Document:

exv4wxayxiiiy

Exhibit 4(a)(iii)

	 				
	
	 	Life Insurance Company (U.S.A.)
	 	[Bloomfield Hills, Michigan]1

	 	 	 

	CONTRACTHOLDER

	 	[Financial Institution]
	 
	 	 
	CONTRACT NUMBER

	 	[12345]

GROUP ANNUITY

The John Hancock Life Insurance Company (U.S.A.) (“the Company”, “we”, “our”) agrees, subject to
the conditions and provisions of the certificate, to provide the benefits, rights and privileges as
stated in the certificate. A certificate evidencing participation under this contract will be
issued to each member of the eligible group from which we received the required premium
contribution.

This contract is issued in consideration of the master application for this contract.

Signed for the Company at Boston, Massachusetts:

	 	 	 	 	 

	
	 	 	 	
	President
	 	 	 	Secretary

Group Annuity

Nonparticipating — Not eligible for dividends

Administrative Office

[601 Congress Street

Boston, Massachusetts 02210]

					
	 	 	 	 	 
	09GRPMAST
	 	 
	 	GP0101

 

 

Contract Provisions

Section

1. Eligibility/Cessation of Participation

2. Certificates

3. Incorporation

4. Termination

			
	 	 	 
	
	 	GP0201

2

 

1. ELIGIBILITY/CESSATION OF PARTICIPATION

A person who is a customer of the contractholder to which this contract is issued may become a
Certificate Owner upon Our approval and receipt of the required premium contribution.

2. CERTIFICATES

We will issue an individual certificate to each Certificate Owner. The certificate will state the
terms, conditions, and benefits of this contract. We may credit interest to Certificate Owners at
rates that vary by certificate issue date, premium amount, or eligible class.

3. INCORPORATION

A sample certificate attached hereto is made a part of this contract. Any provisions of this
contract which are inconsistent with provisions of the certificate are waived and superseded by the
certificate provisions.

4. TERMINATION

This contract will terminate when the contractholder requests termination in writing to us or when
no Certificate Owners hold any certificate issued under this contract.

Any certificates in force when the contract terminates will continue to be in force in accordance
with our administrative rules in effect, until terminated by the Certificate Owner.

			
	 	 	 
	 
	 	GP0301

3exv4wxayxivy

Exhibit 4(a)(iv)

			
	 	 	 
	JOHN HANCOCK LIFE INSURANCE COMPANY

(U.S.A.) 

Bloomfield Hills, Michigan
	 	

	 	 	 

	Overnight Mailing Address:

	 	Annuity Service Office:
	[164 Corporate Drive

	 	[P.O. Box 9505
	Portsmouth, NH 03801-6815]

	 	Portsmouth, NH 03802-9505
	 

	 	For Inquiries or Assistance in
	 

	 	Resolving Complaints:
	 

	 	1-800-344-1029
	 

	 	www.jhannuities.com]

This is a legal Certificate — read it carefully.

We agree to pay the benefits of this Certificate in accordance with its terms.

This Certificate is issued in consideration of the Payment.

John Hancock Life Insurance Company (U.S.A.) (“the Company”) will pay an annuity benefit commencing
on the Maturity Date to the Payee as directed by the Owner, in accordance with the Annuity Payments
provision of this Certificate. Unless another available option under this Certificate is elected,
Annuity Payments will be payable for a period of 10 years and as long thereafter as the Annuitant
lives. If the Owner dies while this Certificate is in effect prior to the Maturity Date, we will
pay a Death Benefit to the Beneficiary upon receipt of all required claim forms and proof of death
of the Owner at the Annuity Service Office.

FIFTEEN DAY RIGHT TO REVIEW

The Owner may cancel the Certificate by returning it to our Annuity Service Office or the agent at
any time within 15 days after receipt of the Certificate. Within 7 days of receipt of the
Certificate by us, we will pay the Account Value to the Owner, adjusted by any Market Value
Adjustment, if applicable, computed on the Date the Certificate is received by us. The Market Value
Adjustment will only be applied where the change in the Guaranteed Margin, as determined in
accordance with the formula in the Specifications Page, is greater than or equal to 0.25%. If the
purchase of this Certificate involves the replacement of any existing life insurance or annuity,
then the right to review provision is extended to 30 days.

When the Certificate is issued as an individual retirement annuity under Section 408 or Section
408A of the Code, or as otherwise required by applicable law, during the first 7 days of the Right
to Review period, we will return the amount equal to the Payment made for the Certificate, if
greater than the Account Value described above.

We hold reserves for our guarantees under this Certificate in a non-unitized [CPI MVA]
Separate Account established within the General Account. The assets of the [CPI MVA]
Separate Account are subject to the liabilities that arise out of the other business that we
conduct. General Account assets are also available to meet the guarantees under this Certificate as
well as our other general obligations.

Signed for us at Boston, Massachusetts, on the Certificate Date.

	 	 	 

	[]	 	[]
	President	 	Secretary

SINGLE PREMIUM MODIFIED GUARANTEE INFLATION INDEXED DEFERRED ANNUITY

NON-PARTICIPATING

AMOUNTS PAYABLE UNDER THIS CERTIFICATE MAY BE SUBJECT TO AN UPWARD OR DOWNWARD MARKET VALUE
ADJUSTMENT (SEE PART 6, PAGE 7 and Specifications Page S.2). AMOUNTS WITHDRAWN UNDER THIS
CERTIFICATE MAY BE SUBJECT TO AN EARLY WITHDRAWAL CHARGE (SEE PART 8, PAGE 8 and Specifications
Page S.3). THIS CERTIFICATE MAY CONTAIN A BENEFIT THAT WAIVES WITHDRAWAL CHARGES.

10MVAGRP-CPI.1

 

 

INTRODUCTION

This is a Single Payment Modified Guarantee Inflation Indexed Deferred Annuity. It is effective
when we receive your Payment at our Annuity Service Office or such other place as we may designate.
We determine Account Value during the first year of the Initial Term based on the Payment and the
Declared Interest Rate as shown on the Specifications Page. We determine Account Value during the
first year of any Subsequent Term based on the Account Value upon the completion of the previous
Term and the new Declared Interest Rate for that Subsequent Term. After the first year of the
Initial Term or the first year of any Subsequent Term, and prior to the Maturity Date while you are
still living, the Account Value will accumulate based on the Indexed Crediting Rate, which is a
rate (as described in Part 7) that we determine based on: 1) the year over year change in the All
Items Consumer Price Index for All Urban Consumers (“CPI-U”) for the U.S. City Average, plus 2) the
Guaranteed Margin. Amounts withdrawn, excluding the Free Withdrawal Amount, prior to the end of any
Term are subject to a Market Value Adjustment and Withdrawal Charges, which could reduce the
withdrawal amount and any remaining Account Value below the Payment.

You must allocate the Payment to one Initial Term.

On the Maturity Date, if the Annuitant and Owner are still living, the Certificate will provide for
Annuity Payments to the Payee based upon the Annuity Option selected. Fixed annuity dollar amounts
are guaranteed by the Company.

	 	 	 	 	 
	TABLE OF CONTENTS	 	PAGE
	 
	PART 1 - DEFINITIONS
	 	 	3	 
	 
	PART 2 - GENERAL PROVISIONS
	 	 	5	 
	 
	PART 3 - OWNER, BENEFICIARY
	 	 	6	 
	 
	PART 4 - PAYMENT
	 	 	7	 
	 
	PART 5 - INITIAL AND SUBSEQUENT TERM
	 	 	7	 
	 
	PART 6 - MARKET VALUE ADJUSTMENT (MVA)
	 	 	7	 
	 
	PART 7 - INTEREST ON ACCOUNT VALUE
	 	 	8	 
	 
	PART 8 - WITHDRAWAL(S)
	 	 	8	 
	 
	PART 9 - FEES AND DEDUCTIONS
	 	 	9	 
	 
	PART 10 - DEATH BENEFITS
	 	 	9	 
	 
	PART 11 - ANNUITY PAYMENTS
	 	 	10	 

10MVAGRP-CPI.1

 

 

PART 1: DEFINITIONS

	 	 	 

	WE AND YOU

	 	“We”, “us” and “our” means the Company. “You” or “your” means the
Owner of this Certificate.
	 
	 	 
	ACCOUNT VALUE

	 	The amount we hold under this Certificate for you at any given time.
On the Certificate Date, the Account Value is equal to the Payment.
Thereafter, we determine the Account Value as specified in the
Certificate, “Part 7: Interest on Account Value.”
	 
	 	 
	ANNUITANT

	 	Any individual person or persons whose life is used to determine the
duration of Annuity Payments involving life contingencies. The
Annuitant is as designated on the Specifications Page, unless changed
prior to the Maturity Date.
	 
	 	 
	ANNUITY OPTION

	 	The method selected by you for Annuity Payments made by us.
	 
	 	 
	ANNUITY PAYMENT(S)

	 	Periodic payment(s) by us to you or your designated Payee, which
generally commence on or after the Maturity Date and are in
accordance with the Annuity Option elected under the terms of this
Certificate.
	 
	 	 
	ANNUITY SERVICE OFFICE

	 	Any office designated by us for the receipt of Payment and processing
of Owner requests. The Annuity Service Office is shown on the
Certificate Cover Page.
	 
	 	 
	BENEFICIARY

	 	The person, persons or entity to whom certain benefits are payable
following the death of an Owner, or if the Owner is a non natural
person, an Annuitant.
	 
	 	 
	CERTIFICATE ANNIVERSARY

	 	The anniversary of the Certificate beginning twelve consecutive
months from the Certificate Date and each year thereafter.
	 
	 	 
	CERTIFICATE DATE

	 	The date of issue of this Certificate as designated on the Specifications
Page.
	 
	 	 
	CERTIFICATE YEAR

	 	The period of time measured twelve consecutive months from the
Certificate Date or any Certificate Anniversary thereafter.
	 
	 	 
	CONTINGENT BENEFICIARY

	 	The person, persons or entity, who becomes the Beneficiary if the
Beneficiary is not alive when a benefit is due and payable.
	 
	 	 
	[CPI MVA] SEPARATE ACCOUNT

	 	A non-registered separate account that we established within the
General Account and in which we hold reserves for our guarantees
under the Certificate. Our other General Account assets are also
available to meet the guarantees under the Certificate and our other
general obligations. The assets of the [CPI MVA] Separate Account
are subject to the liabilities that arise out of the other business that we
conduct.
	 
	 	 
	CPI-U

	 	As used in this Certificate, the CPI-U is referring to the broadest and
most comprehensive CPI-U which is called the All Items Consumer
Price Index for All Urban Consumers (CPI-U) for the U.S. City
Average. It is published monthly by the Department of Labor and
reflects spending patterns of almost all residents of urban or
metropolitan areas. If this index is discontinued or if the calculation is
changed substantially the Company may substitute a comparable
index.
	 
	 	 
	DECLARED INTEREST RATE

	 	The interest credited on any given day will be at a rate that, if
compounded daily for one year, would equal the rate we declare for
the first year of any selected Term under the terms of the Certificate,
as shown on the Specifications Page of the Certificate.

			
	 	 	 
	10MVAGRP-CPI.1
	 	 

Page 3

 

	 	 	 

	ENDORSEMENT

	 	An Endorsement modifies the Certificate to which it is attached.
Endorsements must be signed by an officer of the Company in order to
be effective.
	 
	 	 
	FLOOR RATE

	 	The minimum rate of interest the Company will credit to the Certificate
regardless of the year-over-year movement in the CPI-U. The Floor
Rate applicable to you will appear on the Specifications Page.
	 
	 	 
	FREE WITHDRAWAL AMOUNT

	 	The amount of the Account Value not subject to withdrawal charges or
a MVA as described in Part 8.
	 
	 	 
	GENERAL ACCOUNT

	 	All of the Company’s assets, other than the assets in segregated asset
accounts, which are maintained as “insulated” separate accounts
under applicable law.
	 
	 	 
	GROSS WITHDRAWAL AMOUNT

	 	The amount deducted from the Account Value for a full or partial
withdrawal. For a full withdrawal such amount is the Account Value.
For a partial withdrawal, the Gross Withdrawal Amount is the amount
you request plus any applicable Withdrawal Charge and adjusted by
any applicable Market Value Adjustment.
	 
	 	 
	GUARANTEED MARGIN

	 	A rate that is used to determine the Indexed Crediting Rate and the
Market Value Adjustment factor. This rate remains constant for the
Term. This rate will be shown on the Specifications Page of the
Certificate.
	 
	 	 
	INDEXED CREDITING RATE

	 	The crediting rate that is based on annual changes in the CPI-U
adjusted by the Guaranteed Margin which starts in the second year of
each Term. If the crediting rate is limited, the limit(s) will be noted in
the Specifications Page.
	 
	 	 
	IN WRITING

	 	Unless otherwise stated, means a notice provided in a format
acceptable to us based on the type of request, which is received at
our Annuity Servicing Office.
	 
	 	 
	INTERNAL REVENUE CODE (CODE)

	 	The Internal Revenue Code of 1986, as amended from time to time,
and any successor statute of similar purposes.
	 
	 	 
	INITIAL TERM

	 	The period of time that you select on the application form, beginning on
the Certificate Date. The Initial Term continues for the period shown
on the Specifications Page of the Certificate.
	 
	 	 
	MATURITY DATE

	 	The date on which Annuity Payments are scheduled to commence. It
is the date specified on the Specifications Page, unless changed.
	 
	 	 
	OWNER(S)

	 	The person, persons or entity entitled to the ownership rights under
this Certificate. The Owner is as designated on the Specifications
Page, unless changed.
	 
	 	 
	PAYEE

	 	Any of the person(s) or entity to whom Annuity Payments are to be
made.
	 
	 	 
	PAYMENT

	 	An amount paid to us by you that we accept as consideration for the
benefits provided by this Certificate. The Payment may consist of
multiple components that we might receive on different dates if your
purchase is part of a tax-free exchange pursuant to Code Section 1035
or a trustee-to-trustee transfer of Qualified Plan funds. The single
Payment may only be received by us within the first sixty days from the
Certificate Date.
	 
	 	 
	QUALIFIED CERTIFICATE

	 	A Certificate issued under a Qualified Plan.
	 
	 	 
	QUALIFIED PLAN

	 	A retirement plan, which receives favorable tax treatment under
sections 401, 403, 408, 408A, 414 or 457, of the Internal Revenue
Code of 1986, as amended.

			
	 	 	 
	10MVAGRP-CPI.1
	 	 

Page 4

 

	 	 	 

	RATE CAP

	 	The maximum Indexed Crediting Rate we will credit to the Certificate
regardless of the year-over-year movement in the CPI-U. The Rate
Cap may vary by Term and premium band. The Rate Cap, if
applicable, will appear on the Specifications Page.
	 
	 	 
	SUBSEQUENT TERM

	 	A period of time beginning on the day following expiry of the
immediately preceding Term.
	 
	 	 
	TERM

	 	The Initial Term or a Subsequent Term.

PART 2: GENERAL PROVISIONS

ENTIRE CERTIFICATE

This Certificate is an agreement between the Owner(s) and the Company. The entire Certificate
consists of this Certificate, any Riders, Endorsements, and Specifications Pages. This Certificate
is incontestable from its Certificate Date.

The benefits and values available under this Certificate are not less than the minimum required by
any statute of the state in which this Certificate is delivered. We have filed a detailed statement
of the method used to calculate the benefits and values with the Department of Insurance in the
state in which this Certificate is delivered, if required by law.

You may also have access to (i) information for you or a member of your family, regarding elder
care needs and questions, either directly or through a third party arrangement, and (ii) assistance
that may help you identify various elder care service agencies available in your community.

MODIFICATION

Only the President, a Vice President, or the Secretary of the Company has authority to agree on our
behalf to any alteration of the Certificate or to any waiver of our rights or requirements. The
alteration or waiver must be in writing. We will not change or modify this Certificate without your
consent except as may be required to make it conform to any applicable law or regulation or any
ruling issued by a government agency; or unless we have reserved the right to change the terms
herein.

CHANGE IN MATURITY DATE

Prior to the Maturity Date, an Owner may request in writing a change of the Maturity Date. Any
extension of the Maturity Date will be subject to our approval.

ASSIGNMENT

You may assign this Certificate, except as otherwise provided, at any time prior to the Maturity
Date. Your interest, any interest of the Annuitant and of any revocable Beneficiary shall be
subject to the terms of the assignment. We will not be on notice of any assignment unless it is in
writing. An assignment, unless otherwise specified by the Owner, shall take effect on the date the
notice of assignment is signed, subject to any payments made or actions taken by the Company prior
to receipt of this notice. We will not be liable for any payments made or actions we take before
the assignment is accepted by us. An absolute assignment will revoke the interest of any revocable
Beneficiary. We assume no responsibility for the validity or sufficiency of any assignment.

If this Certificate is issued to a Qualified Plan, this Certificate is subject to assignment
restrictions for federal income tax purposes. In such event, this Certificate shall not be sold,
assigned, discounted, or
pledged as collateral for a loan or as security for the performance of an obligation or for any
other purpose, to any person other than us.

CLAIMS OF CREDITORS

All benefits and payments under this Certificate shall be exempt from the claims of creditors of
the Certificate Owner to the extent permitted by law.

			
	 	 	 
	10MVAGRP-CPI.1
	 	 

Page 5

 

MISSTATEMENT AND PROOF OF AGE, SEX OR SURVIVAL

We may require proof of age, sex or survival of any person upon whose age, sex or survival an
Annuity Payment depends. If the age or sex of the Annuitant has been misstated, the benefits will
be those which the Annuity Payment would have provided for the correct age and sex. If we have made
incorrect Annuity Payments, the amount of any underpayment will be paid immediately. The amount of
any overpayment will be deducted from future Annuity Payments. We will uniformly charge or credit
interest in accordance with state law, as applicable.

NON-PARTICIPATING

Your Certificate is non-participating and will not share in our profits or surplus earnings. We
will pay no dividends on your Certificate.

CANCELLATION FOR MINIMUM ACCOUNT VALUE

If, as a result of any partial withdrawal, the Account Value would be reduced to less than the
Minimum Account Value, indicated on the Specifications Page, we may cancel this Certificate and pay
you the amount equal to that which would be paid as a result of a Total Withdrawal, as described in
Part 8, “Withdrawals”.

REPORTS

We will send you a report at least annually. The report will at least contain a notification of the
Account Value prior to the application of any MVA formula, and the MVA amount used to determine the
cash surrender value.

CURRENCY AND PLACE OF PAYMENTS

All payments made to or by us shall be made in the lawful currency of the United States of America
at the Annuity Service Office or elsewhere if we consent.

NOTICES AND ELECTIONS

To be effective, all notices and elections you make under this Certificate must be in writing,
signed by you and received by us at the Annuity Service Office. Unless otherwise provided in this
Certificate, all notices, requests and elections will be effective when received by us at our
Annuity Service Office, complete with all necessary information and your signature.

ISSUE STATE

This Certificate will be governed by the laws of the jurisdiction indicated on the Specifications
Page.

SECTION 72(s)

The provisions of this Certificate shall be interpreted so as to comply with the requirements of
Section 72(s) of the Internal Revenue Code.

PART 3: OWNER, BENEFICIARY

OWNER

The Owner of this Certificate shall be the person, persons or entity designated on the
Specifications Page unless otherwise changed by you in writing. If amounts become payable to the
Beneficiary under this Certificate, the Beneficiary becomes the Owner of this Certificate.

			
	 	 	 
	10MVAGRP-CPI.1
	 	 

Page 6

 

BENEFICIARY

Upon the death of the Owner, any surviving Owner will become the Beneficiary. If there is no
surviving Owner, the Beneficiary will be as designated on the Specifications Page, unless otherwise
changed during the Owner’s lifetime. If no such Beneficiary is living, the Beneficiary is the
“Contingent Beneficiary”. If no Beneficiary or Contingent Beneficiary is living, the Beneficiary is
the estate of the deceased Owner.

CHANGE OF OWNER, ANNUITANT, BENEFICIARY

Subject to the rights of an irrevocable Beneficiary, you may request to change the Owner,
Annuitant, or Beneficiary by sending us notice in writing. Any such request must be received at our
Annuity Service Office and approved by us. If we approved a change of Beneficiary, it will take
effect on the date the request is signed. If an irrevocable Beneficiary is named in this
Certificate, the Beneficiary cannot be changed without the consent of the irrevocable Beneficiary.
If we approve a change of Owner or Annuitant, it will take effect on the date we received the
request at the Annuity Service Office. The Annuitant may not be changed after the Maturity Date.
You need not send us the Certificate unless we request it. We will not be liable for any payments
or actions we take before we approve the change.

If any Annuitant is changed and any Owner is not an individual, the entire interest in the
Certificate must be distributed to the Owner within five years of the change.

PART 4: PAYMENT

The Certificate is not effective until Payment is received by us at our Annuity Service Office
or such other place as we may designate. The Payment deposited into the Certificate can not be less
than the Minimum Payment nor exceed the Maximum Payment shown on the Specifications Page. Upon
request, we will consider applying nondiscriminatory financial factors waiving the Payment limits.

ALLOCATION OF PAYMENT

When we receive the Payment, it will be allocated to the Initial Term as shown on the
Specifications Page.

PART 5: INITIAL AND SUBSEQUENT TERM

TERM

The Term means the Initial Term or the Subsequent Term. We allocate the Payment to the Initial Term
elected as shown on the Specifications Page. Thereafter, any allocation of your Account Value will
be in a Subsequent Term then available under this Certificate. The Initial Term is measured from
the Certificate Date. All Subsequent Terms are measured from the first day following the last day
of the immediately preceding Term.

SUBSEQUENT TERM

At the end of your Initial Term you may elect a Subsequent Term. You will have a period of 30 days
commencing with the expiration of a Term to elect in writing a Subsequent Term from among those
that are available. At least 15 days, but not more than 45 days prior to the expiration of the
Initial Term and any Subsequent Term, we will provide you with a written notice of the expiry of
the Term and notice of the Subsequent Terms available. Unless we receive written instructions from
you selecting a Subsequent Term from those then available, upon expiration of any Term, your
Account Value will be placed in the shortest available Term. Any Subsequent Term will begin the day
after the expiration of the immediately preceding Term. We do not subject your Account Value to a
Market Value Adjustment when it is applied to a Subsequent Term. Once the Subsequent Term has been
in effect for 30 days, the MVA formula may be applicable to any withdrawal.

If your Subsequent Term extends beyond the Maturity Date shown on the Specifications Page, your
Maturity Date will be extended to the last day of that Subsequent Term. In no event will you be
permitted to elect a Subsequent Term longer than the shortest Term ending on or after the Maximum
Maturity Date shown on the Specifications Page.

			
	 	 	 
	10MVAGRP-CPI.1
	 	 

Page 7

 

PART 6: MARKET VALUE ADJUSTMENT (MVA)

Any amounts withdrawn or converted to Annuity Payments on any date other than the period 30
days after the expiration of a Term may be adjusted upward or downward by the application of a
Market Value Adjustment Factor described in the Specifications Page.

The operation of the Market Value Adjustment factor upon withdrawal is set forth in Part 8,
“Withdrawals.”

PART 7: INTEREST ON ACCOUNT VALUE

In the first year of each Term only, the credited interest rate received on the Certificate
will be the Declared Interest Rate that is not linked to the CPI-U. The interest credited on any
given day will be at a rate that, if compounded daily for one year, would equal the Declared
Interest Rate as determined by us, as shown on the Specifications Page. Beginning on the first
Certificate Anniversary within the Initial Term, and repeating on each first Certificate
Anniversary within any Subsequent Term, the Indexed Crediting Rate will be linked to the CPI-U and
will be adjusted (upward or downward) by the Guaranteed Margin. The Indexed Crediting Rate will be
reset annually, at each Certificate Anniversary. We will look back to the CPI-U value published
three months earlier than the Certificate Anniversary to calculate the Indexed Crediting Rate.

The formula is shown in the Specifications Page.

PART 8: WITHDRAWALS

You may withdraw part or all of the Account Value at any time before the earlier of the death
of an Owner, or Annuitant if the Owner is a non natural person, or the Maturity Date by sending us
a notice in writing.

We will not defer payment more than six months beyond the date we receive such notice. If we defer
payment for more than 30 days, the amount deferred will earn interest at a rate not less than the
minimum required by law.

FREE WITHDRAWAL AMOUNT

The Free Withdrawal Amount will equal the greater of; a) the annual Required Minimum
Distribution amount for Owners of Qualified Certificates aged 70 1/2 or more; or b) the amount of any
interest credited to the Account Value during the 12 months prior to the date of your request, less
any Gross Withdrawal Amount(s) taken during this 12 month period.

30 DAY WINDOW

We will not apply a Market Value Adjustment factor or assess Withdrawal Charges if you request a
withdrawal or annuitize any amount during the 30 day period after the expiration of any Term. We
must receive your written request for withdrawal after the end of a Term and during the 30 day
period following the end of that Term.

WITHDRAWAL CHARGE

If a withdrawal is made from the Certificate prior to the Maturity Date, a Withdrawal Charge
may be assessed against the portion of the Account Value being withdrawn. The amount of the
Withdrawal Charge and when it is assessed is discussed below

	 	1)	 	The Free Withdrawal Amount is defined above and may be withdrawn free of a Withdrawal
Charge and is not subject to a Market Value Adjustment.
	 
	 	2)	 	Any amounts withdrawn in excess of the Free Withdrawal Amount will be subject to a
Withdrawal Charge, if any. The Withdrawal Charge is determined by multiplying the Gross
Withdrawal Amount, less any annual administration fee and Free Withdrawal Amount, by the
applicable Withdrawal Charge percentage shown on the Specifications Page.

			
	 	 	 
	10MVAGRP-CPI.1
	 	 

Page 8

 

	 	3)	 	No Withdrawal Charge will apply to withdrawals made at the end of a Term as
described in “Part 5: Initial Term and Subsequent Term”. A request for withdrawal at
the end of a Term must be received in writing during the 30 day period immediately
following the end of that Term in order to avoid the application of a Withdrawal
Charge.

TOTAL WITHDRAWAL

Upon receipt of your request to withdraw all of your Account Value, we will terminate the
Certificate and we will pay you an amount determined by the following formula:

F + [(A-F) x Z] – [(A-F) x W], WHERE:

F = the Free Withdrawal Amount;

A = the Account Value, reduced by any
applicable Annual Fee;

Z = the Market Value Adjustment Factor, as shown on the Specifications Page;

W = the Withdrawal Charge Percentage.

PARTIAL WITHDRAWAL(S)

You may withdraw less than your entire Account Value. However, requests for amounts in excess
of the Free Withdrawal Amount are subject to a Withdrawal Charge, a Market Value Adjustment and
will be determined using the following calculation:

F +
[(G -F) x Z] – [(G-F) x W], where:

F = the
Free Withdrawal Amount;

G = the Gross Withdrawal Amount;

Z = the Market Value Adjustment Factor, as
shown on the Specifications Page;

W = the Withdrawal Charge Percentage.

We do not restrict the frequency of withdrawals. However, the Gross Withdrawal Amount withdrawn
must be no less than the Minimum Partial Withdrawal Amount shown on the Certificate’s
Specifications Pages. Any withdrawal which would reduce the Account Value to less than the Minimum
Account Value, indicated on the Specifications Page, may be treated as a request for a Total
Withdrawal of your Account Value.

PART 9: FEES AND DEDUCTIONS

ANNUAL FEE

To compensate us for assuming certain administrative expenses, we may charge an Annual Fee as set
forth on the Specifications Page. Prior to the Maturity Date, the Annual Fee is deducted from the
Account Value on each Certificate Anniversary. If the Account Value is totally withdrawn on any
date other than the Certificate Anniversary, we will deduct the total amount of the Annual Fee from
the Account Value before the amount to be paid is calculated.

TAXES

We may charge certain taxes against your Payment, Account Value, payment of death benefit, or
Annuity Payments when appropriate. Such taxes may include premium taxes, personal income taxes, or
other taxes levied on the Payment, Account Value, death benefit or Annuity Payments by any
government entity which we determine have resulted from the establishment or maintenance of the
[CPI MVA] Separate Account, or from the receipt by us of Payments, or from the issuance
of this Certificate, or from the commencement or continuance of Annuity Payments under this
Certificate.

			
	 	 	 
	10MVAGRP-CPI.1
	 	 

Page 9

 

PART 10: DEATH BENEFITS

DEATH BEFORE MATURITY DATE

A death benefit will be paid if any Owner dies prior to the date Annuity Payments begin. The Death
Benefit will be equal to the Account Value, as of the date on which written notice and proof of
death and all required claim forms are received in good order at the Company’s Annuity Service
Office. Interest on any death benefit, if applicable, will be paid in accordance with state law.

On the death of the last surviving Annuitant, the Owner becomes the new Annuitant, if the Owner is
an individual. If any Owner is a non natural person, the death of an Annuitant is treated as the
death of an Owner.

If the co-Owner predeceases the Owner, the Owner will be treated as the Beneficiary.

The Beneficiary may continue the Certificate as the Owner, subject to the requirements of Section
72(s) of the Internal Revenue Code. If the Certificate cannot continue under Section 72(s), or if
the Beneficiary elects not to continue the Certificate, the Death Benefit will be distributed under
one of the following provisions:

	 	(i)	 	as an Annuity Option as described within Part 11: “Annuity Payments”; or
	 
	 	(ii)	 	over the life of the Beneficiary, or over a period not to extend beyond the life expectancy
of the Beneficiary, with all such distributions beginning within one year from the date of the
Owner’s Death; or
	 
	 	(iii)	 	the entire interest in the Certificate must be distributed within five (5) years of the
Owner’s Death; or
	 
	 	(iv)	 	in one lump sum.

Withdrawal Charges will be waived and a Market Value Adjustment will not apply on any of the
distributions shown above. If the Beneficiary dies before distributions under (ii) or (iii) are
complete, the remaining Death Benefit must be distributed in a lump sum immediately. If there is
more than one Beneficiary, the foregoing provisions will independently apply to each Beneficiary.

The Certificate will terminate if the Death Benefit is taken in one sum.

If the Beneficiary decides to continue the Certificate as the Owner, subject to Section 72(s),
the new Owner must carry out the current Term and thereafter, applicable charges and adjustments
will apply to amounts withdrawn as described under the Certificate. Such amounts may be adjusted
upward or downward by the application of a Market Value Adjustment Factor. Subject to the rights of
an irrevocable Beneficiary, the new Owner in such instance may name a new Beneficiary and, if no
Beneficiary is so named, the decedent Beneficiary’s estate will
be the Beneficiary.

If the
Certificate is held as part of a Qualified Plan, the terms of your Qualified Plan Endorsement form
will control.

We will permit the Owner to limit the Death Benefit option(s) to be offered to any
named Beneficiary, if the Owner provides notice in writing to the Company prior to death and the
desired option(s) is one provided for in this Certificate.

DEATH BENEFIT ON OR AFTER MATURITY DATE

On or after the date Annuity Payments begin, if the Annuitant dies, the Death Benefit will depend
on the Annuity Option selected in accordance with Part 11: “Annuity Payments”.

PROOF OF DEATH

Proof of death is required upon the death of the Annuitant or the Owner. Proof of death is one of
the following received at the Annuity Service Office:

	 	a)	 	A certified copy of a death certificate.
	 
	 	b)	 	A certified copy of a decree of a court of competent jurisdiction as to the finding of death.
	 
	 	c)	 	Any other proof satisfactory to us.

			
	 	 	 
	10MVAGRP-CPI.1
	 	 

Page 10

 

PART 11: ANNUITY PAYMENTS

GENERAL

Any amounts payable under this Certificate may be converted to Annuity Payments in accordance with
one or more of the Annuity Options described below, subject to any restrictions of Internal Revenue
Code section 72(s). Once Annuity Payments commence, the Annuity Option and the Annuitant may not be
changed.

We will pay annuity benefits in the form of Annuity Payment(s) on the life of the Annuitant, to the
Payee, if living, on the Maturity Date. Annuity Payments will commence on or after the Maturity
Date and continue for the period of time provided for under the Annuity Option you elect.

MATURITY DATE

On the Maturity Date or other date elected to commence Annuity Payments, we will convert the
Account Value adjusted by any Market Value Adjustment as described in Part 6 of this Certificate
and the Specifications Page, into Annuity Payments. The amount used to determine the first Annuity
Payment will be measured as of a date not more than 10 business days prior to the Maturity Date or
other date elected to commence Annuity Payments.

Only an Account Value of $5,000 or more may be applied to one of the Annuity Payment options
offered. If the amount of the first Annuity Payment would be less than our minimum requirements
then in effect, we may make a single payment, adjusted by any Market Value Adjustment as described
in Part 6 of this Certificate, on the date the first payment is payable. This single payment is in
place of all other benefits provided by this Certificate.

CALCULATION USED TO DETERMINE ANNUITY PAYMENT(S)

The amount of each Annuity Payment is determined by applying the amounts which will be converted to
Annuity Payment(s) to the appropriate table(s) identified by this Certificate. We guarantee the
dollar amount of each Annuity Payment. Annuity Payments will never be less than that available by
applying the Account Value adjusted by any Market Value Adjustment as described in Part 6 of this
Certificate, to buy a single premium immediate annuity then offered by us, or by one of our
affiliated companies if we do not offer a single premium immediate annuity.

DESCRIPTION OF ANNUITY OPTIONS

The following Annuity Options are available under this Certificate for a single life:

	 	a.	 	Life Annuity with a guarantee of Annuity Payments for a Period of 5, 10, or 20 Years. Under
this option we will make payments for the period elected, and as long thereafter as the
Annuitant lives.
	 
	 	b.	 	Non-Refund Life Annuity. Under this option, we will make payments throughout the lifetime of
the Annuitant. No further payments will be made after the death of the Annuitant.
	 
	 	c.	 	Any other option which we may make available including joint lives.

ALTERNATIVE ANNUITY OPTIONS

Instead of settlement in accordance with the Annuity Options described above, you may choose an
alternate form of settlement acceptable to us. Once Annuity Payments commence, the form of
settlement may not be changed.

ANNUITY PAYMENT INTERVALS

You may elect to receive your Annuity Payments monthly, quarterly, semi-annually or annually.

			
	 	 	 
	10MVAGRP-CPI.1
	 	 

Page 11

 

TABLE OF PAYMENT RATES

The rates shown below are guaranteed minimum rates. The actual rates that we will apply will be the
greater of these guaranteed minimum rates and the current rates in effect at the time Annuity
Payments begin. Information regarding our current rates will be available to any Owner upon
request.

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	MONTHLY ANNUITY PAYMENT RATE TABLE
	Age of Annuitant’s	 	Life Annuity with a Guaranteed
	 
	Birthday	 	 
	Nearest Date	 	Period
	of First Payment	 	5 Years	 	10 Years	 	20 Years	 	Life Annuity
	55
	 	 	3.07	 	 	 	3.05	 	 	 	3.00	 	 	 	3.07	 
	56
	 	 	3.14	 	 	 	3.13	 	 	 	3.07	 	 	 	3.14	 
	57
	 	 	3.21	 	 	 	3.20	 	 	 	3.13	 	 	 	3.22	 
	58
	 	 	3.29	 	 	 	3.28	 	 	 	3.20	 	 	 	3.30	 
	59
	 	 	3.38	 	 	 	3.36	 	 	 	3.27	 	 	 	3.39	 
	60
	 	 	3.47	 	 	 	3.45	 	 	 	3.34	 	 	 	3.48	 
	61
	 	 	3.57	 	 	 	3.54	 	 	 	3.42	 	 	 	3.58	 
	62
	 	 	3.67	 	 	 	3.64	 	 	 	3.50	 	 	 	3.68	 
	63
	 	 	3.78	 	 	 	3.74	 	 	 	3.58	 	 	 	3.79	 
	64
	 	 	3.89	 	 	 	3.85	 	 	 	3.66	 	 	 	3.91	 
	65
	 	 	4.02	 	 	 	3.97	 	 	 	3.74	 	 	 	4.03	 
	66
	 	 	4.15	 	 	 	4.09	 	 	 	3.83	 	 	 	4.17	 
	67
	 	 	4.29	 	 	 	4.22	 	 	 	3.91	 	 	 	4.31	 
	68
	 	 	4.44	 	 	 	4.36	 	 	 	4.00	 	 	 	4.46	 
	69
	 	 	4.60	 	 	 	4.50	 	 	 	4.08	 	 	 	4.63	 
	70
	 	 	4.78	 	 	 	4.66	 	 	 	4.17	 	 	 	4.81	 
	71
	 	 	4.96	 	 	 	4.82	 	 	 	4.25	 	 	 	5.00	 
	72
	 	 	5.16	 	 	 	4.99	 	 	 	4.32	 	 	 	5.21	 
	73
	 	 	5.38	 	 	 	5.17	 	 	 	4.40	 	 	 	5.44	 
	74
	 	 	5.61	 	 	 	5.36	 	 	 	4.47	 	 	 	5.69	 
	75
	 	 	5.83	 	 	 	5.56	 	 	 	4.53	 	 	 	5.95	 
	76
	 	 	6.13	 	 	 	5.76	 	 	 	4.59	 	 	 	6.24	 
	77
	 	 	6.41	 	 	 	5.97	 	 	 	4.64	 	 	 	6.55	 
	78
	 	 	6.71	 	 	 	6.18	 	 	 	4.69	 	 	 	6.89	 
	79
	 	 	7.03	 	 	 	6.40	 	 	 	4.73	 	 	 	7.25	 
	80
	 	 	7.38	 	 	 	6.62	 	 	 	4.77	 	 	 	7.65	 
	81
	 	 	7.74	 	 	 	6.83	 	 	 	4.80	 	 	 	8.08	 
	82
	 	 	8.13	 	 	 	7.04	 	 	 	4.82	 	 	 	8.55	 
	83
	 	 	8.54	 	 	 	7.25	 	 	 	4.84	 	 	 	9.06	 
	84
	 	 	8.97	 	 	 	7.45	 	 	 	4.86	 	 	 	9.61	 
	85
	 	 	9.41	 	 	 	7.63	 	 	 	4.87	 	 	 	10.21	 
	86
	 	 	9.87	 	 	 	7.80	 	 	 	4.88	 	 	 	10.86	 
	87
	 	 	10.33	 	 	 	7.96	 	 	 	4.89	 	 	 	11.57	 
	88
	 	 	10.80	 	 	 	8.10	 	 	 	4.90	 	 	 	12.32	 
	89
	 	 	11.26	 	 	 	8.23	 	 	 	4.90	 	 	 	13.12	 
	90
	 	 	11.71	 	 	 	8.35	 	 	 	4.91	 	 	 	13.96	 
	91
	 	 	12.15	 	 	 	8.45	 	 	 	4.91	 	 	 	14.84	 
	92
	 	 	12.57	 	 	 	8.54	 	 	 	4.91	 	 	 	15.75	 
	93
	 	 	12.97	 	 	 	8.62	 	 	 	4.91	 	 	 	16.69	 
	94
	 	 	13.35	 	 	 	8.69	 	 	 	4.91	 	 	 	17.66	 
	95 and over
	 	 	13.73	 	 	 	8.75	 	 	 	4.91	 	 	 	18.67	 

These rates are based on the Annuity 2000 mortality table for Females projected for improvement
using projection scale G. Interest is at an annual effective rate of 1.5%.

			
	 	 	 
	10MVAGRP-CPI.1
	 	 

Page 12

 

Communications about this annuity Certificate may be sent to the Company at its Servicing Office.

Single Payment Modified Guarantee Inflation Indexed Deferred Annuity

Non-Participating

Amounts withdrawn under this Certificate may be subject to a Withdrawal Charge and a Market Value
Adjustment

			
	 	 	 
	JOHN HANCOCK LIFE INSURANCE COMPANY

(U.S.A.)
	 	

			
	 	 	 
	10MVAGRP-CPI.1
	 	 

Page 13

Source: [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00191-of-00352.parquet"}, [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00191-of-00352.parquet"}]]