Document:

rila287

  RILA287            Jackson National Life Insurance Company®    Thank you for choosing Jackson National Life Insurance Company, also referred to as "the  Company" or "Jackson®."    READ YOUR CONTRACT CAREFULLY.    This annuity contract is issued by the Company and is a legal agreement between the Owner  ("You") and Jackson.    PLEASE NOTE THAT THIS CONTRACT HAS REFERENCES TO AND UTILIZATION OF  EXTERNAL INDEXES. WHILE THE CONTRACT VALUES MAY BE AFFECTED BY THE  EXTERNAL INDEXES, THE CONTRACT DOES NOT DIRECTLY PARTICIPATE IN ANY  STOCK OR EQUITY INVESTMENTS. AN INDEX ADJUSTMENT TO THE INDEX ACCOUNT  IS NOT GUARANTEED AND MAY VARY BASED UPON THE PERFORMANCE OF THE  INDEXES.    WHEN ALL OR ANY PORTION OF THE INDEX ACCOUNT VALUE IS WITHDRAWN,  ANNUITIZED, OR TRANSFERRED TO THE FIXED ACCOUNT, IT MAY BE SUBJECT TO A  MARKET VALUE ADJUSTMENT (MVA) AS SET FORTH IN THE CONTRACT DATA PAGES.  THE WITHDRAWAL VALUE AVAILABLE UNDER THIS CONTRACT IS EQUAL TO THE  CONTRACT VALUE ADJUSTED FOR ANY APPLICABLE MVA.    NOTICE OF RIGHT TO EXAMINE CONTRACT  YOU MAY RETURN THIS CONTRACT TO THE FINANCIAL PROFESSIONAL WHO SOLD  YOU THE CONTRACT OR THE COMPANY WITHIN [10] DAYS AFTER YOU RECEIVE IT  ([30] DAYS AFTER YOU RECEIVE IT IF IT WAS PURCHASED AS A REPLACEMENT  CONTRACT). THE COMPANY WILL REFUND THE PREMIUM PAID TO THE FIXED  ACCOUNT, LESS THE AMOUNT OF ANY PARTIAL WITHDRAWALS FROM THE FIXED  ACCOUNT, PLUS THE INDEX ACCOUNT VALUE WITHOUT DEDUCTION FOR ANY FEES  AND CHARGES. RETURNED CONTRACTS ARE VOID.    The Telephone Number for the [Issue State] Department of Insurance is [Insurance Department  telephone number].  INDIVIDUAL SINGLE PREMIUM DEFERRED  REGISTERED INDEX-LINKED ANNUITY.  DEATH BENEFIT AVAILABLE.  INCOME OPTION AVAILABLE.  NON-PARTICIPATING.      This Contract is signed by the Company President    Secretary [Home Office: [Service Center:  1 Corporate Way P.O. Box 24068  Lansing, Michigan 48951 Lansing, MI 48909-4068    1-800-644-4565] www.jackson.com]  

 

  RILA287 2  TABLE OF CONTENTS     Provision Page Number    Contract Data Pages [3a    Definitions  4    General Provisions 8    Contract Option Provisions 12    Withdrawal Provisions 14    Death Benefit Provisions 16    Income Provisions 19    Termination Provisions 22]    If You have questions about this Contract or require information about coverage or complaint  resolutions, You may contact the Company's Service Center identified on the Contract's cover  page.    

 

  RILA287-FB1 3a  CONTRACT DATA PAGES    Contract Number: [1234567890]     Owner: [John Doe]     Owner Issue Age: [80]     Joint Owner: [No Joint Owner]     Joint Owner Issue Age: [N/A]     Annuitant: [John Doe]     Annuitant Issue Age: [80]     Joint Annuitant: [No Joint Annuitant]     Joint Annuitant Issue Age: [N/A]     Issue Date: [January 15, 2021]     Issue State: [MI]     Premium Amount: [$25,000]     Income Date: [January 15, 2036]     Primary Beneficiary(ies): [Brian Doe]     Contingent Beneficiary(ies): [Jane Doe]                                  

 

  RILA287-FB1 3b  CONTRACT DATA PAGES (CONT'D)    FIXED ACCOUNT INFORMATION:    Fixed Account Minimum Interest Rate (FAMIR): [1.00%]    Fixed Account Minimum Value Percentage: [87.50%]    Fixed Account Minimum Value Annual Expense Allowance: [$50]    INTEREST RATE FOR ADJUSTMENTS DUE TO MISSTATEMENT OF AGE OR SEX: [1.00%]    WITHDRAWALS:    Minimum partial withdrawal amount unless as a scheduled part of an automatic  withdrawal program: [$500]    Minimum partial withdrawal amount as a scheduled part of an automatic withdrawal  program: [$50]    Minimum Contract Value remaining after a partial withdrawal: [$2,000]    MVA Free Withdrawal Percentage: [10%]     PREMIUM:    Premium is money paid into this Contract for allocation into a Contract Option. This is a single  Premium Contract. The Company may waive minimum and maximum Premium at any time, on  a nondiscriminatory basis.     Minimum Premium: [$25,000]    Maximum Premium: [$1,000,000]    SEPARATE ACCOUNT:    [Jackson National RILA Separate Account I]  

 

  RILA287-FB1 3c  CONTRACT DATA PAGES (CONT'D)    MARKET VALUE ADJUSTMENT (MVA):    An MVA is a positive or negative adjustment the Company applies to amounts You remove from  an Index Account Option due to withdrawals, annuitizations or transfers to the Fixed Account  during the MVA Period. In the event of a total withdrawal, any applicable MVA is applied to the  Index Account value, less any MVA Free Withdrawal amount available at the time of the total  withdrawal.     MVA Period: First [six (6)] Contract Years.    The MVA reflects the movement in the MVA Reference Rate since the Issue Date.    The MVA may:  1. reduce the value of the amount paid, annuitized or transferred if the MVA Reference Rate  on the date You remove Index Account value from an Index Account Option is greater than  the MVA Reference Rate on the Issue Date of Your Contract; or  2. increase the value of the amount paid, annuitized or transferred if the MVA Reference Rate  on the date You remove Index Account value from an Index Account Option is less than the  MVA Reference Rate on the Issue Date of Your Contract.    The Company applies the same MVA formula regardless of whether the formula results in an  increase or decrease to amounts You remove from an Index Account Option.    MVA formula. The Company calculates the MVA by multiplying the amount You withdraw less  any applicable charges by the result of the formula below:          where:    I is the MVA Reference Rate on the Issue Date  J is the MVA Reference Rate on the date of withdrawal  m is the number of complete months remaining from the date of the removal to the end of the  MVA Period.    The Company will not apply an MVA to:  1. death benefit proceeds;  2. payment of charges or fees;   3. amounts You allocate to an Income Option that is life contingent or results in payments  spread over at least five (5) years;  4. transfers within the Index Account;  5. exercise of Your Notice of Right to Examine Contract Provision;  6. withdrawals taken under the MVA Free Withdrawal provision;  7. withdrawals taken to satisfy the Required Minimum Distribution (RMD);  8. amounts You remove on the Latest Income Date;  9. amounts You remove from Your Contract after the end of MVA Period; or  10. withdrawals or transfers from the Fixed Account.    -1 [1+ I ]  (m/12)  [1+ J ] (m/12)   

 

  RILA287-FB1 3d  CONTRACT DATA PAGES (CONT'D)    MARKET VALUE ADJUSTMENT (MVA) (continued):    MVA Reference Rate: [Bloomberg Barclays U.S. Intermediate Corporate Bond Index Yield to  Maturity]    The MVA Reference Rate applied on any day will be the MVA Reference Rate published on the  prior Business Day.    If the MVA Reference Rate is not published on the Business Day before the MVA is calculated,  the Company will use the MVA Reference Rate for the most recent Business Day it was  published.    Discontinuation of or Substantial Change to the MVA Reference Rate. In the event that the  MVA Reference Rate is no longer published, is discontinued, or if the calculation is substantially  changed on the date You remove Contract Value from Your Contract then the Company may  substitute a comparable method for determining the MVA Reference Rate. The Company will  obtain approval from Your state insurance department and will notify You and any assignee  before using a substitute method to calculate the MVA.  

 

  RILA287-FB1 3e  CONTRACT DATA PAGES (CONT'D)    TABLE OF INCOME OPTIONS    The following table shows income values for each $1,000 of net proceeds applied to the Income  Option.    UNDER OPTION 4 MONTHLY INSTALLMENTS UNDER OPTIONS 1 OR 3      No. of  Monthly  Install- ments      Monthly  Install- ments      Age of  Annui- tant      No. of Mos.  Certain      Age of  Annui- tant      No. of Mos.  Certain      Age of  Annui- tant      No. of Mos.  Certain      Age of  Annui- tant      No. of Mos.  Certain  Male Life 120 240 Male Life 120 240 Female Life 120 240 Female Life 120 240  60 17.09 40 2.33 2.32 2.31 68 4.72 4.57 4.02 40 2.22 2.22 2.21 68 4.36 4.26 3.86  72 14.31 41 2.37 2.36 2.35 69 4.90 4.72 4.09 41 2.26 2.26 2.25 69 4.52 4.40 3.94  84 12.33 42 2.41 2.41 2.39 70 5.09 4.89 4.16 42 2.30 2.30 2.29 70 4.69 4.55 4.02  96 10.84 43 2.45 2.45 2.43 71 5.31 5.06 4.23 43 2.34 2.34 2.32 71 4.87 4.70 4.09  108 9.68 44 2.50 2.50 2.47 72 5.54 5.24 4.29 44 2.38 2.38 2.36 72 5.06 4.87 4.16  120 8.76 45 2.55 2.54 2.52 73 5.79 5.43 4.34 45 2.42 2.42 2.40 73 5.28 5.04 4.22  132 8.00 46 2.60 2.59 2.56 74 6.06 5.63 4.39 46 2.47 2.47 2.45 74 5.51 5.23 4.28  144 7.37 47 2.65 2.64 2.61 75 6.35 5.83 4.43 47 2.52 2.51 2.49 75 5.76 5.42 4.34  156 6.84 48 2.71 2.70 2.66 76 6.67 6.04 4.47 48 2.57 2.56 2.54 76 6.03 5.62 4.38  168 6.38 49 2.77 2.76 2.71 77 7.02 6.26 4.50 49 2.62 2.61 2.59 77 6.33 5.83 4.43  180 5.98 50 2.83 2.82 2.76 78 7.40 6.48 4.52 50 2.67 2.67 2.64 78 6.65 6.04 4.46  192 5.64 51 2.89 2.88 2.82 79 7.81 6.70 4.54 51 2.73 2.72 2.69 79 7.01 6.26 4.49  204 5.33 52 2.96 2.94 2.88 80 8.27 6.92 4.56 52 2.79 2.78 2.74 80 7.40 6.48 4.52  216 5.06 53 3.03 3.01 2.94 81 8.76 7.13 4.57 53 2.85 2.84 2.80 81 7.83 6.70 4.54  228 4.82 54 3.10 3.08 3.00 82 9.30 7.34 4.58 54 2.92 2.91 2.85 82 8.29 6.92 4.56  240 4.60 55 3.18 3.16 3.06 83 9.89 7.53 4.58 55 2.99 2.98 2.91 83 8.80 7.13 4.57  252 4.40 56 3.26 3.23 3.13 84 10.54 7.72 4.59 56 3.07 3.05 2.98 84 9.35 7.33 4.58  264 4.22 57 3.35 3.32 3.19 85 11.26 7.88 4.59 57 3.14 3.12 3.04 85 9.95 7.52 4.58  276 4.06 58 3.44 3.40 3.26 86 12.05 8.03 4.59 58 3.23 3.20 3.11 86 10.59 7.70 4.59  288 3.90 59 3.54 3.49 3.34 87 12.91 8.17 4.59 59 3.31 3.29 3.18 87 11.28 7.87 4.59  300 3.77 60 3.64 3.59 3.41 88 13.86 8.28 4.60 60 3.40 3.37 3.25 88 12.03 8.02 4.59  312 3.64 61 3.74 3.69 3.48 89 14.88 8.38 4.60 61 3.50 3.46 3.32 89 12.84 8.15 4.59  324 3.52 62 3.86 3.79 3.56 90 15.99 8.46 4.60 62 3.60 3.56 3.40 90 13.71 8.27 4.60  336 3.41 63 3.98 3.91 3.64 91 17.17 8.53 4.60 63 3.71 3.66 3.47 91 14.66 8.37 4.60  348 3.31 64 4.11 4.02 3.71 92 18.43 8.58 4.60 64 3.82 3.77 3.55 92 15.70 8.45 4.60  360 3.21 65 4.24 4.15 3.79 93 19.78 8.63 4.60 65 3.95 3.88 3.63 93 16.86 8.53 4.60    66 4.39 4.28 3.87 94 21.20 8.66 4.60 66 4.07 4.00 3.71 94 18.13 8.58 4.60    67 4.55 4.42 3.95 95 22.67 8.68 4.60 67 4.21 4.12 3.79 95 19.53 8.63 4.60    Note: Due to the volume of relevant information, the Table does not provide income values for  Option 2 described in the Income Provisions. Those values are available from the Company's  Service Center upon request. You may contact the Company's Service Center as shown on the  cover page of the Contract.    BASIS OF COMPUTATION. The [2012 Individual Annuity Mortality Period Table, with an  interest rate of 1.00% and a 0% expense load], provides the actuarial basis for the Table of  Income Options. The Table of Income Options does not include any applicable tax.  

 

  RILA287 4  DEFINITIONS    ANNUITANT. The natural person(s) so designated on the Contract Data Pages, or by  subsequent designation, on whose life the Company determines the amount of Income  Payments provided by the Contract. References to the Annuitant include all Joint Annuitants, if  applicable.    BENEFICIARY(IES). The natural person(s) or legal entity(ies) You designate as Primary or  Contingent Beneficiary(ies) to receive any death benefit provided by the Contract. The initial  Beneficiary(ies) are shown on the Contract Data Pages.    BUSINESS DAY. Any day that the Company and the New York Stock Exchange (NYSE) are  open for business. The Business Day ends when the NYSE closes for the day.    CONTRACT. The Individual Single Premium Deferred Registered Index-Linked Annuity  described herein.    CONTRACT ANNIVERSARY. Each one-year anniversary of the Issue Date.    CONTRACT OPTION(S). The Contract Options for this Contract are the Fixed Account and the  Index Account.     CONTRACT VALUE. The Contract Value is equal to the sum of the Fixed Account value and  the Index Account value. See the Contract Option Provisions for details of how the Fixed  Account value and Index Account value are determined.     CONTRACT YEAR. The twelve-month period beginning on the Issue Date and on any Contract  Anniversary thereafter while the Contract remains in force.    CREDITING METHOD. A method of calculating the Index Adjustment. See the Supplemental  Contract Data Pages and Crediting Method Endorsements for details.     DUE PROOF. Evidence of death, including but not limited to a certified death certificate issued  by the governmental authority for the location of the death, or other lawful evidence the  Company requires.    FIXED ACCOUNT. A Contract Option in which amounts earn a declared rate of interest for a  certain period.    FIXED ACCOUNT MINIMUM INTEREST RATE (FAMIR). The Fixed Account Minimum Interest  Rate is the minimum annual percentage at which Your money allocated to the Fixed Account  will grow. The Company uses this rate to determine the Fixed Account Minimum Value (FAMV).  The FAMIR is shown on the Contract Data Pages and is guaranteed for the life of the Contract.  

 

  RILA287 5  DEFINITIONS (CONT'D)    FIXED ACCOUNT MINIMUM VALUE (FAMV). The FAMV is equal to all amounts allocated to  the Fixed Account, net of applicable taxes, multiplied by the Fixed Account Minimum Value  Percentage, and;  1. reduced by partial withdrawals and transfers from the Fixed Account, and the Fixed  Account Minimum Value Annual Expense Allowance; then  2. accumulated at the FAMIR.    FIXED ACCOUNT MINIMUM VALUE ANNUAL EXPENSE ALLOWANCE. An annual  deduction from the FAMV. On each Contract Anniversary, the Company will deduct the Fixed  Account Minimum Value Annual Expense Allowance from the FAMV. The Fixed Account  Minimum Value Annual Expense Allowance is shown on the Contract Data Pages.    FIXED ACCOUNT MINIMUM VALUE PERCENTAGE. The Fixed Account Minimum Value  Percentage is multiplied by Premiums and transfers allocated to the Fixed Account in the  determination of the FAMV. The Fixed Account Minimum Value Percentage is shown on the  Contract Data Pages.    GOOD ORDER. The Company's receipt of all Premium, information, documentation, and/or  instructions the Company requires before it will issue the Contract, credit any interest, or  execute any transaction.     INCOME DATE. The date on which Income Payments are scheduled to begin as described in  the Income Provisions. The Income Date is shown on the Contract Data Pages.    INCOME OPTION. Payment options as provided under the Income Provisions.     INDEX(ES). A benchmark used to determine the Index Adjustment, if any, for a particular Index  Account Option. See the Supplemental Contract Data Pages for the available Indexes as of the  Issue Date.     INDEX ACCOUNT. A Contract Option in which amounts are subject to an Index Adjustment for  a specified period of time. See the Supplemental Contract Data Pages and Crediting Method  Endorsements for detailed descriptions of the Index Account Options within the Index Account.  Index Account Option availability is subject to change at the discretion of the Company on a  non-discriminatory basis.    INDEX ACCOUNT OPTION. An option within the Index Account for allocation of Contract  Value. Each Index Account Option is defined by its term, Index and Crediting Method.    INDEX ACCOUNT OPTION ANNIVERSARY. The Business Day concurrent with or immediately  following each anniversary of the Issue Date.    

 

  RILA287 6  DEFINITIONS (CONT'D)    INDEX ACCOUNT OPTION TERM ANNIVERSARY. The Business Day concurrent with or  immediately following the end of an Index Account Option term.    INDEX ADJUSTMENT (IA). The adjustment amount to an Index Account Option on the Index  Account Option Term Anniversary. This adjustment can be positive or negative, depending on  Index performance and Crediting Method.    INDEX ADJUSTMENT FACTOR(S). Parameters used to determine the Index Adjustment.  These parameters are specific to the applicable Crediting Method(s). See the Supplemental  Contract Data Pages and Crediting Method endorsements for additional details.    INTERIM VALUE. The quantity used to adjust the Index Account Option value for withdrawals  prior to the end of the Index Account Option term. The Interim Value uses prorated Index  Adjustment Factors based on the elapsed portion of the Index Account Option term and the  Interim Value Proration Factor (IVPF). For detailed information on the Interim Value, see the  Crediting Method endorsements and the Supplemental Contract Data Pages.    ISSUE DATE. The date the Company issued the Contract. The Issue Date is shown on the  Contract Data Pages.    JOINT ANNUITANT. Each of multiple Annuitants.    JOINT OWNER. Each of multiple Owners.    LATEST INCOME DATE (LID). The Contract Anniversary on which You will be 95 years old, or  such earlier date required by a Qualified Plan, law or regulation.    MARKET VALUE ADJUSTMENT (MVA). A positive or negative adjustment to amounts You  remove from an Index Account Option due to withdrawals, annuitizations or transfers to the  Fixed Account during the MVA Period. The MVA formula and the MVA Period are shown on the  Contract Data Pages.    NON-QUALIFIED PLAN. A retirement plan which does not qualify for favorable tax treatment  under Sections 401, 403, 408, or 408A of the Internal Revenue Code, as amended.    OWNER ("YOU," "YOUR"). The natural person(s) or legal entity(ies) that has all rights under  the Contract, and is shown on the Contract Data Pages, or by subsequent designation. In this  Contract, "You" and "Your" also mean the Owner. References to the Owner include all Joint  Owners, if applicable.    PREMIUM. Money paid into this Contract for allocation into the Contract Options.    QUALIFIED PLAN. A retirement plan which qualifies for favorable tax treatment under Sections  401, 403, 408, or 408A of the Internal Revenue Code, as amended.    

 

  RILA287 7  DEFINITIONS (CONT'D)    REQUIRED MINIMUM DISTRIBUTION (RMD). For certain Qualified Plan contracts, the RMD is  the amount defined by the Internal Revenue Code and the implementing regulations as the  minimum distribution requirement that applies to this Contract only.    SERVICE CENTER. The Company's administrative address and telephone number as identified  on the Contract's cover page or as the Company may designate from time to time.    WITHDRAWAL VALUE. The amount available upon a total withdrawal. The Withdrawal Value is  equal to the Contract Value, adjusted for any applicable MVA.    

 

  RILA287 8   GENERAL PROVISIONS    ANNUITANT. You may change the Annuitant at any time before the Income Date, unless the  Contract is owned by a legal entity. If the Contract is owned by a legal entity, the Company will  use the oldest Annuitant's age for all Contract purposes unless otherwise specified in the  Contract. Unless You specify otherwise, a change of Annuitant will take effect on the date the  request is signed by You, subject to any payments the Company has made or other actions the  Company has taken before the Company receives and records Your request. The Company  reserves the right to limit the number of Joint Annuitants to two (2). When the Owner is a legal  entity, the Annuitant may not be changed.    ASSIGNMENT. To the extent allowed by state law, the Company may refuse consent to any  assignment at any time, on a nondiscriminatory basis, if the assignment or ownership change  would result in noncompliance with any applicable state or federal regulation. Unless restricted  by endorsement, You may assign ownership of this Contract subject to the interests of  assignees and irrevocable Beneficiaries. The Company will only be bound by an assignment if a  request is submitted in a form acceptable to the Company, received in Good Order at the  Company's Service Center, recorded and acknowledged by the Company. Unless You specify  otherwise, an assignment will take effect on the date the request is signed by You, subject to  any payments the Company has made or other actions the Company has taken before the  Company receives and records Your request.     The Company assumes no responsibility for the validity or tax consequences of any  assignment. If You make an assignment, You may have to pay taxes. The Company  encourages You to seek legal and/or tax advice.    BENEFICIARY. You may change the Beneficiaries, subject to the interest of assignees and  irrevocable Beneficiaries. The Company will only be bound by a change in Beneficiary if a  request is submitted in a form acceptable to the Company, received in Good Order at the  Company's Service Center and recorded. Any previously designated irrevocable Beneficiary  must consent in writing to any change in Beneficiary. Unless You specify otherwise, a change of  Beneficiary will take effect on the date the request is signed by You, subject to any payments  the Company has made or other actions the Company has taken before the Company receives  and records Your request, and while You are alive.    CONFORMITY WITH LAWS. This Contract will be interpreted under the law of the state in  which it is issued and any applicable federal laws. Any provision that is in conflict with the laws  of the state in which the Contract is issued, or any federal law is amended to conform to the  minimum requirements of such law.    DEFERRAL OF PAYMENTS. If approved in writing by the chief insurance regulator of the  Company's state of domicile, the Company may defer payment of Your request for a partial  and/or total withdrawal from the Contract for a period not exceeding six (6) months. The  Company will credit interest on deferred amounts as required by law. The Company will not  defer payment of death benefits.    

 

  RILA287 9  GENERAL PROVISIONS (CONT'D)    ENTIRE CONTRACT. The Contract, application, if any, and any attached endorsements and  amendments together make up the entire Contract between You and the Company. All  statements made by the applicant to procure the Contract will, in the absence of fraud, be  deemed representations and not warranties.    INCONTESTABILITY. The Company may only contest this Contract when an applicant has  procured the Contract by fraud, and only if permitted by law in the state in which the Company  delivered the Contract or issued the Contract for delivery.    MINIMUM VALUES. Any Withdrawal Values and death benefits that may be available under  this Contract are not less than the minimum benefits required by any statute of the state in  which the Contract is delivered.    MISSTATEMENT OF AGE AND/OR SEX. If Your or the Annuitant's age and/or sex is misstated  at the time the Contract's Income Payments become payable, the Company will adjust the  payments to reflect income consistent with the correct age and/or sex. Immediately upon  discovery, the Company will adjust the next payment due as a credit or charge, as appropriate,  for any underpayments or overpayments using the Interest Rate for Adjustments Due to  Misstatement of Age or Sex shown on the Contract Data Pages.    MODIFICATION OF CONTRACT. No financial professional has authority to change or waive  any of this Contract's provisions. No change to or waiver of this Contract's terms is valid unless  in writing and signed by the Company's President, Vice President, Secretary or Assistant  Secretary; provided, however, that the Company may amend any Contract term, and administer  the Contract, to conform to the Internal Revenue Code.    NONPARTICIPATING. This Contract is nonparticipating and does not share in the Company's  surplus or earnings.    OWNER. To the extent allowed by state law, the Company may refuse consent to an ownership  change at any time, on a nondiscriminatory basis, if the ownership change would result in  noncompliance with any applicable state or federal regulation. Unless restricted by  endorsement, You may change the Owner or any Joint Owner. The Company will use the oldest  Owner's age for all Contract purposes unless otherwise specified in the Contract. The Company  will only be bound by a change of ownership if submitted in a form acceptable to the Company,  received in Good Order at the Company's Service Center, recorded and acknowledged by the  Company. No person whose age exceeds the maximum issue age in effect for this Contract as  of the Issue Date may become a new Owner. Unless You specify otherwise, a change of  ownership will take effect on the date the request is signed by You, subject to any payments the  Company has made or other actions the Company has taken before the Company receives and  records Your request. Joint Owners have equal ownership rights; therefore, each Owner must  authorize any exercise of Contract rights unless the Joint Owners instruct the Company in  writing to act upon authorization of an individual Joint Owner. The Company reserves the right  to limit the number of Joint Owners to two (2).    The Company assumes no responsibility for the validity or tax consequences of any  ownership change. If You make an ownership change, You may have to pay taxes. The  Company encourages You to seek legal and/or tax advice.  

 

  RILA287 10  GENERAL PROVISIONS (CONT'D)    PROOF OF AGE, SEX AND/OR SURVIVAL. The Company may require proof of age and/or  sex, satisfactory to the Company, at any time. If any payment required by this Contract depends  on a living Annuitant, Owner, or Beneficiary, the Company may require proof of that person's  survival, satisfactory to the Company.    PROTECTION OF PROCEEDS. A Beneficiary may not assign Contract proceeds before the  proceeds are payable. Contract proceeds are not subject to the claims of creditors or to legal  process unless required by applicable law.    REPORTS. The Company will send a report to Your last address in the Company's records at  least annually before the Income Date. In the case of Joint Owners, the Company will send  reports only to the primary Owner's address. If You have elected electronic delivery, a report  may be provided in the form of an email to Your last email address in the Company's records, or  a notice to You of a document's availability on the Company's website. Each report will provide  at least the following information:  1. the dates that begin and end the reporting period;   2. the Contract Value at the beginning and at the end of the current reporting period prior to the  application of any MVA;  3. the Withdrawal Value at the end of the reporting period;   4. the MVA amount the Company used to determine the Withdrawal Value;   5. the amounts the Company has credited to and deducted from the Contract Value during the  reporting period;  6. the death benefit at the end of the reporting period; and  7. any other information state and federal law require.     You may receive copies of reports the Company provides upon request at no additional charge.    You will receive a confirmation statement for certain transactions at the time they occur.    SEPARATE ACCOUNT. The Company holds certain investments supporting the assets  allocated to the Index Account in a non-insulated, non-unitized Separate Account. The Separate  Account is established pursuant to the laws of the Company's domiciliary state solely for the  purpose of supporting obligations under the Contract. You do not directly participate in the  performance of assets held in the Separate Account; and do not have any direct claim on them.  Assets of the Separate Account are chargeable with the claims of any of the Company's  contract owners as well as the Company's creditors and are subject to the liabilities arising out  of any other business the Company conducts. The Separate Account is not registered under the  Investment Company Act of 1940. The name of the Separate Account is shown on the Contract  Data Pages.    TAXES. This Contract is intended to be treated as an annuity contract for federal income tax  purposes. Accordingly, for all Non-Qualified Contracts all provisions of this Contract shall be  interpreted and administered in accordance with the requirements of Section 72(s) of the  Internal Revenue Code. The Company will deduct any taxes attributed to the Contract and  payable to a government entity from the Contract Value. The Company reserves the right to  deduct any amounts the Company might advance to pay taxes from the Contract Value. The  Company will withhold taxes required by law from any amounts payable from this Contract. 

 

  RILA287 11  GENERAL PROVISIONS (CONT'D)    WRITTEN NOTICE. Written information or instructions You intend to give the Company must be  in Good Order and delivered to the Company's Service Center, unless the Company advises  You otherwise. Instructions included in the Written Notice will take effect on the date the  Company receives the notice in Good Order at the Company's Service Center, unless otherwise  provided in the notice or in this Contract, or unless the Company advises You otherwise.    The Company will deliver any notice or communication to Your last address in the Company's  records unless You request otherwise in writing. If You have elected electronic delivery,  communication may be provided in the form of an email to Your last email address in the  Company's records, or a notice to You of a document's availability on the Company's website.  You are responsible for notifying the Company of any address change, email address change,  or any error in a Company notice sent to You. In the case of Joint Owners, the Company will  send notices and other communications to the primary Owner's address.    

 

  RILA287 12  CONTRACT OPTION PROVISIONS    The Contract contains two (2) types of Contract Options: Fixed Account and Index Account.    Upon Good Order, all Premium will be allocated to the Contract Options as elected on the  application. The Company reserves the right to restrict or prohibit allocation of Premium to the  Fixed Account at its discretion, on a non-discriminatory basis, at any time. No Premium will be  accepted after the Issue Date.    TRANSFERS.    Transfers may only occur on the Contract Anniversary, when transferring out of the Fixed  Account, and on the Index Account Option Term Anniversary when transferring out of an Index  Account Option. When the Contract Anniversary or Index Account Option Term Anniversary  occurs on a non-Business Day, the transfer will be effective on the following Business Day using  the following Business Day's values. You will receive notice thirty (30) days prior to the Index  Account Option Term Anniversary. The notice will include information on the Contract Options  available to You. You may request a transfer to or from the Fixed Account and to or from the  Index Account Options. You may also request transfers among the available Index Account  Options within the Index Account. Transfers from an Index Account Option to the Fixed Account  may incur an MVA. A request for a transfer must be received in Good Order prior to the Index  Account Option Term Anniversary. If no transfer request is received on or prior to the Index  Account Option Term Anniversary, the Fixed Account value will remain in the Fixed Account and  the Index Account Option value(s) will be reallocated to the same Index Account Option(s) for the  same term, Crediting Method and Index, if available.     If the Crediting Method, or Index is no longer available as of the Index Account Option Term  Anniversary, the Index Account Option value(s) will be reallocated to the Fixed Account, without  being subject to an MVA, until further instruction is received.     If You do not select an Index Account Option term within thirty (30) days prior to the end of the  expired Index Account Option term:  1. if the same Index Account Option term is available at the time and does not extend beyond  the Income Date, the Company will renew the Index Account Option into the same Index  Account Option term.  2. if the same Index Account Option term is available at the time but extends beyond the Income  Date, the Company will select the available Index Account Option term that ends closest to  but before the Income Date.  3. if the same Index Account Option term is not available at the time but would not extend  beyond the Income Date were it available, the Company will select the available Index  Account Option term with the period closest to but less than the Index Account Option term  that just ended.    Unless specified otherwise, transfers will be taken from the Index Account Options and the Fixed  Account in proportion to their current value. The Company reserves the right to restrict or prohibit  transfers from the Index Account Option to the Fixed Account, at its discretion, on a  nondiscriminatory basis, at any time.  

 

  RILA287 13  CONTRACT OPTION PROVISIONS (CONT'D)    Transfers from a Fixed Account will reduce the Fixed Account value by the transfer amount  requested. Transfers into a Fixed Account will increase the Fixed Account value by the transfer  amount requested. Transfers from an Index Account Option will reduce the Index Account  Option value by the transfer amount requested. Transfers into an Index Account Option will  increase the Index Account Option value by the transfer amount requested.    Fixed Account. The Fixed Account is an annually renewable fixed account. The Company will  credit interest to amounts allocated to the Fixed Account. Such interest will be credited at such  rate(s) as the Company prospectively declares on a periodic basis, at the sole discretion of the  Company. On each Contract Anniversary the interest rate for the Fixed Account is subject to  change. In no event will the interest rate credited by the Company to the Fixed Account be less  than the FAMIR, as shown on the Contract Data Pages, per annum.    Index Account Option. An option within the Index Account for allocation of Contract Value,  defined by term, Index, and Crediting Method. The terms, Indexes, and Crediting Methods  available as of the Issue Date are shown on the Supplemental Contract Data Pages. Availability  of terms, Indexes, and Crediting Methods are subject to change at the sole discretion of the  Company on a non-discriminatory basis.    Fixed Account Value. The Fixed Account value is equal to (1) the value of Premium and any  amounts transferred from the Index Account into the Fixed Account, adjusted for any applicable  MVA; (2) plus interest credited daily at a rate not less than the FAMIR, as shown on the  Contract Data Pages, per annum; (3) less any gross partial withdrawals; (4) less any amounts  transferred out of the Fixed Account. The Fixed Account Value will never be less than the  FAMV.    Index Account Value. The Index Account value is equal to the sum of the Index Account  Option values.    The Index Account Option value at the beginning of the Index Account Option term is equal to  the amount allocated or transferred to the Index Account Option less the amount transferred out  of the Index Account Option. Transfers out of the Index Account Option to the Fixed Account will  be adjusted for any applicable MVA.    During the Index Account Option term, the Index Account Option value is equal to the Interim  Value, which is the greater of the Index Account Option value at the beginning of the term  reduced for any partial withdrawals from the Index Account Option during the Index Account  Option term, including any MVA, in the same proportion as the Interim Value was reduced on  the date of the withdrawal, plus the prorated Index Adjustment subject to prorated Index  Adjustment Factors and the IVPF, or zero. Additional detail on Index Adjustment Factors can be  found in the Crediting Method endorsements and Supplemental Contract Data Pages.    On the Index Account Option Term Anniversary, the Index Account Option value is equal to the  greater of the Index Account Option value at the beginning of the Index Account Option term,  reduced for any partial withdrawals from the Index Account Option during the Index Account  Option term, including any MVA, in the same proportion as the Interim Value was reduced on  the date of the withdrawal, plus the Index Adjustment subject to Index Adjustment Factors, or  zero. Additional detail on Index Adjustment Factors can be found in the Crediting Method  endorsements and Supplemental Contract Data Pages.  

 

  RILA287 14  WITHDRAWAL PROVISIONS    On or before the Income Date, You may request a total or partial withdrawal of the Contract  Value by submitting a request to the Company's Service Center in a form acceptable to the  Company.    The withdrawal will be processed after a withdrawal request is received at the Service Center in  Good Order. If a total withdrawal is requested, You must submit the Contract to the Service  Center with the withdrawal request.    TOTAL WITHDRAWAL. During the MVA Period, the Withdrawal Value for a total withdrawal  from the Contract is equal to the Contract Value adjusted for any applicable MVA. After the  expiration of the MVA Period, the Withdrawal Value for a total withdrawal from the Contract is  equal to Contract Value. A total withdrawal terminates Your Contract.    In no event will a total withdrawal from the Fixed Account be less than the FAMV.    No withdrawal may exceed the Withdrawal Value.    PARTIAL WITHDRAWAL. Any partial withdrawal from an Index Account Option may be subject  to an MVA. At least the Minimum Contract Value remaining after a partial withdrawal, as shown  on the Contract Data Pages, must remain after any partial withdrawal. With the exception of an  MVA Free Withdrawal, unless You request otherwise, a gross partial withdrawal will be  deducted from the Fixed Account and the Index Account Option(s) in proportion to their current  values. The gross partial withdrawal deducted from the Index Account Option(s) will then be  adjusted for any applicable MVA.    If the gross amount of the partial withdrawal would reduce the Contract Value below the  Minimum Contract Value remaining after a partial withdrawal, as shown on the Contract Data  Pages, the Company will treat the withdrawal request as a total withdrawal and the Withdrawal  Value will be paid.    The amount payable as a result of the partial withdrawal will be determined at the end of the  Business Day on which the Company receives Your request for withdrawal in Good Order at the  Company's Service Center.     Partial Withdrawals will reduce each Index Account Option's value at the beginning of the term  in the same proportion that its Interim Value was reduced on the date of the withdrawal.    QUALIFIED PLAN CONTRACT REQUIRED MINIMUM DISTRIBUTIONS. Qualified Plan  Contract RMDs are based upon Your Contract Value, and applicable federal tax law  requirements. You may request a withdrawal for an RMD by submitting a written request to the  Service Center on a Company provided form.  

 

  RILA287 15  WITHDRAWAL PROVISIONS (CONT'D)    The Company will waive any MVA if the gross amount withdrawn does not exceed the  Contract's RMD amount. However, if a gross withdrawal amount is greater than the Contract's  RMD amount, the excess amount of the gross partial withdrawal is subject to an MVA in the  same proportion as the gross withdrawal amount is deducted from the Index Account Option(s).    AUTOMATIC WITHDRAWAL. You may elect to take an automatic withdrawal by withdrawing a  specific sum or a certain percentage of the Contract Value on a monthly, quarterly, semiannual  or annual basis, subject to the Minimum Partial Withdrawal amount made as a scheduled part of  an automatic withdrawal program, as shown on the Contract Data Pages. Automatic  withdrawals are treated as partial withdrawals and will be counted in determining the amount  taken as an MVA Free Withdrawal in any Contract Year. Automatic withdrawals in excess of the  MVA Free Withdrawal amount may be subject to an MVA. If an automatic withdrawal causes the  Withdrawal Value to fall to zero, future automatic withdrawals will terminate. If the automatic  withdrawal would reduce the Contract Value below the Minimum Contract Value remaining after  a partial withdrawal, as shown on the Contract Data Pages, the Company will treat the  automatic withdrawal as a total withdrawal and the Withdrawal Value will be paid.    MVA FREE WITHDRAWAL. During each Contract Year, certain partial withdrawals from the  Index Account will not incur an MVA. The amount of MVA Free Withdrawal available in any  Contract Year is equal to the greater of:  1. the MVA Free Withdrawal Percentage, as shown on the Contract Data Pages, multiplied by  the Index Account value at the beginning of the Contract Year; or   2. zero.    The MVA Free Withdrawal can be taken as a single withdrawal or multiple withdrawals  throughout the Contract Year. The amount of Your MVA Free Withdrawal available will vary  throughout the Contract Year depending on previous withdrawals of Your MVA Free Withdrawal  amount. The amount of Your MVA Free Withdrawal available will reduce due to withdrawals  from the Index Account during the Contract Year.    MVA Free Withdrawals will be deducted from the Index Account Options in proportion to their  current values within the Index Account.     Any amount withdrawn to satisfy an RMD may reduce the amount of Your MVA Free  Withdrawal available.    No MVA Free Withdrawal may exceed the Withdrawal Value.    Withdrawals during the Contract Year in excess of the MVA Free Withdrawal may be subject to  any applicable MVA.  

 

  RILA287 16  DEATH BENEFIT PROVISIONS    NATURAL OWNER'S DEATH BEFORE THE INCOME DATE. Upon Your death or the death of  any Joint Owner, before the Income Date, the Company will pay the death benefit to the  Beneficiary(ies) designated by You.     Upon the death of the first Joint Owner, the surviving Joint Owner will become the Primary  Beneficiary and will receive the death benefit payable. Any other Beneficiary designation on  record at the Company's Service Center at the time of the first Joint Owner's death will be  treated as a Contingent Beneficiary.    ANNUITANT'S DEATH BEFORE THE INCOME DATE. Upon the death of an Annuitant who is  not an Owner before the Income Date, the Contract remains in force and the Owner becomes  the Annuitant. The Owner may designate a new Annuitant, subject to the Company's  administrative rules then in effect. No death benefit is payable on the death of an Annuitant who  is not also an Owner.     If the Contract is owned by a legal entity, upon the death of the Annuitant, (in the case of Joint  Annuitants, upon the death of the first Annuitant) the Company will pay the death benefit to the  Beneficiary(ies) designated by the Owner, or, if no Beneficiary(ies) survive the applicable death,  to the Owner.     DEATH BENEFIT AMOUNT BEFORE THE INCOME DATE. The death benefit amount before  the Income Date is equal to the current Contract Value.    DEATH BENEFIT PAYMENT OPTIONS BEFORE THE INCOME DATE. Unless You  designated a Pre-selected Death Benefit Option, a Beneficiary entitled to the death benefit  before the Income Date must request that the Company pay the death benefit according to one  of the death benefit options below:    Option 1 - single lump-sum payment;  Option 2 - payment of the entire death benefit distributed within five (5) years of the date of the  relevant death; or  Option 3 - Income Payments of the death benefit with distributions beginning within one (1) year  of the date of the relevant death:  (i) over the lifetime of the Beneficiary; or  (ii) over a period not extending beyond the life expectancy of the Beneficiary.     The Company may make available other death benefit payment options.    A Beneficiary that wishes to elect payment under Option 3 must do so no later than sixty (60)  days from the date the Company receives Due Proof of death in Good Order at the Company's  Service Center.  

 

  RILA287 17   DEATH BENEFIT PROVISIONS (CONT'D)    Any portion of the death benefit not applied under Option 3 must be paid within five (5) years  from Your death. The death benefit will remain invested in accordance with the allocation  selected by You until a payout option is selected or the Beneficiary specifies otherwise.    DEATH BENEFIT PAYMENT OPTIONS FOR QUALIFIED PLANS. For Qualified Plans, the  death benefit payment options may be limited under the terms of the plan endorsement in order  to qualify under the Internal Revenue Code.     BENEFICIARY'S ENTITLEMENT TO DEATH BENEFIT BEFORE THE INCOME DATE. The  Company will pay the death benefit to Primary Beneficiaries or, if none exist, to Contingent  Beneficiaries, in equal shares (the "default allocation") unless You have designated otherwise  (the "designated allocation"). A Beneficiary that dies before or within ten (10) days (or different  period as prescribed by applicable law) of Your death is not entitled to any death benefit. In that  circumstance, the Company will pay the deceased Beneficiary's share of the death benefit to  surviving Beneficiaries in the same proportion as the designated allocation or, if applicable, the  default allocation. If no Beneficiary survives You, the Company will pay the death benefit to Your  estate.    PAYMENT OF DEATH BENEFIT. The Company will pay the death benefit to the Beneficiary  upon receipt of a request for payment with Due Proof of the relevant death in Good Order at the  Company's Service Center. If the Company has received Due Proof of death, the Company will  calculate the share of the death benefit due to a Beneficiary using Contract values established  at the end of the Business Day on the date the Company receives a claim form with a payment  option elected from that Beneficiary. If the Company has not received Due Proof of death or any  other required documentation, the Company will calculate the share of the death benefit due to  a Beneficiary using Contract values established at the end of the Business Day on the date the  Company receives any remaining required documentation. The Index Adjustments may cause  the calculation of a Beneficiary's death benefit share to differ from the calculation of another  Beneficiary's death benefit share. The Company will pay interest on a Beneficiary's death  benefit share as required by law.     Each Beneficiary entitled to the death benefit bears the investment risk associated with amounts  allocated to any Index Account Option until the Company calculates their share of the death  benefit.    If any death benefit is due to an Owner's estate, the Company will pay the benefit in a single  lump-sum payment.     If a single lump-sum payment is elected, the Contract will remain in force and will accrue  interest, at current rate(s) based on the Contract's current Crediting Method/Index combinations,  until the Company first receives Due Proof of death in Good Order. After that time, the rate of  interest will equal the rate of interest applicable to death benefit left on deposit with the  Company on the date of Your death.    The Company will pay the death benefit in accordance with applicable laws and regulations  governing death benefit payments and in accordance with the Company's administrative  procedures.  

 

  RILA287 18   DEATH BENEFIT PROVISIONS (CONT'D)    Spousal Continuation Option Instead of Death Benefit. Unless the Contract is subject to a  Pre-selected Death Benefit Option, a spouse who is a Joint Owner or Beneficiary of the  deceased Owner may elect to continue the Contract in his or her own name as described below  and exercise the Owner's rights under the Contract instead of taking the standard death benefit.    For purposes of the Spousal Continuation Option, the "continuation date" is the date on which  the Company receives the spouse's written request to elect the Spousal Continuation Option  and Due Proof of the relevant death in Good Order at the Company's Service Center.    The Spousal Continuation Option is void in the event the original Contract Owner is no longer  the Contract Owner or in the event the Contract has been assigned. The Spousal Continuation  Option may be exercised only once and may not be available if You designated a Pre-selected  Death Benefit Option.    Pre-selected Death Benefit Option. Before the Income Date, You may designate the option  according to which the Company will pay the death benefit from the death benefit payment  options described in the Contract, or other death benefit options made available by the  Company. You may do so by submitting a designation in a form acceptable to the Company in  Good Order to the Company's Service Center. Pre-selected Death Benefit Options are effective  only after being recorded by the Company. The Company will pay the death benefit consistent  with Your Pre-selected Death Benefit Option unless the Internal Revenue Code requires  otherwise, or Your election requires payment over a period that exceeds the Beneficiary's life  expectancy as determined by the Company.    Only You may revoke or change a Pre-selected Death Benefit Option. To do so, You must  submit a request in a form acceptable to the Company to the Company's Service Center.  Revocations of and changes to a Pre-selected Death Benefit Option are effective only after  being recorded by the Company.  

 

  RILA287 19  INCOME PROVISIONS    INCOME DATE. Income Payments begin on the Income Date. If You do not select an Income  Date, the Income Date is the LID. You may change the Income Date to any date that is not later  than the LID by submitting Written Notice in Good Order to the Company's Service Center at  least seven (7) days before the Income Date.    INCOME PAYMENT. On or before the Income Date, You may elect payment in a single lump- sum. A single lump-sum payment is considered a total withdrawal and terminates the Contract.  The Company will make payment to You or another payee You specify. Alternatively, You may  elect an Income Option to begin on the Income Date. The Company will apply the Contract  Value, less applicable taxes, adjusted for any applicable MVA, to provide You income according  to Your selected Income Option.    INCOME OPTIONS. You may elect payment as provided in Options 1, 2, 3, or 4 below. You  may elect an Income Option up to thirty (30) days before the Income Date by submitting Written  Notice in Good Order to the Company's Service Center. The Company will make payment to  You or another payee You specify.    If You do not select an Income Option the Company will make payments as provided in Option 3  below, with 120 months certain. The Company will make payments monthly, quarterly,  semiannually or annually as You elect. However, if the Contract Value on the Income Date is  less than $2,000, the Company may pay out the Contract Value in one (1) lump-sum payment  instead of providing Income Payments according to the Income Option You elect. If the first  monthly payment provided would be less than $20, the Company may make payments  quarterly, semiannually or annually to achieve an initial payment of at least $20, or the  Company may pay out the Contract Value in one (1) single lump-sum payment.    At the time of their commencement, Income Payments will not be less than those that would be  provided by the application of an equivalent amount to purchase a single premium immediate  annuity contract from the Company at purchase rates the Company offered on the Income Date  to annuitants in the same class as the Annuitant.    YOU MAY NOT TAKE WITHDRAWALS DURING ANY PERIOD THE COMPANY IS MAKING  PAYMENTS FOR AN ANNUITANT'S LIFETIME.    OPTION 1 - LIFE INCOME. A monthly payment for the Annuitant's lifetime. All payments end  upon the Annuitant's death. However, in the event of the Annuitant's death before the first  monthly payment, the Company will pay the amount allocated to this Income Option to You or, if  You are deceased, to Your Beneficiary. No MVA applies to Contract Value applied to Option 1.    OPTION 2 - JOINT AND SURVIVOR INCOME. A monthly payment for the longer of the  Annuitant's lifetime or that of a second person You designate. Upon the occasion of the first  person to die, monthly payments continue during the survivor's lifetime at either the full amount  previously payable or as a percentage (either one-half or two-thirds) of the full amount, as You  select at the time You elect the Income Option.    All payments end upon the death of the last surviving Annuitant. However, in the event of the  deaths of the Annuitant and the designated second person before the first monthly payment, the  Company will pay the amount allocated to this Income Option to You or, if You are deceased,  Your Beneficiary. No MVA applies to Contract Value applied to Option 2.  

 

  RILA287 20  INCOME PROVISIONS (CONT'D)    OPTION 3 - LIFE INCOME WITH 120 OR 240 MONTHLY PAYMENTS GUARANTEED. A  monthly payment for the Annuitant's lifetime with the guarantee that the Company will make no  fewer than 120 or 240 monthly payments to You. If the Owner is an entity, at the Annuitant's  death, if fewer than the guaranteed number of payments have been made, the remaining  guaranteed payments will be made to the Owner as previously scheduled. If the Owner is the  Annuitant, in the event You die before the Company makes the specified number of guaranteed  payments, Your Beneficiary may elect to continue to receive the Income Payments according to  the terms of this Contract, or alternatively may elect to receive the present value of any  remaining guaranteed payments in a single lump-sum payment. The present value of any  remaining guaranteed payments will be based on the total Income Payments as of the date of  the calculation. The Company will determine the interest rate used in this present value  calculation, but in no instance will it be greater than (one) 1 percentage point higher than the  rate used to calculate the initial Income Payment. No MVA applies to Contract Value applied to  Option 3.    OPTION 4 - INCOME FOR A SPECIFIED PERIOD. A monthly payment for any whole number  of years ranging from 5 to 30. In the event You die before the Company makes the specified  number of payments, Your Beneficiary may elect to continue to receive the Income Payments  according to the terms of this Contract, or alternatively may elect to receive the present value of  any remaining guaranteed payments in a single lump-sum payment. The present value of any  remaining guaranteed payments will be based on the total Income Payments as of the date of  the calculation. The Company will determine the interest rate used in this present value  calculation, but in no instance will it be greater than (one) 1 percentage point higher than the  rate used to calculate the initial Income Payment. No MVA applies to Contract Value applied to  payments spread over five (5) years or more under Option 4.    ADDITIONAL INCOME OPTIONS. The Company may make available other Income Options.    DEATH BENEFIT AMOUNT AFTER THE INCOME DATE. On or after the Income Date, upon  any Owner's death, any remaining Income Payments will be paid in accordance with the Income  Options of this Contract and will be paid at least as rapidly as the payment method in effect as  of the Owner's death.     OWNER'S DEATH AFTER THE INCOME DATE. Upon the death of any Owner who is not also  an Annuitant after the Income Date, any remaining Income Payments due will continue at least  as rapidly as the payment method in effect as of the date of the Owner's death. Upon the death  of the last surviving Joint Owner after the Income Date, any remaining Income Payments will be  paid to the Beneficiary.    ANNUITANT'S DEATH AFTER THE INCOME DATE. Upon the death of the Annuitant after the  Income Date, the death benefit, if any, will be as specified in the Income Option elected. Any  life-contingent Income Payments cease on the death of the Annuitant.  

 

  RILA287 21  INCOME PROVISIONS (CONT'D)    BENEFICIARY'S ENTITLEMENT TO INCOME PAYMENTS AFTER THE INCOME DATE.  Upon the death of any Owner, the Company will pay any remaining Income Payments due to  Primary Beneficiaries or, if none exist, to the Contingent Beneficiaries, in equal shares (the  "default allocation") unless You have designated otherwise (the "designated allocation"). A  Beneficiary that dies before or within ten (10) days (or different period as prescribed by  applicable law) of Your death is not entitled to remaining Income Payments due; in that  circumstance, the Company will pay any remaining Income Payments due the deceased  Beneficiary to surviving Beneficiaries in the same proportion as the designated allocation or, if  applicable, the default allocation. If no Beneficiary survives You, the Company will pay  remaining Income Payments to Your estate. 

 

  RILA287 22  TERMINATION PROVISIONS    This Contract terminates and all Contract benefits, will end on the earlier of:  1. the date You take a total withdrawal;  2. the date the Contract Value is reduced to zero for any reason, or;  3. the date upon which the Company receives Due Proof of Your (or any Joint Owner's) death  and all Beneficiaries' election of a death benefit payment option in Good Order at the  Company's Service Center, unless the Contract is continued by the spouse under the  Spousal Continuation Option.r28501-2104x07x21modifie

Linking/BIN/Brokerage Acct. Number (if applicable) Page 1 of 11 R285 01/21 Home Office:  Lansing, Michigan www.jackson.com ICC20 R280 11/20 Jackson   pre-assigned Contract Number (if applicable) APPLICATION FOR AN INDIVIDUAL SINGLE PREMIUM DEFERRED REGISTERED INDEX-LINKED ANNUITY (RILA285/RILA287) Primary Owner First Name Middle Name Last Name Non-Natural Owner/Entity Name (if applicable) Social Security Number Phone Number (include area code) Individual/Joint Corporation/Pension PlanCustodian Government Entity Tax ID Numberor Trust Physical Address Line 1 (No P.O. Boxes) Physical Address City State ZIP Mailing Address City State ZIP Physical Address Line 2 Mailing Address Line 1 Mailing Address Line 2 (mm/dd/yyyy)Date of Birth Email Address (print clearly) Country of Residence Sex Male FemaleU.S. Citizen Yes No JACKSON MARKET LINK PRO ADVISORY    (01/21)  SM Customer Care: 800-873-5654 Fax: 800-943-6761 Email: customercare@jackson.com First Class Mail: P.O. Box 30314 Lansing, MI 48909-7814 Overnight Mail: 1 Corporate Way Lansing, MI 48951 PLEASE PRINT  CLEARLY Please see the  Good Order  Checklist for  additional  requirements. Type of Ownership: If U.S. citizenship is not selected, and a Social Security Number with a U.S. address is listed, along with the absence of any other foreign indicator, Jackson National Life Insurance Company (Jackson) will assume an active U.S. citizenship status. 

 

Page 2 of 11 R285 01/21ICC20 R280 11/20 First Name Middle Name Last Name Relationship to Owner Social Security Number Phone Number (include area code) Physical Address Line 1 (No P.O. Boxes) Physical Address City State ZIP Physical Address Line 2 First Name Middle Name Last Name Social Security Number Physical Address Line 1 (No P.O. Boxes) Physical Address City State ZIP Physical Address Line 2 Date of Birth (mm/dd/yyyy) First Name Middle Name Last Name Relationship to Primary Annuitant Social Security Number Phone Number (include area code) Physical Address Line 1 (No P.O. Boxes) Physical Address City State ZIP Physical Address Line 2 Joint Owner Primary Annuitant Joint Annuitant Phone Number (include area code) (mm/dd/yyyy)Date of Birth Email Address (print clearly)Date of Birth (mm/dd/yyyy) Sex Male FemaleU.S. Citizen Yes No Country of Residence Sex Male FemaleU.S. Citizen Yes No Country of Residence Sex Male FemaleU.S. Citizen Yes No Country of Residence Joint Annuitant Not Applicable Complete this  section if  different than  Primary Owner.  If Primary  Annuitant  section is left  blank, the  Annuitant will  default to the  Primary Owner. Complete this  section if  different than  Joint Owner. If  Joint Annuitant  section is left  blank, the Joint  Annuitant will  default to the  Joint Owner. In the case of  Joint Owners,  all  correspondence  and required  documentation  will be sent to  the address of  the Primary  Owner. 

 

Page 3 of 11 R285 01/21ICC20 R280 11/20 Beneficiary(ies) Primary % Percentage of Death Benefit First Name Middle Name Last Name Non-Natural Owner/Entity Name (if applicable) Phone Number (include area code) Physical Address Line 1 (No P.O. Boxes) Physical Address City State ZIP Physical Address Line 2 Social Security/Tax ID Number Relationship to OwnerDate of Birth (mm/dd/yyyy) Primary % Percentage of Death Benefit First Name Middle Name Last Name Non-Natural Owner/Entity Name (if applicable) Phone Number (include area code) Physical Address Line 1 (No P.O. Boxes) Physical Address City State ZIP Physical Address Line 2 Social Security/Tax ID Number Relationship to OwnerDate of Birth (mm/dd/yyyy) Primary % Percentage of Death Benefit First Name Middle Name Last Name Non-Natural Owner/Entity Name (if applicable) Phone Number (include area code) Physical Address Line 1 (No P.O. Boxes) Physical Address City State ZIP Physical Address Line 2 Social Security/Tax ID Number Relationship to OwnerDate of Birth (mm/dd/yyyy) Contingent Contingent Sex Male Female Sex Male Female Sex Male Female It is required for  Good Order  that the Death  Benefit  Percentage be  whole  numbers and  must total  100% for each  beneficiary  type.  If Percentage of  Death Benefit is  left blank, all  beneficiaries  will receive  equal shares. Please use the  Beneficiary  Designation  Supplement  form X3041  for additional  beneficiaries. 

 

Page 4 of 11 R285 01/21ICC20 R280 11/20 Annuity Type Non-Tax Qualified Roth IRA* Other: SEP Roth Conversion *Tax Contribution Year(s) and Amounts: Year:                      $ IRA - Traditional* Stretch IRA Non-Qualified Stretch Year:                      $ 403(b) TSA  Premium Payment Statement Regarding Existing Policies or Annuity Contracts (Please select one) Select method of payment and note approximate amount: Anticipated total amount from internal transfer(s) Check Attached WireCheck In Transit Financial Professional or Owner (Jackson will NOT request funds) $ $ $ Anticipated total amount from external transfer(s) $ $ Company releasing funds Account number Full Partial Full Partial Maturity date Transfer type $ $ Anticipated transfer amount to be requested by Jackson Anticipated total amount from external transfer(s) $ to be requested by If Jackson is NOT requesting funds, please provide the following information: NoYes Are you replacing or changing an existing life insurance policy or annuity contract?  It is required for  Good Order  that this entire  section be  completed. COMPLETE  X0512  "REPLACEMENT  OF LIFE  INSURANCE OR  ANNUITIES"  WHERE  REQUIRED (must be dated  on or before  the Application  Sign Date to be  in Good Order). External  Transfers: The  Request for  Transfer or  Exchange of  Assets form  (X3783) must  be submitted if  Jackson is to  request the  release of  funds. For more than  two account  transfers,  please provide  account  information on  the Letter of  Instruction form  (X4250) and  submit with  application. Notice to Financial Professional: If the Applicant does have existing life insurance policies or annuity  contracts you must present and read to the Applicant the Replacement of Life Insurance or Annuities form  (X0512 - state variations apply) and return the notice, signed by both the Financial Professional and  Applicant, with the Application. I (We) do have existing life insurance  policies or annuity contracts. I (We) do not have existing life  insurance policies or annuity contracts. I (We) certify that with regard to Jackson or any other company:   The Registered  Index-Linked  Annuity  Automatic  Withdrawal Request form  (R4370) will be required if a  Stretch Annuity  Type is elected. We reserve the right to refuse a Premium payment that is comprised of multiple payments over a period of  time. If we permit you to make multiple payments as part of your Premium payment, the Contract will not  be issued until all such payments are received. We reserve the right to hold such multiple payments in a  non-interest bearing account until the Issue Date.  

 

Page 5 of 11 R285 01/21ICC20 R280 11/20 Contract Options 1-Year    %Index Account Options S&P 500   Index BUFFER 10% 20% Cap Performance Trigger Cap 6-Year    % Cap Performance Trigger Cap FLOOR 10% 20% 1-Year    %Index Account Options BUFFER 10% 20% Cap Performance Trigger Cap 6-Year    % Cap Performance Trigger Cap FLOOR 10% 20% Russell 2000   Index MSCI EAFE Index 1-Year    %Index Account Options BUFFER 10% 20% Cap Performance Trigger Cap 6-Year    % Cap Performance Trigger Cap FLOOR 10% 20% Tell us how  you want  your annuity  premium  invested.  Whole percentages only. TOTAL  ALLOCATION MUST EQUAL  100%. Certain  broker-dealers  may limit the  Index Account  Options and/or  Fixed Account  under the  Contract. Please  see Client  Acknowledg- ments on page  9. PLEASE NOTE: Contract Options are subject to availability. CONTRACT OPTIONS CONTINUED ON PAGE 6. 

 

Contract Options Page 6 of 11 R285 01/21ICC20 R280 11/20 (continued from page 5) Fixed Account Fixed Account 1-Year    % MSCI Emerging Markets Index MSCI KLD 400 Social Index 1-Year    %Index Account Options BUFFER 10% 20% Cap Performance Trigger Cap 6-Year    % Cap Performance Trigger Cap FLOOR 10% 20% 1-Year    %Index Account Options BUFFER 10% 20% Cap Performance Trigger Cap 6-Year    % Cap Performance Trigger Cap FLOOR 10% 20% Tell us how  you want  your annuity  premium  invested.  Whole percentages only. TOTAL  ALLOCATION MUST EQUAL  100%. Certain  broker-dealers  may limit the  Index Account  Options and/or  Fixed Account  under the  Contract. Please  see Client  Acknowledg- ments on page  9. PLEASE NOTE: Contract Options are subject to availability. 

 

Telephone/Electronic Information Authorization First Name Middle Name Last Name Social Security Number Date of Birth (mm/dd/yyyy) Telephone and written communicationTelephone communication Written communication Page 7 of 11 R285 01/21ICC20 R280 11/20 Telephone/Electronic Transaction Authorization Annuitization/Income Date Specify Income Date (mm/dd/yyyy) If you want to authorize an individual other than your Financial Professional to receive Contract information via  telephone and/or in writing, please provide that individual's information here. Select one option. This  authorization  is not extended  to Telephone/ Electronic  Transaction Authorization. If no election is  made, Jackson  will default to  " Telephone and written  communication." By checking "Yes," I (we) authorize Jackson to accept Contract Option changes via telephone, internet, or other  electronic medium from me (us) and my (our) Financial Professional, subject to Jackson's administrative procedures.  Do you consent to Telephone/Electronic Transfer Authorization?          Yes           No        Jackson has administrative procedures that are designed to provide reasonable assurances that telephone/electronic authorizations are genuine. If Jackson fails to employ such procedures, it may be held liable for losses resulting from a failure to use such procedures. I (We) release Jackson, its affiliates, subsidiaries, and agents from all  damages related in any way to its acting upon any unauthorized telephone/electronic instruction. I (We)  understand and agree that Jackson reserves the right to terminate or modify these telephone/electronic privileges  at any time, without cause and without notice to me (us). This  authorization  is not extended  to the  Telephone/ Electronic  Information  Authorization. If no election  is made,  Jackson will  default to  " No." If an Annuitization/Income Date is not specified, the  Company will default to the Latest Income Date as shown  in the Contract. 

 

Page 8 of 11 R285 01/21ICC20 R280 11/20 Electronic Delivery Authorization Do you consent to electronic delivery of documents? Yes No Transaction confirmations Other Contract-related correspondence ALL DOCUMENTS Contract and prospectus Disclosure documents Annual statements If no election is  made, Jackson  will default to  " No." Check the box(es) next to the types of documents you wish to receive electronically. If electronic delivery is  authorized, but no document type is selected, the selection will default to "All Documents." Please provide  one email  address and  print clearly. If you authorize  electronic  delivery but do  not provide an   email address  or the address  is illegible,  electronic  delivery  will  not be initiated. Authorizing   electronic  delivery of  annual  statements will  automatically  enroll you to  receive  quarterly  summaries.  Quarterly  summaries are  only available  via electronic  delivery. Registration at  Jackson.com is  required for  electronic  delivery of  documents. My email address is:                                                                                                                                                I (We) will notify the company of any new email address. Jackson offers the ability to receive documents via electronic delivery (e-delivery). This disclosure will help you  decide whether you would like to consent to e-delivery. If you do not consent to e-delivery, you will continue to  receive documents via physical mail. Please read this carefully and in its entirety. If you consent, Jackson will provide documents related to your Contract by e-delivery. Jackson will provide  documents via e-delivery as long as it is consistent with applicable state and federal law, delivery preferences are  updated, and the Contract is still active. For security purposes, if your jackson.com account is not accessed within  18 months, we may remove your registration and change your delivery method to physical mail. Any document  that we send by e-delivery, which complies with applicable law, will have the same force and effect as if that  document were sent in a paper form.  This consent covers all electronic documents and communications as related to any eligible* Contract(s) through  the Company, which may include, but are not limited to, applications, supplements, Contract delivery notices,  Contracts, prospectuses, prospectus supplements, statements of additional information, annual and semiannual  reports, confirmation statements, annual or quarterly statements, and any Contract-related correspondence  including claims and servicing correspondence. You may continue to receive some paper documents for compliance  reasons. When additional document types are available, they will be sent via e-delivery automatically if consent was  previously provided.  Please note election for electronic tax documents must be completed once you log onto your account on  Jackson.com. The Company will notify you of the availability of your document(s) by email or attach your document(s) within the  email. Jackson will not charge a fee for this service. Please make sure a current email address is provided and  update your profile on jackson.com if your email address changes. Please login to your Contract on jackson.com  and access your Client Filing Cabinet to view your document(s) or click the link that will be provided in the email  notification in order to view the material.  To successfully receive electronic transmissions, your electronic device must have Internet access, an active email  account, Adobe Acrobat Reader, and pop-up blockers turned off. Please note some Internet browsers may not  function well with jackson.com. If a browser error occurs, use a different Internet browser. If you do not already  have Adobe Acrobat Reader, it can be downloaded for free from www.adobe.com.  Paper copies of documents may be requested by calling the Service Center, whether or not you consent or revoke  your consent for e-delivery, at any time for no additional charge. Consent can be revoked by updating your  preferences on jackson.com or by calling the Service Center. If you choose to enroll in e-delivery, you consent to the terms outlined above for electronic transmissions.  *Eligible refers to Contracts that are currently inforce or that will be inforce and are available for electronic transmission.  

 

Client Acknowledgments ICC20 R280 11/20 Page 9 of 11 R285 01/21 Notice to Applicant 1. I (We) hereby represent to the best of my (our) knowledge and belief that each of the statements and  answers contained in this application are true, complete and correctly recorded. 2. I (We) certify that the Social Security or Taxpayer Identification number(s) shown above is (are) correct. 3. I (We) certify that the date of birth of the Owner and any Joint Owner, primary spousal Beneficiary, Annuitant  or Joint Annuitant, if applicable, stated in this application is (are) true and correctly recorded. 4. I (We) hereby represent to the best of my (our) knowledge and belief that I have made an informed decision  to purchase this product and, if applicable, have reviewed the differences between this product and my  original product. The product fits  my investment needs and objectives, liquidity needs, time horizon, risk  tolerance and my (our) general financial situation.  5. I understand the restrictions imposed by 403(b)(11) of the Internal Revenue Code. I understand the  investment alternatives available under my employer's 403(b) plan, to which I may elect to transfer my  contract value. 6. I (We) understand that while the values of the Contract may be affected by an external Index, the Contract  does not participate in any stock or equity investment. 7. I (We) understand that the capping component in this Contract may limit the Index Adjustment credited to  the Index Account Option Value on each Index Account Option Term Anniversary, regardless of the  performance of the Indices. 8. I (We) have received the applicable current Buffers/Floors, Caps/Rates and any other Index Adjustment Factors  associated with this Contract. 9. I (We) understand that to the extent I (we) have been permitted to make a Premium payment comprised of  multiple payments over a period of time, my (our) Contract will not be issued until all such payments are  received, and all Premium payments will be held in a non-interest bearing account until the date my (our)  Contract is issued.  10. I (We) have been given a current prospectus for this registered index-linked annuity product. 11. I (We) understand that Jackson issues other annuities with similar features, limitations, minimum Caps/Rates  and charges. I (We) have discussed the alternatives with my (our) Financial Professional, including that similar  products with higher or lower Caps/Rates may be available through other broker-dealers. 12. I (We) understand that allocations to the Index Account Options, with certain exceptions, are subject to  a Market Value Adjustment if withdrawn, annuitized, or transferred to the Fixed Account which may reduce amounts paid, annuitized, or transferred. (Only applicable to Contracts with a Market Value Adjustment.) 13. I (We) understand that the product being applied for is a registered index-linked annuity product. 14. I acknowledge and represent that I have executed this application, and that my signature below (including  my electronic signature) is my true and valid signature. I further authorize Jackson to accept any electronic  signature that I may make to this application. 15. I (We) understand that certain broker-dealers may limit the Contract Options available under the Contract. I  (We) have discussed these limitations with my (our) financial professional and have been provided with a list  of Contract Options currently available for election through my (our) broker-dealer.  I (We) understand that  any application including an election of a Contract Option not available through my (our) broker-dealer will  not be accepted. I (We) understand that the Contract Options not available through my (our) broker-dealer  may be available through other broker-dealers. Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal  offense and subject to penalties under state law. 

 

Page 10 of 11 R285 01/21ICC20 R280 11/20 Owner's Signature Date Signed (mm/dd/yyyy) State where signed Owner's Title (required if owned by an Entity) Date Signed (mm/dd/yyyy)Joint Owner's Signature Date Signed (mm/dd/yyyy) Date Signed (mm/dd/yyyy) Annuitant's Signature (if other than Owner) Joint Annuitant's Signature (if other than Joint Owner) Client Signatures State where signed U.S. Tax Certifications Check this box if the IRS has notified you that you are subject to backup withholding.  Not FDIC/NCUA Insured    Not Bank/CU guaranteed    May lose value Not a deposit    Not insured by any federal agency It is required for  Good Order  that all  applicable  parties to the  Contract sign  here. Required  replacement  forms must be  signed on or  before the  application  signature  date. Under penalties of perjury, I certify that: 1. My Social Security Number or Tax ID Number shown on this application is my correct taxpayer  identification number,  2. I am not subject to backup withholding,  3. I am a U.S. citizen or other U.S. person (including a U.S. resident alien), and 4. I am exempt from Foreign Account Tax Compliance Act (FATCA) reporting.  For items 3 and 4, if I am not a U.S. citizen, U.S. resident alien or other U.S. person, I am submitting the  applicable IRS Form W-8 to certify my foreign status and, if applicable, claim treaty benefits.  The Internal Revenue Service does not require your consent to any provision of this document other than  the certifications to avoid backup withholding. 

 

Financial Professional Acknowledgments I did not use sales material(s) during the presentation of this Jackson product to the applicant. I used only Jackson-approved sales material(s) during the presentation of this Jackson product to the applicant. In addition, copies of all approved sales material(s) used during the presentation were left with the applicant. ICC20 R280 11/20 Page 11 of 11 R285 01/21 Financial Professional # 1 Signature Date Signed(mm/dd/yyyy) First Name Middle Name Last Name Email Address Business Phone Number (include area code) Jackson Assigned ID Financial Professional Name # 2 Financial Professional Name # 3 Jackson Assigned ID Jackson Assigned ID (print clearly) Extension Financial Professional Name # 4 Jackson Assigned ID I certify that: Complete this  certification  regarding sales  material section  only if:   Your client  has other  existing policies  or annuity  contracts AND  Will be either  terminating any  of those  existing policies  or using the  funds from  existing policies  to fund this  new Contract.  By signing this form, I certify that: 1. I am authorized and qualified to discuss the Contract herein applied for. 2. I have reviewed all of the client's information, and I believe that my recommendation to purchase this annuity is  in line with the client's financial situation and investment needs, and meets the appropriate standard of care (i.e.  suitability or best interest) based on the facts disclosed to said client. I also attest that I have provided the client  with all pertinent information about the product, including disclosure of risks involved, allowing the client to  make an educated and informed decision about this purchase. Based on my completion of the required general  annuity and/or Jackson product training, I believe this transaction is suitable and in the best interest of the client  given the client's financial situation and needs. 3. The applicable current Buffers/Floors, Caps/Rates and any other Index Adjustment Factors associated with this  Contract have been presented and explained to the Owner(s).  4. I have not made statements that differ from this material nor have I made any promises about the expected  future Index Account Option values of this Contract. 5. I have read Jackson's Position With Respect to the Acceptability of Replacements (XADV5790) and ensure that  this replacement (if applicable) is consistent with that position. 6. The applicant's Statement Regarding Existing Policies or Annuity Contracts has been answered correctly to the  best of my knowledge and belief. 7. The applicant's statement as to whether or not an existing life insurance policy or annuity contract is being  replaced is true and accurate to the best of my knowledge and belief. 8. I have discussed all applicable limitations to Contract Options availability with the applicant and have provided  the applicant with a list of Contract Options currently available for election.   If more than one Financial Professional is participating on this case, please provide the additional Financial  Professional names and Jackson Assigned IDs for each. All Financial  Professional  certifications,  licenses and  trainings must  be completed  prior to  application  execution.

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