Period Certain - Payments will be made during the lifetime of the Annuitant 

 

	2.	10 Years Certain - Payments will be made for the longer of the Annuitant’s lifetime or ten years In the event of the death of the person receiving payments prior
to the end of the guarantee period for which the election was made, payments will be continued to that person’s beneficiary. 

Option 3-V(1) is not available for Adjusted Age(s) greater than 85.

 Option 5–V – Joint and Survivor Annuity: 

Payments are made as long as either the Annuitant or the joint Annuitant is living. 
 Option 5–V is not available for Adjusted Age(s) greater than 85. 
 Determination of
Subsequent Variable Payments 
 The amount of each variable annuity payment after the first will increase or decrease according to the value
of the variable annuity units which reflect the investment experience of the selected Subaccounts. Each variable annuity payment after the first will be equal to the number of variable annuity units in the selected Subaccounts multiplied by the
variable annuity unit value on the date the payment is made. The number of variable annuity units in each selected Subaccount is determined by dividing the first variable annuity payment allocated to the Subaccount by the variable annuity unit value
of that Subaccount on the Annuity Commencement Date. 
 Once Annuity Payments begin, neither expenses actually incurred other than taxes on the
investment return, nor mortality actually experienced by the Company, shall adversely affect the dollar amount of Variable Annuity Payments to any Annuitant for whom such payments have commenced.

 

  

					
	AV1396 101 179 1003	  	Page 15	  	CB937R

 GUARANTEED FIXED INCOME OPTIONS ** 

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

 

																																													
	 Option 1, Table I
	 	 	 	 	 	Option 2, Table II	 	 	Option 2, Table III	 	 	Option 2, Table IV	 
	 Number
 of

Years

Payable
	 	Amount of
Monthly
Installment	 	 	 	 	 	Monthly Installment
For Life of No
Period
Certain.	 	 	Monthly Installment For
Life 10 Years
Certain	 	 	Monthly Installment For
Life Guaranteed
Return
of Policy Proceeds	 
	 	 	 	 	 	Age*	 	 	Male	 	 	Female	 	 	Unisex	 	 	Male	 	 	Female	 	 	Unisex	 	 	Male	 	 	Female	 	 	Unisex	 
		 				 	 	50	  	 	$	2.97	  	 	$	2.86	  	 	$	2.90	  	 	$	2.96	  	 	$	2.66	  	 	$	2.89	  	 	$	2.79	  	 	$	2.74	  	 	$	2.76	  
		 				 	 	51	  	 	 	3.04	  	 	 	2.92	  	 	 	2.96	  	 	 	3.02	  	 	 	2.91	  	 	 	2.94	  	 	 	2.84	  	 	 	2.79	  	 	 	2.80	  
		 				 	 	52	  	 	 	3.10	  	 	 	2.98	  	 	 	3.02	  	 	 	3.08	  	 	 	2.97	  	 	 	3.01	  	 	 	2.89	  	 	 	2.84	  	 	 	2.85	  
		 				 	 	53	  	 	 	3.18	  	 	 	3.05	  	 	 	3.09	  	 	 	3.15	  	 	 	3.03	  	 	 	3.07	  	 	 	2.94	  	 	 	2.89	  	 	 	2.90	  
	5	 	 	17.28	  	 	 	54	  	 	 	3.25	  	 	 	3.11	  	 	 	3.15	  	 	 	3.22	  	 	 	3.10	  	 	 	3.14	  	 	 	3.00	  	 	 	2.94	  	 	 	2.96	  
	6	 	 	14.51	  	 	 	55	  	 	 	3.33	  	 	 	3.18	  	 	 	3.23	  	 	 	3.30	  	 	 	3.17	  	 	 	3.21	  	 	 	3.06	  	 	 	3.00	  	 	 	3.02	  
	7	 	 	12.53	  	 	 	56	  	 	 	3.41	  	 	 	3.26	  	 	 	3.30	  	 	 	3.38	  	 	 	3.24	  	 	 	3.28	  	 	 	3.12	  	 	 	3.06	  	 	 	3.07	  
	8	 	 	11.04	  	 	 	57	  	 	 	3.50	  	 	 	3.34	  	 	 	3.39	  	 	 	3.46	  	 	 	3.32	  	 	 	3.36	  	 	 	3.18	  	 	 	3.12	  	 	 	3.14	  
	9	 	 	9.89	  	 	 	58	  	 	 	3.60	  	 	 	3.42	  	 	 	3.47	  	 	 	3.55	  	 	 	3.39	  	 	 	3.44	  	 	 	3.25	  	 	 	3.18	  	 	 	3.20	  
	10	 	 	8.96	  	 	 	59	  	 	 	3.69	  	 	 	3.51	  	 	 	3.58	  	 	 	3.65	  	 	 	3.48	  	 	 	3.53	  	 	 	3.32	  	 	 	3.25	  	 	 	3.27	  
	11	 	 	8.21	  	 	 	60	  	 	 	3.80	  	 	 	3.60	  	 	 	3.66	  	 	 	3.75	  	 	 	3.57	  	 	 	3.62	  	 	 	3.39	  	 	 	3.32	  	 	 	3.34	  
	12	 	 	7.58	  	 	 	61	  	 	 	3.91	  	 	 	3.70	  	 	 	3.76	  	 	 	3.85	  	 	 	3.66	  	 	 	3.72	  	 	 	3.46	  	 	 	3.39	  	 	 	3.41	  
	13	 	 	7.05	  	 	 	62	  	 	 	4.03	  	 	 	3.81	  	 	 	3.87	  	 	 	3.96	  	 	 	3.76	  	 	 	3.82	  	 	 	3.54	  	 	 	3.47	  	 	 	3.49	  
	14	 	 	6.59	  	 	 	63	  	 	 	4.16	  	 	 	3.92	  	 	 	3.99	  	 	 	4.07	  	 	 	3.87	  	 	 	3.93	  	 	 	3.83	  	 	 	3.55	  	 	 	3.57	  
	15	 	 	6.20	  	 	 	64	  	 	 	4.30	  	 	 	4.04	  	 	 	4.12	  	 	 	4.20	  	 	 	3.98	  	 	 	4.04	  	 	 	3.72	  	 	 	3.63	  	 	 	3.66	  
	16	 	 	5.85	  	 	 	65	  	 	 	4.45	  	 	 	4.16	  	 	 	4.25	  	 	 	4.32	  	 	 	4.09	  	 	 	4.16	  	 	 	3.81	  	 	 	3.72	  	 	 	3.75	  
	17	 	 	5.55	  	 	 	66	  	 	 	4.60	  	 	 	4.30	  	 	 	4.39	  	 	 	4.46	  	 	 	4.22	  	 	 	4.29	  	 	 	3.91	  	 	 	3.81	  	 	 	3.84	  
	18	 	 	5.27	  	 	 	67	  	 	 	4.77	  	 	 	4,45	  	 	 	4.54	  	 	 	4.60	  	 	 	4.35	  	 	 	4.42	  	 	 	4.01	  	 	 	3.91	  	 	 	3.94	  
	19	 	 	5.03	  	 	 	68	  	 	 	4.95	  	 	 	4.60	  	 	 	4.71	  	 	 	4.75	  	 	 	4.49	  	 	 	4.57	  	 	 	4.11	  	 	 	4.01	  	 	 	4.04	  
	20	 	 	4.81	  	 	 	69	  	 	 	5.14	  	 	 	4.77	  	 	 	4.88	  	 	 	4.90	  	 	 	4.64	  	 	 	4.71	  	 	 	4.23	  	 	 	4.12	  	 	 	4.15	  
		 				 	 	70	  	 	 	5.34	  	 	 	4.95	  	 	 	5.07	  	 	 	5.06	  	 	 	4.79	  	 	 	4.87	  	 	 	4.34	  	 	 	4.24	  	 	 	4.27	  
		 				 	 	71	  	 	 	5.56	  	 	 	5.15	  	 	 	5.27	  	 	 	5.22	  	 	 	4.95	  	 	 	5.03	  	 	 	4.47	  	 	 	4.36	  	 	 	4.39	  
		 				 	 	72	  	 	 	5.79	  	 	 	5.36	  	 	 	5.49	  	 	 	5.39	  	 	 	5.12	  	 	 	5.20	  	 	 	4.60	  	 	 	4.49	  	 	 	4.52	  
		 				 	 	73	  	 	 	6.03	  	 	 	5.59	  	 	 	5.72	  	 	 	5.56	  	 	 	5.30	  	 	 	5.38	  	 	 	4.73	  	 	 	4.62	  	 	 	4.66	  
		 				 	 	74	  	 	 	6.30	  	 	 	5.83	  	 	 	5.97	  	 	 	5.74	  	 	 	5.49	  	 	 	5.57	  	 	 	4.88	  	 	 	4.77	  	 	 	4.80	  
		 				 	 	75	  	 	 	6.58	  	 	 	6.10	  	 	 	6.24	  	 	 	5.93	  	 	 	5.68	  	 	 	5.76	  	 	 	5.03	  	 	 	4.92	  	 	 	4.95	  
		 				 	 	76	  	 	 	6.88	  	 	 	6.39	  	 	 	6.53	  	 	 	6.11	  	 	 	5.88	  	 	 	5.95	  	 	 	5.18	  	 	 	5.08	  	 	 	5.11	  
		 				 	 	77	  	 	 	7.20	  	 	 	6.70	  	 	 	6.85	  	 	 	6.30	  	 	 	6.09	  	 	 	6,15	  	 	 	5.35	  	 	 	5.25	  	 	 	5.28	  
		 				 	 	78	  	 	 	7.55	  	 	 	7.03	  	 	 	7.19	  	 	 	6.49	  	 	 	6.30	  	 	 	6.36	  	 	 	5.53	  	 	 	5.43	  	 	 	5.46	  
		 				 	 	79	  	 	 	7.92	  	 	 	7.40	  	 	 	7.55	  	 	 	6.68	  	 	 	8.51	  	 	 	6.56	  	 	 	5.71	  	 	 	5.61	  	 	 	5.64	  
		 				 	 	80	  	 	 	8.32	  	 	 	7.79	  	 	 	7.95	  	 	 	6.87	  	 	 	6.72	  	 	 	6.77	  	 	 	5.90	  	 	 	5.81	  	 	 	5.84	  
		 				 	 	81	  	 	 	8.75	  	 	 	822	  	 	 	8.38	  	 	 	7.06	  	 	 	6.93	  	 	 	6.97	  	 	 	6.11	  	 	 	6.02	  	 	 	6.05	  
		 				 	 	82	  	 	 	9.20	  	 	 	8.69	  	 	 	8.84	  	 	 	7.24	  	 	 	7.13	  	 	 	7.16	  	 	 	6.32	  	 	 	6.24	  	 	 	6.27	  
		 				 	 	83	  	 	 	9.69	  	 	 	9.19	  	 	 	9.34	  	 	 	7.41	  	 	 	7.33	  	 	 	7.36	  	 	 	6.55	  	 	 	6.48	  	 	 	6.50	  
		 				 	 	84	  	 	 	10.21	  	 	 	9.74	  	 	 	9.88	  	 	 	7.58	  	 	 	7.52	  	 	 	7.54	  	 	 	6.78	  	 	 	6.72	  	 	 	6.74	  
		 				 	 	85	  	 	 	10.77	  	 	 	10.33	  	 	 	10.46	  	 	 	7.74	  	 	 	7.69	  	 	 	7.71	  	 	 	7.03	  	 	 	6.98	  	 	 	7.00	  
		 				 	 	86	  	 				 				 				 	 	7.89	  	 	 	7.86	  	 	 	7.87	  	 	 	7.29	  	 	 	7.26	  	 	 	7.27	  
		 				 	 	87	  	 				 				 				 	 	8.03	  	 	 	8.01	  	 	 	8.01	  	 	 	7.57	  	 	 	7.54	  	 	 	7.55	  
		 				 	 	88	  	 				 				 				 	 	8.16	  	 	 	8.15	  	 	 	8.15	  	 	 	7.86	  	 	 	7.84	  	 	 	7.85	  
		 				 	 	89	  	 				 				 				 	 	8.28	  	 	 	8.27	  	 	 	8.27	  	 	 	8.17	  	 	 	8.15	  	 	 	8.16	  
		 				 	 	90	  	 				 				 				 	 	8.38	  	 	 	8.38	  	 	 	8.38	  	 	 	8.49	  	 	 	8.48	  	 	 	8.48	  
		 				 	 	91	  	 				 				 				 	 	8.48	  	 	 	8.48	  	 	 	8.48	  	 	 	8.83	  	 	 	8.82	  	 	 	8.83	  
		 				 	 	92	  	 				 				 				 	 	8.57	  	 	 	8.57	  	 	 	8,57	  	 	 	9.19	  	 	 	9.18	  	 	 	9.19	  
		 				 	 	93	  	 				 				 				 	 	8.65	  	 	 	8.64	  	 	 	8.65	  	 	 	9.58	  	 	 	9.56	  	 	 	9.57	  
		 				 	 	94	  	 				 				 				 	 	8.72	  	 	 	8.71	  	 	 	8.71	  	 	 	10.00	  	 	 	9.97	  	 	 	9.98	  
		 				 	 	95	  	 				 				 				 	 	8.78	  	 	 	8.77	  	 	 	8.77	  	 	 	10.45	  	 	 	10.40	  	 	 	10.42	  

  

	*	Adjusted Age as defined in Section 10.A. 

	**	The guaranteed fixed income amounts are based on a guaranteed interest rate of 1.5%. 

 Dollar amounts of monthly, quarterly, semi-annual and annual installments not shown in the above tables will be calculated on the same basis as those shown and may be obtained from the Company (if the
option is available based on Adjusted Age as described in Section 10). 

  

					
	AV1396 101 179 1003	  	Page 16	  	T1027R

 Fixed Income Option 4, Table V 

Monthly Installment For Joint and Full Survivor 
  

																													
	 Adjusted Age
of

Male
Annuitant*
	 	Adjusted Age of Female Annuitants	 
	 	15 Years
Less Than
Male	 	 	12 Years
Less Than
Male	 	 	9 Years
Less Than
Male	 	 	6 Years
Less Than
Male	 	 	3 Years
Less Than
Male	 	 	Same As
Male	 	 	3 Years
More Than
Male	 
	50	 	$	2.20	  	 	$	2.27	  	 	$	2.34	  	 	$	2.41	  	 	$	2.48	  	 	$	2.55	  	 	$	2.62	  
	55	 	 	2.35	  	 	 	2.44	  	 	 	2.52	  	 	 	2.61	  	 	 	2.71	  	 	 	2.80	  	 	 	2.88	  
	60	 	 	2.54	  	 	 	2.84	  	 	 	2.76	  	 	 	2.88	  	 	 	2.99	  	 	 	3.11	  	 	 	3.23	  
	65	 	 	2.77	  	 	 	2.91	  	 	 	3.06	  	 	 	3.22	  	 	 	3.38	  	 	 	3.54	  	 	 	3.69	  
	70	 	 	3.08	  	 	 	3.26	  	 	 	3.46	  	 	 	3.67	  	 	 	3.89	  	 	 	4,11	  	 	 	4.33	  
	75	 	 	3.47	  	 	 	3.72	  	 	 	3.99	  	 	 	4.29	  	 	 	4.60	  	 	 	4.93	  	 	 	5.24	  
	80	 	 	4.01	  	 	 	4.35	  	 	 	4.74	  	 	 	5.17	  	 	 	5.62	  	 	 	6.08	  	 	 	6.53	  
	85	 	 	4.75	  	 	 	5.25	  	 	 	5.81	  	 	 	6.44	  	 	 	7.09	  	 	 	7.75	  	 	 	8.36	  
	
	 Monthly Installment For Unisex Joint and Full Survivor

 
	 
	 Adjusted Age
 of
 First

Annuitant*
	 	Adjusted Age of Joint Annuitant*	 
	 	15 Years
Less Than
First	 	 	12 Years
Less Than
First	 	 	9 Years
Less Than
First	 	 	6 Years
Less Than
First	 	 	3 Years
Less Than
First	 	 	Same As
First	 	 	3 Years
More Than
First	 
	50	 	$	2.20	  	 	$	2.27	  	 	$	2.34	  	 	$	2.41	  	 	$	2.48	  	 	$	2.55	  	 	$	2.61	  
	55	 	 	2.36	  	 	 	2.44	  	 	 	2.53	  	 	 	2.62	  	 	 	2.70	  	 	 	2.79	  	 	 	2.87	  
	60	 	 	2.55	  	 	 	2.65	  	 	 	2.76	  	 	 	2.88	  	 	 	2.99	  	 	 	3.10	  	 	 	3.20	  
	65	 	 	2.79	  	 	 	2.92	  	 	 	3.07	  	 	 	3.22	  	 	 	3.37	  	 	 	3,52	  	 	 	3.66	  
	70	 	 	3.10	  	 	 	3.28	  	 	 	3.47	  	 	 	3.67	  	 	 	3.88	  	 	 	4.09	  	 	 	4.28	  
	75	 	 	3.50	  	 	 	3.75	  	 	 	4.02	  	 	 	4.30	  	 	 	4.60	  	 	 	4.89	  	 	 	5.16	  
	80	 	 	4.06	  	 	 	4.40	  	 	 	4.78	  	 	 	5.19	  	 	 	5.62	  	 	 	6.04	  	 	 	6.44	  
	85	 	 	4.83	  	 	 	5.32	  	 	 	5.87	  	 	 	6.47	  	 	 	7.10	  	 	 	7.71	  	 	 	8.28	  

  

	*	Adjusted Age as defined in Section 10.A. 

Dollar amounts of monthly, quarterly, semi-annual, and annual installments not shown in the above tables will be calculated on the same basis as those
shown and may be obtained from the Company (if the option is available based on Adjusted Age as described in Section 10). 

  

					
	AV1396 101 179 1003	  	Page 17	  	TB1O27R

 VARIABLE INCOME OPTIONS 

BASED ON ASSUMED INVESTMENT RETURN ** 
 The amounts shown in these tables are the initial payment amounts based on a 5.0% Assumed Investment Return for each $1,000 of the proceeds. 

 

																									
	 	 	Option 3-V. Table I	 	 	Option 3-V. Table II	 
	 	 	Monthly Installment for Life
No Period
Certain	 	 	Monthly Installment for Life
10 Years
Certain	 
	 Age*
	 	Male	 	 	Female	 	 	Unisex	 	 	Male	 	 	Female	 	 	Unisex	 
	50	 	$	5.07	  	 	$	4.93	  	 	$	4. 98	  	 	$	5.04	  	 	$	4.92	  	 	$	4.95	  
	51	 	 	5.13	  	 	 	4.99	  	 	 	5.03	  	 	 	5.09	  	 	 	4.96	  	 	 	5.00	  
	52	 	 	5.19	  	 	 	5.04	  	 	 	5.08	  	 	 	5.15	  	 	 	5.01	  	 	 	5.05	  
	53	 	 	5.26	  	 	 	5.10	  	 	 	5.14	  	 	 	5.21	  	 	 	5.07	  	 	 	5.11	  
	54	 	 	5.33	  	 	 	5.16	  	 	 	5.21	  	 	 	5.27	  	 	 	5.12	  	 	 	5.17	  
	55	 	 	5.40	  	 	 	5.22	  	 	 	5.27	  	 	 	5.34	  	 	 	5.18	  	 	 	5.23	  
	56	 	 	5.48	  	 	 	5.29	  	 	 	5.35	  	 	 	5.41	  	 	 	5.25	  	 	 	5.30	  
	57	 	 	5.57	  	 	 	5.36	  	 	 	5.42	  	 	 	5.49	  	 	 	5.32	  	 	 	5.37	  
	58	 	 	5.66	  	 	 	5.44	  	 	 	5.50	  	 	 	5.57	  	 	 	5.39	  	 	 	5.44	  
	59	 	 	5.75	  	 	 	5.52	  	 	 	5.59	  	 	 	5.66	  	 	 	5.47	  	 	 	5.52	  
	60	 	 	5.85	  	 	 	5.61	  	 	 	5.68	  	 	 	5.75	  	 	 	5.55	  	 	 	5.61	  
	61	 	 	5.97	  	 	 	5.70	  	 	 	5.78	  	 	 	5.85	  	 	 	5.63	  	 	 	5.70	  
	62	 	 	6.09	  	 	 	5.81	  	 	 	5.89	  	 	 	5.95	  	 	 	5.72	  	 	 	5.79	  
	63	 	 	6.21	  	 	 	5.91	  	 	 	6.00	  	 	 	6.06	  	 	 	5.82	  	 	 	5.89	  
	64	 	 	6.35	  	 	 	6.03	  	 	 	6.13	  	 	 	6.17	  	 	 	5.92	  	 	 	6.00	  
	65	 	 	6.50	  	 	 	6.16	  	 	 	6.26	  	 	 	6.29	  	 	 	6.03	  	 	 	6.11	  
	66	 	 	6.66	  	 	 	6.29	  	 	 	6.40	  	 	 	6.42	  	 	 	6.15	  	 	 	6.23	  
	67	 	 	6.83	  	 	 	6.43	  	 	 	6.55	  	 	 	6.55	  	 	 	6.27	  	 	 	6.36	  
	68	 	 	7.01	  	 	 	6.59	  	 	 	6.71	  	 	 	6.89	  	 	 	6.40	  	 	 	6.49	  
	69	 	 	7.21	  	 	 	6.76	  	 	 	6.89	  	 	 	6.83	  	 	 	6.54	  	 	 	6,63	  
	70	 	 	7.41	  	 	 	6.94	  	 	 	7.08	  	 	 	6,98	  	 	 	6.69	  	 	 	6.77	  
	71	 	 	7.63	  	 	 	7.14	  	 	 	7.28	  	 	 	7.13	  	 	 	6.84	  	 	 	6.93	  
	72	 	 	7.87	  	 	 	7.35	  	 	 	7.50	  	 	 	7.28	  	 	 	7.00	  	 	 	7.09	  
	73	 	 	8.12	  	 	 	7.58	  	 	 	7.74	  	 	 	7.45	  	 	 	7.17	  	 	 	7.25	  
	74	 	 	8.39	  	 	 	7.83	  	 	 	8.00	  	 	 	7.61	  	 	 	7.34	  	 	 	7.42	  
	75	 	 	8.68	  	 	 	8.11	  	 	 	8.28	  	 	 	7.78	  	 	 	7.52	  	 	 	7.60	  
	76	 	 	8.99	  	 	 	8.40	  	 	 	8.58	  	 	 	7.95	  	 	 	7.71	  	 	 	7.78	  
	77	 	 	9.32	  	 	 	8.72	  	 	 	8.90	  	 	 	8.12	  	 	 	7.90	  	 	 	7.97	  
	78	 	 	9.88	  	 	 	9.07	  	 	 	9.25	  	 	 	8.29	  	 	 	8.09	  	 	 	8.16	  
	79	 	 	10.06	  	 	 	9.45	  	 	 	9.63	  	 	 	8.47	  	 	 	8.29	  	 	 	8.34	  
	80	 	 	10.47	  	 	 	9.85	  	 	 	10.04	  	 	 	8.64	  	 	 	8.48	  	 	 	8.53	  
	81	 	 	10.91	  	 	 	10.30	  	 	 	10.48	  	 	 	8.80	  	 	 	8.67	  	 	 	8.71	  
	82	 	 	11.38	  	 	 	10.78	  	 	 	10.96	  	 	 	8.97	  	 	 	8.86	  	 	 	8.89	  
	83	 	 	11.88	  	 	 	11.30	  	 	 	11.47	  	 	 	9.12	  	 	 	9.04	  	 	 	9.06	  
	84	 	 	12.42	  	 	 	11.87	  	 	 	12.03	  	 	 	9.27	  	 	 	9.21	  	 	 	9.23	  
	85	 	 	12.99	  	 	 	12.48	  	 	 	12.63	  	 	 	9.41	  	 	 	9.37	  	 	 	9.38	  
	86	 				 				 				 	 	9.54	  	 	 	9.51	  	 	 	9.52	  
	87	 				 				 				 	 	9.67	  	 	 	9.65	  	 	 	9.65	  
	88	 				 				 				 	 	9.78	  	 	 	9.77	  	 	 	9.77	  
	89	 				 				 				 	 	9.89	  	 	 	9.88	  	 	 	9.88	  
	90	 				 				 				 	 	9.98	  	 	 	9.98	  	 	 	9.98	  
	91	 				 				 				 	 	10.07	  	 	 	10.07	  	 	 	10.07	  
	92	 				 				 				 	 	10.15	  	 	 	10.15	  	 	 	10.15	  
	93	 				 				 				 	 	10.22	  	 	 	10.22	  	 	 	10.22	  
	94	 				 				 				 	 	10.28	  	 	 	10.28	  	 	 	10.28	  
	95	 				 				 				 	 	10.34	  	 	 	10.33	  	 	 	10.33	  

  

	*	Adjusted Age as defined in Section 10.A. 

	**	The discount factor per day which corresponds to the Assumed Investment Return of 5.0% is .99986634. 

Dollar amounts of monthly, quarterly, semi-annual, and annual installments not shown in the above tables will be calculated on the same basis as those
shown and may be obtained from the Company (if the option is available based on Adjusted Age as described in Section 10). 

  

					
	AV1396 101 179 1003	  	Page 18	  	H1313R

 Variable Income Option 5-V. Table Ill 

Monthly Installment For Joint and Full Survivor 
  

																													
	 Adjusted Age
 of
 Male

Annuitant*
	  	Adjusted Age of Female Annuitant*	 
	  	15 Years
Less Than
Male	 	  	12 Years
Less Than
Male	 	  	9 Years
Less Than
Male	 	  	6 Years
Less Than
Male	 	  	3 Years
Less Than
Male	 	  	Same As
Male	 	  	3 Years
More Than
Male	 
	 50
	  	$	4.37	  	  	$	4.42	  	  	$	4.46	  	  	$	4.51	  	  	$	4.56	  	  	$	4.62	  	  	$	4.67	  
	 55
	  	 	4.48	  	  	 	4.64	  	  	 	4.60	  	  	 	4.67	  	  	 	4.74	  	  	 	4.81	  	  	 	4.88	  
	 60
	  	 	4.62	  	  	 	4.70	  	  	 	4.79	  	  	 	4.88	  	  	 	4.98	  	  	 	5.08	  	  	 	5.18	  
	 65
	  	 	4.81	  	  	 	4.92	  	  	 	5.04	  	  	 	5.17	  	  	 	6.31	  	  	 	5.46	  	  	 	5.61	  
	 70
	  	 	5.07	  	  	 	5.23	  	  	 	5.40	  	  	 	5.59	  	  	 	5.79	  	  	 	6.00	  	  	 	6.22	  
	 75
	  	 	5.43	  	  	 	5.65	  	  	 	5.90	  	  	 	6.18	  	  	 	6.48	  	  	 	6.79	  	  	 	7.11	  
	 80
	  	 	5.94	  	  	 	6.26	  	  	 	6.63	  	  	 	7.04	  	  	 	7.49	  	  	 	7.95	  	  	 	8.40	  
	 85
	  	 	6.67	  	  	 	7.15	  	  	 	7.70	  	  	 	8.31	  	  	 	8.97	  	  	 	9.63	  	  	 	10.26	  
	
	 Monthly Installment For Unisex Joint and Full Survivor

 
	 
	 Adjusted Age
 of
 First

Annuitant*
	  	Adjusted Age of Joint Annuitant*	 
	  	15 Years
Less Than
First	 	  	12 Years
Less Than
j First	 	  	9 Years
Less Than
First	 	  	6 Years
Less Than
First	 	  	3 Years
Less Than
First	 	  	Same As
First	 	  	3 Years
More Than
First	 
	 50
	  	$	4.38	  	  	$	4.42	  	  	$	4.47	  	  	$	4.51	  	  	$	4.56	  	  	$	4.61	  	  	$	4.66	  
	 55
	  	 	4.48	  	  	 	4.54	  	  	 	4.60	  	  	 	4.67	  	  	 	4.73	  	  	 	4.80	  	  	 	4.87	  
	 60
	  	 	4.63	  	  	 	4.70	  	  	 	4.79	  	  	 	4.88	  	  	 	4.97	  	  	 	5.07	  	  	 	5.16	  
	 65
	  	 	4,82	  	  	 	4.93	  	  	 	5.05	  	  	 	5.17	  	  	 	5.30	  	  	 	5.44	  	  	 	5.57	  
	 70
	  	 	5.09	  	  	 	5.24	  	  	 	5.41	  	  	 	5.59	  	  	 	5.78	  	  	 	5.97	  	  	 	6.16	  
	 75
	  	 	5.46	  	  	 	5.68	  	  	 	5.93	  	  	 	6.19	  	  	 	6.47	  	  	 	6.75	  	  	 	7.03	  
	 80
	  	 	5.99	  	  	 	6.31	  	  	 	6.67	  	  	 	7.07	  	  	 	7.48	  	  	 	7.90	  	  	 	8.30	  
	 85
	  	 	6.75	  	  	 	7.23	  	  	 	7.76	  	  	 	8.35	  	  	 	8.97	  	  	 	9.59	  	  	 	10.17	  

  

	*	Adjusted Age as defined in Section 10.A 

Dollar amounts of monthly, quarterly, semi-annual, and annual installments not shown in the above tables will be calculated on the same basis as those
shown and may be obtained from the Company (if the option is available based on Adjusted Age as described in Section 10). 

  

					
	AV1396 101 179 1003	  	Page 19	  	J1313R

 SECTION 11 - GENERAL PROVISIONS 

 
  

 

 THE ENTIRE CONTRACT 
 The entire contract consists of this policy, the Policy Data page, endorsements, and riders, if any and the application signed by You, a copy of which is attached hereto. No insertion in or other
alteration of any written application can be made by any person other than the Owner without his or her written consent except that insertions may be made by the Company for administrative purposes only in such manner as to clearly indicate that the
insertions are not to be ascribed to the Owner. All statements in the application made by or under the authority of the applicant are representations and not warranties. Nothing is incorporated by reference, unless a copy is endorsed upon or
attached to the Policy. Nothing in the policy or any attached endorsements or riders thereto invalidates or impairs any right granted to the Owner by New York law or this policy. 
 MODIFICATION OF POLICY 
 No change in this policy is valid unless made in writing by us and
approved by one of our officers. No Registered Representative has .authority to change or waive any provision of Your policy. 
 TAX
QUALIFICATION 
 This policy is intended to qualify as an annuity contract for federal income tax purposes. The provisions of this policy are
to be interpreted to maintain such qualification, notwithstanding any other provisions to the contrary. To maintain such tax qualification, we reserve the right to amend this policy to reflect any clarifications that may be needed or are appropriate
to maintain such tax qualification or to conform this policy to any applicable changes in the tax qualification requirements. Any such amendment will be filed with and approved by the New York Department of Insurance prior to use. We will send You a
copy in the event of any such amendment If You refuse such an amendment it must be by giving us written notice, and Your refusal may result in adverse tax consequences. 
 NON-PARTICIPATING 
 This policy will not share in our surplus earnings. 

AGE OR SEX CORRECTIONS 
 If the age or
sex of the Annuitant has been misstated, the benefits will be those, which the premiums paid, would have purchased for the correct age and sex. If required by law to ignore differences in the sex of the Annuitant, the annuity payments will be
determined using the unisex factors. 
 Any underpayment made by us will be paid with the next payment Any overpayment made by us will be
deducted from future payments. Any underpayment or overpayment will include interest at 5% per year, from the date of the wrong payment to the date of the adjustment. 
 INCONTESTABILITY 
 This policy shall be incontestable from the Policy Data.

 EVIDENCE OF SURVIVAL 
 We have the right to require reasonable evidence that a person is alive if a payment is based on that person being alive. No payment will be made until we receive the evidence. 

SETTLEMENT 
 Any payment by us under this
policy is payable at our Home Office. 
 RIGHTS OF OWNER The Owner may, while the Annuitant is living: 

 

	 	1.	Assign this policy. 

  

	 	2.	Surrender the policy to us. 

  

	 	3.	Amend or modify the policy with our written consent. 

  

	 	4.	Receive annuity payments or name a Payee to receive the payments. 

  

	 	5.	Exercise, receive and enjoy every other right and benefit contained in the policy. 

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

Unless we have been notified of a community or marital property interest in this policy, we will rely on our good faith belief that no such interest
exists and will assume no responsibility for inquiry. 
 SUCCESSOR OWNER 
 A successor Owner will be the new Owner as described in Section 9, C, II. 
 CHANGE OF
OWNERSHIP 
 In the case of a non-tax-qualified annuity, You can change the Owner of this policy, from yourself to a new Owner, in a notice
You sign which gives us the facts that we need. When this change takes effect all rights of ownership in this policy will pass to the new Owner. 
 A change of Owner will not be effective until it is received by Us. After it has been received, the change will take effect as of the date You signed the notice. However, if the Annuitant dies before the
notice has been received, it will not be effective as to those proceeds we have paid before the change was received by Us. 
 We may require
that the change be endorsed in the policy. Changing the Owner does not change the beneficiary or the Annuitant. 
 A change of ownership may
result in adverse tax consequences. 
 ANNUITY COMMENCEMENT DATE 
 The Annuity Commencement Date is the date annuity payments begin. In no event can this date be later than the last day of the month following the month in which the Annuitant attains age 95. You may
change the Annuity Commencement Date at any time before the Annuity Commencement date by giving us 30 days’ written notice. The Annuity Commencement Date may not be scheduled at issue to be earlier than the first day of the calendar month
coinciding with or next following the first policy anniversary. 

 

  

					
	AV1396 101 179 1003	  	Page 20	  	R313R

 SECTION 11 - CONTINUED 
  

 

 ASSIGNMENT 
  

	(a)	In the case of a non tax-qualified annuity, this Policy may be assigned. The assignment must be in writing and received by us. 

 

	(b)	We assume no responsibility for the validity of any assignment Any claim made under an assignment shall be subject to proof of interest and the extent of the
assignment. 

  

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

 Assignment of this policy may result in adverse
tax consequences. 
 BENEFICIARY 

Death proceeds, when payable in accordance with Section 9, are payable to the designated beneficiary or beneficiaries. Such beneficiary(ies) must be
named and may be changed without consent (unless irrevocably designated or required by law) by notifying us in writing on a form acceptable to us. The change will take effect upon the date You sign it whether or not You are living when we receive it
The notice must have been postmarked (or show other evidence of delivery that is acceptable to us) on or before the date of death. Your most recent change of beneficiary notice will replace any prior beneficiary designations. No change will apply to
any payment we made before the written notice was received. If an irrevocable beneficiary dies, You may designate a new beneficiary. 
 You may
direct that the beneficiary shall not have the right to withdraw, assign or commute any sum payable under an option. In the absence of such election or direction, the beneficiary may change the manner of payment or make an election of any option.

 If any primary or contingent beneficiary dies before the Annuitant, that beneficiary’s interest in this policy ends with that
beneficiary’s death. Only those beneficiaries living at the time of the Annuitants death will be eligible to receive their share of the death proceeds. In the event no beneficiaries have been named or all beneficiaries have died before the
death proceeds become payable, the Owner(s) will become the beneficiary(ies) unless elected otherwise in accordance with Section 9. If both primary and contingent beneficiaries have been named, payment will be made to the named primary
beneficiaries living at the time the death proceeds become payable. If there is more than one beneficiary and You failed to specify their interest they will share equally. Payment

 
will be made to the named contingent beneficiary(ies) only, if all primary beneficiaries have died before the death proceeds become payable. If any primary beneficiary is alive at the time the
death proceeds become payable, but dies before receiving their payment their share will be paid to their estate. 
 PROTECTION OF PROCEEDS

 Unless You so direct by filing written notice with us, no beneficiary may assign any payments under this policy before the same are due.
To the extent permitted by law, no payments under this policy will be subject to the claims of creditors of any beneficiary. 
 DEFERMENT

 We will pay any partial Withdrawals or Surrender proceeds from the Separate Account within 7 days after we receive all requirements that
we need. However, it may happen that the New York Stock Exchange is closed for trading (other than the usual weekend or holiday closings), or the Securities and Exchange Commission restricts trading or determines that an emergency exists. If so, it
may not be practical for us to determine the investment experience of the Separate Account In that case, we may defer transfers among the Subaccounts and to the Fixed Account and determination or payment of partial Withdrawals or Surrender proceeds,
until such time as is practical. 
 We may defer paying any partial Withdrawals or Surrender proceeds from the Fixed Account for up to 6 months
from the date we receive Your request If payment of the partial Withdrawal or full Surrender is not made within 10 business days of our receipt of the request, we will pay interest on that amount from the date of receipt of the request to the date
of payment, at an annual interest rate of 1.5%, or the guaranteed annual rate used for calculating settlement options, whichever is greater. If the Owner dies after the request is received, but before the request is processed, the request will be
processed before the death proceeds are determined. 

 

  

					
	AV1396 101 179 1003	  	Page 21	  	RB313R

 SECTION 11 - CONTINUED 
  

 
 ASSET ALLOCATION PORTFOLIOS 
 The Company may, from time to time, offer one or more asset allocation underlying fund portfolios Each such asset allocation portfolio seeks to achieve its investment objective by generally investing a
substantial portion of its assets in a diversified combination of other underlying fund portfolios and mutual funds “(the underlying portfolios/funds).” 
 In seeking to achieve its investment objective, each asset allocation portfolio generally follows these investment strategies: (1) under normal market conditions, each expects to adjust its
investments in the underlying portfolios and funds to achieve its desired mix of assets in equities, bonds, and cash, cash equivalents, or money market instruments (the percentage mix may vary at different times); (2) each asset allocation
portfolio decides how much of its assets to allocate to each underlying portfolio and fund based on its outlook for the markets in which it invests, historical performance, global markets current valuations, and other economic factors; (3) each
seeks to periodically adjust its allocations to favor investments in those underlying portfolios and funds that are expected to provide the most favorable outlook for achieving its investment objective; and (4) each asset allocation portfolio
may also invest directly in government securities, short-term commercial paper, or other appropriate investments.

 Each such asset allocation portfolio expects to adjust its allocations to favor investments that it
believes will provide a favorable outlook for achieving its investment objective. It is not possible to predict the extent to which an asset allocation portfolio will be invested in a particular underlying portfolio or fund at any time. 

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

 

  

					
	AV1396 101 179 1003	  	Page 22	  	R639R

  

			
	
 

  
 A Stock Company (Hereafter called
the Company, we, our or us)
	  	  Home Office located at;

440 Mamaroneck Avenue, Harrison, New York 10528

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

 INDEX 

 

					
	 	  	Page	 
	Accumulation Units	  	 	7, 8	  
	Age or Sex Corrections	  	 	20	  
	Annuity Commencement Date	  	 	20	  
	Annuity Payments	  	 	12	  
	Assignment	  	 	21	  
	Beneficiary	  	 	21	  
	Cash Value	  	 	5	  
	Contract	  	 	20	  
	Death Proceeds	  	 	10, 11, 12	  
	Definitions	  	 	2	  
	Dollar Cost Averaging Option	  	 	9	  
	Evidence of Survival	  	 	20	  
	Fixed Account	  	 	8	  
	Guaranteed Minimum Death Benefit	  	 	1 0	  
	Guaranteed Period Option	  	 	8	  

					
	 	  	Page	 
	Incontestability	  	 	20	  
	Income Option Tables	  	 	16, 17, 18, 19	  
	Modification of Policy	  	 	20	  
	Non-participating	  	 	20	  
	Option to Change Annuity Commencement Date	  	 	20	  
	Partial Withdrawals	  	 	5	  
	Payee	  	 	13	  
	Payment of Premiums	  	 	4	  
	Policy Data Page	  	 	3	  
	Policy Value	  	 	4	  
	Proof of Age	  	 	13	  
	Protection of Proceeds	  	 	21	  
	Right to Cancel	  	 	1	  
	Rights of Owner	  	 	20	  
	Separate Account	  	 	6, 7	  
	Service Charge	  	 	4, 5	  
	Settlement	  	 	20	  
	Transfers	  	 	9, 10	  

 

  
 Flexible Premium
Deferred Variable Annuity 
 Income Payable At Annuity Commencement Date 

Benefits Based On The Performance Of The Separate Account Are Variable And Are Not 

Guaranteed As To Dollar Amount And Will Increase Or Decrease In Value Based Upon 

Investment Experience (See Sections 6 and bC) 
 Non-Participating 
 AFTER THE POLICY DATE. WE RESERVE THE RIGHT TO (I) REFUSE
PREMIUM PAYMENTS TO 
 THE FIXED ACCOUNT, AND (II) PROHIBIT TRANSFERS TO THE FIXED ACCOUNT 

  

					
	AV1396 101 179 1003	  		  	Y1028R

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