Document:

EX-4(A)

 

Exhibit 4(a)

Home Office: Cincinnati, Ohio

Variable Administrative Office: P.O. Box 5423, Cincinnati, Ohio 45201-5423

Group Flexible Premium Deferred Variable Annuity Contract

We have issued this Group Flexible Premium Deferred Variable Annuity Contract (“Contract”) in
consideration of the payment of Purchase Payments, and of any application and/or participation
enrollment forms. The Contract Owner is set out on the Contract Specifications page. It is
effective as of the Contract Effective Date, which is set out on the Contract Specifications page.
It is subject to all of the terms and conditions that are set out on the following pages.

As you read through this Contract, please note that the words “we”, “us”, “our”, and “Company”
refer to Annuity Investors Life Insurance Company. The words “you” and “your” refer to the
Contract Owner. “Administrative Office” means our home office or any other place of business that
we may designate.

	 	 	 
	
	 	
	MARK F. MUETHING 

SECRETARY
	 	CHARLES R. SCHEPER

PRESIDENT

NONPARTICIPATING — NO DIVIDENDS

PAYMENTS AND OTHER VALUES DESCRIBED IN THIS CONTRACT, WHEN BASED ON THE INVESTMENT EXPERIENCE OF
THE SEPARATE ACCOUNT, MAY INCREASE OR DECREASE AND ARE NOT GUARANTEED. NO MINIMUM CONTRACT VALUE
IS GUARANTEED, EXCEPT FOR AMOUNTS IN THE FIXED ACCOUNT.

 

 

CONTRACT SPECIFICATIONS

CONTRACT OWNER: [JOHN DOE]

CONTRACT NUMBER: [000000000]

CONTRACT EFFECTIVE DATE: [DECEMBER 1, 2007]

SEPARATE ACCOUNT: Annuity Investors Variable Account [C]

Following is a list of the Funds in which the currently available Sub-Accounts invest:

[AIM V.I. Capital Development Fund — Series II]

[AIM V.I. Global Real Estate Fund – Series II]]

[[AIM V.I. International Growth Fund – Series II]]

[[AIM V.I. Mid Cap Core Equity Fund – Series II]]

[[AIM V.I. Small Cap Equity Fund – Series I]]

[AllianceBernstein VPS International Value Portfolio – Class B]

[American Century VP Large Company Value Fund – Class II]

[American Century VP Mid Cap Value Fund – Class II]

[American Century VP VistaSM Fund – Class II]

[Calamos Growth and Income Portfolio]

[Davis Value Portfolio]

[The Dreyfus Socially Responsible Growth Fund – Service Shares]

[Dreyfus Stock Index Fund, Inc. – Service Shares]

[Dreyfus IP MidCap Stock Portfolio – Service Shares]

[Dreyfus VIF Money Market Portfolio]

[DWS Global Thematic Fund VIP – Class A]

[Financial Investors VIT Ibbotson Balanced ETF Asset Allocation-Class II]

[Financial Investors VIT Ibbotson Conservative ETF Asset Allocation-Class II]

[Financial Investors VIT Ibbotson Growth ETF Asset Allocation-Class II]

[Financial Investors VIT Ibbotson Income/Growth ETF Asset Allocation-Class II]

[Franklin Templeton Mutual Shares Securities Fund – Class 2]

[Franklin Templeton Foreign Securities Fund-Class 2]

[Franklin Templeton U.S. Government Fund – Class 2]

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[Janus Aspen Series Balanced Portfolio – Service Shares]

[Janus Aspen Series International Growth Portfolio – Service Shares]

[Janus Aspen Series Large Cap Growth Portfolio – Service Shares]

[Janus Aspen Series Mid Cap Growth Portfolio – Service Shares]

[Neuberger Berman AMT Guardian Portfolio – Class S]

[Oppenheimer Balanced Fund /VA – Service Shares]

[Oppenheimer Capital Appreciation Fund/VA – Service Shares]

[Oppenheimer Global Securities Fund/VA – Service Shares]

[Oppenheimer Main Street Fund® /VA – Service Shares]

[Oppenheimer Main Street Small Cap Fund/ VA – Service Shares]

[PIMCO VIT High Yield Portfolio – Administrative Class]

[PIMCO VIT Real Return Portfolio – Administrative Class]

[PIMCO VIT Total Return Portfolio – Administrative Class]

[Van Kampen UIF Core Plus Fixed Income Portfolio – Class I]

[Van Kampen UIF Mid-Cap Growth Portfolio – Class I]

[Van Kampen UIF Mid Cap Value Portfolio – Class I]

[Van Kampen UIF Value Portfolio – Class I]

[Wilshire VIT Wilshire 2015 Moderate Fund]

[Wilshire VIT Wilshire 2025 Moderate Fund]

[Wilshire VIT Wilshire 2035 Moderate Fund]

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FIXED ACCOUNT:

Following is a list of the currently available Fixed Account options, with the guarantee periods as
may be applicable:

Fixed Accumulation Account

[Fixed Account One-Year Guarantee Period]

We may add or delete Fixed Account options at any time.

FIXED ACCOUNT GUARANTEED INTEREST RATE: [3.00%]

TRANSFER FEE: [$25] per transfer by Participant in excess of [twelve (12)] in any Certificate
Year.

EARLY WITHDRAWAL CHARGE SCHEDULE:

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Certificate Year

	 	 	1	 	 	 	2	 	 	 	3	 	 	 	4	 	 	 	5	 	 	 	6+	 
	Early Withdrawal Charge

	 	 	5%	 	 	 	4%	 	 	 	3%	 	 	 	2%	 	 	 	1%	 	 	 	0%	 

Please see the FEES AND CHARGES section of this Contract for additional information.

	 	 	 
	EARLY WITHDRAWAL CHARGE WAIVER(S):

	 	[PARTICIPANT’S SEPARATION FROM SERVICE]
	 

	 	[December 1, 2012]

CERTIFICATE MAINTENANCE FEE: [$30] Annually

MORTALITY AND EXPENSE RISK CHARGE: A charge equal to an effective annual rate of [0.85%] of the
daily Net Asset Value of the Sub-Accounts.

ADMINISTRATION CHARGE: A charge equal to an effective annual rate of [0.15%] of the daily Net
Asset Value of the Sub-Accounts.

MINIMUM REQUIRED VALUE: [$500]

MINIMUM TRANSFER AMOUNT: [$500]

	 	 	 
	INQUIRIES:	 	For information and assistance, or to make a complaint, call or write:
	 

	 

	 	Policyowner Services Department
	 

	 	Annuity Investors Life Insurance Company
	 

	 	Post Office Box 5423
	 

	 	Cincinnati, Ohio 45201-5423
	 

	 	1-800-789-6771
	 
	 	 
	 

	 	If you prefer, you may visit us at our website, www.GAFRI.com.

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	TABLE OF CONTENTS	 	Page	 
	 
	DEFINITIONS
	 	 	7	 
	 
	 	 	 	 
	GENERAL PROVISIONS
	 	 	9	 
	 
	 	 	 	 
	Entire Contract
	 	 	9	 
	Changes – Waivers
	 	 	9	 
	Nonparticipating
	 	 	9	 
	Misstatement
	 	 	10	 
	Required Reports
	 	 	10	 
	Exclusive Benefit
	 	 	10	 
	State Law
	 	 	10	 
	Claims of Creditors
	 	 	10	 
	Company Liability
	 	 	10	 
	Voting Rights
	 	 	10	 
	Incontestability
	 	 	10	 
	Discharge of Liability
	 	 	11	 
	Transfer by the Company
	 	 	11	 
	Taxes
	 	 	11	 
	 
	 	 	 	 
	PURCHASE PAYMENTS
	 	 	11	 
	 
	 	 	 	 
	Purchase Payments
	 	 	11	 
	Allocation of Purchase Payments
	 	 	11	 
	 
	 	 	 	 
	FIXED ACCOUNT
	 	 	11	 
	 
	 	 	 	 
	Fixed Account
	 	 	11	 
	Interest Crediting
	 	 	12	 
	Fixed Account Value
	 	 	12	 
	 
	 	 	 	 
	SEPARATE ACCOUNT
	 	 	12	 
	 
	 	 	 	 
	General Description
	 	 	12	 
	Sub-Accounts of the Separate Account
	 	 	13	 
	Valuation of Assets
	 	 	13	 
	Variable Account Value
	 	 	13	 
	Accumulation Unit Value
	 	 	14	 
	 
	 	 	 	 
	TRANSFERS
	 	 	15	 
	 
	 	 	 	 
	Transfers From the Fixed Account
	 	 	15	 
	Transfers From a Sub-Account
	 	 	15	 
	Other Transfer Rules
	 	 	15	 
	 
	 	 	 	 
	FEES AND CHARGES
	 	 	16	 
	 
	 	 	 	 
	Mortality and Expense Risk Charge
	 	 	16	 
	Administration Charge
	 	 	16	 
	Certificate Maintenance Fee
	 	 	16	 
	Early Withdrawal Charge
	 	 	17	 
	 
	 	 	 	 
	SURRENDER AND WITHDRAWALS
	 	 	17	 
	 
	 	 	 	 
	Surrender
	 	 	17	 
	Withdrawals
	 	 	17	 
	Exchanges, Transfers, and Rollovers
	 	 	18	 
	Termination
	 	 	18	 
	Deferral of Payment
	 	 	18	 

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	TABLE OF CONTENTS	 	Page	 
	 
	OWNERSHIP PROVISIONS
	 	 	19	 
	 
	 	 	 	 
	Ownership of Separate Account
	 	 	19	 
	Ownership of the Contract and Participant Account
	 	 	19	 
	Transfer and Assignment
	 	 	19	 
	Successor Owner
	 	 	19	 
	Community Property
	 	 	19	 
	 
	 	 	 	 
	BENEFICIARY PROVISIONS
	 	 	19	 
	 
	 	 	 	 
	Beneficiary
	 	 	19	 
	Designation of Beneficiary
	 	 	20	 
	 
	 	 	 	 
	ANNUITY BENEFIT
	 	 	20	 
	 
	 	 	 	 
	Annuity Commencement Date
	 	 	20	 
	Annuity Benefit Amount
	 	 	20	 
	Annuity Benefit Payments
	 	 	21	 
	Form of Annuity Benefit
	 	 	21	 
	 
	 	 	 	 
	DEATH BENEFIT
	 	 	21	 
	 
	 	 	 	 
	Death Benefit
	 	 	21	 
	Death Benefit Amount
	 	 	22	 
	Step Up in Account Value for Successor Owner
	 	 	22	 
	Transfers After Death
	 	 	22	 
	Death Benefit Commencement Date
	 	 	23	 
	Death Benefit Payments
	 	 	23	 
	Form of Death Benefit
	 	 	23	 
	Interest on Death Benefit
	 	 	24	 
	 
	 	 	 	 
	SETTLEMENT OPTIONS
	 	 	24	 
	 
	 	 	 	 
	Conditions
	 	 	24	 
	Benefit Payments
	 	 	24	 
	Fixed Dollar Payments
	 	 	25	 
	Variable Dollar Payments
	 	 	25	 
	Limitation on Election of Settlement Option
	 	 	26	 
	Settlement Option Computations
	 	 	26	 
	Available Settlement Options
	 	 	26	 
	Commuted Values
	 	 	26	 
	Settlement Option Tables
	 	 	26	 

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DEFINITIONS

Account Value: For a Participant, the aggregate value of his or her interest in all of the
Sub-Accounts and the Fixed Account options as of the end of any Valuation Period. The value of his
or her interest in all of the Sub-Accounts is his or her “Variable Account Value”. The value of
his or her interest in all of the Fixed Account options is his or her “Fixed Account Value”.

Accumulation Unit: A unit of measure used to calculate the value of a Sub-Account prior to the
Commencement Date. The value of an Accumulation Unit is referred to as “Accumulation Unit Value”.

Annuity Benefit: The payments that may be made under the ANNUITY BENEFIT section of this Contract.

Annuity Commencement Date: For a Participant, the first day of the first payment interval for
which payment of an Annuity Benefit is to be made.

Beneficiary: The person entitled to receive any Death Benefit with respect to the interest of a
Participant in this Contract.

Benefit Unit: A unit of measure used to determine the dollar value of any Variable Dollar
payments. The value of a Benefit Unit is referred to as “Benefit Unit Value”.

Certificate: Evidence that is provided to a Participant of his or her interest in this Contract.

Certificate Anniversary: For a Participant, the date in each year that is the annual anniversary
of his or her Certificate Effective Date.

Certificate Effective Date: For a Participant, the date on which his or her interest in this
Contract took effect. This date is set out on his or her Certificate Specifications page.

Certificate Year: For a Participant, each twelve (12) month period that begins on his or her
Certificate Effective Date or on a Certificate Anniversary.

Commencement Date: For the interest of a Participant in this Contract:

	 	1)	 	his or her Annuity Commencement Date if an Annuity Benefit is payable; or
	 
	 	2)	 	the Death Benefit Commencement Date if a Death Benefit is payable.

Contract Anniversary: The date in each year that is the annual anniversary of the Contract
Effective Date.

Contract Effective Date: The date that this Contract is issued, which is set out on the Contract
Specifications page.

Contract Year: Each twelve (12) month period that begins on the Contract Effective Date or on a
Contract Anniversary.

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Death Benefit: The benefit described in the DEATH BENEFIT section of this Contract.

Death Benefit Commencement Date: For the interest of a Participant in this Contract:

	 	1)	 	the first day of the first payment interval for a Death Benefit that is paid as
periodic payments; or
	 
	 	2)	 	the date of payment for a Death Benefit that is paid as a lump sum.

Death Benefit Valuation Date: For the interest of a Participant in this Contract, the earlier of:

	 	1)	 	the date that we have received both Due Proof of Death and a Written Request
with instructions as to the form of Death Benefit; or
	 
	 	2)	 	the date that is the Death Benefit Commencement Date.

Due Proof of Death: One (1) of the following:

	 	1)	 	a certified copy of a death certificate; or
	 
	 	2)	 	a certified copy of a decree that is made by a court of competent jurisdiction
as to the finding of death.

We will also accept other proof that is satisfactory to us.

Fund: A management investment company (or a portfolio of it) that is registered under the
Investment Company Act of 1940, as amended. Each Sub-Account invests in a Fund.

Net Asset Value: The amount computed by an investment company as the price at which its shares or
units may be purchased or redeemed. This price is computed in accordance with the rules of the
Securities and Exchange Commission. It is computed no less frequently than each Valuation Period.

Participant: A person who has an interest in this Contract, as evidenced by a Certificate. The
name of each Participant is set out on his or her Certificate Specifications page.

Purchase Payment: An amount received by us for an interest in this Contract. This amount is after
the deduction of premium tax or other taxes that may apply.

Separate Account: An account that is established and maintained by the Company pursuant to the
laws of the Company’s domiciliary state. The Separate Account is registered as a unit investment
trust under the Investment Company Act of 1940, as amended.

Sub-Account: A subdivision of the Separate Account. Each of the Sub-Accounts invests in the
shares of a designated Fund.

Surrender Value: For a Participant, an amount equal to his or her Account Value as of the end of
the applicable Valuation Period, reduced by:

	 	1)	 	any charges or fees that would apply upon a surrender;
	 
	 	2)	 	any applicable premium tax or other taxes not previously deducted; and
	 
	 	3)	 	the outstanding balance of any loans.

-8-

 

Valuation Date: Each day on which the New York Stock Exchange is open for business.

Valuation Period: The period commencing at the close of regular trading on the New York Stock
Exchange on any Valuation Date, and ending at the close of trading on the next succeeding Valuation
Date.

Written Request: Information provided, or a request made, that is:

	 	1)	 	complete and satisfactory to us;
	 
	 	2)	 	on our form or in a manner satisfactory to us, which may, at our discretion, be
by telephone or electronic means; and
	 
	 	3)	 	received by us at our Administrative Office.

A Written Request is subject to any payment that we make before we acknowledge it. It is also
subject to any action that we take before we acknowledge it. We will deem a Written Request to be
a standing order. It may be modified or revoked only by a subsequent Written Request, when
permitted by the terms of this Contract. A Participant may be required to return his or her
Certificate to us in connection with a Written Request.

GENERAL PROVISIONS

Entire Contract

This Contract is a group flexible premium deferred variable annuity contract. It is restricted as
required to obtain favorable tax treatment under the Internal Revenue Code. It is not valid
without the requisite endorsement(s) being attached. This Contract, which includes any riders or
endorsements to it, and the application(s) for them, if any, forms the entire agreement between you
and us. A Certificate is not a contract and is not a part of this Contract.

Only statements that you have made in consideration for this Contract or an interest in it will be
used to void this Contract or an interest in it, or to pursue or defend a claim based on it. Such
statements are treated as representations and not warranties.

Changes – Waivers

No changes or waivers of the terms of this Contract are valid unless made in writing and signed by
our President, Vice President, or Secretary. No other person or producer has authority to change
or waive any provision of this Contract. We reserve the right both to administer and to change the
terms of this Contract to conform to pertinent laws and governmental regulations and rulings.

Nonparticipating

This Contract does not pay dividends or share in the Company’s divisible surplus.

-9-

 

Misstatement

If the age of a person is misstated, payments will be adjusted to the amount that would have been
payable based on the correct age. If payments based on the correct age would have been higher, we
will promptly pay the underpaid amount in one (1) sum, with interest. If payments based on the
correct age would have been lower, we may deduct the overpaid amount, with interest, from
succeeding payments. We may also pursue other remedies at law or in equity.

Required Reports

At least once each Certificate Year, we will send the Participant a report of his or her current
values. We will also provide any other information required by law. These reports will stop when
his or her interest in this Contract is fully surrendered, or on the Commencement Date, whichever
is first.

The reports will be mailed to a Participant’s last known address. If permitted by law, in lieu of
that we may deliver these and other required documents in electronic form. The reported values
will be based on the information in our possession at the time that we prepare the report. We may
adjust the reported values at a later date if that information proves to be incorrect or has
changed.

Exclusive Benefit

The rights of a Participant in this Contract are for the exclusive benefit of the Participant and
his or her Beneficiaries. Those rights are nonforfeitable by us.

State Law

All factors, values, benefits, and reserves under this Contract will not be less than those
required by the law of the state in which this Contract is delivered.

Claims of Creditors

To the extent allowed by law, this Contract and all values and benefits under it are not subject to
the claims of creditors or to legal process.

Company Liability

We will not be liable for any loss that is related to a failure by you, by a Participant, or by any
other person having rights or benefits under this Contract, to comply with pertinent laws or
governmental regulations or rulings.

Voting Rights

To the extent required by law, we will vote all shares of the Funds held in the Separate Account at
regular and special shareholder meetings of the Funds. We will vote the shares attributable to an
interest in this Contract in accordance with instructions received from the Participant, or if
applicable, from the payee of a settlement option. If there is a change in the law that permits us
to vote the shares of the Funds without such instructions, then we reserve the right to do so.

Incontestability

This Contract is not contestable by us except to the extent stated in a rider or endorsement.

-10-

 

Discharge of Liability

We will be discharged from all liability to the extent of each payment that is made for a
withdrawal, surrender, Annuity Benefit, or Death Benefit.

Transfer by the Company

We reserve the right to transfer our obligations under this Contract to another qualified life
insurance company under an assumption or reinsurance arrangement. We may make such a transfer
without your consent or the consent of the Participants.

Taxes

Some states impose on the Company a premium tax or other taxes on annuities. If a premium tax or
other taxes are charged or due, we reserve the right to deduct this amount from the Purchase
Payment or Account Value of a Participant at the time that it is imposed.

PURCHASE PAYMENTS

Purchase Payments

One (1) or more Purchase Payments may be paid to us for a Participant at any time before his or her
Annuity Commencement Date, so long as:

	 	1)	 	he or she is still living; and
	 
	 	2)	 	his or her interest in this Contract has not been surrendered.

The initial Purchase Payment for a Participant must be received by us on or before his or her
Certificate Effective Date. Each Purchase Payment must be received by us at our Administrative
Office. Each Purchase Payment is subject to any minimums or maximums that we set from time to time.
Upon request, we will provide you with a receipt as proof of payment.

As Contract Owner, it is your duty to collect Purchase Payments by payroll deduction or otherwise.
It is your duty to remit Purchase Payments to us in the proper amount. It is your duty to provide
us with all information needed to apply such amounts properly to the interests of Participants.

Allocation of Purchase Payments

We will allocate Purchase Payments to the available Sub-Accounts and Fixed Account option(s)
according to the instructions from the Participant. Those instructions must be made by Written
Request. Allocations must be made in whole percentages. The minimum amount that can be allocated
to a Fixed Account option or to a Sub-Account is $10.00. We may, in our sole discretion, restrict
or prohibit allocations to the Fixed Account or Sub-Accounts from time to time on a
nondiscriminatory basis.

FIXED ACCOUNT

Fixed Account

The Fixed Account is part of the Company’s general account. The value of the Fixed Account is not
dependent upon the investment performance of the Sub-Accounts.

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Interest Crediting

Amounts held under the Fixed Account will be credited with interest at an annual effective rate
that is at least equal to the Fixed Account Guaranteed Interest Rate. The Fixed Account Guaranteed
Interest Rate is set out on the Contract Specifications page. We may from time to time pay a
higher current interest rate for amounts held under the Fixed Account. Such higher rate would be
as declared by the Company in its discretion. Once declared, such rate will be credited until
changed.

Interest on amounts held under the Fixed Account is earned daily. We will stop crediting interest
on an amount as of the date that it is transferred, withdrawn, surrendered, or applied to charges.
We will stop crediting interest on an amount that is applied to a settlement option as of the
Commencement Date.

The interest rate credited to each Purchase Payment allocated to the Fixed Account will not be
changed for at least twelve (12) months following the date on which it was received. Thereafter,
the interest rate credited will not be changed more frequently than once per calendar quarter. In
the case of transfers from the Sub-Accounts to the Fixed Account, the interest rate will not be
changed more frequently than once per calendar quarter.

Fixed Account Value

For a Participant, the Fixed Account Value at any time is equal to:

	 	1)	 	Purchase Payment(s) for his or her interest in this Contract that are allocated
to the Fixed Account; plus
	 
	 	2)	 	amounts transferred to the Fixed Account for him or her; plus
	 
	 	3)	 	interest credited to the Fixed Account for him or her; less
	 
	 	4)	 	any withdrawals, surrender, deductions, and transfers from the Fixed Account
for him or her; and less
	 
	 	5)	 	other charges and adjustments to his or her interest made as described
elsewhere in this Contract.

SEPARATE ACCOUNT

General Description

The variable benefits under this Contract are provided through the Separate Account.

The income, if any, and any gains or losses, realized or unrealized, on the Separate Account will
be credited to or charged against the amounts allocated to such account. This credit or charge
will be made without regard to other income, gains, or losses of the Company. The Separate Account
is not chargeable with any liabilities of the Company to the extent that its value is equal to the
reserves and other contractual liabilities under all of the policies, annuities, and other
contracts identified with it. The Company is not, and does not hold itself out to be, a trustee
with respect to such amounts.

We have the right to transfer certain assets from the Separate Account to our general account. We
may transfer any assets that are in excess of the required reserves and other contractual
liabilities under all of the policies, annuities, and other contracts identified with the Separate
Account. We may make these transfers in our sole discretion at any time and without prior notice.

-12-

 

We may merge or combine the Separate Account with any other separate account of the Company. We
may transfer the assets of the Separate Account to another life insurance company by means of a
merger or reinsurance. We may convert the Separate Account into a managed separate account. We
may de-register the Separate Account under the Investment Company Act of 1940. Such a change will
be made in accordance with pertinent laws. It will be made only after obtaining any approvals that
may be needed, including those of the Company’s domiciliary state and the Securities and Exchange
Commission.

Sub-Accounts of the Separate Account

The Separate Account is divided into Sub-Accounts. All of the Sub-Accounts that are available as
of the Contract Effective Date are listed on the Contract Specifications page. Each of the
Sub-Accounts invests exclusively in shares of an underlying Fund. These Funds are shown on the
Contract Specifications page. Any amounts of income on the shares of a Fund will be reinvested in
additional shares of that Fund at its Net Asset Value. Any gains on the shares of a Fund will also
be reinvested.

We may add or delete Sub-Accounts. We may substitute shares of a different Fund or different class
or series of a Fund for shares held in a Sub-Account. We may merge or combine Sub-Accounts. Such
a change will be made in accordance with pertinent laws. It will be made only after obtaining any
approvals that may be needed.

Valuation of Assets

Shares of Funds held by each Sub-Account will be valued at their Net Asset Value at the end of each
Valuation Period, as reported by each such Fund.

Variable Account Value

Purchase Payment(s) that are allocated to a Sub-Account, and amounts that are transferred to a
Sub-Account, are converted into Accumulation Units. The number of Accumulation Units credited is
determined by dividing the dollar amount directed to that Sub-Account by the value of the
Accumulation Unit for that Sub-Account at the end of the Valuation Period during which the amount
is received.

The following events will result in the cancellation of an appropriate number of Accumulation Units
of a Sub-Account:

	 	1)	 	a transfer from a Sub-Account;
	 
	 	2)	 	the surrender or a withdrawal of the Variable Account Value;
	 
	 	3)	 	the payment of a Death Benefit;
	 
	 	4)	 	the application of the Variable Account Value to a settlement option; or
	 
	 	5)	 	the deduction of the charges, fees, or other adjustments described in this
Contract.

Accumulation Units will be canceled as of:

	 	1)	 	the end of the Valuation Period during which we receive a Written Request that
gives rise to such cancellation;
	 
	 	2)	 	the Commencement Date; or
	 
	 	3)	 	the end of the Valuation Period on which a charge, fee, or other adjustment is
due.

-13-

 

At any time, the Variable Account Value of a Participant is equal to the sum of the values of his
or her interest in each Sub-Account. The value of his or her interest in a Sub-Account is equal to
the number of his or her Accumulation Units for that Sub-Account multiplied by the Accumulation
Unit Value for that Sub-Account. These values are determined as of the end of the preceding
Valuation Period.

Accumulation Unit Value

The initial Accumulation Unit Value for the Money Market Sub-Account was set at $1.00. The initial
Accumulation Unit Value for each of the other Sub-Accounts was set at $10.00. After that, the
Accumulation Unit Value at the end of each Valuation Period is the Accumulation Unit Value as of
the end of the prior Valuation Period multiplied by the Net Investment Factor. The Net Investment
Factor is described below. The Accumulation Unit Values will vary as a result of the varying
investment experience of the Funds.

The Net Investment Factor is a measure of the investment performance of a Sub-Account from one
Valuation Period to the next. Each Sub-Account has a Net Investment Factor for each Valuation
Period. The Net Investment Factor may be greater than one, or it may be less than one. This means
that the Accumulation Unit Value for each Sub-Account may increase or it may decrease. The Net
Investment Factor for any Sub-Account for any Valuation Period is determined by dividing (1) by (2)
and then subtracting (3) from the result, where:

	 	1)	 	is equal to:

	 	a)	 	the Net Asset Value per share of the Fund held in the Sub-Account,
determined at the end of the applicable Valuation Period; plus
	 
	 	b)	 	the per share amount of any dividend or net capital gain distributions
made by the Fund held in the Sub-Account, if the “ex-dividend” date occurs during
the applicable Valuation Period; plus or minus
	 
	 	c)	 	a per share credit or charge for any taxes reserved for, which is
determined by the Company to have resulted from the investment operations of the
Sub-Account;

	 	2)	 	is the Net Asset Value per share of the Fund held in the Sub-Account,
determined at the end of the preceding Valuation Period; and
	 
	 	3)	 	is the sum of the Mortality and Expense Risk Charge and the Administration
Charge to be deducted from the Sub-Account for the number of days in the applicable
Valuation Period.

-14-

 

TRANSFERS

Prior to a Commencement Date, a Participant may transfer amounts in a Sub-Account or Fixed Account
option as set out below.

Transfers From the Fixed Account

If allowed by the Company, in its sole discretion, a Participant may transfer amounts from his or
her interest in the Fixed Account to a Sub-Account during the thirty (30) day period each year
following the Certificate Anniversary. No transfer from the Fixed Account is allowed during the
first Certificate Year. Transfers from the Fixed Account during any other Certificate Year may not
exceed in the aggregate the greater of $1,000 or twenty percent (20%) of the Fixed Account Value as
of the most recent Certificate Anniversary. We may, in our sole discretion, restrict or prohibit
this type of transfer or the availability of any Sub-Account from time to time on a
nondiscriminatory basis.

Transfers From a Sub-Account

If allowed by the Company, in its sole discretion, a Participant may transfer amounts from his or
her interest in a Sub-Account to another Sub-Account or to the Fixed Account. Amounts transferred
from the Fixed Account to the Sub-Accounts may not be transferred back to the Fixed Account for a
period of twelve (12) months from the date of transfer. We may, in our sole discretion, restrict
or prohibit this type of transfer or the availability of any Sub-Account or Fixed Account option
from time to time on a nondiscriminatory basis.

Other Transfer Rules

A transfer must be made by Written Request. A transfer must be at least the Minimum Transfer
Amount or the balance of the Participant’s interest in the Sub-Account or the Fixed Account, if
less. The Minimum Transfer Amount is set out on the Contract Specifications page.

If the amount allocated by a Participant to a Sub-Account is less than the Minimum Required Value,
we reserve the right to transfer the amount to the other Sub-Accounts and the Fixed Account. Such
a transfer will be in the same proportion as each of his or her other Sub-Account’s value and his
or her Fixed Account Value is to his or her total Account Value, as of the end of the Valuation
Period that precedes the transfer, less the amount transferred. If the amount allocated to his or
her Fixed Account is less than the Minimum Required Value, we reserve the right to transfer the
amount to his or her Sub-Accounts. Such a transfer will be in the same proportion as each of his
or her Sub-Account’s value is to his or her total Account Value, as of the end of the Valuation
Period that precedes the transfer, less the amount transferred. The Minimum Required Value is set
out on the Contract Specifications page.

We will charge a Transfer Fee on each transfer made with respect to the interest of a Participant
over a certain number per year. The amount of the Transfer Fee, and the number of transfers that
may be made before it applies, are set out on the Contract Specifications page.

-15-

 

We may modify our transfer procedures at any time and at our sole discretion. Such modifications
could be applied to transfers to or from some or all of the Sub-Accounts or the Fixed Account, and
may include, but not be limited to, the following:

	 	1)	 	the requirement of a minimum time period between each transfer with respect to
the interest of a Participant;
	 
	 	2)	 	the means for submitting a Written Request;
	 
	 	3)	 	limits on the dollar amount that may be transferred between available
Sub-Accounts or the Fixed Account at any one time with respect to the interest of a
Participant; or
	 
	 	4)	 	as required by a Fund.

FEES AND CHARGES

Mortality and Expense Risk Charge

The Mortality and Expense Risk Charge is shown on the Contract Specifications page. It is deducted
daily from each of the Sub-Accounts. This deduction is made to compensate us for assuming the
mortality and expense risks under this Contract. We may reduce the charge in our sole discretion.

Administration Charge

The Administration Charge is shown on the Contract Specifications page. It is deducted daily from
each of the Sub-Accounts. This deduction is made to reimburse us for certain expenses incurred in
the administration of this Contract and the Separate Account. We may reduce or eliminate the
charge in our sole discretion.

Certificate Maintenance Fee

The Certificate Maintenance Fee (“Fee”) is shown on the Contract Specifications page. It is
deducted from the interest of a Participant in this Contract as of the Valuation Date after each
Certificate Anniversary that his or her interest in this Contract is in effect. The Fee will be
taken pro-rata from:

	 	1)	 	each Sub-Account in which he or she has an interest at the time that the Fee is
deducted; and
	 
	 	2)	 	the Fixed Account if he or she has an interest in the Fixed Account at the time
that the Fee is deducted.

The full annual Fee will also be deducted at the time of a surrender.

After the Commencement Date, the Fee will be deducted pro-rata from each payment. This deduction
will result in a reduction in the amount of such payment.

We may waive the Fee in whole or in part in our sole discretion.

-16-

 

Early Withdrawal Charge

An Early Withdrawal Charge may apply to a Participant’s interest in this Contract if:

	 	1)	 	a withdrawal is taken from it;
	 
	 	2)	 	it is surrendered; or
	 
	 	3)	 	it is annuitized.

The Early Withdrawal Charge will be equal to the Early Withdrawal Charge rate multiplied by the
amount that is withdrawn, surrendered, or annuitized. It will include the amount needed to pay the
Early Withdrawal Charge itself. The Early Withdrawal Charge rate for each Certificate Year is set
out on the Contract Specifications page.

No charge applies if the Participant’s interest in this Contract is annuitized for life or for a
fixed period of at least ten (10) years.

Other circumstances, if any, under which we will waive the Early Withdrawal Charge are set out on
the Contract Specifications page. In addition, we may, in our sole discretion, waive the Early
Withdrawal Charge in whole or in part.

SURRENDER AND WITHDRAWALS

Surrender

A Participant may surrender his or her interest in this Contract in full at any time so long as:

	 	1)	 	it is before his or her Annuity Commencement Date; and
	 
	 	2)	 	he or she is still living.

The amount available for surrender will be his or her Surrender Value at the end of the Valuation
Period in which the Written Request is received.

A surrender must be made by Written Request. In the case of a surrender of the interest of a
Participant, his or her interest in this Contract will terminate.

Withdrawals

A Participant may take withdrawals from his or her interest in this Contract at any time so long
as:

	 	1)	 	it is before his or her Annuity Commencement Date;
	 
	 	2)	 	he or she is still living; and
	 
	 	3)	 	his or her interest in this Contract has not been surrendered.

A withdrawal must be made by Written Request. The amount of any withdrawal must be at least $500.
No withdrawal can be made that would reduce his or her Surrender Value to less than the Minimum
Required Value. The Minimum Required Value is set out on the Contract Specifications page.

-17-

 

A withdrawal will result in the cancellation of Accumulation Units from each of the applicable
Sub-Accounts and/or a reduction of the Fixed Account Value. Unless a Participant states otherwise
in his or her request for a withdrawal, the reduction in each Sub-Account and Fixed Account option
will be in the same proportion as the reduction in the total Account Value.

The amount available for withdrawal will be based on the Surrender Value as of the end of the
Valuation Period in which we receive the Written Request.

Exchanges, Transfers, and Rollovers

An amount paid on a withdrawal or surrender may be paid to or for another annuity or tax-qualified
account in a tax-free exchange, transfer, or rollover to the full extent allowed by federal tax
law.

Termination

We may terminate this Contract by giving you sixty (60) days advance notice in writing. You may
terminate this Contract by giving us sixty (60) days advance notice in writing. If this Contract
is terminated, each Participant may continue his or her interest in it, but no more Purchase
Payments will be allowed. Termination of this Contract will not affect payments being made by us.
Termination of this Contract will not affect our right to any fees or charges, loans, or applicable
premium tax or other taxes not previously deducted.

We reserve the right to terminate the interest of a Participant in this Contract at any time that
his or her Surrender Value is less than the Minimum Required Value. The Minimum Required Value is
set out on the Contract Specifications page. If we terminate a Participant’s interest in this
Contract, we will pay his or her Surrender Value to the Participant. We will not terminate the
interest of a Participant if a distribution to the Participant is prohibited by the tax
qualification or employer plan endorsement.

Deferral of Payment

The Company has the right to suspend or delay the date of payment of a withdrawal or surrender of
the Variable Account Value at certain times. We may do this for any period:

	 	1)	 	when the New York Stock Exchange is closed, or when trading on the New York
Stock Exchange is restricted; or
	 
	 	2)	 	when an emergency exists (as determined by the Securities and Exchange
Commission) as a result of which:

	 	a)	 	the disposal of securities in the Separate Account is not reasonably
practicable; or
	 
	 	b)	 	it is not reasonably practicable to determine fairly the value of the
net assets in the Separate Account; or

	 	3)	 	when the Securities and Exchange Commission so permits for the protection of
security holders.

The Company further reserves the right to delay payment of a withdrawal or surrender of the Fixed
Account Value. We may delay such payment for up to six (6) months after we receive the Written
Request.

-18-

 

OWNERSHIP PROVISIONS

Ownership of Separate Account

The Company has absolute ownership of the assets in the Separate Account. We are not, and do not
hold ourselves out to be, a trustee in respect of any amounts under the Separate Account.

Ownership of the Contract and Participant Account

The Owner of this Contract is shown on the Contract Specifications page and must be the employer or
the trustee of an employer’s retirement plan. You hold this Contract for the benefit of the
Participants and Beneficiaries.

Each person for whom Purchase Payment(s) are made will have an interest in this Contract as a
Participant. An account will be established for each Participant.

Transfer and Assignment

Neither you nor a Participant may transfer, sell, assign, pledge, charge, encumber, or in any way
alienate an interest in this Contract.

Successor Owner

In some cases, the spouse of a Participant may succeed to the ownership of the interest of a
Participant in this Contract after the death of the Participant. Specifically, if a Participant
dies before his or her Annuity Commencement Date and the spouse is the sole surviving Beneficiary,
the spouse will become the successor owner of the Participant’s interest if:

	 	1)	 	the Participant makes that Written Request before his or her death; or
	 
	 	2)	 	after the Participant’s death, his or her spouse makes that Written Request
within one (1) year of the Participant’s death and before the Death Benefit
Commencement Date.

As successor owner, the spouse will then succeed to all rights of the Participant under this
Contract except the right to name another successor owner.

Community Property

If a Participant lives in a community property state and has a spouse at any time while he or she
has an interest in this Contract, the laws of that state may vary his or her ownership rights.

BENEFICIARY PROVISIONS

Beneficiary

For each Participant, the Beneficiary is the person or persons that he or she designates under the
Designation of Beneficiary provision of this Contract. If there is no designated Beneficiary that
survives the Participant, then his or her estate will be his or her Beneficiary.

A Beneficiary will be deemed not to have survived the Participant if he or she dies within thirty
(30) days after the death of the Participant.

-19-

 

Designation of Beneficiary

A Participant may make or change a designation of Beneficiary at any time so long as:

	 	1)	 	the Participant has not specified that a prior designation is irrevocable; and
	 
	 	2)	 	the Participant is still living.

A designation of Beneficiary must be made by Written Request. The Written Request must be received
on or before the date of death for which a Death Benefit is payable. Except as otherwise elected
or as required by law, it will not cancel a settlement option election.

A Participant may designate two (2) or more persons jointly as the Beneficiary. Unless the
Participant states otherwise, joint Beneficiaries that survive him or her will be entitled to equal
shares. A Participant may also designate one (1) or more persons as contingent Beneficiary.
Unless the Participant states otherwise, a contingent Beneficiary will be entitled to a benefit
only if there is no primary Beneficiary that survives him or her.

ANNUITY BENEFIT

Annuity Commencement Date

The Annuity Commencement Date for a Participant is set out on his or her Certificate Specifications
page. A Participant may change his or her Annuity Commencement Date by Written Request. Such a
request must be made at least thirty (30) days prior to the date that Annuity Benefit payments are
scheduled to begin.

A Participant may not change his or her Annuity Commencement Date to a date earlier than the first
Certificate Anniversary. A Participant may not change his or her Annuity Commencement Date to a
date later than the Certificate Anniversary following his or her 95th birthday, unless we agree.

Annuity Benefit Amount

If payments are to be made for life or over a fixed period of at least ten (10) years, then the
amount used to provide Annuity Benefit payments for a Participant will be equal to his or her
Account Value as of his or her Annuity Commencement Date. Otherwise his or her Surrender Value as
of his or her Annuity Commencement Date will be used to provide Annuity Benefit payments.

If his or her Account Value is used to provide Annuity Benefit payments, it will be reduced by:

	 	1)	 	any fees and charges under this Contract;
	 
	 	2)	 	applicable premium tax or other taxes not previously deducted; and
	 
	 	3)	 	the outstanding balance of any loans.

-20-

 

Annuity Benefit Payments

Annuity Benefit payments will be made to the Participant as payee unless amounts are paid as a
tax-free exchange, transfer, or rollover to or for an annuity or tax-qualified account as permitted
by federal tax law.

Annuity Benefit payments that are payable with respect to a payment interval that ends after the
death of the payee will be made to the contingent payee designated by the Participant. If there is
no such contingent payee surviving, then such payments will be made to the person or persons
designated as contingent payee by the last payee who received payments. Failing that, such
payments will be made to the estate of the last payee who received payments.

A designation or change of a payee or contingent payee must be made by Written Request. Unless it
has been specified that a prior designation is irrevocable, a Participant may change the payee or
contingent payee at any time.

The Participant will be the person on whose life Annuity Benefit payments are based. No change of
payee or contingent payee at any time will change this.

Form of Annuity Benefit

Annuity Benefit payments will be made annually under the terms of Option B with a fixed period of
ten (10) years, as described in the SETTLEMENT OPTIONS section of this Contract.

In lieu of that, a Participant may elect to have Annuity Benefit payments made pursuant to any
other available option that is described in the SETTLEMENT OPTIONS section of this Contract. Such
an election must be made before his or her Annuity Commencement Date. A Participant may change his
or her election so long as we receive his or her request for a change at least thirty (30) days
prior to the date that Annuity Benefit payments are scheduled to begin.

Any election or change of election must be made by Written Request.

An election of a settlement option may be subject to restrictions stated in the tax qualification
endorsement.

DEATH BENEFIT

Death Benefit

A Death Benefit will be paid with respect to the interest of a Participant in this Contract if he
or she dies before his or her Annuity Commencement Date and before his or her interest in this
Contract is surrendered.

If a Death Benefit becomes payable:

	 	1)	 	it will be in lieu of all other benefits with respect to his or her interest in
this Contract; and

	 	2)	 	all other rights with respect to his or her interest in this Contract will be
terminated except for rights related to the Death Benefit.

No Death Benefit will be paid on the death of a Participant if his or her spouse becomes the
successor owner of his or her interest in this Contract. Only one (1) Death Benefit will be paid
with respect to the interest of a Participant in this Contract.

-21-

 

Death Benefit Amount

The amount of the Death Benefit will be based on the greater of:

	 	1)	 	the Account Value of the Participant on the Death Benefit Valuation Date; or
	 
	 	2)	 	the total of all Purchase Payments for the interest of the Participant in this
Contract, reduced proportionally for any withdrawals.

The reduction for withdrawals will be in the same proportion that the Account Value of the
Participant was reduced on the date of the withdrawal.

The Death Benefit will be reduced by:

	 	1)	 	any charges or fees due under this Contract;
	 
	 	2)	 	applicable premium tax or other taxes not previously deducted; and
	 
	 	3)	 	the outstanding balance of any loans.

As of the Death Benefit Valuation Date for a Participant, the amount of the Death Benefit will be
allocated among the Sub-Accounts and the Fixed Account. The allocation will be in the same
proportion as each Sub-Account’s and Fixed Account’s value is to the total Account Value of the
Participant as of the end of the Valuation Period that precedes the Death Benefit Valuation Date.
After this allocation, the amount of the Death Benefit to be paid will be based on his or her
Account Value.

Step Up in Account Value for Successor Owner

If a spouse becomes the successor owner of the interest of a Participant in this Contract, his or
her Account Value will be increased to equal the amount of the Death Benefit which would have been
payable if the spouse had not become the successor owner. This increase will occur as of the date
that would have been the Death Benefit Valuation Date. If the Account Value of a Participant is
increased under this provision, we will add the amount in the same proportion as each Sub-Account’s
and Fixed Account’s value is to the total Account Value of the Participant as of the end of the
Valuation Period that precedes the Death Benefit Valuation Date.

If the Death Benefit that would have been payable is equal to the Account Value of a Participant as
of the date that would have been the Death Benefit Valuation Date, then there will be no such
change to the Account Value.

The election to become successor owner will be deemed to be instructions as to the form of Death
Benefit. Therefore, the date that would have been the Death Benefit Valuation Date will be the
later of the date that we receive Due Proof of Death, or the date we receive the successor owner
election. This date will never be later than one (1) year after the Participant’s date of death.

Transfers After Death

Between the Death Benefit Valuation Date for a Participant and the Death Benefit Commencement Date
for a Participant, the Beneficiary may transfer funds among Sub-Accounts and Fixed Account
option(s). Such transfers are subject to the limitations set out in the TRANSFERS section of this
Contract.

-22-

 

Death Benefit Commencement Date

The Beneficiary of a Participant may designate the Death Benefit Commencement Date by Written
Request. This request must be made within one (1) year of the death of the Participant. If no
designation is made, then the Death Benefit Commencement Date will be one (1) year after the death
of the Participant. No Death Benefit will be paid until we receive Due Proof of Death.

Death Benefit Payments

Death Benefit payments will be made to the Beneficiary as payee unless:

	 	1)	 	amounts are paid as a tax-free exchange, transfer, or rollover to or for an
annuity or tax-qualified account as permitted by federal tax law; or

	 	2)	 	the Beneficiary is a non-natural person, and elects to have Death Benefit
payments made to a payee to whom the Beneficiary is obligated to make corresponding
payments.

Death Benefit payments that are payable with respect to payment intervals that end after the death
of the Beneficiary will be made to the contingent payee designated as part of any Death Benefit
settlement option election made by the Participant. If there is no such contingent payee
surviving, then such payments will be made to the person or persons designated as contingent payee
by the Beneficiary. Failing that, such payments will be made to the estate of the last payee who
received payments.

A designation or change of a payee or contingent payee must be made by Written Request. A
Beneficiary may not change a contingent payee designation made as part of a Death Benefit
settlement option election made by the Participant. A Beneficiary may make or change any other
payee or contingent payee designation at any time.

The Beneficiary will be the person on whose life Death Benefit payments under a settlement option
will be based. No change of payee or contingent payee at any time will change this. A Beneficiary
that is a non-natural person may elect to have payments based on the life of a person to whom the
Beneficiary is obligated. Such an election must be made by Written Request before the Death
Benefit Commencement Date.

Form of Death Benefit

Death Benefit payments will be made annually under the terms of Option A with a period certain of
four (4) years, as described in the SETTLEMENT OPTIONS section of this Contract.

In lieu of that, a Participant may elect at any time before his or her death to have Death Benefit
payments made in one (1) lump sum or pursuant to any available option described in the SETTLEMENT
OPTIONS section of this Contract. A Participant may change his or her election of a settlement
option at any time before his or her death.

If the Participant does not make any such election, the Beneficiary may make that election at any
time after the death of the Participant and before the Death Benefit Commencement Date. A
Beneficiary may change his or her own election of a settlement option so long as we receive the
request for a change at least thirty (30) days prior to the date that Death Benefit payments are
scheduled to begin.

Any election or change of election must be made by Written Request.

An election of a settlement option is subject to restrictions stated in the tax qualification
endorsement.

-23-

 

Interest on Death Benefit

We will accrue interest on a Death Benefit payable under this Contract as required by law. Such
interest, if any, will be added to the Death Benefit when paid.

SETTLEMENT OPTIONS

Conditions

Payments under a settlement option are subject to any minimum amounts, payment intervals, and other
terms and conditions that we may from time to time require. If we change our minimums, we may
change any current or future payment amounts and/or payment intervals to conform to the change.
More than one (1) settlement option may be elected if the requirements for each settlement option
elected are satisfied. Once payment begins under a settlement option, the settlement option may
not be changed.

All elected settlement options must comply with pertinent laws and governmental regulations and
rulings.

If more than one (1) person is the payee under a settlement option, payments will be made to the
payees jointly. No more than two (2) persons may be initial payees under a joint and survivor
settlement option.

If payment under a settlement option depends on whether a specified person is still alive, we may
at any time require proof that such person is still living. We will require proof of the age of
any person on whose life payments are based.

Benefit Payments

Payments may be calculated and paid:

	 	1)	 	as Fixed Dollar payments;
	 
	 	2)	 	as Variable Dollar payments; or
	 
	 	3)	 	as a combination of both.

The amount to be applied to Variable Dollar payments is the Variable Account Value of the
Participant as of the end of the Valuation Period that precedes the Commencement Date. It will
include the amount of any transfer to Variable Dollar payments that is made from his or her
interest in the Fixed Account as of that same time. It will be reduced by the amount of any
transfer to Fixed Dollar payments that is to be made from his or her interest in the Separate
Account on the Commencement Date. An amount that is transferred from the Fixed Account will be
allocated among the Sub-Accounts by Written Request.

The amount to be applied to Fixed Dollar payments is the Fixed Account Value of the Participant as
of the Commencement Date. It will include the amount of any transfer to Fixed Dollar payments that
is made from his or her interest in the Separate Account on that date. It will not include the
amount of any transfer to Variable Dollar payments that is made from his or her interest in the
Fixed Account as of the end of the Valuation Period that precedes the Commencement Date.

In each case, the amount to be applied to payments will be reduced by any fees and charges, loans,
or applicable premium tax or other taxes not previously deducted.

-24-

 

No transfers between Fixed Dollar payments and Variable Dollar payments will be allowed after the
Commencement Date. Twelve (12) months or more after the Commencement Date, the payee may transfer
all or part of the Benefit Units upon which Variable Dollar payments are based from the
Sub-Account(s) then held, to Benefit Units in other Sub-Account(s) that are then available. Such
transfers of Benefit Units may not occur more than once in any twelve (12) month period. Such
transfers are subject to the other limitations set out in the TRANSFERS section of this Contract.

Fixed Dollar Payments

Fixed Dollar payments are determined as follows. We start with the amount to be applied to Fixed
Dollar payments. We then deduct a pro-rata portion of the Certificate Maintenance Fee. The
resulting amount, expressed in thousands of dollars, is then multiplied by the amount of the
periodic payment per $1,000 of value. This payment is obtained from the Settlement Option Table
for the option that is elected. Fixed Dollar payments will remain level for the duration of the
payment period.

Variable Dollar Payments

The Variable Dollar base payment is determined as follows. We start with the amount to be applied
to Variable Dollar payments, expressed in thousands of dollars. This amount is then multiplied by
the amount of the periodic payment per $1,000 of value. This payment is obtained from the
Settlement Option Table for the option that is elected.

The number of Benefit Units in each Sub-Account held for Variable Dollar payments is determined as
follows. We divide the dollar amount of the Variable Dollar base payment from each Sub-Account by
the Benefit Unit Value for that Sub-Account as of the Commencement Date. The number of Benefit
Units in each Sub-Account will change if the payee makes transfers among Sub-Accounts. The Benefit
Units in each Sub-Account will change proportionally to a change in the base payment due to any
change in the payment interval or as specified by the settlement option. Otherwise, the number of
Benefit Units remains fixed during the payment period.

The actual amount of each Variable Dollar payment will reflect the investment performance of the
Sub-Account(s) selected. It may vary from payment to payment. The total amount of each Variable
Dollar payment will be equal to the sum of the payments from each Sub-Account. We will deduct a
pro-rata portion of the Certificate Maintenance Fee from this total.

The payment from each Sub-Account is found by multiplying the number of Benefit Units held in that
Sub-Account for such Variable Dollar payments by the Benefit Unit Value for that Sub-Account. We
do this as of the end of the fifth (5th) Valuation Period before the date that the payment is due.

The Benefit Unit Value for each Sub-Account is originally established in the same manner as
Accumulation Unit Values. For any date after that, the value of a Benefit Unit for a Sub-Account
is determined by multiplying the Benefit Unit Value as of the end of the preceding Valuation Period
by the Net Investment Factor. This factor is determined as set forth in the Accumulation Unit
Value provision of this Contract. The product is then multiplied by the assumed daily investment
factor for the number of days in the Valuation Period. The factor is based on the assumed net
investment rate for the Settlement Option Table that is used to fix the base payment. This factor
shall be no greater than [0.99997236], which is the factor based on a net investment rate of [one
percent (1%)] per year, compounded annually, as reflected in the guaranteed Settlement Option
Tables.

-25-

 

Limitation on Election of Settlement Option

Fixed periods shorter than five (5) years are generally not available. A fixed period of less than
five (5) years is available only as a Death Benefit settlement option.

Settlement Option Computations

The Annuity 2000 Mortality Table for blended lives (60% female/40% male) with interest at [one
percent (1%)] per year, compounded annually, is used to compute all guaranteed settlement option
factors, values, and benefits under this Contract.

Available Settlement Options

The available settlement options are set out below.

Option A Income for a Fixed Period

We will make periodic payments for a fixed period. The first payment will be paid as of the
last day of the initial payment interval. The maximum time over which we will make payments
or money will be held by us is thirty (30) years. The Option A Table applies to this
Option.

Option B Life Annuity with Payments for at Least a Fixed Period

We will make periodic payments for at least a fixed period. If the person on whose life
payments are based lives longer than the fixed period, then we will make payments until his
or her death. The first payment will be paid as of the last day of the initial payment
interval. The Option B Table applies to this Option.

Option C Joint and One-half Survivor Annuity

We will make periodic payments until the death of the primary person on whose life payments
are based; thereafter, we will make one-half (1/2) of the periodic payment until the death
of the secondary person on whose life payments are based. The first payment will be paid as
of the last day of the initial payment interval. The Option C Table applies to this Option.

We will make periodic payments in any other form of settlement option that is acceptable to us at
the time of an election.

Commuted Values

Commuted values are not available unless we agree otherwise.

Settlement Option Tables

The Option Tables show the payments that we will make at sample payment intervals for each $1,000
applied based on the guaranteed settlement option factors. Amounts may vary with the payment
interval and the age of the person on whose life payments are based. For purposes of calculating
payments based on the age of a person, we will use the person’s age as of his or her last birthday.
Upon request, we will provide information on the payments that we will make for other payment
intervals and ages.

-26-

 

OPTION A TABLE — INCOME FOR A FIXED PERIOD

Payments for fixed number of years for each $1,000 applied.

	 	 	 	 	 	 	 	 	 
	Term of	 	 	 	Semi-	 	 	 	 
	Payments	 	Annual	 	Annual	 	Quarterly	 	Monthly
	Years
	 	 	 	 	 	 	 	 
	1

	 	[$1,010.00]
	 	[$503.74]
	 	[$251.55]
	 	[$83.78]
	2

	 	[507.51]
	 	[253.12]
	 	[126.40]
	 	[42.10]
	3

	 	[340.02]
	 	[169.58]
	 	[84.68]
	 	[28.20]
	4

	 	[256.28]
	 	[127.82]
	 	[63.83]
	 	[21.25]
	5

	 	[206.03]
	 	[102.76]
	 	[51.31]
	 	[17.09]
	6

	 	[172.54]
	 	[86.05]
	 	[42.97]
	 	[14.31]
	7

	 	[148.62]
	 	[74.12]
	 	[37.01]
	 	[12.32]
	8

	 	[130.69]
	 	[65.18]
	 	[32.55]
	 	[ 10.84]
	9

	 	[116.74]
	 	[58.22]
	 	[29.07]
	 	[ 9.68]
	10

	 	[105.58]
	 	[52.65]
	 	[26.29]
	 	[8.75]
	11

	 	[96.45]
	 	[48.10]
	 	[24.02]
	 	[8.00]
	12

	 	[88.84]
	 	[44.31]
	 	[22.12]
	 	[7.37]
	13

	 	[82.41]
	 	[41.10]
	 	[20.52]
	 	[6.83]
	14

	 	[76.90]
	 	[38.35]
	 	[19.15]
	 	[6.37]
	15

	 	[72.12]
	 	[35.97]
	 	[17.96]
	 	[5.98]
	16

	 	[67.94]
	 	[33.88]
	 	[16.92]
	 	[5.63]
	17

	 	[64.25]
	 	[32.04]
	 	[16.00]
	 	[5.33]
	18

	 	[60.98]
	 	[30.41]
	 	[15.18]
	 	[5.05]
	19

	 	[58.05]
	 	[28.95]
	 	[14.45]
	 	[4.81]
	20

	 	[55.41]
	 	[27.63]
	 	[13.80]
	 	[4.59]

The values stated for years 1-4 are available only as a Death Benefit option.

-27-

 

OPTION B TABLE — LIFE ANNUITY

Monthly payments by age of the person named for each $1,000 applied.

	 	 	 	 	 	 	 	 	 	 	 
	 	 	Number of Months Certain
	Age*	 	0	 	60	 	120	 	180	 	240
	55

	 	[$3.25]
	 	[$3.24]
	 	$[3.22]
	 	[$3.18]
	 	[$3.12]
	 
	 	 	 	 	 	 	 	 	 	 
	56

	 	[3.33]
	 	[3.33]
	 	[3.30]
	 	[3.26]
	 	[3.18]
	57

	 	[3.42]
	 	[3.42]
	 	[3.39]
	 	[3.34]
	 	[3.25]
	58

	 	[3.52]
	 	[3.51]
	 	[3.48]
	 	[3.42]
	 	[3.32]
	59

	 	[3.62]
	 	[3.61]
	 	[3.58]
	 	[3.51]
	 	[3.40]
	60

	 	[3.73]
	 	[3.72]
	 	[3.68]
	 	[3.60]
	 	[ 3.47]
	 
	 	 	 	 	 	 	 	 	 	 
	61

	 	[3.85]
	 	[3.83]
	 	[3.79]
	 	[3.69]
	 	[3.54]
	62

	 	[3.97]
	 	[3.95]
	 	[3.90]
	 	[3.79]
	 	[3.62]
	63

	 	[4.10]
	 	[4.08]
	 	[4.02]
	 	[3.89]
	 	[3.69]
	64

	 	[4.24]
	 	[4.22]
	 	[4.14]
	 	[4.00]
	 	[3.77]
	65

	 	[4.39]
	 	[4.36]
	 	[4.27]
	 	[4.10]
	 	[3.84]
	 
	 	 	 	 	 	 	 	 	 	 
	66

	 	[4.55]
	 	[4.52]
	 	[4.41]
	 	[4.21]
	 	[3.91]
	67

	 	[4.72]
	 	[4.68]
	 	[4.56]
	 	[4.33]
	 	[3.99]
	68

	 	[4.90]
	 	[4.86]
	 	[4.71]
	 	[4.44]
	 	[4.05]
	69

	 	[5.10]
	 	[5.04]
	 	[4.87]
	 	[4.55]
	 	[4.12]
	70

	 	[5.30]
	 	[5.24]
	 	[5.03]
	 	[4.67]
	 	[4.18]
	 
	 	 	 	 	 	 	 	 	 	 
	71

	 	[5.53]
	 	[5.45]
	 	[5.21]
	 	[4.78]
	 	[4.24]
	72

	 	[5.77]
	 	[5.68]
	 	[5.39]
	 	[4.89]
	 	[4.29]
	73

	 	[6.03]
	 	[5.92]
	 	[5.57]
	 	[5.00]
	 	[4.34]
	74

	 	[6.31]
	 	[6.18]
	 	[5.76]
	 	[5.11]
	 	[4.38]
	75

	 	[6.61]
	 	[6.45]
	 	[5.95]
	 	[5.21]
	 	[4.42]
	 
	 	 	 	 	 	 	 	 	 	 
	76

	 	[6.93]
	 	[6.74]
	 	[6.15]
	 	[5.31]
	 	[4.45]
	77

	 	[7.28]
	 	[7.04]
	 	[6.35]
	 	[5.40]
	 	[4.48]
	78

	 	[7.66]
	 	[7.37]
	 	[6.55]
	 	[5.48]
	 	[4.50]
	79

	 	[8.07]
	 	[7.71]
	 	[6.75]
	 	[5.56]
	 	[4.52]
	80

	 	[8.51]
	 	[8.07]
	 	[6.94]
	 	[5.63]
	 	[4.54]

 

			
	*	 	Age as of last birthday

-28-

 

OPTION C TABLE — JOINT AND ONE-HALF SURVIVOR ANNUITY

Monthly payments by ages of the persons named for each $1,000 applied.*

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Secondary Age**
	Primary	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Age**	 	60	 	61	 	62	 	63	 	64	 	65	 	66	 	67	 	68	 	69	 	70
	60

	 	[$3.39]
	 	[$3.42]
	 	[$3.44]
	 	[$3.46]
	 	[$3.48]
	 	[$3.50]
	 	[$3.52]
	 	[$3.54]
	 	[$3.56]
	 	[$3.57]
	 	[$3.59]
	61

	 	[3.47]
	 	[3.49]
	 	[3.52]
	 	[3.54]
	 	[3.56]
	 	[3.59]
	 	[3.61]
	 	[3.63]
	 	[3.65]
	 	[3.66]
	 	[3.68]
	62

	 	[3.54]
	 	[3.57]
	 	[3.59]
	 	[3.62]
	 	[3.65]
	 	[3.67]
	 	[3.69]
	 	[3.72]
	 	[3.74]
	 	[3.76]
	 	[3.78]
	63

	 	[3.61]
	 	[3.64]
	 	[3.67]
	 	[3.70]
	 	[3.73]
	 	[3.76]
	 	[3.79]
	 	[3.81]
	 	[3.83]
	 	[3.86]
	 	[3.88]
	64

	 	[3.69]
	 	[3.72]
	 	[3.76]
	 	[3.79]
	 	[3.82]
	 	[3.85]
	 	[3.88]
	 	[3.91]
	 	[3.93]
	 	[3.96]
	 	[3.98]
	65

	 	[3.77]
	 	[3.80]
	 	[3.84]
	 	[3.88]
	 	[3.91]
	 	[3.94]
	 	[3.98]
	 	[4.01]
	 	[4.04]
	 	[4.07]
	 	[4.09]
	66

	 	[3.85]
	 	[3.89]
	 	[3.93]
	 	[3.97]
	 	[4.00]
	 	[4.04]
	 	[4.08]
	 	[4.11]
	 	[4.14]
	 	[4.18]
	 	[4.21]
	67

	 	[3.93]
	 	[3.97]
	 	[4.02]
	 	[4.06]
	 	[4.10]
	 	[4.14]
	 	[4.18]
	 	[4.22]
	 	[4.25]
	 	[4.29]
	 	[4.32]
	68

	 	[4.01]
	 	[4.06]
	 	[4.11]
	 	[4.15]
	 	[4.20]
	 	[4.24]
	 	[4.28]
	 	[4.33]
	 	[4.37]
	 	[4.41]
	 	[4.44]
	69

	 	[4.10]
	 	[4.15]
	 	[4.20]
	 	[4.25]
	 	[4.30]
	 	[4.34]
	 	[4.39]
	 	[4.44]
	 	[4.48]
	 	[4.53]
	 	[4.57]
	70

	 	[4.18]
	 	[4.24]
	 	[4.29]
	 	[4.34]
	 	[4.40]
	 	[4.45]
	 	[4.50]
	 	[4.55]
	 	[4.60]
	 	[4.65]
	 	[4.70]

 

			
	*	 	Payments after the death of the primary payee will be one-half (1/2) of the amount shown.

	 
	**	 	Age as of last birthday

-29-

 

Group Flexible Premium Deferred Variable Annuity Contract

NONPARTICIPATING — NO DIVIDENDSEX-4(B)

 

Exhibit 4(b)

Home Office: Cincinnati, Ohio

Variable Administrative Office: P.O. Box 5423, Cincinnati, Ohio 45201-5423

Certificate of Participation

Under a Group Flexible Premium Deferred Variable Annuity Contract

This is your Certificate of Participation (“Certificate”). It is evidence of your interest in the
Group Flexible Premium Deferred Variable Annuity Contract (“Contract”) that is identified on the
Certificate Specifications page. We have issued the Contract to the Contract Owner that is
identified on the Certificate Specifications page.

As you read through this Certificate, please note that the words “we”, “us”, “our”, and “Company”
refer to Annuity Investors Life Insurance Company. The words “you” and “your” refer to the
Participant. “Administrative Office” means our home office or any other place of business that we
may designate.

	 	 	 
	
	 	
	MARK F. MUETHING
	 	CHARLES R. SCHEPER
	SECRETARY
	 	PRESIDENT

NONPARTICIPATING — NO DIVIDENDS

PAYMENTS AND OTHER VALUES DESCRIBED IN THIS CERTIFICATE, WHEN BASED ON THE INVESTMENT EXPERIENCE OF
THE SEPARATE ACCOUNT, MAY INCREASE OR DECREASE AND ARE NOT GUARANTEED. NO MINIMUM CONTRACT VALUE
IS GUARANTEED, EXCEPT FOR AMOUNTS IN THE FIXED ACCOUNT.

 

 

CERTIFICATE SPECIFICATIONS

PARTICIPANT: [JOHN DOE]

AGE OF PARTICIPANT AS OF CERTIFICATE EFFECTIVE DATE: [35]

GROUP CONTRACT OWNER: [JOHN DOE]

GROUP CONTRACT NUMBER: [000000000]

CERTIFICATE NUMBER: [000000000]

CERTIFICATE EFFECTIVE DATE: [DECEMBER 1, 2007]

ANNUITY COMMENCEMENT DATE: [DECEMBER 1, 2067]

SEPARATE ACCOUNT: Annuity Investors Variable Account [C]

Following is a list of the Funds in which the currently available Sub-Accounts invest:

[AIM V.I. Capital Development Fund — Series II]

[AIM V.I. Global Real Estate Fund – Series II]]

[[AIM V.I. International Growth Fund – Series II]]

[[AIM V.I. Mid Cap Core Equity Fund – Series II]]

[[AIM V.I. Small Cap Equity Fund – Series I]]

[AllianceBernstein VPS International Value Portfolio – Class B]

[American Century VP Large Company Value Fund – Class II]

[American Century VP Mid Cap Value Fund – Class II]

[American Century VP VistaSM Fund – Class II]

[Calamos Growth and Income Portfolio]

[Davis Value Portfolio]

-2-

 

[The Dreyfus Socially Responsible Growth Fund – Service Shares]

[Dreyfus Stock Index Fund, Inc. – Service Shares]

[Dreyfus IP MidCap Stock Portfolio – Service Shares]

[Dreyfus VIF Money Market Portfolio]

[DWS Global Thematic Fund VIP – Class A]

[Financial Investors VIT Ibbotson Balanced ETF Asset Allocation-Class II]

[Financial Investors VIT Ibbotson Conservative ETF Asset Allocation-Class II]

[Financial Investors VIT Ibbotson Growth ETF Asset Allocation-Class II]

[Financial Investors VIT Ibbotson Income/Growth ETF Asset Allocation-Class II]

[Franklin Templeton Mutual Shares Securities Fund – Class 2]

[Franklin Templeton Foreign Securities Fund-Class 2]

[Franklin Templeton U.S. Government Fund – Class 2]

[Janus Aspen Series Balanced Portfolio – Service Shares]

[Janus Aspen Series International Growth Portfolio – Service Shares]

[Janus Aspen Series Large Cap Growth Portfolio – Service Shares]

[Janus Aspen Series Mid Cap Growth Portfolio – Service Shares]

[Neuberger Berman AMT Guardian Portfolio – Class S]

[Oppenheimer Balanced Fund /VA – Service Shares]

[Oppenheimer Capital Appreciation Fund/VA – Service Shares]

[Oppenheimer Global Securities Fund/VA – Service Shares]

[Oppenheimer Main Street Fund® /VA – Service Shares]

[Oppenheimer Main Street Small Cap Fund/ VA – Service Shares]

[PIMCO VIT High Yield Portfolio – Administrative Class]

[PIMCO VIT Real Return Portfolio – Administrative Class]

[PIMCO VIT Total Return Portfolio – Administrative Class]

[Van Kampen UIF Core Plus Fixed Income Portfolio – Class I]

[Van Kampen UIF Mid-Cap Growth Portfolio – Class I]

[Van Kampen UIF Mid Cap Value Portfolio – Class I]

[Van Kampen UIF Value Portfolio – Class I]

-3-

 

[Wilshire VIT Wilshire 2015 Moderate Fund]

[Wilshire VIT Wilshire 2025 Moderate Fund]

[Wilshire VIT Wilshire 2035 Moderate Fund]

FIXED ACCOUNT:

Following is a list of the currently available Fixed Account options, with the guarantee periods as
may be applicable:

Fixed Accumulation Account

[Fixed Account One-Year Guarantee Period]

We may add or delete Fixed Account options at any time.

FIXED ACCOUNT GUARANTEED INTEREST RATE: [3.00%]

TRANSFER FEE: [$25] per transfer in excess of [twelve (12)] in any Certificate Year.

EARLY WITHDRAWAL CHARGE SCHEDULE:

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Certificate Year
	 	 	1	 	 	 	2	 	 	 	3	 	 	 	4	 	 	 	5	 	 	 	6+	 
	Early Withdrawal Charge
	 	 	5	%	 	 	4	%	 	 	3	%	 	 	2	%	 	 	1	%	 	 	0	%

     Please see the FEES AND CHARGES section of this Certificate for additional information.

EARLY WITHDRAWAL CHARGE WAIVER(S): [YOUR SEPARATION FROM SERVICE]

                                         
;       
                                        [<
/B>December 1,
2012]

CERTIFICATE MAINTENANCE FEE: [$30] Annually

MORTALITY AND EXPENSE RISK CHARGE: A charge equal to an effective annual rate of [0.85%] of the
daily Net Asset Value of the Sub-Accounts.

ADMINISTRATION CHARGE: A charge equal to an effective annual rate of [0.15%] of the daily Net
Asset Value of the Sub-Accounts.

-4-

 

MINIMUM REQUIRED VALUE: [$500]

MINIMUM TRANSFER AMOUNT: [$500]

	 	 	 
	INQUIRIES:	 	For
information and assistance, or to make a complaint, call or write:
	 
	 

	 	Policyowner Services Department
	 

	 	Annuity Investors Life Insurance Company
	 

	 	Post Office Box 5423
	 

	 	Cincinnati, Ohio 45201-5423
	 

	 	1-800-789-6771
	 
	 	 
	 

	 	If you prefer, you may visit us at our website, www.GAFRI.com.

-5-

 

	 	 	 	 	 
	TABLE OF CONTENTS	 	Page	 
	DEFINITIONS
	 	 	8	 
	 
	 	 	 	 
	GENERAL PROVISIONS
	 	 	10	 
	 
	 	 	 	 
	Entire Contract
	 	 	10	 
	Changes — Waivers
	 	 	10	 
	Nonparticipating
	 	 	10	 
	Misstatement
	 	 	10	 
	Required Reports
	 	 	11	 
	Exclusive Benefit
	 	 	11	 
	State Law
	 	 	11	 
	Claims of Creditors
	 	 	11	 
	Company Liability
	 	 	11	 
	Voting Rights
	 	 	11	 
	Incontestability
	 	 	11	 
	Discharge of Liability
	 	 	11	 
	Transfer by the Company
	 	 	11	 
	Taxes
	 	 	12	 
	 
	 	 	 	 
	PURCHASE PAYMENTS
	 	 	12	 
	 
	 	 	 	 
	Purchase Payments
	 	 	12	 
	Allocation of Purchase Payments
	 	 	12	 
	 
	 	 	 	 
	FIXED ACCOUNT
	 	 	12	 
	 
	 	 	 	 
	Fixed Account
	 	 	12	 
	Interest Crediting
	 	 	12	 
	Fixed Account Value
	 	 	13	 
	 
	 	 	 	 
	SEPARATE ACCOUNT
	 	 	13	 
	 
	 	 	 	 
	General Description
	 	 	13	 
	Sub-Accounts of the Separate Account
	 	 	14	 
	Valuation of Assets
	 	 	14	 
	Variable Account Value
	 	 	14	 
	Accumulation Unit Value
	 	 	15	 
	 
	 	 	 	 
	TRANSFERS
	 	 	15	 
	 
	 	 	 	 
	Transfers From the Fixed Account
	 	 	15	 
	Transfers From a Sub-Account
	 	 	16	 
	Other Transfer Rules
	 	 	16	 
	 
	 	 	 	 
	FEES AND CHARGES
	 	 	16	 
	 
	 	 	 	 
	Mortality and Expense Risk Charge
	 	 	16	 
	Administration Charge
	 	 	17	 
	Certificate Maintenance Fee
	 	 	17	 
	Early Withdrawal Charge
	 	 	17	 

-6-

 

	 	 	 	 	 
	TABLE OF CONTENTS	 	Page	 
	SURRENDER AND WITHDRAWALS
	 	 	18	 
	 
	 	 	 	 
	Surrender
	 	 	18	 
	Withdrawals
	 	 	18	 
	Exchanges, Transfers, and Rollovers
	 	 	18	 
	Termination
	 	 	18	 
	Deferral of Payment
	 	 	19	 
	 
	 	 	 	 
	OWNERSHIP PROVISIONS
	 	 	19	 
	 
	 	 	 	 
	Ownership of Separate Account
	 	 	19	 
	Ownership of the Contract and Participant Account
	 	 	19	 
	Transfer and Assignment
	 	 	19	 
	Successor Owner
	 	 	20	 
	Community Property
	 	 	20	 
	 
	 	 	 	 
	BENEFICIARY PROVISIONS
	 	 	20	 
	 
	 	 	 	 
	Beneficiary
	 	 	20	 
	Designation of Beneficiary
	 	 	20	 
	 
	 	 	 	 
	ANNUITY BENEFIT
	 	 	21	 
	 
	 	 	 	 
	Annuity Commencement Date
	 	 	21	 
	Annuity Benefit Amount
	 	 	21	 
	Annuity Benefit Payments
	 	 	21	 
	Form of Annuity Benefit
	 	 	22	 
	 
	 	 	 	 
	DEATH BENEFIT
	 	 	22	 
	 
	 	 	 	 
	Death Benefit
	 	 	22	 
	Death Benefit Amount
	 	 	22	 
	Step Up in Account Value for Successor Owner
	 	 	23	 
	Transfers After Death
	 	 	23	 
	Death Benefit Commencement Date
	 	 	23	 
	Death Benefit Payments
	 	 	23	 
	Form of Death Benefit
	 	 	24	 
	Interest on Death Benefit
	 	 	24	 
	 
	 	 	 	 
	SETTLEMENT OPTIONS
	 	 	24	 
	 
	 	 	 	 
	Conditions
	 	 	24	 
	Benefit Payments
	 	 	25	 
	Fixed Dollar Payments
	 	 	25	 
	Variable Dollar Payments
	 	 	25	 
	Limitation on Election of Settlement Option
	 	 	26	 
	Settlement Option Computations
	 	 	26	 
	Available Settlement Options
	 	 	26	 
	Commuted Values
	 	 	27	 
	Settlement Option Tables
	 	 	28	 

-7-

 

DEFINITIONS

The following definitions apply to your interest in the Contract:

Account Value: The sum of your Variable Account Value and your Fixed Account Value as of the end
of a Valuation Period. Your “Variable Account Value” is the value of your interest in all of the
Sub-Accounts. Your “Fixed Account Value” is the value of your interest in the Fixed Account.

Accumulation Unit: A unit of measure used to calculate the value of a Sub-Account prior to the
Commencement Date. The value of an Accumulation Unit is referred to as “Accumulation Unit Value”.

Annuity Benefit: The payments that may be made as described in the ANNUITY BENEFIT section of this
Certificate.

Annuity Commencement Date: The first day of the first payment interval for which payment of an
Annuity Benefit is to be made.

Beneficiary: The person entitled to receive any Death Benefit that is to be paid.

Benefit Unit: A unit of measure used to determine the dollar value of any Variable Dollar
payments. The value of a Benefit Unit is referred to as “Benefit Unit Value”.

Certificate Anniversary: The date in each year that is the annual anniversary of your Certificate
Effective Date.

Certificate Effective Date: The date on which you interest in the Contract took effect. This date
is set out on the Certificate Specifications page.

Certificate Year: Each twelve (12) month period that begins on your Certificate Effective Date or
on a Certificate Anniversary.

Commencement Date: Your Annuity Commencement Date if an Annuity Benefit is payable; or the Death
Benefit Commencement Date if a Death Benefit is payable.

Death Benefit: The benefit described in the DEATH BENEFIT section of this Certificate.

Death Benefit Commencement Date: The first day of the first payment interval for a Death Benefit
that is paid as periodic payments; or the date of payment for a Death Benefit that is paid as a
lump sum.

Death Benefit Valuation Date: The earlier of:

	 	1)	 	the date that we have received both Due Proof of Death and a Written Request
with instructions as to the form of Death Benefit; or
	 
	 	2)	 	the date that is the Death Benefit Commencement Date.

-8-

 

Due Proof of Death: One (1) of the following:

	 	1)	 	a certified copy of a death certificate; or
	 
	 	2)	 	a certified copy of a decree that is made by a court of competent jurisdiction
as to the finding of death.

We will also accept other proof that is satisfactory to us.

Fund: A management investment company (or a portfolio of it) that is registered under the
Investment Company Act of 1940, as amended. Each Sub-Account invests in a Fund.

Net Asset Value: The amount computed by an investment company as the price at which its shares or
units may be purchased or redeemed. This price is computed in accordance with the rules of the
Securities and Exchange Commission. It is computed no less frequently than each Valuation Period.

Participant: The person identified on the Certificate Specifications page who has an interest in
the Contract, as evidenced by this Certificate.

Purchase Payment: An amount received by us for your interest in the Contract. This amount is
after the deduction of premium tax or other taxes that may apply.

Separate Account: An account that is established and maintained by the Company pursuant to the
laws of the Company’s domiciliary state. The Separate Account is registered as a unit investment
trust under the Investment Company Act of 1940, as amended.

Sub-Account: A subdivision of the Separate Account. Each of the Sub-Accounts invests in the
shares of a designated Fund.

Surrender Value: An amount equal to your Account Value as of the end of the applicable Valuation
Period, reduced by:

	 	1)	 	any charges or fees that would apply upon a surrender;
	 
	 	2)	 	any applicable premium tax or other taxes not previously deducted; and
	 
	 	3)	 	the outstanding balance of any loans.

Valuation Date: Each day on which the New York Stock Exchange is open for business.

Valuation Period: The period commencing at the close of regular trading on the New York Stock
Exchange on any Valuation Date, and ending at the close of trading on the next succeeding Valuation
Date.

-9-

 

Written Request: Information provided, or a request made, that is:

	 	1)	 	complete and satisfactory to us;
	 
	 	2)	 	on our form or in a manner satisfactory to us, which may, at our discretion, be
by telephone or electronic means; and
	 
	 	3)	 	received by us at our Administrative Office.

A Written Request is subject to any payment that we make before we acknowledge it. It is also
subject to any action that we take before we acknowledge it. We will deem a Written Request to be
a standing order. It may be modified or revoked only by a subsequent Written Request, when
permitted by the terms of the Contract. You may be required to return this Certificate to us in
connection with a Written Request.

GENERAL PROVISIONS

Entire Contract

The Contract is a group flexible premium deferred variable annuity contract. The Contract and this
Certificate are restricted as required to obtain favorable tax treatment under the Internal Revenue
Code. Neither is valid without the requisite endorsement(s) being attached. The Contract, which
includes any riders or endorsements to it, and the application(s) for them, if any, and any
application(s) and enrollment forms of participants, forms the entire agreement between the
Contract Owner and us. This Certificate is not a contract and is not a part of the Contract.

Only statements made in consideration for the Contract or an interest in it will be used to void
the Contract or an interest in it, or to pursue or defend a claim based on it. Such statements are
treated as representations and not warranties.

Changes – Waivers

No changes or waivers of the terms of the Contract or this Certificate are valid unless made in
writing and signed by our President, Vice President, or Secretary. No other person or producer has
authority to change or waive any provision of the Contract or this Certificate. We reserve the
right both to administer and to change the terms of the Contract to conform to pertinent laws and
governmental regulations and rulings.

Nonparticipating

The Contract does not pay dividends or share in the Company’s divisible surplus.

Misstatement

If the age of a person is misstated, payments will be adjusted to the amount that would have been
payable based on the correct age. If payments based on the correct age would have been higher, we
will promptly pay the underpaid amount in one (1) sum, with interest. If payments based on the
correct age would have been lower, we may deduct the overpaid amount, with interest, from
succeeding payments. We may also pursue other remedies at law or in equity.

-10-

 

Required Reports

At least once each Certificate Year, we will send you a report of your current values. We will
also provide any other information required by law. These reports will stop when your interest in
the Contract is fully surrendered, or on the Commencement Date, whichever is first.

The reports will be mailed to your last known address. If permitted by law, in lieu of that we may
deliver these and other required documents in electronic form. The reported values will be based
on the information in our possession at the time that we prepare the report. We may adjust the
reported values at a later date if that information proves to be incorrect or has changed.

Exclusive Benefit

Your rights as a Participant in the Contract are for the exclusive benefit of you and your
Beneficiaries. Those rights are nonforfeitable by us.

State Law

All factors, values, benefits, and reserves under the Contract will not be less than those required
by the law of the state in which the Contract is delivered.

Claims of Creditors

To the extent allowed by law, the Contract and all values and benefits under it are not subject to
the claims of creditors or to legal process.

Company Liability

We will not be liable for any loss that is related to a failure by the Contract Owner, by you, or
by any other person having rights or benefits under the Contract, to comply with pertinent laws or
governmental regulations or rulings.

Voting Rights

To the extent required by law, we will vote all shares of the Funds held in the Separate Account at
regular and special shareholder meetings of the Funds. We will vote the shares attributable to
your interest in the Contract in accordance with instructions received from you, or if applicable,
from the payee of a settlement option. If there is a change in the law that permits us to vote the
shares of the Funds without such instructions, then we reserve the right to do so.

Incontestability

The Contract, and your interest in it, is not contestable by us except to the extent stated in a
rider or endorsement.

Discharge of Liability

We will be discharged from all liability to the extent of each payment that is made for a
withdrawal, surrender, Annuity Benefit, or Death Benefit.

Transfer by the Company

We reserve the right to transfer our obligations under the Contract to another qualified life
insurance company under an assumption or reinsurance arrangement. We may make such a transfer
without your consent or the consent of the Contract Owner.

-11-

 

Taxes

Some states impose on the Company a premium tax or other taxes on annuities. If a premium tax or
other taxes are charged or due, we reserve the right to deduct this amount from the Purchase
Payment or your Account Value at the time that it is imposed.

PURCHASE PAYMENTS

Purchase Payments

One (1) or more Purchase Payments may be paid to us at any time before your Annuity Commencement
Date, so long as:

	 	1)	 	you are still living; and
	 
	 	2)	 	your interest in the Contract has not been surrendered.

The initial Purchase Payment for you must be received by us on or before your Certificate Effective
Date. Each Purchase Payment must be received by us at our Administrative Office. Each Purchase
Payment is subject to any minimums or maximums that we set from time to time. Upon request, we
will provide you with a receipt as proof of payment.

It is the duty of the Contract Owner to collect Purchase Payments by payroll deduction or
otherwise. It is the duty of the Contract Owner to remit Purchase Payments to us in the proper
amount. It is the duty of the Contract Owner to provide us with all information needed to apply
such amounts properly to your interest in the Contract.

Allocation of Purchase Payments

We will allocate Purchase Payments to the available Sub-Accounts and Fixed Account option(s)
according to your instructions. Those instructions must be made by Written Request. Allocations
must be made in whole percentages. The minimum amount that can be allocated to a Fixed Account
option or to a Sub-Account is $10.00. We may, in our sole discretion, restrict or prohibit
allocations to the Fixed Account or Sub-Accounts from time to time on a nondiscriminatory basis.

FIXED ACCOUNT

Fixed Account

The Fixed Account is part of the Company’s general account. The value of the Fixed Account is not
dependent upon the investment performance of the Sub-Accounts.

Interest Crediting

Amounts held under the Fixed Account will be credited with interest at an annual effective rate
that is at least equal to the Fixed Account Guaranteed Interest Rate. The Fixed Account Guaranteed
Interest Rate is set out on the Certificate Specifications page. We may from time to time pay a
higher current interest rate for amounts held under the Fixed Account. Such higher rate would be
as declared by the Company in its discretion. Once declared, such rate will be credited until
changed.

Interest on amounts held under the Fixed Account is earned daily. We will stop crediting interest
on an amount as of the date that it is transferred, withdrawn, surrendered, or applied to charges.
We will stop crediting interest on an amount that is applied to a settlement option as of the
Commencement Date.

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The interest rate credited to each Purchase Payment allocated to the Fixed Account will not be
changed for at least twelve (12) months following the date on which it was received. Thereafter,
the interest rate credited will not be changed more frequently than once per calendar quarter. In
the case of transfers from the Sub-Accounts to the Fixed Account, the interest rate will not be
changed more frequently than once per calendar quarter.

Fixed Account Value

Your Fixed Account Value at any time is equal to:

	 	1)	 	Purchase Payment(s) for your interest in the Contract that are allocated to the
Fixed Account; plus
	 
	 	2)	 	amounts transferred to the Fixed Account for you; plus
	 
	 	3)	 	interest credited to the Fixed Account for you; less
	 
	 	4)	 	any withdrawals, surrender, deductions, and transfers from the Fixed Account
for you; and less
	 
	 	5)	 	other charges and adjustments to your interest made as described elsewhere in
this Certificate.

SEPARATE ACCOUNT

General Description

The variable benefits under the Contract are provided through the Separate Account.

The income, if any, and any gains or losses, realized or unrealized, on the Separate Account will
be credited to or charged against the amounts allocated to such account. This credit or charge
will be made without regard to other income, gains, or losses of the Company. The Separate Account
is not chargeable with any liabilities of the Company to the extent that its value is equal to the
reserves and other contractual liabilities under all of the policies, annuities, and other
contracts identified with it. The Company is not, and does not hold itself out to be, a trustee
with respect to such amounts.

We have the right to transfer certain assets from the Separate Account to our general account. We
may transfer any assets that are in excess of the required reserves and other contractual
liabilities under all of the policies, annuities, and other contracts identified with the Separate
Account. We may make these transfers in our sole discretion at any time and without prior notice.

We may merge or combine the Separate Account with any other separate account of the Company. We
may transfer the assets of the Separate Account to another life insurance company by means of a
merger or reinsurance. We may convert the Separate Account into a managed separate account. We
may de-register the Separate Account under the Investment Company Act of 1940. Such a change will
be made in accordance with pertinent laws. It will be made only after obtaining any approvals that
may be needed, including those of the Company’s domiciliary state and the Securities and Exchange
Commission.

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Sub-Accounts of the Separate Account

The Separate Account is divided into Sub-Accounts. All of the Sub-Accounts that are available as
of the Certificate Effective Date are listed on the Certificate Specifications page. Each of the
Sub-Accounts invests exclusively in shares of an underlying Fund. These Funds are shown on the
Certificate Specifications page. Any amounts of income on the shares of a Fund will be reinvested
in additional shares of that Fund at its Net Asset Value. Any gains on the shares of a Fund will
also be reinvested.

We may add or delete Sub-Accounts. We may substitute shares of a different Fund or different class
or series of a Fund for shares held in a Sub-Account. We may merge or combine Sub-Accounts. Such
a change will be made in accordance with pertinent laws. It will be made only after obtaining any
approvals that may be needed.

Valuation of Assets

Shares of Funds held by each Sub-Account will be valued at their Net Asset Value at the end of each
Valuation Period, as reported by each such Fund.

Variable Account Value

Purchase Payment(s) that are allocated to a Sub-Account, and amounts that are transferred to a
Sub-Account, are converted into Accumulation Units. The number of Accumulation Units credited is
determined by dividing the dollar amount directed to that Sub-Account by the value of the
Accumulation Unit for that Sub-Account at the end of the Valuation Period during which the amount
is received.

The following events will result in the cancellation of an appropriate number of Accumulation Units
of a Sub-Account:

	 	1)	 	a transfer from a Sub-Account;
	 
	 	2)	 	the surrender or a withdrawal of the Variable Account Value;
	 
	 	3)	 	the payment of a Death Benefit;
	 
	 	4)	 	the application of the Variable Account Value to a settlement option; or
	 
	 	5)	 	the deduction of the charges, fees, or other adjustments described in this
Certificate.

Accumulation Units will be canceled as of:

	 	1)	 	the end of the Valuation Period during which we receive a Written Request that
gives rise to such cancellation;
	 
	 	2)	 	the Commencement Date; or
	 
	 	3)	 	the end of the Valuation Period on which a charge, fee, or other adjustment is
due.

At any time, your Variable Account Value is equal to the sum of the values of your interest in each
Sub-Account. The value of your interest in a Sub-Account is equal to the number of your
Accumulation Units for that Sub-Account multiplied by the Accumulation Unit Value for that
Sub-Account. These values are determined as of the end of the preceding Valuation Period.

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Accumulation Unit Value

The initial Accumulation Unit Value for the Money Market Sub-Account was set at $1.00. The initial
Accumulation Unit Value for each of the other Sub-Accounts was set at $10.00. After that, the
Accumulation Unit Value at the end of each Valuation Period is the Accumulation Unit Value as of
the end of the prior Valuation Period multiplied by the Net Investment Factor. The Net Investment
Factor is described below. The Accumulation Unit Values will vary as a result of the varying
investment experience of the Funds.

The Net Investment Factor is a measure of the investment performance of a Sub-Account from one
Valuation Period to the next. Each Sub-Account has a Net Investment Factor for each Valuation
Period. The Net Investment Factor may be greater than one, or it may be less than one. This means
that the Accumulation Unit Value for each Sub-Account may increase or it may decrease. The Net
Investment Factor for any Sub-Account for any Valuation Period is determined by dividing (1) by (2)
and then subtracting (3) from the result, where:

	 	1)	 	is equal to:

	 	a)	 	the Net Asset Value per share of the Fund held in the Sub-Account,
determined at the end of the applicable Valuation Period; plus
	 
	 	b)	 	the per share amount of any dividend or net capital gain distributions
made by the Fund held in the Sub-Account, if the “ex-dividend” date occurs during
the applicable Valuation Period; plus or minus
	 
	 	c)	 	a per share credit or charge for any taxes reserved for, which is determined by the
Company to have resulted from the investment operations of the Sub-Account;

	 	2)	 	is the Net Asset Value per share of the Fund held in the Sub-Account,
determined at the end of the preceding Valuation Period; and
	 
	 	3)	 	is the sum of the Mortality and Expense Risk Charge and the Administration
Charge to be deducted from the Sub-Account for the number of days in the applicable
Valuation Period.

TRANSFERS

Prior to a Commencement Date, you may transfer amounts in a Sub-Account or Fixed Account option as
set out below.

Transfers From the Fixed Account

If allowed by the Company, in its sole discretion, you may transfer amounts from your interest in
the Fixed Account to a Sub-Account during the thirty (30) day period each year following your
Certificate Anniversary. No transfer from the Fixed Account is allowed during your first
Certificate Year. Transfers from the Fixed Account during any other Certificate Year may not
exceed in the aggregate the greater of $1,000 or twenty percent (20%) of the Fixed Account Value as
of your most recent Certificate Anniversary. We may, in our sole discretion, restrict or prohibit
this type of transfer or the availability of any Sub-Account from time to time on a
nondiscriminatory basis.

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Transfers From a Sub-Account

If allowed by the Company, in its sole discretion, you may transfer amounts from your interest in a
Sub-Account to another Sub-Account or to the Fixed Account. Amounts transferred from the Fixed
Account to the Sub-Accounts may not be transferred back to the Fixed Account for a period of twelve
(12) months from the date of transfer. We may, in our sole discretion, restrict or prohibit this
type of transfer or the availability of any Sub-Account or Fixed Account option from time to time
on a nondiscriminatory basis.

Other Transfer Rules

A transfer must be made by Written Request. A transfer must be at least the Minimum Transfer
Amount or the balance of your interest in the Sub-Account or the Fixed Account, if less. The
Minimum Transfer Amount is set out on the Certificate Specifications page.

If the amount allocated by you to a Sub-Account is less than the Minimum Required Value, we reserve
the right to transfer the amount to the other Sub-Accounts and the Fixed Account. Such a transfer
will be in the same proportion as each of your other Sub-Account’s value and your Fixed Account
Value is to your total Account Value, as of the end of the Valuation Period that precedes the
transfer, less the amount transferred. If the amount allocated to your Fixed Account is less than
the Minimum Required Value, we reserve the right to transfer the amount to your Sub-Accounts. Such
a transfer will be in the same proportion as each of your Sub-Account’s value is to your total
Account Value, as of the end of the Valuation Period that precedes the transfer, less the amount
transferred. The Minimum Required Value is set out on the Certificate Specifications page.

We will charge a Transfer Fee on each transfer with respect to your interest in the Contract over a
certain number per year. The amount of the Transfer Fee, and the number of transfers that may be
made before it applies, are set out on the Certificate Specifications page.

We may modify our transfer procedures at any time and at our sole discretion. Such modifications
could be applied to transfers to or from some or all of the Sub-Accounts or the Fixed Account, and
may include, but not be limited to, the following:

	 	1)	 	the requirement of a minimum time period between each transfer with respect to
your interest in the Contract;
	 
	 	2)	 	the means for submitting a Written Request;
	 
	 	3)	 	limits on the dollar amount that may be transferred between available
Sub-Accounts or the Fixed Account at any one time with respect to your interest in the
Contract; or
	 
	 	4)	 	as required by a Fund.

FEES AND CHARGES

Mortality and Expense Risk Charge

The Mortality and Expense Risk Charge is shown on the Certificate Specifications page. It is
deducted daily from each of the Sub-Accounts. This deduction is made to compensate us for assuming
the mortality and expense risks under the Contract. We may reduce this charge in our sole
discretion.

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Administration Charge

The Administration Charge is shown on the Certificate Specifications page. It is deducted daily
from each of the Sub-Accounts. This deduction is made to reimburse us for certain expenses
incurred in the administration of the Contract and the Separate Account. We may reduce or
eliminate this charge in our sole discretion.

Certificate Maintenance Fee

The Certificate Maintenance Fee (“Fee”) is shown on the Certificate Specifications page. It is
deducted as of the Valuation Date after each Certificate Anniversary that your interest in the
Contract is in effect. The Fee will be taken pro-rata from:

	 	1)	 	each Sub-Account in which you have an interest at the time that the Fee is
deducted; and

	 	2)	 	the Fixed Account if you have an interest in the Fixed Account at the time that
the Fee is deducted.

The full annual Fee will also be deducted at the time of a surrender.

After the Commencement Date, the Fee will be deducted pro-rata from each payment. This deduction
will result in a reduction in the amount of such payment.

We may waive the Fee in whole or in part in our sole discretion.

Early Withdrawal Charge

An Early Withdrawal Charge may apply to your interest in the Contract if:

	1)	 	a withdrawal is taken from it;
	 
	2)	 	it is surrendered; or
	 
	3)	 	it is annuitized.

The Early Withdrawal Charge will be equal to the Early Withdrawal Charge rate multiplied by the
amount that is withdrawn, surrendered, or annuitized. It will include the amount needed to pay the
Early Withdrawal Charge rate itself. The Early Withdrawal Charge rate for each Certificate Year is
set out on the Certificate Specifications page.

No charge applies if your interest in the Contract is annuitized for life or for a fixed period of
at least ten (10) years.

Other circumstances, if any, under which we will waive the Early Withdrawal Charge are set out on
the Certificate Specifications page. In addition, we may, in our sole discretion, waive the Early
Withdrawal Charge in whole or in part.

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SURRENDER AND WITHDRAWALS

Surrender

You may surrender your interest in the Contract in full for your Account Value at any time so long
as:

	 	1)	 	it is before your Annuity Commencement Date; and
	 
	 	2)	 	you are still living.

The amount available for surrender will be your Surrender Value at the end of the Valuation Period
in which the Written Request is received.

A surrender must be made by Written Request. In the case of a surrender of your interest, your
interest in the Contract will terminate.

Withdrawals

You may take withdrawals from your interest in the Contract at any time so long as:

	 	1)	 	it is before your Annuity Commencement Date;
	 
	 	2)	 	you are still living; and
	 
	 	3)	 	your interest in the Contract has not been surrendered.

A withdrawal must be made by Written Request. The amount of any withdrawal must be at least $500.
No withdrawal can be made that would reduce your Surrender Value to less than the Minimum Required
Value. The Minimum Required Value is set out on the Certificate Specifications page.

A withdrawal will result in the cancellation of Accumulation Units from each of the applicable
Sub-Accounts and/or a reduction of the Fixed Account Value. Unless you state otherwise in your
request for a withdrawal, the reduction in each Sub-Account and Fixed Account option will be in the
same proportion as the reduction in the total Account Value.

The amount available for withdrawal will be based on the Surrender Value as of the end of the
Valuation Period in which we receive the Written Request.

Exchanges, Transfers, and Rollovers

An amount paid on a withdrawal or surrender may be paid to or for another annuity or tax-qualified
account in a tax-free exchange, transfer, or rollover to the full extent allowed by federal tax
law.

Termination

We may terminate the Contract by giving the Contract Owner sixty (60) days advance notice in
writing. The Contract Owner may terminate the Contract by giving us sixty (60) days advance notice
in writing. If the Contract is terminated, you may continue your interest in it, but no more
Purchase Payments will be allowed. Termination of the Contract will not affect payments being made
by us. Termination of the Contract will not affect our right to collect any fees and charges due
under the contract, the outstanding balance of any loans, and applicable premium tax or other taxes
not previously deducted.

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We reserve the right to terminate your interest in the Contract at any time that your Surrender
Value is less than the Minimum Required Value. The Minimum Required Value is set out on the
Certificate Specifications page. If we terminate your interest in the Contract, we will pay your
Surrender Value to you. We will not terminate your interest if a distribution to you is prohibited
by the tax qualification or employer plan endorsement.

Deferral of Payment 

The Company has the right to suspend or delay the date of payment of a withdrawal or surrender of
the Variable Account Value at certain times. We may do this for any period:

	 	1)	 	when the New York Stock Exchange is closed, or when trading on the New York
Stock Exchange is restricted; or
	 
	 	2)	 	when an emergency exists (as determined by the Securities and Exchange
Commission) as a result of which:

	 	a)	 	the disposal of securities in the Separate Account is not reasonably
practicable; or

	 	b)	 	it is not reasonably practicable to determine fairly the value of the
net assets in the Separate Account; or

	 	3)	 	when the Securities and Exchange Commission so permits for the protection of
security holders.

The Company further reserves the right to delay payment of a withdrawal or surrender of the Fixed
Account Value. We may delay such payment for up to six (6) months after we receive your Written
Request.

OWNERSHIP PROVISIONS

Ownership of Separate Account

The Company has absolute ownership of the assets in the Separate Account. We are not, and do not
hold ourselves out to be, a trustee in respect of any amounts under the Separate Account.

Ownership of the Contract and Participant Account

The owner of the Contract (the “Contract Owner”) is your employer or the trustee of your employer’s
retirement plan. The Contract Owner is shown on the Certificate Specifications page. The Contract
is held by the Contract Owner for the benefit of the participants and Beneficiaries.

Each person for whom Purchase Payment(s) are made will have an interest in the Contract as a
participant. An account will be established for each participant.

Transfer and Assignment

Neither you nor the Contract Owner may transfer, sell, assign, pledge, charge, encumber, or in any
way alienate an interest in the Contract.

-19-

 

Successor Owner

In some cases, your spouse may succeed to the ownership of your interest in the Contract after your
death. Specifically, if you die before your Annuity Commencement Date and your spouse is your sole
surviving Beneficiary, he or she will become the successor owner of your interest if:

	 	1)	 	you make that Written Request before your death; or
	 
	 	2)	 	after your death, your spouse makes that Written Request within one (1) year of
your death and before the Death Benefit Commencement Date.

As successor owner, your spouse will then succeed to all your rights under the Contract except the
right to name another successor owner.

Community Property 

If you live in a community property state and have a spouse at any time while you have an interest
in the Contract, the laws of that state may vary your ownership rights.

BENEFICIARY PROVISIONS

Beneficiary

Your Beneficiary is the person or persons that you designate in the manner described in the
Designation of Beneficiary provision of this Certificate. If there is no designated Beneficiary
that survives you, then your estate will be your Beneficiary.

A Beneficiary will be deemed not to have survived you if he or she dies within thirty (30) days
after your death.

Designation of Beneficiary

You may make or change a designation of Beneficiary at any time so long as:

	 	1)	 	you have not specified that a prior designation is irrevocable; and
	 
	 	2)	 	you are still living.

A designation of Beneficiary must be made by Written Request. The Written Request must be received
on or before the date of death for which a Death Benefit is payable. Except as otherwise elected
or as required by law, it will not cancel a settlement option election.

You may designate two (2) or more persons jointly as the Beneficiary. Unless you state otherwise,
joint Beneficiaries that survive you will be entitled to equal shares. You may also designate one
(1) or more persons as contingent Beneficiary. Unless you state otherwise, a contingent
Beneficiary will be entitled to a benefit only if there is no primary Beneficiary that survives
you.

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ANNUITY BENEFIT

Annuity Commencement Date

Your Annuity Commencement Date is set out on the Certificate Specifications page. You may change
your Annuity Commencement Date by Written Request. Such a request must be made at least thirty
(30) days prior to the date that Annuity Benefit payments are scheduled to begin.

You may not change your Annuity Commencement Date to a date earlier than your first Certificate
Anniversary. You may not change your Annuity Commencement Date to a date later than your
Certificate Anniversary following your 95th birthday, unless we agree.

Annuity Benefit Amount

If payments are to be made for life or over a fixed period of at least ten (10) years, then the
amount used to provide Annuity Benefit payments will be equal to your Account Value as of your
Annuity Commencement Date. Otherwise your Surrender Value as of your Annuity Commencement Date
will be used to provide Annuity Benefit payments.

If your Account Value is used to provide Annuity Benefit payments, it will be reduced by:

	 	1)	 	any fees and charges under the Contract;
	 
	 	2)	 	applicable premium tax or other taxes not previously deducted; and
	 
	 	3)	 	the outstanding balance of any loans.

Annuity Benefit Payments

Annuity Benefit payments will be made to you as payee unless amounts are paid as a tax-free
exchange, transfer, or rollover to or for an annuity or tax-qualified account as permitted by
federal tax law.

Annuity Benefit payments that are payable with respect to a payment interval that ends after the
death of the payee will be made to the contingent payee designated by you. If there is no such
contingent payee surviving, then such payments will be made to the person or persons designated as
contingent payee by the last payee who received payments. Failing that, such payments will be made
to the estate of the last payee who received payments.

A designation or change of a payee or contingent payee must be made by Written Request. Unless it
has been specified that a prior designation is irrevocable, you may change the payee or contingent
payee at any time.

You will be the person on whose life Annuity Benefit payments are based. No change of payee or
contingent payee at any time will change this.

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Form of Annuity Benefit

Annuity Benefit payments will be made annually under the terms of Option B with a fixed period of
ten (10) years, as described in the SETTLEMENT OPTIONS section of this Certificate. In lieu of
that, you may elect to have Annuity Benefit payments made pursuant to any other available option
that is described in the SETTLEMENT OPTIONS section of this Certificate. Such an election must be
made before your Annuity Commencement Date. You may change your election so long as we receive
your request for a change at least thirty (30) days prior to the date that Annuity Benefit payments
are scheduled to begin.

Any election or change of election must be made by Written Request.

An election of a settlement option may be subject to restrictions stated in the tax qualification
endorsement.

DEATH BENEFIT

Death Benefit

A Death Benefit will be paid with respect to your interest in the Contract if you die before your
Annuity Commencement Date and before your interest in the Contract is surrendered.

If a Death Benefit becomes payable:

	 	1)	 	it will be in lieu of all other benefits with respect to your interest in the
Contract; and
	 
	 	2)	 	all other rights with respect to your interest in the Contract will be
terminated except for rights related to the Death Benefit.

No Death Benefit will be paid on your death if your spouse becomes the successor owner of your
interest in the Contract. Only one (1) Death Benefit will be paid with respect to your interest in
the Contract.

Death Benefit Amount

The amount of the Death Benefit will be based on the greater of:

	 	1)	 	your Account Value on the Death Benefit Valuation Date; or
	 
	 	2)	 	the total of all Purchase Payments for your interest in the Contract, reduced
proportionally for any withdrawals.

The reduction for withdrawals will be in the same proportion that your Account Value was reduced on
the date of the withdrawal.

The Death Benefit will be reduced by:

	 	1)	 	any charges and fees due under the Contract;
	 
	 	2)	 	applicable premium tax or other taxes not previously deducted; and
	 
	 	3)	 	the outstanding balance of any loans.

As of the Death Benefit Valuation Date, the amount of the Death Benefit will be allocated among the
Sub-Accounts and the Fixed Account. The allocation will be in the same proportion as each
Sub-Account’s and Fixed Account’s value is to your total Account Value as of the end of the
Valuation Period that precedes the Death Benefit Valuation Date. After this allocation, the amount
of the Death Benefit to be paid will be based on your Account Value.

-22-

 

Step Up in Account Value for Successor Owner

If your spouse becomes the successor owner of your interest in the Contract, your Account Value
will be increased to equal the amount of the Death Benefit which would have been payable if your
spouse had not become the successor owner. This increase will occur as of the date that would have
been the Death Benefit Valuation Date. If your Account Value is increased under this provision, we
will add the amount in the same proportion as each Sub-Account’s and Fixed Account’s value is to
your total Account Value as of the end of the Valuation Period that precedes the Death Benefit
Valuation Date.

If the Death Benefit that would have been payable is equal to your Account Value as of the date
that would have been the Death Benefit Valuation Date, then there will be no such change to your
Account Value.

The election to become successor owner will be deemed to be instructions as to the form of Death
Benefit. Therefore, the date that would have been the Death Benefit Valuation Date will be the
later of the date that we receive Due Proof of Death, or the date we receive the successor owner
election. This date will never be later than one (1) year after the date of your death.

Transfers After Death 

Between the Death Benefit Valuation Date and the Death Benefit Commencement Date, the Beneficiary
may transfer funds among Sub-Accounts and Fixed Account option(s). Such transfers are subject to
the limitations set out in the TRANSFERS section of this Certificate.

Death Benefit Commencement Date

Your Beneficiary may designate the Death Benefit Commencement Date by Written Request. This
request must be made within one (1) year of your death. If no designation is made, then the Death
Benefit Commencement Date will be one (1) year after your death. No Death Benefit will be paid
until we receive Due Proof of Death.

Death Benefit Payments

Death Benefit payments will be made to the Beneficiary as payee unless:

	 	1)	 	amounts are paid as a tax-free exchange, transfer, or rollover to or for an
annuity or tax-qualified account as permitted by federal tax law; or
	 
	 	2)	 	the Beneficiary is a non-natural person, and elects to have Death Benefit
payments made to a payee to whom the Beneficiary is obligated to make corresponding
payments.

Death Benefit payments that are payable with respect to payment intervals that end after the death
of the Beneficiary will be made to the contingent payee designated as part of any Death Benefit
settlement option election made by you. If there is no such contingent payee surviving, then such
payments will be made to the person or persons designated as contingent payee by the Beneficiary.
Failing that, such payments will be made to the estate of the last payee who received payments.

A designation or change of a payee or contingent payee must be made by Written Request. A
Beneficiary may not change a contingent payee designation made as part of a Death Benefit
settlement option election made by you. A Beneficiary may make or change any other payee or
contingent payee designation at any time.

-23-

 

The Beneficiary will be the person on whose life Death Benefit payments under a settlement option
will be based. No change of payee or contingent payee at any time will change this. A Beneficiary
that is a non-natural person may elect to have payments based on the life of a person to whom the
Beneficiary is obligated. Such an election must be made by Written Request before the Death
Benefit Commencement Date.

Form of Death Benefit

Death Benefit payments will be made annually under the terms of Option A with a period certain of
four (4) years, as described in the SETTLEMENT OPTIONS section of this Certificate.

In lieu of that, you may elect at any time before your death to have Death Benefit payments made in
one (1) lump sum or pursuant to any available option described in the SETTLEMENT OPTIONS section of
this Certificate. You may change your election of a settlement option at any time before your
death.

If you do not make any such election, the Beneficiary may make that election at any time after your
death and before the Death Benefit Commencement Date. A Beneficiary may change his or her own
election of a settlement option so long as we receive the request for a change at least thirty (30)
days prior to the date that Death Benefit payments are scheduled to begin.

Any election or change of election must be made by Written Request.

An election of a settlement option is subject to restrictions stated in the tax qualification
endorsement.

Interest on Death Benefit

We will accrue interest on a Death Benefit payable under the Contract as required by law. Such
interest, if any, will be added to the Death Benefit when paid.

SETTLEMENT OPTIONS

Conditions

Payments under a settlement option are subject to any minimum amounts, payment intervals, and other
terms and conditions that we may from time to time require. If we change our minimums, we may
change any current or future payment amounts and/or payment intervals to conform to the change.
More than one (1) settlement option may be elected if the requirements for each settlement option
elected are satisfied. Once payment begins under a settlement option, the settlement option may
not be changed.

All elected settlement options must comply with pertinent laws and governmental regulations and
rulings.

If more than one (1) person is the payee under a settlement option, payments will be made to the
payees jointly. No more than two (2) persons may be initial payees under a joint and survivor
settlement option.

If payment under a settlement option depends on whether a specified person is still alive, we may
at any time require proof that such person is still living. We will require proof of the age of
any person on whose life payments are based.

-24-

 

Benefit Payments

Payments may be calculated and paid:

	 	1)	 	as Fixed Dollar payments;
	 
	 	2)	 	as Variable Dollar payments; or
	 
	 	3)	 	as a combination of both.

The amount to be applied to Variable Dollar payments is your Variable Account Value as of the end
of the Valuation Period that precedes the Commencement Date. It will include the amount of any
transfer to Variable Dollar payments that is made from your interest in the Fixed Account as of
that same time. It will be reduced by the amount of any transfer to Fixed Dollar payments that is
to be made from your interest in the Separate Account on the Commencement Date. An amount that is
transferred from the Fixed Account will be allocated among the Sub-Accounts by Written Request.

The amount to be applied to Fixed Dollar payments is your Fixed Account Value as of the
Commencement Date. It will include the amount of any transfer to Fixed Dollar payments that is
made from your interest in the Separate Account on that date. It will not include the amount of
any transfer to Variable Dollar payments that is made from your interest in the Fixed Account as of
the end of the Valuation Period that precedes the Commencement Date.

In each case, the amount to be applied to payments will be reduced by any fees and charges, loans,
or applicable premium tax or other taxes not previously deducted.

No transfers between Fixed Dollar payments and Variable Dollar payments will be allowed after the
Commencement Date. Twelve (12) months or more after the Commencement Date, the payee may transfer
all or part of the Benefit Units upon which Variable Dollar payments are based from the
Sub-Account(s) then held, to Benefit Units in other Sub-Account(s) that are then available. Such
transfers of Benefit Units may not occur more than once in any twelve (12) month period. Such
transfers are subject to the other limitations set out in the TRANSFERS section of this
Certificate.

Fixed Dollar Payments

Fixed Dollar payments are determined as follows. We start with the amount to be applied to Fixed
Dollar payments. We then deduct a pro-rata portion of the Certificate Maintenance Fee. The
resulting amount, expressed in thousands of dollars, is then multiplied by the amount of the
periodic payment per $1,000 of value. This payment is obtained from the Settlement Option Table
for the option that is elected. Fixed Dollar payments will remain level for the duration of the
payment period.

Variable Dollar Payments

The Variable Dollar base payment is determined as follows. We start with the amount to be applied
to Variable Dollar payments, expressed in thousands of dollars. This amount is then multiplied by
the amount of the periodic payment per $1,000 of value. This payment is obtained from the
Settlement Option Table for the option that is elected.

-25-

 

The number of Benefit Units in each Sub-Account held for Variable Dollar payments is determined as
follows. We divide the dollar amount of the Variable Dollar base payment from each Sub-Account by
the Benefit Unit Value for that Sub-Account as of the Commencement Date. The number of Benefit
Units in each Sub-Account will change if the payee makes transfers among Sub-Accounts. The Benefit
Units in each Sub-Account will change proportionally to a change in the base payment due to any
change in the payment interval or as specified by the settlement option. Otherwise, the number of
Benefit Units remains fixed during the payment period.

The actual amount of each Variable Dollar payment will reflect the investment performance of the
Sub-Account(s) selected. It may vary from payment to payment. The total amount of each Variable
Dollar payment will be equal to the sum of the payments from each Sub-Account. We will deduct a
pro-rata portion of the Certificate Maintenance Fee from this total.

The payment from each Sub-Account is found by multiplying the number of Benefit Units held in that
Sub-Account for such Variable Dollar payments by the Benefit Unit Value for that Sub-Account. We
do this as of the end of the fifth (5th) Valuation Period before the date that the payment is due.

The Benefit Unit Value for each Sub-Account is originally established in the same manner as
Accumulation Unit Values. For any date after that, the value of a Benefit Unit for a Sub-Account
is determined by multiplying the Benefit Unit Value as of the end of the preceding Valuation Period
by the Net Investment Factor. This factor is determined as set forth in the Accumulation Unit
Value provision of this Certificate. The product is then multiplied by the assumed daily
investment factor for the number of days in the Valuation Period. The factor is based on the
assumed net investment rate for the Settlement Option Table that is used to fix the base payment.
This factor shall be no greater than [0.99997236], which is the factor based on a net investment
rate of [one percent (1%)] per year, compounded annually, as reflected in the guaranteed Settlement
Option Tables.

Limitation on Election of Settlement Option

Fixed periods shorter than five (5) years are generally not available. A fixed period of less than
five (5) years is available only as a Death Benefit settlement option.

Settlement Option Computations

The Annuity 2000 Mortality Table for blended lives (60% female/40% male) with interest at [one
percent (1%)] per year, compounded annually, is used to compute all guaranteed settlement option
factors, values, and benefits under the Contract.

Available Settlement Options

The available settlement options are set out below.

Option A Income for a Fixed Period

We will make periodic payments for a fixed period. The first payment will be paid as of the
last day of the initial payment interval. The maximum time over which we will make payments
or money will be held by us is thirty (30) years. The Option A Table applies to this
Option.

-26-

 

Option B Life Annuity with Payments for at Least a Fixed Period

We will make periodic payments for at least a fixed period. If the person on whose life
payments are based lives longer than the fixed period, then we will make payments until his
or her death. The first payment will be paid as of the last day of the initial payment
interval. The Option B Table applies to this Option.

Option C Joint and One-half Survivor Annuity

We will make periodic payments until the death of the primary person on whose life payments
are based; thereafter, we will make one-half (1/2) of the periodic payment until the death
of the secondary person on whose life payments are based. The first payment will be paid as
of the last day of the initial payment interval. The Option C Table applies to this Option.

We will make periodic payments in any other form of settlement option that is acceptable to us at
the time of an election.

Commuted Values

Commuted values are not available unless we agree otherwise.

-27-

 

Settlement Option Tables

The Option Tables show the payments that we will make at sample payment intervals for each $1,000
applied based on the guaranteed settlement option factors. Amounts may vary with the payment
interval and the age of the person on whose life payments are based. For purposes of calculating
payments based on the age of a person, we will use the person’s age as of his or her last birthday.
Upon request, we will provide information on the payments that we will make for other payment
intervals and ages.

OPTION A TABLE — INCOME FOR A FIXED PERIOD

Payments for fixed number of years for each $1,000 applied.

	 	 	 	 	 	 	 	 	 
	Term of	 	 	 	Semi-	 	 	 	 
	Payments	 	Annual	 	Annual	 	Quarterly	 	Monthly
	Years	 	 	 	 	 	 	 	 
	1
	 	[$1,010.00]       
	 	[$503.74]    
	 	[$251.55]    
	 	[$83.78]    
	2
	 	[507.51]  
	 	[253.12]  
	 	[126.40]  
	 	[42.10]  
	3
	 	[340.02]  
	 	[169.58]  
	 	[84.68]
	 	[28.20]  
	4
	 	[256.28]  
	 	[127.82]  
	 	[63.83]
	 	[21.25]  
	5
	 	[206.03]  
	 	[102.76]  
	 	[51.31]
	 	[17.09]  
	6
	 	[172.54]  
	 	[86.05]
	 	[42.97]
	 	[14.31]  
	7
	 	[148.62]  
	 	[74.12]
	 	[37.01]
	 	[12.32]  
	8
	 	[130.69]  
	 	[65.18]
	 	[32.55]
	 	[10.84]  
	9
	 	[116.74]  
	 	[58.22]
	 	[29.07]
	 	[9.68]
	10
	 	[105.58]  
	 	[52.65]
	 	[26.29]
	 	[8.75]
	11
	 	[96.45]
	 	[48.10]
	 	[24.02]
	 	[8.00]
	12
	 	[88.84]
	 	[44.31]
	 	[22.12]
	 	[7.37]
	13
	 	[82.41]
	 	[41.10]
	 	[20.52]
	 	[6.83]
	14
	 	[76.90]
	 	[38.35]
	 	[19.15]
	 	[6.37]
	15
	 	[72.12]
	 	[35.97]
	 	[17.96]
	 	[5.98]
	16
	 	[67.94]
	 	[33.88]
	 	[16.92]
	 	[5.63]
	17
	 	[64.25]
	 	[32.04]
	 	[16.00]
	 	[5.33]
	18
	 	[60.98]
	 	[30.41]
	 	[15.18]
	 	[5.05]
	19
	 	[58.05]
	 	[28.95]
	 	[14.45]
	 	[4.81]
	20
	 	[55.41]
	 	[27.63]
	 	[13.80]
	 	[4.59]

The values stated for years 1-4 are available only as a Death Benefit option.

-28-

 

OPTION B TABLE — LIFE ANNUITY

Monthly payments by age of the person named for each $1,000 applied.

	 	 	 	 	 	 	 	 	 	 	 
	 	 	Number of Months Certain
	Age*	 	0	 	60	 	120	 	180	 	240
	55
	 	[$3.25]  
	 	[$3.24]  
	 	[$3.22]  
	 	[$3.18]  
	 	[$3.12]  
	 
	56
	 	[3.33]
	 	[3.33]
	 	[3.30]
	 	[3.26]
	 	[3.18]
	57
	 	[3.42]
	 	[3.42]
	 	[3.39]
	 	[3.34]
	 	[3.25]
	58
	 	[3.52]
	 	[3.51]
	 	[3.48]
	 	[3.42]
	 	[3.32]
	59
	 	[3.62]
	 	[3.61]
	 	[3.58]
	 	[3.51]
	 	[3.40]
	60
	 	[3.73]
	 	[3.72]
	 	[3.68]
	 	[3.60]
	 	[3.47]
	 
	61
	 	[3.85]
	 	[3.83]
	 	[3.79]
	 	[3.69]
	 	[3.54]
	62
	 	[3.97]
	 	[3.95]
	 	[3.90]
	 	[3.79]
	 	[3.62]
	63
	 	[4.10]
	 	[4.08]
	 	[4.02]
	 	[3.89]
	 	[3.69]
	64
	 	[4.24]
	 	[4.22]
	 	[4.14]
	 	[4.00]
	 	[3.77]
	65
	 	[4.39]
	 	[4.36]
	 	[4.27]
	 	[4.10]
	 	[3.84]
	 
	66
	 	[4.55]
	 	[4.52]
	 	[4.41]
	 	[4.21]
	 	[3.91]
	67
	 	[4.72]
	 	[4.68]
	 	[4.56]
	 	[4.33]
	 	[3.99]
	68
	 	[4.90]
	 	[4.86]
	 	[4.71]
	 	[4.44]
	 	[4.05]
	69
	 	[5.10]
	 	[5.04]
	 	[4.87]
	 	[4.55]
	 	[4.12]
	70
	 	[5.30]
	 	[5.24]
	 	[5.03]
	 	[4.67]
	 	[4.18]
	 
	71
	 	[5.53]
	 	[5.45]
	 	[5.21]
	 	[4.78]
	 	[4.24]
	72
	 	[5.77]
	 	[5.68]
	 	[5.39]
	 	[4.89]
	 	[4.29]
	73
	 	[6.03]
	 	[5.92]
	 	[5.57]
	 	[5.00]
	 	[4.34]
	74
	 	[6.31]
	 	[6.18]
	 	[5.76]
	 	[5.11]
	 	[4.38]
	75
	 	[6.61]
	 	[6.45]
	 	[5.95]
	 	[5.21]
	 	[4.42]
	 
	76
	 	[6.93]
	 	[6.74]
	 	[6.15]
	 	[5.31]
	 	[4.45]
	77
	 	[7.28]
	 	[7.04]
	 	[6.35]
	 	[5.40]
	 	[4.48]
	78
	 	[7.66]
	 	[7.37]
	 	[6.55]
	 	[5.48]
	 	[4.50]
	79
	 	[8.07]
	 	[7.71]
	 	[6.75]
	 	[5.56]
	 	[4.52]
	80
	 	[8.51]
	 	[8.07]
	 	[6.94]
	 	[5.63]
	 	[4.54]

 

*Age as of last birthday

-29-

 

OPTION C TABLE — JOINT AND ONE-HALF SURVIVOR ANNUITY

Monthly payments by ages of the persons named for each $1,000 applied.*

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Secondary Age**
	Primary	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Age**	 	60	 	61	 	62	 	63	 	64	 	65	 	66	 	67	 	68	 	69	 	70
	60
	 	[$3.39]  
	 	[$3.42]  
	 	[$3.44]  
	 	[$3.46]  
	 	[$3.48]  
	 	[$3.50]  
	 	[$3.52]  
	 	[$3.54]  
	 	[$3.56]  
	 	[$3.57]  
	 	[$3.59]  
	61
	 	[3.47]
	 	[3.49]
	 	[3.52]
	 	[3.54]
	 	[3.56]
	 	[3.59]
	 	[3.61]
	 	[3.63]
	 	[3.65]
	 	[3.66]
	 	[3.68]
	62
	 	[3.54]
	 	[3.57]
	 	[3.59]
	 	[3.62]
	 	[3.65]
	 	[3.67]
	 	[3.69]
	 	[3.72]
	 	[3.74]
	 	[3.76]
	 	[3.78]
	63
	 	[3.61]
	 	[3.64]
	 	[3.67]
	 	[3.70]
	 	[3.73]
	 	[3.76]
	 	[3.79]
	 	[3.81]
	 	[3.83]
	 	[3.86]
	 	[3.88]
	64
	 	[3.69]
	 	[3.72]
	 	[3.76]
	 	[3.79]
	 	[3.82]
	 	[3.85]
	 	[3.88]
	 	[3.91]
	 	[3.93]
	 	[3.96]
	 	[3.98]
	65
	 	[3.77]
	 	[3.80]
	 	[3.84]
	 	[3.88]
	 	[3.91]
	 	[3.94]
	 	[3.98]
	 	[4.01]
	 	[4.04]
	 	[4.07]
	 	[4.09]
	66
	 	[3.85]
	 	[3.89]
	 	[3.93]
	 	[3.97]
	 	[4.00]
	 	[4.04]
	 	[4.08]
	 	[4.11]
	 	[4.14]
	 	[4.18]
	 	[4.21]
	67
	 	[3.93]
	 	[3.97]
	 	[4.02]
	 	[4.06]
	 	[4.10]
	 	[4.14]
	 	[4.18]
	 	[4.22]
	 	[4.25]
	 	[4.29]
	 	[4.32]
	68
	 	[4.01]
	 	[4.06]
	 	[4.11]
	 	[4.15]
	 	[4.20]
	 	[4.24]
	 	[4.28]
	 	[4.33]
	 	[4.37]
	 	[4.41]
	 	[4.44]
	69
	 	[4.10]
	 	[4.15]
	 	[4.20]
	 	[4.25]
	 	[4.30]
	 	[4.34]
	 	[4.39]
	 	[4.44]
	 	[4.48]
	 	[4.53]
	 	[4.57]
	70
	 	[4.18]
	 	[4.24]
	 	[4.29]
	 	[4.34]
	 	[4.40]
	 	[4.45]
	 	[4.50]
	 	[4.55]
	 	[4.60]
	 	[4.65]
	 	[4.70]
	 
	 	 
	 	 
	 	 
	 	 
	 	 
	 	 
	 	 
	 	 
	 	 
	 	 
	 	 

 

			
	*	 	Payments after the death of the primary payee will be one-half (1/2) of the amount shown.

	**	 	
Age as of last birthday

-30-

 

Certificate of Participation

Under a Group Flexible Premium Deferred Variable Annuity Contract

NONPARTICIPATING — NO DIVIDENDS

Source: [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00141-of-00352.parquet"}, [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00141-of-00352.parquet"}]]