Document:

Exhibit 4(b)

     ||||GOLDEN                               FLEXIBLE PREMIUM
   ||||||AMERICAN                             DEFERRED COMBINATION
  |||||||LIFE INSURANCE                       VARIABLE AND FIXED
    |||||COMPANY                              ANNUITY CONTRACT

Golden American is a stock company domiciled in Delaware.
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

This is a legal Contract between its Owner and us. Please read it carefully. In
this Contract you or your refers to the Owner shown above. We, our or us refers
to Golden American Life Insurance Company. You may allocate this Contract's
Accumulation Value among the Variable Separate Account, the General Account and
the Fixed Account shown in the Schedule.

If this Contract is in force, we will make income payments to you starting on
the Annuity Commencement Date. If the Owner dies prior to the Annuity
Commencement Date, we will pay a Death Benefit to the Beneficiary. The amount
of such benefits is subject to the terms of this Contract.

ALL PAYMENTS AND VALUES, WHEN BASED ON THE INVESTMENT EXPERIENCE OF A VARIABLE
SEPARATE ACCOUNT, MAY INCREASE OR DECREASE, DEPENDING ON THE CONTRACT'S
INVESTMENT RESULTS. ALL PAYMENTS AND VALUES, WHEN BASED ON THE FIXED ACCOUNT,
MAY BE SUBJECT TO A MARKET VALUE ADJUSTMENT, THE OPERATION OF WHICH MAY CAUSE
SUCH PAYMENTS AND VALUES TO INCREASE OR DECREASE.

RIGHT TO EXAMINE THIS CONTRACT: YOU MAY RETURN THIS CONTRACT TO US OR THE AGENT
THROUGH WHOM YOU PURCHASED IT WITHIN 10 DAYS AFTER YOU RECEIVE IT. IF SO
RETURNED, WE WILL TREAT THE CONTRACT AS THOUGH IT WERE NEVER ISSUED. UPON
RECEIPT WE WILL PROMPTLY REFUND THE ACCUMULATION VALUE, ADJUSTED FOR ANY MARKET
VALUE ADJUSTMENT, PLUS ANY CHARGES WE HAVE DEDUCTED AS OF THE DATE THE RETURNED
CONTRACT IS RECEIVED BY US.

Customer Service Center                      Secretary: /s/Myles R. Tashman
1475 Dunwoody Drive
West Chester, PA  19380                      President: /s/Barnett Chernow
1-800-366-0066

-------------------------------------------------------------------------------
FLEXIBLE PREMIUM DEFERRED COMBINATION VARIABLE AND
FIXED ANNUITY CONTRACT - NO DIVIDENDS
Variable Cash Surrender Values while the Annuitant and Owner are
living and prior to the Annuity Commencement Date.
Death Benefit subject to guaranteed minimum.  Partial Withdrawal Option.
Non-participating.  Investment results
reflected in values.

GA-IA-1082

<PAGE>

                                CONTRACT CONTENTS

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THE SCHEDULE                                     YOUR CONTRACT BENEFITS....16
  Payment and Investment Information...      3A    Cash Value Benefit.
  The Variable Separate Accounts.......      3B    Partial Withdrawal Option
  The General Account..................      3C    Proceeds Payable to the
                                                    Beneficiary
  Contract Facts.......................      3D
  Charges and Fees.....................      3E  CHOOSING AN INCOME PLAN...18
  Income Plan Factors..................      3F    Annuity Benefits
                                                   Annuity Commencement Date
                                                    Selection

IMPORTANT TERMS........................      4     Frequency Selection
                                                   The Income Plan

INTRODUCTION TO THIS CONTRACT..........      6     The Annuity Options
  The Contract                                     Payment When Named Person
                                                   Dies
  The Owner
  The Annuitant                                  OTHER IMPORTANT INFORMATION.20
  The Beneficiary                                  Sending Notice to Us
  Change of Owner or Beneficiary                   Reports to Owner
                                                   Assignment - Using this
                                                    Contract as

PREMIUM PAYMENTS AND ALLOCATION CHANGES      8     Collateral Security
  Initial Premium Payment                          Changing this Contract
  Additional Premium Payments                      Contract Changes - Applicable
                                                    Tax Law
  Your Right to Change Allocation of               Misstatement of Age or Sex
    Accumulation Value                             Non-Participating
  What Happens if a Variable Separate Account      Contestability

    Division is Not Available                      Payments We May Defer
  Restricted Funds                                 Authority to Make Agreements
  Thresholds                                       Required Note on Our
  Dollar Cap                                         Computations
  Premium Threshold
  Allocation Threshold
  Thresholds - Effect on Withdrawals
  Threshold Processing

HOW WE MEASURE THE CONTRACT'S

   ACCUMULATION VALUE.................       11
  The Variable Separate Accounts
  The General Account
  Valuation Period
  Accumulation Value
  Accumulation Value in each Division and
    Fixed Allocation
  Fixed Account
  Measurement of Investment Experience
  Charges Deducted from Accumulation Value on
    each Contract Processing Date
  Copies of any additional Riders and Endorsements
   are at the back of this Contract.

         THE SCHEDULE

        The Schedule gives specific facts about this Contract and its
        coverage. Please refer to the Schedule while reading this
        Contract.

GA-IA-1082                             2

<PAGE>

                                  THE SCHEDULE

                       PAYMENT AND INVESTMENT INFORMATION
-------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                 Owner                                              |
|[THOMAS J. DOE]           [JOHN Q. DOE]                                      |
|-----------------------------------------------------------------------------|
|Annuitant's Issue Age     Annuitant's Sex         Owner's Issue Age          |
| [55]                     [MALE]                  [35]                       |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option          Annuity Commencement Date  |
|[$10,000]                 [LIFE 10-YEAR CERTAIN]  [JANUARY 1, 2026]          |
|-----------------------------------------------------------------------------|
|Contract Date             Issue Date              Residence Status           |
|[JANUARY 1, 1996]         [JANUARY 1, 1996]       [DELAWARE]                 |
|-----------------------------------------------------------------------------|
|Separate Account(s)                               Contract Number            |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]        [123456]                   |
|-----------------------------------------------------------------------------|

INITIAL INVESTMENT

Initial Premium Payment received:                    [$10,000]

Your initial Accumulation Value has been invested as follows:

                                                  Percentage of
               Divisions                        Accumulation Value
               ---------                        ------------------
            [Equity Income                             10%
             Fully Managed                             10%
         Capital Appreciation                          10%
           Rising Dividends                            10%
                Growth                                 10%
              Real Estate                              10%
             Value Equity                               5%
              Hard Assets                               5%
           Emerging Markets                             5%
            Managed Global                              5%
         Limited Maturity Bond                          5%
             Liquid Asset                               5%
           Strategic Equity                             5%
       Fixed Allocation - 1 Year                       5%]

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

                 Total                                 100%
                 =====                                 ====

GA-IA-1082                             3A1

<PAGE>

                                  THE SCHEDULE

                 PAYMENT AND INVESTMENT INFORMATION (continued)
-------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                 Owner                                              |
|[THOMAS J. DOE]           [JOHN Q. DOE]                                      |
|-----------------------------------------------------------------------------|
|Annuitant's Issue Age     Annuitant's Sex         Owner's Issue Age          |
| [55]                     [MALE]                  [35]                       |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option          Annuity Commencement Date  |
|[$10,000]                 [LIFE 10-YEAR CERTAIN]  [JANUARY 1, 2026]          |
|-----------------------------------------------------------------------------|
|Contract Date             Issue Date              Residence Status           |
|[JANUARY 1, 1996]         [JANUARY 1, 1996]       [DELAWARE]                 |
|-----------------------------------------------------------------------------|
|Separate Account(s)                               Contract Number            |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]        [123456]                   |
|-----------------------------------------------------------------------------|

ADDITIONAL PREMIUM PAYMENT INFORMATION

Except in the case of a Contract issued as an IRA, we will accept additional
Premium Payments until either the Annuitant or Owner reaches the Attained Age
of [86]. The minimum additional payment which may be made is $[500.00].

If this Contract is issued as an IRA, no contributions may be made for the
taxable year in which you attain age 70 1/2 and thereafter (except for rollover
contributions). The minimum additional payment which may be made to a Contract
issued as an IRA is $250.00.

ACCUMULATION VALUE ALLOCATION RULES

We reserve the right to impose a charge for any allocation change in excess of
twelve per Contract Year. The Excess Allocation Charge is shown in the
Schedule.Allocations into and out of the Guaranteed Interest Divisions are
subject to restrictions (see General Account).

ALLOCATION CHANGES BY TELEPHONE

You may request allocation changes by telephone during our telephone request
business hours. You may call our Customer Service Center at 1-800-366-0066 to
make allocation changes by using the personal identification number you will
receive. You may also mail any notice or request for allocation changes to our
Customer Service Center at the address shown on the cover page.

GA-IA-1082                             3A2

<PAGE>

                                  THE SCHEDULE

                         THE VARIABLE SEPARATE ACCOUNTS
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

DIVISIONS INVESTING IN SHARES OF A MUTUAL FUND

Separate Account B (the "Account") is a unit investment trust Separate Account,
organized in and governed by the laws of the State of Delaware, our state of
domicile. The Account is divided into Divisions. Each Division listed below
invests in shares of the mutual fund portfolio (the "Series").

  SERIES                     SERIES                         SERIES
  ------                     ------                         ------
  [All Cap                  Capital Growth                 Liquid Asset
  Equity Income             Managed Global                 Strategic Equity
  Fully Managed             Asset Allocation Growth        Research
  Value Equity              Diversified Mid-Cap            Growth
  Small Cap                 Investors                      Global Fixed Income
  Capital Appreciation      Large Cap Value                Developing World
  Rising Dividends          Real Estate                    Equity Income
  Mid-Cap Growth            Hard Assets                    Growth and Income
  Total Return              Limited Maturity Bond          Special Situations

     The Division listed below invests in shares of the mutual fund portfolio
     (the "Portfolio") designated. The portfolio is a part of the ING Variable
     Insurance Trust managed by ING Investment Management.

         PORTFOLIO
         ---------
         ING Global Brand Names Fund

     The Division listed below invests in shares of the mutual fund portfolio
     (the "Portfolio") designated. The portfolios are a part of the Prudential
     Series Fund, Inc. managed by Jennison Associates, LLC.

         PORTFOLIO
         ---------
         Prudential Jennison

     The Division listed below invests in shares of the mutual fund portfolio
     (the "Portfolio") designated. The portfolio is a part of the Warburg
     Pincus Trust managed by Credit Suisse Asset Management, LLC.

         PORTFOLIO
         ---------
         International Equity
         International Growth

     The Division listed below invests in shares of the mutual fund portfolio
     (the "Portfolio") designated. The portfolios are a part of the PIMCO Trust
     managed by Pacific Investment Management Company.

         PORTFOLIO
         ---------
         PIMCO High Yield Bond
         PIMCO StocksPlus Growth & Income]

GA-IA-1082                             3B

<PAGE>

                                  THE SCHEDULE
                               THE GENERAL ACCOUNT
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

GENERAL ACCOUNT

[Guaranteed Interest Division
A Guaranteed Interest Division provides an annual minimum interest rate of 3%.
At our sole discretion, we may periodically declare higher interest rates for
specific Guarantee Periods. Such rates will apply to periods following the date
of declaration. Any declaration will be by class and will be based on our
future expectations.

Limitations of Allocations
We reserve the right to restrict allocations into and out of the General
Account. Such limits may be dollar restrictions on allocations into the General
Account or we may restrict reallocations into the General Account.

Transfers from a Guaranteed Interest Division
We currently require that an amount allocated to a Guarantee Period not be
transferred until the Maturity Date, except pursuant to our published rules. We
reserve the right not to allow amounts previously transferred from a Guaranteed
Interest Division to the Variable Separate Account Divisions or to a Fixed
Allocation to be transferred back to a Guaranteed Interest Division for a
period of at least six months from the date of transfer.]

GA-IA-1082                             3C

<PAGE>

                                 THE SCHEDULE (STANDARD)
                                 CONTRACT FACTS
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

CONTRACT FACTS

Contract Processing Date
The Contract Processing Date for your Contract is [April 1] of each year.

Specially Designated Division
When a distribution is made from an investment portfolio underlying a Separate
Account Division in which reinvestment is not available, we will allocate the
amount of the distribution to the [Liquid Asset Division] unless you specify
otherwise.

PARTIAL WITHDRAWALS

The maximum amount that can be withdrawn each Contract Year without being
considered an Excess Partial Withdrawal is described below. We will collect a
Surrender Charge for Excess Partial Withdrawals and a charge for any
unrecovered Premium Taxes. In no event may a Partial Withdrawal be greater
than 90% of the Cash Surrender Value. After a Partial Withdrawal, the
remaining Accumulation Value must be at least $100 to keep the Contract
in force.

Systematic Partial Withdrawals and Conventional Partial Withdrawals may not be
taken in the same Contract Year.

To determine the Surrender Charge on Excess Partial Withdrawals, the
withdrawals will occur in the following order:
  (1) Earnings;
  (2) The Free Amount;
  (3) Premium Payments made [four] or more years prior to the withdrawal; and,
  (4) Premium Payments made less than [four] years prior to withdrawal.

Earnings and Free Amounts are not treated as withdrawals of Premium Payments
for purposes of calculating any Surrender Charge.

Conventional Partial Withdrawals
Minimum Withdrawal Amount:       $100

The maximum amount that can be taken as a Conventional Partial Withdrawal each
Contract Year without being considered an Excess Partial Withdrawal is the
greater of:

     (1) Earnings (defined below) not previously withdrawn, but not less
         than zero; and
     (2) The Free Amount, equal to 10% of Premium Payments not previously
         withdrawn, which were received within [four] years prior to the date
         of withdrawal.

Earnings are equal to the Accumulation Value, less Premium Payments, plus prior
withdrawals.

Any Conventional Partial Withdrawal is subject to a Market Value Adjustment
unless withdrawn from a Fixed Allocation within 30 days prior to the Maturity
Date.

GA-IA-1082                             3D1

<PAGE>

                                  THE SCHEDULE
                           CONTRACT FACTS (continued)
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

Systematic Partial Withdrawals
Systematic Partial Withdrawals may be elected to commence after 28 days from
the Contract Issue Date and may be taken on a monthly, quarterly or annual
basis. You select the day withdrawals will be made, but no later than the
28th day of the month. If you do not elect a day, the Contract Date will be
used.

Maximum Withdrawal Amounts:

 Variable Separate Account Divisions: .833% of Premium Payments monthly,
                                      2.5% of Premium Payments
                                      quarterly or 10% of Premium Payments
                                      annually

 Fixed Allocations and
 Guaranteed Interest Divisions:       Interest earned on a Fixed Allocation
                                      or Guaranteed Interest
                                      Division for the prior month, quarter
                                      or year (depending on the
                                      frequency selected).

The Maximum Withdrawal Amount Available as a Systematic Partial Withdrawal is
10% of Premium Payment not previously withdrawn. Systematic Partial Withdrawals
from Fixed Allocations are not subject to a Market Value Adjustment. A
Systematic Partial Withdrawal in excess of Earnings and the Free Amount may be
subject to a Surrender Charge.

IRA Partial Withdrawals for Qualified Plans Only
Partial Withdrawals may be taken from a Contract issued as IRA on a monthly,
quarterly or annual basis. A minimum withdrawal of $100.00 is required. You
select the day the withdrawals will be made, but no later than the 28th day of
the month. If you do not elect a day, the Contract Date will be used.
Systematic Partial Withdrawals and Conventional Partial Withdrawals are not
allowed when IRA Partial Withdrawals are being taken. An IRA Partial Withdrawal
in excess of the maximum amount allowed under the Systematic Partial
Withdrawal option may be subject to a Market Value Adjustment.

DEATH BENEFIT

The Death Benefit is the greatest of (i), (ii) and (iii) below, where:
     (i)    is the Accumulation Value;
     (ii)   is the Guaranteed Death Benefit;
     (iii)  is the Cash Surrender Value.

GA-IA-1082                             3D2

<PAGE>

                                  THE SCHEDULE
                                CONTRACT FACTS (continued)
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

GUARANTEED DEATH BENEFIT

The Guaranteed Death Benefit for the Contract is equal to the sum of I and
II below.
     I.  The Guaranteed Death Benefit Base for non-Special Funds
     II. The Accumulation Value allocated to Special Funds

On the Contract Date, the Guaranteed Death Benefit Base for non-Special Funds
is the initial premium allocated to non-Special Funds. On subsequent Valuation
Dates, the Guaranteed Death Benefit Base for non-Special Funds is calculated as
follows:

(1)      Start with the Guaranteed Death Benefit Base for non-Special
         Funds from the prior Valuation Date.
(2)      Add any additional premiums paid and allocated to non-Special
         Funds during the current Valuation Period to (1).
(3)      Adjust (2) for any transfers to or from Special Funds during
         the current Valuation Period.
(4)      Subtract from (3) any Prorata Partial Withdrawal Adjustments
         for any Partial Withdrawal made from non-Special
         Funds during the current Valuation Period.

The Guaranteed Death Benefit Base for Special Funds has a corresponding
definition, but with respect to amounts allocated to Special Funds.

Transfers from Special Funds to non-Special Funds will reduce the Guaranteed
Death Benefit Base for Special Funds on a prorata basis. The resulting increase
in the Guaranteed Death Benefit Base for non-Special Funds will equal the
lesser of the reduction in the Guaranteed Death Benefit Base for Special
Funds and the net Accumulation Value transferred.

Transfers from non-Special Funds to Special Funds will reduce the Guaranteed
Death Benefit Base for non-Special Funds on a prorata basis. The resulting
increase in the Guaranteed Death Benefit Base for Special Funds will equal the
reduction in Guaranteed Death Benefit Base for non-Special Funds.

GA-IA-1082                             3D3

<PAGE>

                                  THE SCHEDULE
                                CONTRACT FACTS (continued)
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

SPECIAL FUNDS

Where used in this Contract, Special Funds are [the Liquid Asset Division, the
Limited Maturity Bond Division, the Fixed Allocations and the Guaranteed
Interest Division]. We may add newly available Divisions as Special Funds. We
may also reclassify an existing Division as a Special Fund or remove such
designation upon 30 days notice to you. Such reclassification will apply to
amounts transferred or otherwise added to such Division after the date of
change. We may reduce the Mortality and Expense Risk Charge (if applicable) for
that portion of the Contract invested in a Special Fund.

PRORATA PARTIAL WITHDRAWAL ADJUSTMENTS

For any partial withdrawal, the Death Benefit components will be reduced by
Prorata Partial Withdrawal Adjustments. The Prorata Partial Withdrawal
Adjustment to a Death Benefit component for a partial withdrawal is equal to
(1) divided by (2) multiplied by (3), where: (1) is the Accumulation Value
withdrawn; (2) is the Accumulation Value immediately prior to withdrawal; and
(3) is the amount of the applicable Death Benefit component immediately prior
to the withdrawal. Separate adjustments will apply to amounts in the Special
and non-Special Funds.

CHANGE OF OWNER

A change of Owner will result in recalculation of the Death Benefit and the
Guaranteed Death Benefit. If the Owner's or the oldest of multiple Owner's
Attained Age at the time of the change is less than [86], the Guaranteed Death
Benefit in effect prior to the change will remain in effect and the Death
Benefit provision shall apply.

If any Owner's or oldest multiple Owner's Attained Age is [86] or greater at
the time of the change, the Guaranteed Death Benefit will be zero, and the
Death Benefit will then be the Cash Surrender Value.

GA-IA-1082                             3D4

<PAGE>

                                  THE SCHEDULE
                                CONTRACT FACTS (continued)
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

SPOUSAL CONTINUATION UPON DEATH OF OWNER

If at the Owner's death, the surviving spouse of the deceased Owner is the
Beneficiary and such surviving spouse elects to continue the Contract as their
own pursuant to Internal Revenue Code Section 72(s) or the equivalent
provisions of U.S. Treasury Department rules for qualified plans, the
following will apply:

(a)   If the Guaranteed Death Benefit as of the date we receive due proof of
      death of the Owner, minus the Accumulation Value, also as of that date,
      is greater than zero, we will add such difference to the Accumulation
      Value. Such addition will be allocated to the Divisions of the Separate
      Account in the same proportion as the Accumulation Value in each Division
      bears to the Accumulation Value in the Separate Account. If there is no
      Accumulation Value in the Separate Account, the addition will be
      allocated to the Liquid Asset Division, or its successor.

(b)   The Guaranteed Death Benefit will continue to apply, with all age
      criteria using the surviving spouse's age as the determining age.

(c)   At subsequent surrender, any Surrender Charge applicable to premiums
      paid prior to the date we receive due proof of death of the Owner will
      be waived. Any premiums paid later will be subject to any applicable
      Surrender Charge.

This addition to Accumulation Value is available only to the spouse of the
Owner as of the date of death of the Owner if such spouse under the provisions
if this Contract elects to continue the Contract as their own.

CHOOSING AN INCOME PLAN

Required Date of Annuity Commencement
Distributions from a Contract funding a qualified plan must commence no later
than [April 1st] of the calendar year following the calendar year in which the
Owner attains age 70 1/2. Otherwise, the Annuity Commencement Date may be no
later than the same date as the Contract Processing Date in the month following
the Annuitant's 90th birthday. In applying the Accumulation Value, we may first
collect any Premium Taxes due us. If, on the Annuity Commencement Date, a
Surrender Charge remains, your elected Annuity Option must include a period
certain of at least five years duration.

Minimum Annuity Income Payment
The minimum monthly annuity income payment that we will make is [$20].

GA-IA-1082                             3D5

<PAGE>

                                THE SCHEDULE
                           CONTRACT FACTS (continued)
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

OPTIONAL BENEFIT RIDERS - [None.]

ATTAINED AGE

The Issue Age of the Annuitant or Owner plus the number of full years elapsed
since the Contract Date.

RESTRICTED FUNDS - [None]

FIXED ACCOUNT

Minimum Fixed Allocation
The minimum allocation to the Fixed Account in any one Fixed Allocation is
[$250.00].

Minimum Guaranteed Interest Rate - [3%.]

Guarantee Periods
We currently offer Guarantee Periods of [1, 3, 5, 7 and 10] year(s). We reserve
the right to offer Guarantee Periods of durations other than those available on
the Contract Date. We also reserve the right to cease offering a particular
Guarantee Period or Periods.

Index Rate
The Index Rate is the average of the Ask Yields for the U.S. Treasury Strips as
reported by a national quoting service for the applicable maturity. The average
is based on the period from the 22nd day of the calendar month two months prior
to the calendar month of Index Rate determination to the 21st day of the
calendar month immediately prior to the month of determination. The applicable
maturity date for these U.S. Treasury Strips is on or next following the last
day of the Guarantee Period. If the Ask Yields are no longer available, the
Index Rate will be determined using a suitable replacement method.

We currently set the Index Rate once each calendar month. However, we reserve
the right to set the Index Rate more frequently than monthly, but in no event
will such Index Rate be based on a period less than 28 days.

GA-IA-1082                             3D6

<PAGE>

                                  THE SCHEDULE
                                CHARGES AND FEES
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

DEDUCTIONS FROM PREMIUMS

None

DEDUCTIONS FROM ACCUMULATION VALUE

Initial Administrative Charge
None

Administrative Charge
We charge a maximum of $30 to cover a portion of our ongoing administrative
expenses for each Contract Processing Period. The charge is incurred at the
beginning of the Contract Processing Period and deducted on the Contract
Processing Date at the end of the period.

At the time of deduction, this charge will be waived if:
  (1) The Accumulation Value is at least $100,000; or
  (2) The sum of premiums paid to date is at least $100,000.

Excess Allocation Charge
Currently none, however, we reserve the right to charge $25 for a change if you
make more than twelve allocation changes per Contract Year. Any charge will be
deducted in proportion to the amount being transferred from each Division.

Surrender Charge
A Surrender Charge is imposed as a percentage of unliquidated premium if the
Contract is surrendered or an Excess Partial Withdrawal is taken. The
percentage imposed at time of surrender or Excess Partial Withdrawal
depends on the number of complete years that have elapsed since a Premium
Payment was made. The Surrender Charge expressed as a percentage of each
Premium Payment is as follows:

          Complete Years Elapsed                     Surrender
           Since Premium Payment                      Charges
          ----------------------                     ---------
                     [0                                  6%
                     1                                   5%
                     2                                   4%
                     3                                   3%
                     4+                                 0%]

Surrender of the Contract is permitted at or before the commencement of Annuity
Payments.

GA-IA-1082                             3E1

<PAGE>

                                  THE SCHEDULE
                               CHARGES AND FEES (continued)
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

Premium Taxes
We deduct the amount of any premium or other state and local taxes levied by any
state or governmental entity when such taxes are incurred.

We reserve the right to defer collection of Premium Taxes until surrender or
until application of Accumulation Value to an Annuity Option. An Excess Partial
Withdrawal will result in the deduction of any Premium Tax then due us on such
amount. We reserve the right to change the amount we charge for Premium Tax
charges on future Premium Payments to conform with changes in the law or if the
Owner changes state of residence.

Deductions from the Divisions
Mortality and Expense Risk Charge - We deduct a charge from the assets in each
---------------------------------
Variable Separate Account Division on a daily basis of not more than
[0.004558]% (equivalent to an annual maximum rate of [1.65]%) for mortality
and expense risks. This charge is not deducted from the Fixed Account or
General Account Accumulation Values.

Asset Based Administrative Charge - We deduct a charge of not more than
---------------------------------
[0.000411]% of the assets in each Variable Separate Account Division on a
daily basis (equivalent to an annual maximum rate of [0.15]%) to compensate
us for a portion of our ongoing administrative expenses. This charge is not
deducted from the Fixed Account or General Account Values.

CHARGE DEDUCTION DIVISION

If elected by you, all charges against the Accumulation Value in this Contract
will be deducted from the [Liquid Asset Division].

GA-IA-1082                             3E2

<PAGE>

                                  THE SCHEDULE
                               INCOME PLAN FACTORS
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

Values for other payment periods, ages or joint life combinations are
available on request. Monthly payments are shown for each $1,000 applied.

                       TABLE FOR INCOME FOR A FIXED PERIOD

 Fixed Period     Monthly   Fixed Period     Monthly   Fixed Period   Monthly
    of Years      Income       of Years      Income       of Years    Income

   [5              17.95          14          7.28           23         5.00
   6               15.18          15          6.89           24         4.85
   7               13.20          16          6.54           25         4.72
   8               11.71          17          6.24           26         4.60
   9               10.56          18          5.98           27         4.49
   10                9.64         19          5.74           28         4.38
   11                8.88         20          5.53           29         4.28
   12                8.26         21          5.33           30        4.19]
   13                7.73         22          5.16

                            TABLE FOR INCOME FOR LIFE

               Male/Female            Male/Female             Male/Female
   Age      10 Years Certain       20 Years Certain          Refund Certain

[50            $4.06/3.83             $3.96/3.77              $3.93/3.75
55              4.43/4.14              4.25/4.05               4.25/4.03
60              4.90/4.56              4.57/4.37               4.66/4.40
65              5.51/5.10              4.90/4.73               5.12/4.83
70              6.26/5.81              5.18/5.07               5.76/5.42
75              7.11/6.70              5.38/5.33               6.58/6.19
80              7.99/7.70              5.48/5.46               7.69/7.21
85              8.72/8.59              5.52/5.51               8.72/8.59
90              9.23/9.18              5.53/5.53            10.63/10.53]

GA-IA-1082                             3F

<PAGE>

                                 IMPORTANT TERMS
-----------------------------------------------------------------------------
ACCUMULATION VALUE - The amount that a Contract provides for investment at any
time. Initially, this amount is equal to the premium paid.

ANNUITANT - The person designated by the Owner to be the measuring life in
determining Annuity Payments.

ANNUITY COMMENCEMENT DATE - For each Contract, the date on which Annuity
Payments begin.

ANNUITY OPTIONS - Options the Owner selects that determine the form and amount
of Annuity Payments.

ANNUITY PAYMENT - The periodic payment an Owner receives.

ATTAINED AGE - The Issue Age of the Annuitant or Owner plus the number of full
years elapsed since the Contract Date.

BENEFICIARY - The person designated to receive benefits in the case of the
death of the Owner.

BUSINESS DAY - Any day the New York Stock Exchange ("NYSE") is open for
trading, exclusive of federal holidays, or any day
on which the Securities and Exchange Commission ("SEC") requires
that mutual funds, unit investment trusts or other investment
portfolios be valued.

CASH SURRENDER VALUE - The amount the Owner receives upon surrender of the
Contract.

CHARGE DEDUCTION DIVISION - The Division from which all charges are deducted if
so designated or elected by the Owner.

CONTINGENT ANNUITANT - The person designated by the Owner who, upon the
Annuitant's death prior to the Annuity Commencement Date, becomes the
Annuitant.

CONTRACT ANNIVERSARY - The anniversary of the Contract Date.

CONTRACT DATE - The date we received the initial premium and upon which we
begin determining the Contract values. It may not be the same as
the Contract Issue Date. This date is used to determine Contract
months, processing dates, years, and anniversaries.

CONTRACT ISSUE DATE - The date the Contract is issued at our Customer Service
Center.

CONTRACT PROCESSING DATES - The days when we deduct certain charges from the
Accumulation Value. If the Contract Processing Date is not a Valuation
Date, it will be on the next succeeding Valuation Date. The Contract
Processing Date will be on the Contract Anniversary of each year.

CONTRACT PROCESSING PERIOD - The period between successive Contract Processing
Dates unless it is the first Contract Processing Period. In that case, it
is the period from the Contract Date to the first Contract Processing
Date.

CONTRACT YEAR - The period between Contract Anniversaries.

GA-IA-1082                             4

<PAGE>

                           IMPORTANT TERMS (continued)
------------------------------------------------------------------------------

EXPERIENCE FACTOR - The factor which reflects the investment experience of the
portfolio in which a Variable Separate Account Division invests and also
reflects the charges assessed against the Division for a Valuation Period.

FIXED ACCOUNT - This is the Separate Account established to support Fixed
Allocations.

FIXEDALLOCATION - An amount allocated to the Fixed Account that is credited
with a Guaranteed Interest Rate for a specified Guarantee Period.

GUARANTEE PERIOD - The period of years a rate of interest is guaranteed to be
credited to a Fixed Allocation or allocations to a Guaranteed Interest
Division.

GUARANTEED INTEREST DIVISION - An investment option available in the General
Account, an account which contains all of our assets other than those held
in our Separate Accounts.

GUARANTEED INTEREST RATE - The effective annual interest rate which we will
credit for a specified Guarantee Period.

GUARANTEED MINIMUM INTEREST RATE - The minimum interest rate which can be
declared by us for Fixed Allocations or allocations to a Guaranteed
Interest Division.

INDEX OF INVESTMENT EXPERIENCE - The index that measures the performance of a
Variable Separate Account Division.

INITIAL PREMIUM - The payment amount required to put each Contract in effect.

ISSUE AGE - The Annuitant's or Owner's age on the last birthday on or before
the Contract Date.

MARKET VALUE ADJUSTMENT - A positive or negative adjustment to a Fixed
Allocation. It may apply if all or part of a Fixed Allocation is
withdrawn, transferred, or applied to an Annuity Option
prior to the end of the Guarantee Period.

MATURITY DATE - The date on which a Guarantee Period matures.

OWNER- The person who owns a Contract and is entitled to exercise all rights of
the Contract. This person's death also initiates payment of the Death
Benefit.

RIDERS - Riders add provisions or change the terms of the Contract.

SPECIALLY DESIGNATED DIVISION - Distributions from a portfolio underlying a
Division in which reinvestment is not available will be allocated to this
Division unless you specify otherwise.

VALUATION DATE - The day at the end of a Valuation Period when each Division is
valued.

VALUATION PERIOD - Each business day together with any non-business days before
it.

VARIABLE SEPARATE ACCOUNT DIVISION - An investment option available in the
Variable Separate Account shown in the Schedule.

GA-IA-1082                             5

<PAGE>

                          INTRODUCTION TO THIS CONTRACT
-------------------------------------------------------------------------------

THE CONTRACT

This is a legal contract between you and us. We provide benefits as stated in
this Contract. In return, you supply us with the Initial Premium Payment
required to put this Contract in effect.

This Contract, together with any attached application, Riders or Endorsements,
constitutes the entire Contract. Riders and Endorsements add provisions or
change the terms of the basic Contract.

THE OWNER

You are the Owner of this Contract. You are also the Annuitant unless another
Annuitant has been named by you and is shown in the Schedule. You have the
rights and options described in this Contract, including but not limited to the
right to receive the Annuity Benefits on the Annuity Commencement Date.

One or more people may own this Contract. If there are multiple Owners named,
the age of the oldest Owner will be used to determine the applicable Death
Benefit. In the case of a sole Owner who dies prior to the Annuity Commencement
Date, we will pay the Beneficiary the Death Benefit then due. If the sole Owner
is not an individual, we will treat the Annuitant as Owner for the purpose of
determining when the Owner dies under the Death Benefit provision (if there is
no Contingent Annuitant), and the Annuitant's age will determine the applicable
Death Benefit payable to the Beneficiary. The sole Owner's estate will be the
Beneficiary if no Beneficiary designation is in effect, or if the designated
Beneficiary has predeceased the Owner. In the case of a joint Owner of the
Contract dying prior to the Annuity Commencement Date, the surviving Owner(s)
will be deemed as the Beneficiary(ies).

THE ANNUITANT

The Annuitant is the measuring life of the Annuity Benefits provided under this
Contract. You may name a Contingent Annuitant. The Annuitant may not be changed
during the Annuitant's lifetime.

If the Annuitant dies before the Annuity Commencement Date, the Contingent
Annuitant becomes the Annuitant. You will be the Contingent Annuitant
unless you name someone else. The Annuitant must be a natural person.
If the Annuitant dies and no Contingent Annuitant has been named, we will
allow you sixty days to designate someone other than yourself as an Annuitant.
If all Owners are not individuals and, through the operation of this
provision, an Owner becomes Annuitant, we will pay the death proceeds
to the Beneficiary. If there are joint Owners, we will treat the youngest
of the Owners as the Contingent Annuitant designated, unless you elect
otherwise.

THE BENEFICIARY

The Beneficiary is the person to whom we pay death proceeds if any Owner dies
prior to the Annuity Commencement Date. See Proceeds Payable to the Beneficiary
for more information. We pay death proceeds to the primary Beneficiary (unless
there are joint Owners in which case the Death Benefit proceeds are payable to
the surviving Owner). If the primary Beneficiary dies before the Owner, the
death proceeds are paid to the Contingent Beneficiary, if any. If there is no
surviving Beneficiary, we pay the death proceeds to the Owner's estate.

GA-IA-1082                             6

<PAGE>

                    INTRODUCTION TO THIS CONTRACT (continued)
------------------------------------------------------------------------------

One or more persons may be named as primary Beneficiary or contingent
Beneficiary. In the case of more than one Beneficiary, we will assume any death
proceeds are to be paid in equal shares to the surviving Beneficiaries. You can
specify other than equal shares.

You have the right to change Beneficiaries, unless you designate the primary
Beneficiary irrevocable. When an irrevocable Beneficiary has been designated,
you and the irrevocable Beneficiary may have to act together to exercise the
rights and options under this Contract.

CHANGE OF OWNER OR BENEFICIARY

During your lifetime and while this Contract is in effect, you can transfer
ownership of this Contract or change the Beneficiary. To make any of these
changes, you must send us written notice of the change in a form satisfactory
to us. The change will take effect as of the day the notice is signed. The
change will not affect any payment made or action taken by us before
recording the change at our Customer Service Center. A Change of Owner
may affect the amount of Death Benefit payable under this Contract.
See Proceeds Payable to Beneficiary.

GA-IA-1082                             7

<PAGE>

                     PREMIUM PAYMENTS AND ALLOCATION CHANGES
------------------------------------------------------------------------------

INITIAL PREMIUM PAYMENT

The Initial Premium Payment is required to put this Contract in effect. The
amount of the Initial Premium Payment is shown in the Schedule.

ADDITIONAL PREMIUM PAYMENTS

You may make additional Premium Payments under this Contract after the end of
the Right to Examine period. Restrictions on additional Premium Payments, such
as the Attained Age of the Annuitant or Owner and the timing and amount of each
payment, are shown in the Schedule. We reserve the right to defer acceptance of
or to return any additional Premium Payments.

As of the date we receive and accept your additional Premium Payment:

     (1) The Accumulation Value will increase by the amount of the Premium
         Payment less any premium deductions as shown in the Schedule.

     (2) The increase in the Accumulation Value will be allocated among the
         Divisions of the Variable Separate Account and General Account and
         allocations to the Fixed Account in accordance with your instructions.
         If you do not provide such instructions, allocation will be among the
         Divisions of the Variable Separate Account and General Account and
         allocations to the Fixed Account in proportion to the amount of
         Accumulation Value in each Division or Fixed Allocation.

Where to Make Payments
Remit the Premium Payments to our Customer Service Center at the address shown
on the cover page. On request we will give you a receipt signed by our
treasurer.

YOUR RIGHT TO CHANGE ALLOCATION OF ACCUMULATION VALUE

You may change the allocation of the Accumulation Value among the Divisions and
Fixed Allocations after the end of the Right to Examine period. Allocation
changes in excess of twelve in any Contract Year are subject to the Excess
Allocation Charge as stated in the Schedule. To make an allocation change, you
must provide us with satisfactory notice at our Customer Service Center. The
change will take effect when we receive the notice. Restrictions for
reallocation into and out of Divisions of the Variable Separate Account and
General Account and allocations to the Fixed Account are shown in the Schedule.
An allocation from the Fixed Account may be subject to a Market Value
Adjustment. See the Schedule.

WHAT HAPPENS IF A VARIABLE SEPARATE ACCOUNT DIVISION IS NOT AVAILABLE

When a distribution is made from an investment portfolio supporting a unit
investment trust Separate Account Division in which reinvestment is not
available, we will allocate the distribution to the Specially Designated
Division shown in the Schedule unless you specify otherwise.

Such a distribution may occur when an investment portfolio or Division matures,
when distribution from a portfolio or Division cannot be reinvested in the
portfolio or Division due to the unavailability of securities, or for other
reasons. When this occurs because of maturity, we will send written notice to
you thirty days in advance of such date. To elect an allocation to other than
the Specially Designated Division shown in the Schedule, you must provide
satisfactory notice to us at least seven days prior to the date the investment
matures. Such allocations will not be counted as an allocation change of the
Accumulation Value for purposes of the number of free allocations permitted.

GA-IA-1082                             8

<PAGE>

               PREMIUM PAYMENTS AND ALLOCATION CHANGES (continued)
------------------------------------------------------------------------------

RESTRICTED FUNDS

Restricted Funds are subject to limits as to amounts which may be invested or
transferred into such Divisions. The designation of a Division as a Restricted
Fund may be changed upon 30 days notice to the Owner with regard to future
transfers and Premium Payments into such Division. When a new Division is made
available it may be designated as a Restricted Fund. If so designated, the
rules regarding its restrictions will be sent to the Owner. Restricted Funds
available under this Contract, if any, as well as applicable total Contract
limits, are shown in the Schedule.

THRESHOLDS

Each Restricted Fund has one or more thresholds at which point no further
amounts may be allocated to that Division. Compliance with a threshold is
verified whenever there is a transaction initiated which is subject to such
threshold (Premium Payments, transfers, withdrawals). A threshold is applied
to the total Accumulation Value of each Restricted Fund. Thresholds may be
changed by the Company for new premiums, transfers or withdrawals by
Restricted Fund upon 30 day notice.

DOLLAR CAP

The Dollar Cap is the dollar amount at which no further Accumulation Value
may be added to Restricted Funds.

PREMIUM THRESHOLD

The threshold for premium by Restricted Fund limits the amount of any premium
which may be allocated to that Division. Should a request for allocation to a
Restricted Fund exceed the limit in effect for that Division or for the
Contract, any excess over that amount shall be allocated prorata to any
non-Restricted Fund(s) in which the Contract is then invested. Should the
Contract not be invested in other non-Restricted Funds, the excess will be
invested in the Specially Designated Division unless we receive written
instructions to do otherwise. Premium allocations must also satisfy the
Allocation Threshold.

ALLOCATION THRESHOLD

Allocations into a Restricted Fund are limited to that amount such that the
Accumulation Value in that Restricted Fund after such allocation does not
exceed the threshold for that Division and does not cause the Contract's
total limit on allocation to Restricted Funds to be exceeded. If the amount
of an allocation would cause either limit to be exceeded, the allocation
will only be executed to the extent the lower limit would allow.

Allocations from a Restricted Fund will be allowed even if the amount remaining
in the Restricted Fund after an allocation exceeds the Allocation Threshold. If
a program of allocations over time is authorized by us, verification of the
threshold will be performed at the initiation of such program. If such program
is modified at a later date, a testing of thresholds will be done at that time.

GA-IA-1082                             9

<PAGE>

               PREMIUM PAYMENTS AND ALLOCATION CHANGES (continued)
-------------------------------------------------------------------------------

THRESHOLDS - EFFECT ON WITHDRAWALS

If a withdrawal is requested while any Accumulation Value is allocated to
Restricted Funds and the Allocation Threshold percentage is currently exceeded,
the percentage for funds invested in Restricted Funds for the total Contract,
after taking into account the withdrawal, may not be higher than prior to the
withdrawal. Should the calculated effect of a withdrawal result in the total
Contract threshold being exceeded, the excess portion of the withdrawal will be
processed prorata from all variable Divisions. Systematic withdrawals, while
the Contract has investments in Restricted Funds, if not withdrawn prorata
from all Divisions, shall be monitored annually to assure threshold compliance.
Should the effect of such withdrawals cause a Restricted Fund to exceed its
threshold, the Divisions from which the withdrawals are processed may be
adjusted to assure that the percentage of Accumulation Value in the
Restricted Funds does not increase.

THRESHOLD PROCESSING

For the purpose of calculating any thresholds, the values for the Divisions
will be determined using the prior day's closing Index of Investment
Experience.

GA-IA-1082                             10

<PAGE>

                HOW WE MEASURE THE CONTRACT'S ACCUMULATION VALUE
-------------------------------------------------------------------------------

The variable Annuity Benefits under this Contract are provided through
investments which may be made in our Separate Accounts.

THE VARIABLE SEPARATE ACCOUNTS

These accounts, which are designated in the Schedule, are kept separate from
ournGeneral Account and any other Separate Accounts we may have.
They are used to support Variable Annuity Contracts and may be used
for other purposes permitted by applicable laws and regulations. We own the
assets in the Separate Accounts. Assets equal to the reserves and other
liabilities of the accounts will not be
charged with liabilities that arise from any other business we conduct; but, we
may transfer to our General Account assets which exceed the reserves and other
liabilities of the Variable Separate Accounts. Income and realized and
unrealized gains or losses from assets in these Variable Separate Accounts are
credited to or charged against the account without regard to other income,
gains or losses in our other investment accounts.

The Variable Separate Account will invest in mutual funds, unit investment
trusts and other investment portfolios which we determine to be suitable for
this Contract's purposes. The Variable Separate Account is treated as a unit
investment trust under Federal securities laws. It is registered with the
Securities and Exchange Commission ("SEC") under the Investment Company Act
of 1940. The Variable Separate Account is also governed by state law as
designated in the Schedule. The trusts may offer non-registered series.

Variable Separate Account Divisions
A unit investment trust Separate Account includes Divisions, each investing in
a designated investment portfolio. The Divisions and the investment portfolios
designated may be managed by a separate investment adviser. Such adviser may be
registered under the Investment Advisers Act of 1940.

Changes within the Variable Separate Accounts
We may, from time to time, make additional Variable Separate Account Divisions
available to you. These Divisions will invest in investment portfolios we find
suitable for this Contract. We also have the right to eliminate Divisions from
a Variable Separate Account, to combine two or more Divisions or to substitute
a new portfolio for the portfolio in which a Division invests. A substitution
may become necessary if, in our judgment, a portfolio or Division no longer
suits the purpose of this Contract. This may happen due to a change in laws or
regulations, or a change in a portfolio's investment objectives or
restrictions, or because the portfolio or Division is no longer available
for investment, or for some other reason. We will obtain any required
regulatory  approvals before making such a substitution.

Subject to any required regulatory approvals, we reserve the right to transfer
assets of the Variable Separate Account which we determine to be associated
with the class of contracts to which this Contract belongs, to another Variable
Separate Account or Division.

When permitted by law, we reserve the right to:

     (1) deregister a Variable Separate Account under the Investment Company
         Act of 1940;
     (2) operate a Variable Separate Account as a management company under the
         Investment Company Act of 1940, if it is operating as a unit
         investment trust;
     (3) operate a Variable Separate Account as a unit investment trust under
         the Investment Company Act of 1940, if it is operating as a managed
         Variable Separate Account;
     (4) restrict or eliminate any voting rights of Owners, or other persons
         who have voting rights to a Variable Separate Account; and
     (5) combine a Variable Separate Account with other Variable
         Separate Accounts.

GA-IA-1082                             11

<PAGE>

            HOW WE MEASURE THE CONTRACT'S ACCUMULATION VALUE (continued)
------------------------------------------------------------------------------

THE GENERAL ACCOUNT

The General Account contains all assets of the Company other than those in the
Separate Accounts we establish. The Guaranteed Interest Divisions available for
investment are shown in the Schedule. We may, from time to time, offer other
Divisions where assets are held in our General Account.

VALUATION PERIOD

Each Division and Fixed Allocation will be valued at the end of each Valuation
Period on a Valuation Date. A Valuation Period is each Business Day together
with any non-Business Days before it. A Business Day is any day the New York
Stock Exchange (NYSE) is open for trading, and the SEC requires mutual funds,
unit investment trusts, or other investment portfolios to value their
securities.

ACCUMULATION VALUE

The Accumulation Value of this Contract is the sum of the amounts in each of
the Divisions of the Variable Separate Account and General Account and
allocations to the Fixed Account. You select the Divisions of the
Variable Separate Account, General Account and the Fixed Allocations to the
Fixed Account to which to allocate the Accumulation Value.

ACCUMULATION VALUE IN EACH DIVISION AND FIXED ALLOCATION

On the Contract Date
On the Contract Date, the Accumulation Value is allocated to each Division and
Fixed Allocation as elected by you, subject to certain terms and conditions
imposed by us. We reserve the right to allocate premium to the Specially
Designated Division during any Right to Examine period. After such time,
allocation will be made proportionately in accordance with the initial
allocation(s) as elected by you.

On each Valuation Date
At the end of each subsequent Valuation Period, the amount of Accumulation
Value in each Division and Fixed Allocation will be calculated as follows:

     (1) We take the Accumulation Value in the Division or Fixed Allocation at
         the end of the preceding Valuation Period.
     (2) We multiply (1) by the Variable Separate Account Division's Net Rate
         of Return for the current Valuation Period or we calculate the
         interest to be credited to a Fixed Allocation or to a Guaranteed
         Interest Division for the current Valuation Period.
     (3) We add (1) and (2).
     (4) We add to (3) any additional Premium Payments (less any premium
         deductions as shown in the Schedule) allocated to the Division or
         Fixed Allocation during the current Valuation Period.
     (5) We add or subtract allocations to or from that Division or Fixed
         Allocation during the current Valuation Period.
     (6) We subtract from (5) any Partial Withdrawals which are allocated to
         the Division or Fixed Allocation during the current Valuation Period.
     (7) We subtract from (6) the amounts allocated to that Division or Fixed
         Allocation for: (a) any charges due for the Optional Benefit Riders as
         shown in the Schedule; (b) any deductions from Accumulation Value as
         shown in the Schedule.

All amounts in (7) are allocated to each Division or Fixed Allocation in the
proportion that (6) bears to the Accumulation Value unless the Charge Deduction
Division has been specified (see the Schedule).

GA-IA-1082                             12

<PAGE>

                 HOW WE MEASURE THE CONTRACT'S ACCUMULATION VALUE (continued)
-------------------------------------------------------------------------------

FIXED ACCOUNT

The Fixed Account is a Separate Account under state insurance law and is not
required to be registered with the Securities and Exchange Commission under the
Investment Company Act of 1940. The Fixed Account includes various Fixed
Allocations which we credit with fixed rates of interest for the Guarantee
Period or Periods you select. We reset the interest rates for new Fixed
Allocations periodically based on our sole discretion.

Guarantee Periods
Each Fixed Allocation is guaranteed an interest rate or rates for a Guarantee
Period. The Guaranteed Interest Rates for a Fixed Allocation are effective for
the entire period. The Maturity Date of a Guarantee Period will be on the last
day of the calendar month in which the Guarantee Period ends. Withdrawals and
transfers made during a Guarantee Period may be subject to a Market Value
Adjustment unless made within thirty days prior to the Maturity Date.

Upon the expiry of a Guarantee Period, we will transfer the Accumulation Value
of the expiring Fixed Allocation to a Fixed Allocation with a Guarantee Period
equal in length to the expiring Guarantee Period, unless you select another
period prior to a Maturity Date. We will notify you at least thirty days prior
to a Maturity Date of your options for renewal. If the period remaining from
the expiry of the previous Guarantee Period to the Annuity Commencement Date
is less than the period you have elected or the period expiring, the next
shortest period then available that will not extend beyond the Annuity
Commencement Date will be offered to you. If a period is not available,
the Accumulation Value will be transferred to the Specially Designated
Division.

We will declare Guaranteed Interest Rates for the then available Fixed
Allocation Guarantee Periods. These interest rates are based solely on our
expectation as to our future earnings. Declared Guaranteed Interest Rates are
subject to change at any time prior to application to specific Fixed
Allocations, although in no event will the rates be less than the Minimum
Guaranteed Interest Rate (see the Schedule).

Market Value Adjustments
A Market Value Adjustment will be applied to a Fixed Allocation upon
withdrawal, transfer or application to an Income Plan if made more than
thirty days prior to such Fixed Allocation's Maturity Date, except on
Systematic Partial Withdrawals and IRA Partial Withdrawals. The Market
Value Adjustment is applied to each Fixed Allocation separately.

The Market Value Adjustment is determined by multiplying the amount of the
Accumulation Value withdrawn, transferred or applied to an Income Plan by the
following factor:

                            1  +  I                N/365
                      ------------------------
                        1  +  J  +  .0050            -  1

Where I is the Index Rate for a Fixed Allocation on the first day of the
applicable Guarantee Period; J is the Index Rate for new Fixed Allocations
with Guarantee Periods equal to the number of years (fractional years
rounded up to the next full year) remaining in the Guarantee Period at
the time of calculation; and N is the remaining number of days in the
Guarantee Period at the time of calculation. (The Index Rate is
described in the Schedule.)

Market Value Adjustments will be applied as follows:

     (1) The Market Value Adjustment will be applied to the amount withdrawn
         before deduction of any applicable Surrender Charge.

     (2) For a Partial Withdrawal, partial transfer or in the case where a
         portion of an allocation is applied to an Income Plan,
         the Market Value
         Adjustment will be calculated on the total amount that must be
         withdrawn, transferred or applied to an Income Plan in
         order to provide the amount requested.

GA-IA-1082                             13

<PAGE>

          HOW WE MEASURE THE CONTRACT'S ACCUMULATION VALUE (continued)
-------------------------------------------------------------------------------

(1)      If the Market Value Adjustment is negative, it will be assessed first
         against any remaining Accumulation Value in the particular Fixed
         Allocation. Any remaining Market Value Adjustment will be applied
         against the amount withdrawn, transferred or applied to an Income
         Plan.

(2)      If the Market Value Adjustment is positive, it will be credited to any
         remaining Accumulation Value in the particular Fixed Allocation. If a
         cash surrender, full transfer or full application to an Income Plan
         has been requested, the Market Value Adjustment is added to the
         amount withdrawn, transferred or applied to an Income Plan.

MEASUREMENT OF INVESTMENT EXPERIENCE

Index of Investment Experience
The Investment Experience of a Variable Separate Account Division is determined
on each Valuation Date. We use an Index to measure changes in each Division's
experience during a Valuation Period. We set the Index at $10 when the first
investments in a Division are made. The Index for a current Valuation Period
equals the Index for the preceding Valuation Period multiplied by the Experience
Factor for the current Valuation Period.

How We Determine the Experience Factor
For Divisions of a unit investment trust Separate Account the Experience Factor
reflects the Investment Experience of the portfolio in which the Division
invests as well as the charges assessed against the Division for a Valuation
Period. The factor is calculated as follows:

     (1) We take the net asset value of the portfolio in which the Division
         invests at the end of the current Valuation Period.
     (2) We add to (1) the amount of any dividend or capital gains distribution
         declared for the investment portfolio and reinvested in such portfolio
         during the current Valuation Period. We subtract from that amount a
         charge for our taxes, if any.
     (3) We divide (2) by the net asset value of the portfolio at the end of
         the preceding Valuation Period.
     (4) We subtract the daily Mortality and Expense Risk Charge for each
         Division described in the Schedule for each
         day in the Valuation Period.
     (5) We subtract the daily Asset Based Administrative Charge described in
         the Schedule for each day in the Valuation Period.

Calculations for Divisions investing in unit investment trusts are on a per
unit basis.

Net Rate of Return for a Variable Separate Account Division
The Net Rate of Return for a Variable Separate Account Division during a
Valuation Period is the Experience Factor for that Valuation Period minus one.

Interest Credited to a Guaranteed Interest Division
Accumulation Value allocated to a Guaranteed Interest Division will be credited
with the Guaranteed Interest Rate for the Guarantee Period in effect on the
date the premium or reallocation is applied. Once applied, such rate will be
guaranteed until the Maturity Date of that Guarantee Period. Interest will be
credited daily at a rate to yield the declared annual Guaranteed Interest Rate.
No Guaranteed Interest Rate will be less than the Minimum Interest Rate shown
in the Schedule.

GA-IA-1082                             14

<PAGE>

        HOW WE MEASURE THE CONTRACT'S ACCUMULATION VALUE (continued)
-------------------------------------------------------------------------------

Interest Credited to a Fixed Allocation
A Fixed Allocation will be credited with the Guaranteed Interest Rate for the
Guarantee Period in effect on the date the premium or reallocation is applied.
Once applied, such rate will be guaranteed until that Fixed Allocation's
Maturity Date. Interest will be credited daily at a rate to yield the declared
annual Guaranteed Interest Rate.

We periodically declare Guaranteed Interest Rates for then available Guarantee
Periods. No Guaranteed Interest Rate will be less than the Minimum Interest
Rate shown in the Schedule.

CHARGES DEDUCTED FROM ACCUMULATION VALUE ON EACH CONTRACT PROCESSING DATE

Expense charges and fees are shown in the Schedule.

Charge Deduction Division Option
We will deduct all charges against the Accumulation Value of this Contract from
the Charge Deduction Division if you elected this option on the application
(see the Schedule). If you did not elect this Option or if the charges are
greater than the amount in the Charge Deduction Division, the charges against
the Accumulation Value will be deducted as follows:

     (1) If these charges are less than the Accumulation Value in the Variable
         Separate Account Divisions, they will be deducted proportionately
         from all Divisions.

     (2) If these charges exceed the Accumulation Value in the Variable
         Separate Account Divisions, any excess over such value will
         be deducted proportionately from any Fixed Allocations and
         Guaranteed Interest Divisions.

Any charges taken from the Fixed Account or the General Account will be taken
from the Fixed Allocations and the Guaranteed Interest Divisions starting with
the Guarantee Period nearest its Maturity Date until such charges have been
paid.

At any time while this Contract is in effect, you may change your election of
this Option. To do this you must send us a written request to our Customer
Service Center. Any change will take effect within seven days of the date we
receive your request.

GA-IA-1082                             15

<PAGE>

                             YOUR CONTRACT BENEFITS
------------------------------------------------------------------------------

While this Contract is in effect, there are important rights and benefits that
are available to you. We discuss these rights and benefits in this section.

CASH VALUE BENEFIT

Cash Surrender Value
The Cash Surrender Value, while the Annuitant is living and before the Annuity
Commencement Date, is determined as follows:

     (1) We take the Contract's Accumulation Value;
     (2) We adjust for any applicable Market Value Adjustment;
     (3) We deduct any Surrender Charges;
     (4) We deduct any charges shown in the Schedule that have been incurred
         but not yet deducted, including:

         (a) any administrative charge that has not yet been deducted;
         (b) the prorata part of any charges for Optional Benefit Riders; and
         (c) any applicable premium or other tax.

Cancelling to Receive the Cash Surrender Value
At any time while the Annuitant is living and before the Annuity Commencement
Date, you may surrender this Contract to us. To do this, you must return this
Contract with a signed request for cancellation to our Customer Service Center.

The Cash Surrender Value will vary daily. We will determine the Cash Surrender
Value as of the date we receive the Contract and your signed request in our
Customer Service Center. All benefits under this Contract will then end.

We will usually pay the Cash Surrender Value within seven days; but, we may
delay payment as described in the Payments We May Defer provision.

PARTIAL WITHDRAWAL OPTION

After the Contract Date, you may make Partial Withdrawals. Partial Withdrawals
may be subject to a Partial Withdrawal Charge (see the Schedule). The minimum
amount that may be withdrawn is shown in the Schedule. The maximum amount that
may be withdrawn without Surrender Charge is shown in the Schedule. To take a
Partial Withdrawal, you must provide us satisfactory notice at our Customer
Service Center.

PROCEEDS PAYABLE TO THE BENEFICIARY

Prior to the Annuity Commencement Date
If the sole Owner dies prior to the Annuity Commencement Date, we will pay
the Beneficiary the Death Benefit. If there are joint Owners and any Owner
dies, we will pay the surviving Owners the Death Benefit. We will pay the
amount on receipt of due proof of the Owner's death at our Customer Service
Center. Such amount may be received in a single lump sum or applied to any
of the Annuity Options (see Choosing an Income Plan). When the Owner (or all
Owners where there are joint Owners) is not an individual, the Death Benefit
will become payable on the death of the Annuitant prior to the Annuity
Commencement Date (unless a Contingent Annuitant survived the Annuitant).
Only one Death Benefit is payable under this Contract. In all events,
distributions under the Contract must be made as required by applicable law.

GA-IA-1082                             16

<PAGE>

                       YOUR CONTRACT BENEFITS (continued)
-------------------------------------------------------------------------------

How to Claim Payments to Beneficiary
We must receive proof of the Owner's (or the Annuitant's) death before we will
make any payments to the Beneficiary. We will calculate the Death Benefit as of
the date we receive due proof of death. The Beneficiary should contact our
Customer Service Center for instructions.

GA-IA-1082                             17

<PAGE>

                             CHOOSING AN INCOME PLAN
-------------------------------------------------------------------------------

ANNUITY BENEFITS

If the Annuitant and Owner are living on the Annuity Commencement Date, we will
begin making payments to the Owner. We will make these payments under the
Annuity Option (or Options) as chosen in the application or as subsequently
selected. You may choose or change an Annuity Option by making a written
request at least 30 days prior to the Annuity Commencement Date. Unless you
have chosen otherwise, Option 2 on a 10-year period certain basis will
become effective. The amounts of the payments will be determined by applying
the Accumulation Value on the Annuity Commencement Date in accordance with
the Annuity Options section below (see Payments We May Defer). Before we pay
any Annuity Benefits, we require the return of this Contract. If this Contract
has been lost, we require the applicable lost Contract form.

ANNUITY COMMENCEMENT DATE SELECTION

You select the Annuity Commencement Date. You may select any date following the
fifth Contract Anniversary but before the required date of Annuity Commencement
as shown in the Schedule. If you do not select a date, the Annuity Commencement
Date will be in the month following the required date of Annuity Commencement.

FREQUENCY SELECTION

You may choose the frequency of the Annuity Payments. They may be monthly,
quarterly, semi-annually or annually. If we do not receive written notice from
you, the payments will be made monthly.

THE INCOME PLAN

While this Contract is in effect and before the Annuity Commencement Date, you
may choose one or more Annuity Options for the payment of Death Benefit
proceeds. If, at the time of the Owner's death, no Option has been chosen for
paying the Death Benefit proceeds, the Beneficiary may choose an Option within
one year. You may also elect an Annuity Option on surrender of the Contract for
its Cash Surrender Value. For each Option we will issue a separate written
agreement putting the Option into effect.

Our approval is needed for any Option where:

     (1) the person named to receive payment is other than the Owner or
         Beneficiary; or
     (2) the person named is not a natural person, such as a
         corporation; or
     (3) any income payment would be less than the minimum
         annuity income payment shown in the Schedule.

THE ANNUITY OPTIONS

There are four Options to choose from.  They are:

Option 1.  Income for a Fixed Period
Payment is made in equal installments for a fixed number of years. We guarantee
each monthly payment will be at least the Income for Fixed Period amount shown
in the Schedule. Values for annual, semiannual or quarterly payments are
available on request.

GA-IA-1082                             18

<PAGE>

                       CHOOSING AN INCOME PLAN (continued)
-------------------------------------------------------------------------------

Option 2.  Income for Life
Payment is made to the person named in equal monthly installments and
guaranteed for at least a period certain. The period certain can be 10 or
20 years. Other periods certain are available on request. A refund certain
may be chosen instead. Under this arrangement, income is guaranteed until
payments equal the amount applied. If the person named lives beyond the
guaranteed period, payments continue until his or her death.

We guarantee each payment will be at least the amount shown in the Schedule. By
age, we mean the named person's age on his or her nearest birthday before the
Option's effective date. Amounts for ages not shown are available on request.

Option 3.  Joint Life Income
This Option is available if there are two persons named to receive payments. At
least one of the persons named must be either the Owner or Beneficiary of this
Contract. Monthly payments are guaranteed and are made as long as at least one
of the named persons is living. The monthly payment amounts are available upon
request. Such amounts are guaranteed and will be calculated on the same basis
as the Table for Income for Life, however, the amounts will be based on two
lives.

Option 4.  Annuity Plan
Payment may be made under any other method mutually agreed upon by you and us.

The minimum rates for Option 1 are based on 3% interest, compounded annually.
The minimum rates for Options 2 and 3 are based on 3% interest, compounded
annually, and the Annuity 2000 Mortality Table. We may pay a higher rate at our
discretion.

PAYMENT WHEN NAMED PERSON DIES

When the person named to receive payment dies, we will pay any amounts still
due as provided by the Option agreement. The amounts still due are determined
as follows:

     (1) For Option 1 or for any remaining guaranteed payments in Option 2,
         payments will be continued.
     (2) For Option 3, no amounts are payable after
         both named persons have died.
     (3) For Option 4, the annuity agreement will
         state the amount due, if any.

GA-IA-1082                             19

<PAGE>

                           OTHER IMPORTANT INFORMATION
------------------------------------------------------------------------------

SENDING NOTICE TO US

Whenever written notice is required, send it to our Customer Service Center.
The address of our Customer Service Center is shown on the cover page. Please
include your Contract number in all correspondence.

REPORTS TO OWNER

We will send you a report at least once during each Contract Year. The report
will show the Accumulation Value and the Cash Surrender Value as of the end of
the Contract Processing Period. The report will also show the allocation of the
Accumulation Value as of such date and the amounts deducted from or added to
the Accumulation Value since the last report. The report will also include any
information that may be currently required by the insurance supervisory
official of the jurisdiction in which the Contract is delivered.

We will also send you copies of any shareholder reports of the portfolios in
which the Divisions of the Variable Separate Account invest, as well as any
other reports, notices or documents required by law to be furnished to Owners.

ASSIGNMENT - USING THIS CONTRACT AS COLLATERAL SECURITY

You can assign this Contract as collateral security for a loan or other
obligation. This does not change the ownership. Your rights and any
Beneficiary's right are subject to the terms of the assignment. To make or
release an assignment, we must receive written notice satisfactory to us,
at our Customer Service Center. We are not responsible for the validity of any
assignment.

CHANGING THIS CONTRACT

This Contract or any additional benefit riders may be changed to another
annuity plan according to our rules at the time of the change.

CONTRACT CHANGES - APPLICABLE TAX LAW

We reserve the right to make changes in this Contract or its Riders to the
extent we deem it necessary to continue to qualify this Contract as an annuity.
Any such changes will apply uniformly to all Contracts that are affected. You
will be given advance written notice of such changes.

MISSTATEMENT OF AGE OR SEX

If an age or sex has been misstated, the amounts payable or benefits provided
by this Contract will be those that the Premium Payment made would have
bought at the correct age or sex.

NON-PARTICIPATING

This Contract does not participate in the divisible surplus of Golden American
Life Insurance Company.

GA-IA-1082                             20

<PAGE>

                     OTHER IMPORTANT INFORMATION (continued)
-------------------------------------------------------------------------------

CONTESTABILITY

This Contract is incontestable from its date of issue.

PAYMENTS WE MAY DEFER

We may not be able to determine the value of the assets of the Variable
Separate Account Divisions because:
     (1) The NYSE is closed for trading;
     (2) the SEC determines that a state of emergency exists;
     (3) an order or pronouncement of the SEC permits a delay for the
         protection of Owners; or
     (4) the check used to pay the premium has not cleared through the banking
         system. This may take up to 15 days.

During such times, as to amounts allocated to the Divisions of the Variable
Separate Account, we may delay;
     (1) determination and payment of the Cash Surrender Value;
     (2) determination and payment of any Death Benefit if death occurs
         before the Annuity Commencement Date;
     (3) allocation changes of the Accumulation Value; or,
     (4) application of the Accumulation Value under an income plan.

As to the amounts allocated to a Guaranteed Interest Division in the General
Account and as to amounts allocated to Fixed Allocations of the Fixed Account,
we may, at any time, defer payment of the Cash Surrender Value for up to six
months after we receive a request for it. We will allow interest of at least
3.00% a year on any Cash Surrender Value payment derived from the Fixed
Allocations or the Guaranteed Interest Divisions that we defer 30 days or more.

AUTHORITY TO MAKE AGREEMENTS

All agreements made by us must be signed by one of our officers. No other
person, including an insurance agent or broker, can:

     (1) change any of this Contract's terms;
     (2) extend the time for Premium Payments; or
     (3) make any agreement binding on us.

REQUIRED NOTE ON OUR COMPUTATIONS

We have filed a detailed statement of our computations with the insurance
supervisory official in the jurisdiction where this Contract is delivered. The
values are not less than those required by the law of that state or
jurisdiction. Any benefit provided by an attached Optional Benefit Rider will
not increase these values unless otherwise stated in that Rider.

GA-IA-1082                             21

<PAGE>

FLEXIBLE PREMIUM DEFERRED VARIABLE ANNUITY CONTRACT - NO DIVIDENDS
-------------------------------------------------------------------------------
Variable Cash Surrender Values while the Annuitant and Owner are living
and prior to the Annuity Commencement Date. Death Benefit subject to guaranteed
minimum.  Partial Withdrawal Option. Non-participating.  Investment results
reflected in values.

GA-IA-1082

<PAGE>

                                 THE SCHEDULE (7% DB)
                                 CONTRACT FACTS
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|
CONTRACT FACTS

Contract Processing Date
The Contract Processing Date for your Contract is [April 1] of each year.

Specially Designated Division
When a distribution is made from an investment portfolio underlying a Separate
Account Division in which reinvestment is not available, we will allocate the
amount of the distribution to the [Liquid Asset Division] unless you specify
otherwise.

PARTIAL WITHDRAWALS

The maximum amount that can be withdrawn each Contract Year without being
considered an Excess Partial Withdrawal is described below. We will collect a
Surrender Charge for Excess Partial Withdrawals and a charge for any
unrecovered Premium Taxes. In no event may a Partial Withdrawal be greater
than 90% of the Cash Surrender Value. After a Partial Withdrawal, the
remaining Accumulation Value must be at least $100 to keep the Contract
in force.

Systematic Partial Withdrawals and Conventional Partial Withdrawals may not be
taken in the same Contract Year.

To determine the Surrender Charge on Excess Partial Withdrawals, the
withdrawals will occur in the following order:
    (1) Earnings;
    (2) The Free Amount;
    (3) Premium Payments made [four] or more years prior to the
        withdrawal; and,
    (4) Premium Payments made less than [four] years prior to withdrawal.

Earnings and Free Amounts are not treated as withdrawals of Premium Payments
for purposes of calculating any Surrender Charge.

Conventional Partial Withdrawals
Minimum Withdrawal Amount: $100

The maximum amount that can be taken as a Conventional Partial Withdrawal each
Contract Year without being considered an Excess Partial Withdrawal is the
greater of:

     (1) Earnings (defined below) not previously withdrawn, but not less
          than zero; and
     (2) The Free Amount, equal to 10% of Premium Payments not previously
         withdrawn, which were received within [four] years prior to the
         date of withdrawal.

Earnings are equal to the Accumulation Value, less Premium Payments, plus prior
withdrawals.

Any Conventional Partial Withdrawal is subject to a Market Value Adjustment
unless withdrawn from a Fixed Allocation within 30 days prior to the Maturity
Date.

GA-IA-1082                             3D1

<PAGE>

                               THE SCHEDULE
                           CONTRACT FACTS (continued)
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

Systematic Partial Withdrawals
Systematic Partial Withdrawals may be elected to commence after 28 days from
the Contract Issue Date and may be taken on a monthly, quarterly or annual
basis. You select the day withdrawals will be made, but no later than the
28th day of the month. If you do not elect a day, the Contract Date will
be used.

Maximum Withdrawal Amounts:

 Variable Separate Account Divisions:     .833% of Premium Payments monthly,
                                           2.5% of Premium Payments
                                           quarterly or 10% of Premium Payments
                                           Annually.

 Fixed Allocations and
 Guaranteed Interest Divisions:           Interest earned on a Fixed Allocation
                                          or Guaranteed Interest
                                          Division for the prior month,
                                          quarter or year (depending on the
                                          frequency selected).

The Maximum Withdrawal Amount available as a Systematic Partial
Withdrawal is 10% of Premium Payments not previously withdrawn.
Systematic Partial Withdrawals from Fixed Allocations are not
subject to a Market Value Adjustment. A Systematic Withdrawal in
Excess of Earnings and the Free Amount may be subject
to a Surrender Charge.

IRA Partial Withdrawals for Qualified Plans Only
Partial Withdrawals may be taken from a Contract issued as an IRA on a
monthly, quarterly or annual basis. A minimum withdrawal of $100.00 is
required. You select the day the withdrawals will be made, but no later
than the 28th day of the month. If you do not elect a day, the Contract
Date will be used. Systematic Partial Withdrawals and Conventional Partial
Withdrawals are not allowed when IRA Partial Withdrawals are being taken.
An IRA Partial Withdrawal in excess of the maximum amount allowed under
the Systematic Partial Withdrawal option may be
subject to a Market Value Adjustment.

DEATH BENEFIT

The Death Benefit is the greatest of (i), (ii), (iii) and (iv) below,
where:
    (i)   is the Accumulation Value;
    (ii)  is the lesser of (a) and (b), where (a) is the Guaranteed Death
          Benefit and (b) is the Maximum Guaranteed
          Death Benefit;
    (iii) is the Cash Surrender Value; and
    (iv)  is the Minimum Death Benefit.

MINIMUM DEATH BENEFIT

The Minimum Death Benefit shall be the sum of the following:

     1.  The Accumulation Value allocated to Special Funds; and
     2.  Adjusted Premium for non-Special Funds.

GA-IA-1082                             3D2

<PAGE>

                                  THE SCHEDULE
                           CONTRACT FACTS (continued)
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

Adjusted Premium for non-Special Funds shall mean all premium allocated to
non-Special Funds, plus an adjustment for any amounts transferred to
non-Special Funds, less a prorata adjustment for any amounts transferred
or withdrawn from non-Special Funds. The amount of the prorata adjustment
will equal (a) times (b) divided by (c), where: (a) is the Adjusted Premium
for non-Special Funds prior to the transfer or withdrawal; (b) is the
Accumulation Value of the transfer or withdrawal; and (c) is the
Accumulation Value allocated to non-Special Funds before the transfer
or withdrawal. Adjusted Premium for Special Funds has the same definition,
but with respect to amounts allocated to Special Funds.

Transfers from Special Funds increase the Adjusted Premium for non-Special
Funds by the lesser of the reduction of the Adjusted Premium for Special
Funds and net Accumulation Value transferred. Transfers from non-Special
Funds increase the Adjusted Premium for Special Funds by the reduction in
the Adjusted Premium for non-Special Funds.

GUARANTEED DEATH BENEFIT

The Guaranteed Death Benefit for the Contract is equal to the sum of I and II
below.
    I.  The Guaranteed Death Benefit Base for non-Special Funds.
    II. The Accumulation Value allocated to Special Funds.

On the Contract Date, the Guaranteed Death Benefit Base for non-Special Funds
is the initial premium, if applicable, allocated to non-Special Funds. On
subsequent Valuation Dates, the Guaranteed Death Benefit Base for non-Special
Funds is calculated as follows:

    (1)  Start with the Guaranteed Death Benefit Base for non-Special
         Funds on the prior Valuation Date.
    (2)  Calculate interest on (1) for the current Valuation Period at
         the Guaranteed Death Benefit Interest Rate for non-Special Funds.
    (3)  Add (1) and (2).
    (4)  Add to (3) any additional premiums allocated to non-Special Funds
         during the current Valuation Period.
    (5)  Add to (or subtract from) (4) adjustments for transfers from (to)
         Special Funds made during the Valuation Period.
    (6)  Subtract from (5) the amount of any Special Partial Withdrawal
         Adjustments and Prorata Partial Withdrawal Adjustments for any partial
         withdrawals made from non-Special Funds during the current Valuation
         Period.

The Guaranteed Death Benefit Base for Special Funds has a corresponding
definition, but with respect to amounts allocated to Special Funds.

Transfers from Special Funds to non-Special Funds will reduce the Guaranteed
Death Benefit Base for Special Funds on a prorata basis. The resulting increase
in the Guaranteed Death Benefit Base for non-Special Funds will equal the
lesser of the reduction in the Guaranteed Death Benefit Base for Special
Funds and the net Accumulation Value transferred.

GA-IA-1082                             3D3

<PAGE>

                                  THE SCHEDULE
                           CONTRACT FACTS (continued)
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

Transfers from non-Special Funds to Special Funds will reduce the Guaranteed
Death Benefit Base for non-Special Funds on a prorata basis. The resulting
increase in the Guaranteed Death Benefit Base for Special Funds will equal the
reduction in Guaranteed Death Benefit Base for non-Special Funds.

GUARANTEED DEATH BENEFIT INTEREST RATE

The Guaranteed Death Benefit Interest Rate is [7%] compounded annually, except:

(a)      For any portion of the Guaranteed Death Benefit Base for Special
         Funds, the Guaranteed Death Benefit Interest
         Rate is [7%] (compounded annually); and
(b)      For any valuation period ending after the Contract Anniversary on
         which the Owner attains age [80], or after the Maximum
         Guaranteed Death Benefit has been reached, the Guaranteed
         Death Benefit Interest Rate is [0%].

SPECIAL FUNDS

Where used in this Contract, Special Funds are [the Liquid Asset Division, the
Limited Maturity Bond Division, the Fixed Allocations and the Guaranteed
Interest Division]. We may add newly available Divisions as Special Funds. We
may also reclassify an existing Division as a Special Fund or remove such
designation upon 30 days notice to you. Such reclassification will apply to
amounts transferred or otherwise added to such Division after the date of
change. We may reduce the Mortality and Expense Risk Charge (if applicable) for
that portion of the Contract invested in a Special Fund.

MAXIMUM GUARANTEED DEATH BENEFIT

The Maximum Guaranteed Death Benefit is equal to [three] times premium paid,
reduced by the amount of any Partial Withdrawal Adjustments. The Maximum
Guaranteed Death Benefit is allocated proportionally based on the Contract's
allocation to Special and non-Special funds. Transfers and withdrawals will
affect the allocation of the Maximum Guaranteed Death Benefit at the same
proportion among the Special and non-Special Funds that they bear to the
Accumulation Value transferred or withdrawn. Any addition due to spousal
continuation will not affect the Maximum Guaranteed Death Benefit or the
Guaranteed Death Benefit Base.

SPECIAL AND PRORATA PARTIAL WITHDRAWAL ADJUSTMENTS

For any partial withdrawal, the Death Benefit components will be reduced by
Prorata Partial Withdrawal Adjustments. A Prorata Partial Withdrawal Adjustment
will be made unless a Special Partial Withdrawal Adjustment applies to the
component for the withdrawal. Special Partial Withdrawal Adjustments are made
when partial withdrawals in any Contract Year do not exceed [7%] of the sum of
cumulative premiums, but only if partial withdrawals in each prior year did not
exceed [7%] of the sum of premiums paid prior to that year. The Special Partial
Withdrawal Adjustment is equal to the amount of the Accumulation Value
withdrawn.

GA-IA-1082                             3D4

<PAGE>

                                  THE SCHEDULE
                           CONTRACT FACTS (continued)
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

Special Partial Withdrawal Adjustments are applicable only in the calculation
of the Maximum Guaranteed Death Benefit and the Guaranteed Death Benefit
Base, and in all other cases withdrawals are treated as Prorata Partial
Withdrawal Adjustments.

The Prorata Partial Withdrawal Adjustment to a Death Benefit component is
equal to (1) divided by (2), multiplied by (3), where: (1) is the
Accumulation Value withdrawn; (2) is the Accumulation Value immediately
prior to withdrawal; and (3) is the amount of the applicable Death Benefit
component immediately prior to the withdrawal. Separate adjustments will
apply to the amounts in the Special and non-Special Funds.

CHANGE OF OWNER

A change of Owner from a sole Owner to a sole Owner (where there have never
been multiple Owners designated) will result in recalculation of the Death
Benefit, the Guaranteed Death Benefit, and the Maximum Guaranteed Death
Benefit. If the new Owner's Attained Age at the time of the change is less
than [80], the Guaranteed Death Benefit and the Maximum Guaranteed Death
Benefit in effect prior to the change will remain in effect and the Death
Benefit provision shall apply. If the new Owner's Attained Age at the time
of the change is [80] or greater, but not greater than [85]:
  (a) The Guaranteed Death Benefit and the Maximum Guaranteed Death Benefit
      following the change will be zero; and
  (b) The Death Benefit will then be the greatest of:
      (1)  the Cash Surrender Value;
      (2)  the Accumulation Value; and
      (3)  the Minimum Death Benefit.

If ownership changes result in multiple Owners or if there has ever been
multiple Owners, the Guaranteed Death Benefit and the Maximum Guaranteed
Death Benefit shall be set to zero. If the oldest Owner is age [85] or
younger at the time of the change, the Death Benefit will then be the
greatest of (b) 1, (b) 2 or (b) 3 above.

If any Owner's or oldest multiple Owner's Attained Age is [86] or greater at
the time of the change, the Guaranteed Death Benefit, the Minimum Death
Benefit, and the Maximum Guaranteed Death Benefit will be zero, and the
Death Benefit will then be the Cash Surrender Value.

When a change of Owner reduces the Guaranteed Death Benefit and the Maximum
Guaranteed Death Benefit to zero, there will be a reduction in the
Mortality and Expense Risk Charge.

GA-IA-1082                             3D5

<PAGE>

                                  THE SCHEDULE
                           CONTRACT FACTS (continued)
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

SPOUSAL CONTINUATION UPON DEATH OF OWNER

If at the Owner's death, the surviving spouse of the deceased Owner is the
Beneficiary and such surviving spouse elects to continue the Contract as their
own pursuant to Internal Revenue Code Section 72(s) or the equivalent
provisions of U.S. Treasury Department rules for qualified plans, the
following will apply:
     (a) If the greater of (ii) and (iv) in the Death
         Benefit provision as of them date we receive due proof of death
         of the Owner minus the Accumulation Value, also as of that date, is
         greater than zero, we will add such difference to the Accumulation
         Value. Such addition will be allocated to the Divisions of the
         Separate
         Account in the same proportion as the Accumulation Value in each
         Division bears to the Accumulation Value in the Separate Account. If
         there is no Accumulation Value in the Separate Account, the addition
         will be allocated to the Liquid Asset Division, or its successor.
     (b) The Guaranteed Death Benefit and the Maximum Guaranteed Death Benefit
         will continue to apply, using the surviving spouse's age as the
         determining age.
     (c) At subsequent surrender, any Surrender Charge applicable to premiums
         paid prior to the date we receive due proof of death of the Owner will
         be waived. Any premiums paid later will be subject to any applicable
         Surrender Charge.

This addition to Accumulation Value is available only to the spouse of the
Owner as of the date of death of the Owner if such spouse under the
provisions of this Contract elects to continue the Contract as their own.

CHOOSING AN INCOME PLAN

Required Date of Annuity Commencement
Distributions from a Contract funding a qualified plan must commence no later
than [April 1st] of the calendar year following the calendar year in which the
Owner attains age 70 1/2. Otherwise, the Annuity Commencement Date may be no
later than the same date as the Contract Processing Date in the month following
the Annuitant's 90th birthday. In applying the Accumulation Value, we may first
collect any Premium Taxes due us. If, on the Annuity Commencement Date, a
Surrender Charge remains, your elected Annuity Option must include a period
certain of at least five years duration.

Minimum Annuity Income Payment
The minimum monthly annuity income payment that we will make is [$20].

GA-IA-1082                             3D6

<PAGE>

                                  THE SCHEDULE
                           CONTRACT FACTS (continued)
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

OPTIONAL BENEFIT RIDERS - [None.]

ATTAINED AGE

The Issue Age of the Annuitant or Owner plus the number of full years elapsed
since the Contract Date.

RESTRICTED FUNDS - [None]

FIXED ACCOUNT

Minimum Fixed Allocation
The minimum allocation to the Fixed Account in any one Fixed Allocation is
[$250.00].

Minimum Guaranteed Interest Rate - [3%.]

Guarantee Periods
We currently offer Guarantee Periods of [1, 3, 5, 7 and 10] year(s). We reserve
the right to offer Guarantee Periods of durations other than those available on
the Contract Date. We also reserve the right to cease offering a particular
Guarantee Period or Periods.

Index Rate
The Index Rate is the average of the Ask Yields for the U.S. Treasury Strips as
reported by a national quoting service for the applicable maturity. The average
is based on the period from the 22nd day of the calendar month two months prior
to the calendar month of Index Rate determination to the 21st day of the
calendar month immediately prior to the month of determination. The applicable
maturity date for these U.S. Treasury Strips is on or next following the last
day of the Guarantee Period. If the Ask Yields are no longer available, the
Index Rate will be determined using a suitable replacement method.

We currently set the Index Rate once each calendar month. However, we reserve
the right to set the Index Rate more frequently than monthly, but in no event
will such Index Rate be based on a period less than 28 days.

GA-IA-1082                             3D7

<PAGE>

                                  THE SCHEDULE
                                CHARGES AND FEES
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|
DEDUCTIONS FROM PREMIUMS

None

DEDUCTIONS FROM ACCUMULATION VALUE

Initial Administrative Charge
None

Administrative Charge
We charge a maximum of $30 to cover a portion of our ongoing administrative
expenses for each Contract Processing Period. The charge is incurred at the
beginning of the Contract Processing Period and deducted on the Contract
Processing Date at the end of the period.

At the time of deduction, this charge will be waived if:
  1.  The Accumulation Value is at least $100,000; or
  2.  The sum of premiums paid to date is at least $100,000.

Excess Allocation Charge
Currently none, however, we reserve the right to charge $25 for a change if you
make more than twelve allocation changes per Contract Year. Any charge will be
deducted in proportion to the amount being transferred from each Division.

Surrender Charge
A Surrender Charge is imposed as a percentage of unliquidated premium if the
Contract is surrendered or an Excess Partial Withdrawal is taken. The
percentage imposed at time of surrender or Excess Partial Withdrawal
depends on the number of complete years that have elapsed
since a Premium Payment was made. The Surrender Charge expressed as a
percentage of each Premium Payment is as follows:

Complete Years Elapsed                               Surrender
Since Premium Payment                                 Charges
---------------------                                ---------
        [0                                               6%
         1                                               5%
         2                                               4%
         3                                               3%
         4+                                              0%]

Surrender of the Contract is permitted at or before the commencement of Annuity
Payments.

GA-IA-1082                             3E1

<PAGE>

                                  THE SCHEDULE
                                CHARGES AND FEES
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

Premium Taxes
We deduct the amount of any premium or other state and local taxes levied by
any state or governmental entity when such taxes are incurred.

We reserve the right to defer collection of Premium Taxes until surrender or
until application of Accumulation Value to an Annuity Option. An Excess Partial
Withdrawal will result in the deduction of any Premium Tax then due us on such
amount. We reserve the right to change the amount we charge for Premium Tax
charges on future Premium Payments to conform with changes in the law or if the
Owner changes state of residence.

Deductions from the Divisions
Mortality and Expense Risk Charge - We deduct a charge from the assets in each
---------------------------------
Variable Separate Account Division on a daily basis of not more than
[0.005535]% (equivalent to an annual maximum rate
of [2.00]%) for mortality and expense
risks. This charge is not deducted from the Fixed Account or General Account
Accumulation Values.

Asset Based Administrative Charge - We deduct a charge of not more than
---------------------------------
[0.000411]% of the assets in each Variable Separate Account Division on a daily
basis (equivalent to an annual maximum rate of [0.15]%) to compensate us for a
portion of our ongoing administrative expenses. This charge is not deducted
from the Fixed Account or General Account Accumulation Values.

CHARGE DEDUCTION DIVISION

If elected by you, all charges against the Accumulation Value in this Contract
will be deducted from the [Liquid Asset Division].

GA-IA-1082                             3E2

<PAGE>

                                  THE SCHEDULE
                               INCOME PLAN FACTORS
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

Values for other payment periods, ages or joint life combinations are available
on request. Monthly payments are shown for each $1,000 applied.

                       TABLE FOR INCOME FOR A FIXED PERIOD

  Fixed Period      Monthly    Fixed Period   Monthly    Fixed Period   Monthly
   of Years         Income      of Years      Income      of Years      Income

    [5            17.95             14          7.28           23         5.00
    6             15.18             15          6.89           24         4.85
    7             13.20             16          6.54           25         4.72
    8             11.71             17          6.24           26         4.60
    9             10.56             18          5.98           27         4.49
    10             9.64             19          5.74           28         4.38
    11             8.88             20          5.53           29         4.28
    12             8.26             21          5.33           30         4.19]
    13             7.73             22          5.16

                            TABLE FOR INCOME FOR LIFE

            Male/Female                Male/Female              Male/Female
Age       10 Years Certain           20 Years Certain           Refund Certain

[50         $4.06/3.83                 $3.96/3.77               $3.93/3.75
55           4.43/4.14                  4.25/4.05                4.25/4.03
60           4.90/4.56                  4.57/4.37                4.66/4.40
65           5.51/5.10                  4.90/4.73                5.12/4.83
70           6.26/5.81                  5.18/5.07                5.76/5.42
75           7.11/6.70                  5.38/5.33                6.58/6.19
80           7.99/7.70                  5.48/5.46                7.69/7.21
85           8.72/8.59                  5.52/5.51                8.72/8.59
90           9.23/9.18                  5.53/5.53             10.63/10.53]

GA-IA-1082                             3F

<PAGE>

                                 THE SCHEDULE (RATCHET)
                                 CONTRACT FACTS
|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|
CONTRACT FACTS

Contract Processing Date
The Contract Processing Date for your Contract is [April 1] of each year.

Specially Designated Division
When a distribution is made from an investment portfolio underlying a Separate
Account Division in which reinvestment is not available, we will allocate the
amount of the distribution to the [Liquid Asset Division] unless you specify
otherwise.

PARTIAL WITHDRAWALS

The maximum amount that can be withdrawn each Contract Year without being
considered an Excess Partial Withdrawal is described below. We will collect a
Surrender Charge for Excess Partial Withdrawals and a charge for any
unrecovered Premium Taxes. In no event may a Partial Withdrawal be
greater than 90% of the Cash Surrender Value. After a Partial Withdrawal,
the remaining Accumulation Value must be at least $100 to keep the Contract
in force.

Systematic Partial Withdrawals and Conventional Partial Withdrawals may not be
taken in the same Contract Year.

To determine the Surrender Charge on Excess Partial Withdrawals, the
withdrawals will occur in the following order:
  (1) Earnings;
  (2) The Free Amount;
  (3) Premium Payments made [four] or more years prior to the
      withdrawal; and
  (4) Premium Payments made less than [four] years prior to
      withdrawal.

Earnings and Free Amounts are not treated as withdrawals of Premium Payments
for purposes of calculating any Surrender Charge.

Conventional Partial Withdrawals
Minimum Withdrawal Amount: $100

The maximum amount that can be taken as a Conventional Partial Withdrawal each
Contract Year without being considered an Excess Partial Withdrawal is the
greater of:

     (1) Earnings (defined below) not previously withdrawn, but not less
         than zero; and
     (2) The Free Amount, equal to 10% of Premium Payments not previously
         withdrawn, which were received within [four] years prior to the
         date of withdrawal.

Earnings are equal to the Accumulation Value, less Premium Payments, plus prior
withdrawals.

Any Conventional Partial Withdrawal is subject to a Market Value Adjustment
unless withdrawn from a Fixed Allocation within 30 days prior to the Maturity
Date.

GA-IA-1082                             3D1

<PAGE>

                                  THE SCHEDULE
                           CONTRACT FACTS (continued)
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

Systematic Partial Withdrawals
Systematic Partial Withdrawals may be elected to commence after 28 days
from the Contract Issue Date and may be taken on a monthly, quarterly or
annual basis. You select the day withdrawals will be made, but no later
than the 28th day of the month. If you do not elect a day, the Contract
Date will be used.

Maximum Withdrawal Amounts:

 Variable Separate Account Divisions:   .833% of Premium Payments monthly,
                                        2.5% of Premium Payments
                                        quarterly or 10% of Premium Payments
                                        Annually.

     Fixed Allocations and
 Guaranteed Interest Divisions:         Interest earned on a Fixed Allocation
                                        or Guaranteed Interest
                                        Division for the prior month,
                                        quarter or year (depending on the
                                        frequency selected).

The Maximum Withdrawal Amount available as a Systematic Partial Withdrawal is
10% of Premium Payments not previously withdrawn. Systematic Partial
Withdrawals from Fixed Allocations are not subject to a Market Value
Adjustment. A Systematic Partial Withdrawal in excess of Earnings and
the Free Amount may be subject to a Surrender Charge.

IRA Partial Withdrawals for Qualified Plans Only
Partial Withdrawals may be taken from a Contract issued as an IRA on a monthly,
quarterly or annual basis. A minimum withdrawal of $100.00 is required. You
select the day the withdrawals will be made, but no later than the 28th day of
the month. If you do not elect a day, the Contract Date will be used.
Systematic Partial Withdrawals and Conventional Partial Withdrawals are
not allowed when IRA Partial Withdrawals are being taken. An IRA Partial
Withdrawal in excess of the maximum amount allowed under the Systematic
Partial Withdrawal option may be
subject to a Market Value Adjustment.

DEATH BENEFIT

The Death Benefit is the greatest of (i), (ii), (iii) and (iv) below, where:
  (i)   is the Accumulation Value;
  (ii)  is the Guaranteed Death Benefit;
  (iii) is the Cash Surrender Value; and
  (iv)  is the Minimum Death Benefit.

GA-IA-1082                             3D2

<PAGE>

                                  THE SCHEDULE
                           CONTRACT FACTS (continued)
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

MINIMUM DEATH BENEFIT

The Minimum Death Benefit shall be the sum of the following:

     1.  The Accumulation Value allocated to Special Funds; and
     2.  Adjusted Premium for non-Special Funds.

Adjusted Premium for non-Special Funds shall mean all premium allocated to
non-Special Funds, plus an adjustment for any amounts transferred to
non-Special Funds, less a prorata adjustment for any amounts transferred
or withdrawn from non-Special Funds. The amount of the prorata adjustment
will equal (a) times (b) divided by (c), where (a) is the Adjusted Premium
for non-Special Funds prior to the transfer or withdrawal; (b) is the
Accumulation Value of the transfer or withdrawal; and (c) is the Accumulation
Value allocated to non-Special Funds before the transfer or withdrawal.
Adjusted Premium for Special Funds has the
same definition, but with respect to amounts allocated to Special Funds.

Transfers from Special Funds increase the Adjusted Premium for non-Special
Funds by the lesser of the reduction of the Adjusted Premium for Special
Funds and net Accumulation Value transferred. Transfers from non-Special
Funds increase the Adjusted Premium for Special Funds by the reduction in
the Adjusted Premium for non-Special Funds.

GUARANTEED DEATH BENEFIT

The Guaranteed Death Benefit for the Contract is equal to the sum of I and
II below.
     I.  The Guaranteed Death Benefit Base for non-Special Funds.
     II. The Accumulation Value allocated to Special Funds.

On the Contract Date, the Guaranteed Death Benefit Base for non-Special Funds
is the initial premium allocated to non-Special Funds. On subsequent Valuation
Dates, the Guaranteed Death Benefit Base for non-Special Funds is calculated
as follows:

(1)      Start with the Guaranteed Death Benefit Base for non-Special Funds
         on the prior Valuation Date.
(2)      Add to (1) any additional premium allocated to the non-Special
         Funds during the current Valuation Period and
         adjustments for transfers from Special Funds during the current
         Valuation Period and subtract from (1) any adjustment for transfers to
         Special Funds during the current Valuation Period and any Prorata
         Partial Withdrawal Adjustments for any Partial Withdrawals taken from
         non-Special Funds during the current Valuation Period.

(3)      On a Valuation Date that occurs on or prior to the Owner's Attained
         Age [90], which is also a Contract Anniversary, we set the Guaranteed
         Death Benefit Base for non-Special Funds equal to the greater of (2)
         or the Accumulation Value allocated to non-Special Funds as of
         such date. On all other Valuation Dates, the Guaranteed Death
         Benefit Base for non-Special Funds is equal to (2).

The Guaranteed Death Benefit Base for Special Funds has a corresponding
definition, but with respect to amounts allocated to Special Funds.

GA-IA-1082                             3D3

<PAGE>

                                  THE SCHEDULE
                           CONTRACT FACTS (continued)
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

Transfers from Special Funds to non-Special Funds will reduce the Guaranteed
Death Benefit Base for Special Funds on a prorata basis. The resulting
increase in the Guaranteed Death Benefit Base for non-Special Funds
will equal the lesser of the reduction in the Guaranteed Death Benefit
Base for Special Funds and the net Accumulation Value transferred.

Transfers from non-Special Funds to Special Funds will reduce the Guaranteed
Death Benefit Base for non-Special Funds on a prorata basis. The resulting
increase in the Guaranteed Death Benefit Base for Special Funds will equal the
reduction in Guaranteed Death Benefit Base for non-Special Funds.

SPECIAL FUNDS

Where used in this Contract, Special Funds are [the Liquid Asset Division, the
Limited Maturity Bond Division, the Fixed Allocations and the Guaranteed
Interest Division]. We may add newly available Divisions as Special Funds. We
may also reclassify an existing Division as a Special Fund or remove such
designation upon 30 days notice to you. Such reclassification will apply to
amounts transferred or otherwise added to such Division after the date of
change. We may reduce the Mortality and Expense Risk Charge (if applicable) for
that portion of the Contract invested in a Special Fund.

PRORATA PARTIAL WITHDRAWAL ADJUSTMENTS

For any partial withdrawal, the Death Benefit components will be reduced by
Prorata Partial Withdrawal Adjustments. The Prorata Partial Withdrawal
Adjustment to a Death Benefit component for a partial withdrawal is equal to
(1) divided by (2) multiplied by (3), where: (1) is the Accumulation Value
withdrawn; (2) is the Accumulation Value immediately prior to withdrawal; and
(3) is the amount of the applicable Death Benefit component immediately prior
to the withdrawal. Separate adjustments will apply to amounts in the Special
and non-Special Funds.

CHANGE OF OWNER

A change of Owner from a sole Owner to a sole Owner (where there have never
been multiple Owners designated) will result in recalculation of the Death
Benefit and the Guaranteed Death Benefit. If the new Owner's Attained Age
at the time of the change is less than [80], the Guaranteed Death Benefit
in effect prior to the change will remain in effect and the Death Benefit
provision will apply. If the new Owner's Attained Age at the time of the
change is [80] or greater, but
not greater than [85]:

   (a) The Guaranteed Death Benefit following the change will be zero; and
   (b) The Death Benefit will then be the greatest of:
        (1)  the Cash Surrender Value;
        (2)  the Accumulation Value; and
        (3)  the Minimum Death Benefit.

GA-IA-1082                             3D4

<PAGE>

                                  THE SCHEDULE
                           CONTRACT FACTS (continued)
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

If ownership changes result in multiple Owners or if there has ever been
multiple Owners, the Guaranteed Death Benefit shall be set to zero. If the
oldest Owner is age [85] or younger at the time of the change, the Death
Benefit will then be the greatest of (b) 1, (b) 2 or (b) 3 above.

If any Owner's or oldest multiple Owner's Attained Age is [86] or greater at
the time of the change, the Guaranteed Death Benefit will be zero, and the
Death Benefit will then be the Cash Surrender Value.

When a change of Owner reduces the Guaranteed Death Benefit to zero, there will
be a reduction in the Mortality and Expense Risk Charge.

SPOUSAL CONTINUATION UPON DEATH OF OWNER

If at the Owner's death, the surviving spouse of the deceased Owner is the
Beneficiary and such surviving spouse elects to continue the Contract as their
own pursuant to Internal Revenue Code Section 72(s) or the equivalent
provisions of U.S. Treasury Department rules for qualified plans, the
following will apply:
    (a)  If the greater of (ii) and (iv) in the Death Benefit provision as
         of the date we receive due proof of death of the Owner minus the
         Accumulation Value, also as of that date, is greater than zero,
         we will add such difference to the Accumulation Value. Such
         addition will be allocated to the Divisions of the Separate
         Account in the same proportion as the Accumulation Value in each
         Division bears to the Accumulation Value in the Separate Account. If
         there is no Accumulation Value in the Separate Account, the addition
         will be allocated to the Liquid Asset Division, or its successor.

    (b)  The Guaranteed Death Benefit and the Maximum Guaranteed Death Benefit
         will continue to apply, using the surviving spouse's age as the
         determining age.

    (c)  At subsequent surrender, any Surrender Charge applicable to premiums
         paid prior to the date we receive due proof of death of the Owner will
         be waived. Any premiums paid later will be subject to any applicable
         Surrender Charge.

This addition to Accumulation Value is available only to the spouse of the
Owner as of the date of death of the Owner if such spouse under the provisions
of this Contract elects to continue the Contract as their own.

CHOOSING AN INCOME PLAN

Required Date of Annuity Commencement
Distributions from a Contract funding a qualified plan must commence no later
than [April 1st] of the calendar year following the calendar year in which the
Owner attains age 70 1/2. Otherwise, the Annuity Commencement Date may be no
later than the same date as the Contract Processing Date in the month following
the Annuitant's 90th birthday. In applying the Accumulation Value, we may first
collect any Premium Taxes due us. If, on the Annuity Commencement Date, a
Surrender Charge remains, your elected Annuity Option must include a period
certain of at least five years duration.

Minimum Annuity Income Payment
The minimum monthly annuity income payment that we will make is [$20].

GA-IA-1082                             3D5

<PAGE>

                                  THE SCHEDULE
                           CONTRACT FACTS (continued)
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

OPTIONAL BENEFIT RIDERS - [None.]

ATTAINED AGE

The Issue Age of the Annuitant or Owner plus the number of full years elapsed
since the Contract Date.

RESTRICTED FUNDS - [None]

FIXED ACCOUNT

Minimum Fixed Allocation
The minimum allocation to the Fixed Account in any one Fixed Allocation is
[$250.00].

Minimum Guaranteed Interest Rate - [3%.]

Guarantee Periods
We currently offer Guarantee Periods of [1, 3, 5, 7 and 10] year(s). We reserve
the right to offer Guarantee Periods of durations other than those available on
the Contract Date. We also reserve the right to cease offering a particular
Guarantee Period or Periods.

Index Rate
The Index Rate is the average of the Ask Yields for the U.S. Treasury Strips as
reported by a national quoting service for the applicable maturity. The average
is based on the period from the 22nd day of the calendar month two months prior
to the calendar month of Index Rate determination to the 21st day of the
calendar month immediately prior to the month of determination. The applicable
maturity date for these U.S. Treasury Strips is on or next following the last
day of the Guarantee Period. If the Ask Yields are no longer available, the
Index Rate will be determined using a suitable replacement method.

We currently set the Index Rate once each calendar month. However, we reserve
the right to set the Index Rate more frequently than monthly, but in no event
will such Index Rate be based on a period less than 28 days.

GA-IA-1082                             3D6

<PAGE>

                                  THE SCHEDULE
                                CHARGES AND FEES
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

DEDUCTIONS FROM PREMIUMS

None

DEDUCTIONS FROM ACCUMULATION VALUE

Initial Administrative Charge
None

Administrative Charge
We charge a maximum of $30 to cover a portion of our ongoing administrative
expenses for each Contract Processing Period. The charge is incurred at the
beginning of the Contract Processing Period and deducted on the Contract
Processing Date at the end of the period.

At the time of deduction, this charge will be waived if: (1) The Accumulation
Value is at least $100,000; or (2) The sum of premiums paid to date is at least
$100,000.

Excess Allocation Charge
Currently none, however, we reserve the right to charge $25 for a change if you
make more than twelve allocation changes per Contract Year. Any charge will be
deducted in proportion to the amount being transferred from each Division.

Surrender Charge
A Surrender Charge is imposed as a percentage of unliquidated premium if the
Contract is surrendered or an Excess Partial Withdrawal is taken. The
percentage imposed at time of surrender or Excess Partial Withdrawal
depends on the number of complete years that have elapsed since a Premium
Payment was made. The Surrender Charge expressed as a percentage of each
Premium Payment is as follows:

          Complete Years Elapsed                     Surrender
           Since Premium Payment                      Charges
          ----------------------                     ---------
                     [0                                  6%
                     1                                   5%
                     2                                   4%
                     3                                   3%
                     4+                                 0%]

Surrender of the Contract is permitted at or before the commencement of Annuity
Payments.

GA-IA-1082                             3E1

<PAGE>

                                  THE SCHEDULE
                                CHARGES AND FEES
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

Premium Taxes
We deduct the amount of any premium or other state and local taxes levied by
any state or governmental entity when such taxes are incurred.

We reserve the right to defer collection of Premium Taxes until surrender or
until application of Accumulation Value to an Annuity Option. An Excess Partial
Withdrawal will result in the deduction of any Premium Tax then due us on such
amount. We reserve the right to change the amount we charge for Premium Tax
charges on future Premium Payments to conform with changes in the law or if the
Owner changes state of residence.

Deductions from the Divisions
Mortality and Expense Risk Charge - We deduct a charge from the assets in each
---------------------------------
Variable Separate Account Division on a daily basis of not more that [0.005255]
% (equivalent to an annual maximum rate of [1.90]%) for mortality and expense
risks. This charge is not deducted from the Fixed Account or General Account
Accumulation Values.

Asset Based Administrative Charge - We deduct a charge of not more than
---------------------------------
[0.000411]% of the assets in each Variable Separate Account Division on a daily
basis (equivalent to an annual maximum rate of [0.15]%) to compensate us for a
portion of our ongoing administrative expenses. This charge is not deducted
from the Fixed Account or General Account Accumulation Values.

CHARGE DEDUCTION DIVISION

If elected by you, all charges against the Accumulation Value in this Contract
will be deducted from the [Liquid Asset Division].

GA-IA-1082                             3E2

<PAGE>

                                  THE SCHEDULE
                                INCOME PLAN FACTORS
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

Values for other payment periods, ages or joint life combinations are available
on request. Monthly payments are shown for each $1,000 applied.

                       TABLE FOR INCOME FOR A FIXED PERIOD

 Fixed Period   Monthly    Fixed Period      Monthly   Fixed Period    Monthly
     of Years    Income        of Years       Income       of Years     Income

   [5           17.95           14           7.28           23          5.00
   6            15.18           15           6.89           24          4.85
   7            13.20           16           6.54           25          4.72
   8            11.71           17           6.24           26          4.60
   9            10.56           18           5.98           27          4.49
   10             9.64          19           5.74           28          4.38
   11             8.88          20           5.53           29          4.28
   12             8.26          21           5.33           30         4.19]
   13             7.73          22           5.16

                            TABLE FOR INCOME FOR LIFE

                 Male/Female           Male/Female               Male/Female
 Age        10 Years Certain      20 Years Certain            Refund Certain

[50              $4.06/3.83            $3.96/3.77                $3.93/3.75
55                4.43/4.14             4.25/4.05                 4.25/4.03
60                4.90/4.56             4.57/4.37                 4.66/4.40
65                5.51/5.10             4.90/4.73                 5.12/4.83
70                6.26/5.81             5.18/5.07                 5.76/5.42
75                7.11/6.70             5.38/5.33                 6.58/6.19
80                7.99/7.70             5.48/5.46                 7.69/7.21
85                8.72/8.59             5.52/5.51                 8.72/8.59
90                9.23/9.18             5.53/5.53              10.63/10.53]

GA-IA-1082                             3F

<PAGE>

                                 THE SCHEDULE (BASE)
                                 CONTRACT FACTS
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

CONTRACT FACTS

Contract Processing Date
The Contract Processing Date for your Contract is [April 1] of each year.

Specially Designated Division
When a distribution is made from an investment portfolio underlying a Separate
Account Division in which reinvestment is not available, we will allocate the
amount of the distribution to the [Liquid Asset Division] unless you specify
otherwise.

PARTIAL WITHDRAWALS

The maximum amount that can be withdrawn each Contract Year without being
considered an Excess Partial Withdrawal is described below. We will collect a
Surrender Charge for Excess Partial Withdrawals and a charge for any
unrecovered Premium Taxes. In no event may a Partial Withdrawal be greater
than 90% of the Cash Surrender Value. After a Partial Withdrawal, the
remaining Accumulation Value must be at least $100 to keep the Contract
in force.

Systematic Partial Withdrawals and Conventional Partial Withdrawals may not be
taken in the same Contract Year.

To determine the Surrender Charge on Excess Partial Withdrawals, the
withdrawals will occur in the following order:
   (1) Earnings;
   (2) The Free Amount;
   (3) Premium Payments made [four] or more years prior to the
       withdrawal; and
   (4) Premium Payments made less than [four] years prior to
       withdrawal.

Earnings and Free Amounts are not treated as withdrawals of Premium Payments
for purposes of calculating any Surrender Charge.

Conventional Partial Withdrawals
Minimum Withdrawal Amount:      $100

The maximum amount that can be taken as a Conventional Partial Withdrawal each
Contract Year without being considered an Excess Partial Withdrawal is the
greater of:

     (1) Earnings (defined below) not previously withdrawn, but not
         less than zero; and
     (2) The Free Amount, equal to 10% of Premium Payments not previously
         withdrawn, which were received within [four] years prior to the date
         of withdrawal.

Earnings are equal to the Accumulation Value, less Premium Payments, plus prior
withdrawals.

Any Conventional Partial Withdrawal is subject to a Market Value Adjustment
unless withdrawn from a Fixed Allocation within 30 days prior to the Maturity
Date.

GA-IA-1082                             3D1

<PAGE>

                                  THE SCHEDULE
                           CONTRACT FACTS (continued)
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

Systematic Partial Withdrawals
Systematic Partial Withdrawals may be elected to commence after 28 days from
the Contract Issue Date and may be taken on a monthly, quarterly or annual
basis. You select the day withdrawals will be made, but no later than the
28th day of the month. If you do not elect a day, the Contract Date will
be used.

Maximum Withdrawal Amounts:

 Variable Separate Account Divisions:  .833% of Premium Payments monthly, 2.5%
                                       of Premium Payments
                                       quarterly or 10% of Premium Payments
                                       Annually.

 Fixed Allocations and
 Guaranteed Interest Divisions:        Interest earned on a Fixed Allocation
                                       or Guaranteed Interest
                                       Division for the prior month,
                                       quarter or year (depending on the
                                       frequency selected).

The Maximum Withdrawal Amount available as a Systematic Partial Withdrawal is
10% of Premium Payments not previously withdrawn. Systematic Partial
Withdrawals from Fixed Allocations are not subject to a Market Value
Adjustment. A Systematic Partial Withdrawal in excess of Earnings and the
Free Amount may be subject to a Surrender Charge.

IRA Partial Withdrawals for Qualified Plans Only
Partial Withdrawals may be taken from a Contract issued as an IRA on a monthly,
quarterly or annual basis. A minimum withdrawal of $100.00 is required. You
select the day the withdrawals will be made, but no later than the 28th day of
the month. If you do not elect a day, the Contract Date will be used.
Systematic Partial Withdrawals and Conventional Partial Withdrawals are
not allowed when IRA Partial Withdrawals are being taken. An IRA Partial
Withdrawal in excess of the maximum amount allowed under the Systematic
Partial Withdrawal option may be subject to a Market Value Adjustment.

DEATH BENEFIT

The Death Benefit is the greatest of (i) and (ii) below, where:
     (i)   is the Accumulation Value; and
     (ii)  is the Cash Surrender Value.

GA-IA-1082                             3D2

<PAGE>

                             THE SCHEDULE
                           CONTRACT FACTS (continued)
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

SPOUSAL CONTINUATION UPON DEATH OF OWNER

If at the Owner's death, the surviving spouse of the deceased Owner is the
Beneficiary and such surviving spouse elects to continue the Contract as their
own pursuant to Internal Revenue Code Section 72(s) or the equivalent
provisions of U.S. Treasury Department rules for qualified plans, on any
subsequent surrender, Surrender Charges applicable to premiums paid prior
to the date we receive due proof of death of the Owner will be waived. Any
premiums paid later will be subject to any applicable Surrender Charge.

CHOOSING AN INCOME PLAN

Required Date of Annuity Commencement
Distributions from a Contract funding a qualified plan must commence no later
than April 1st of the calendar year following the calendar year in which the
Owner attains age 70 1/2. Otherwise, the Annuity Commencement Date may be no
later than the same date as the Contract Processing Date in the month following
the Annuitant's 90th birthday. In applying the Accumulation Value, we may first
collect any Premium Taxes due us. If, on the Annuity Commencement Date, a
Surrender Charge remains, your elected Annuity Option must include a period
certain of at least five years duration.

Minimum Annuity Income Payment
The minimum monthly annuity income payment that we will make is [$20].

GA-IA-1082                             3D3

<PAGE>

                           THE SCHEDULE
                           CONTRACT FACTS (continued)
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

OPTIONAL BENEFIT RIDERS - [None]

ATTAINED AGE

The Issue Age of the Annuitant or Owner plus the number of full years elapsed
since the Contract Date.

RESTRICTED FUNDS - [None]

FIXED ACCOUNT

Minimum Fixed Allocation
The minimum allocation to the Fixed Account in any one Fixed Allocation is
[$250.00].

Minimum Guaranteed Interest Rate - [3%.]
Guarantee Periods

We currently offer Guarantee Periods of [1, 3, 5, 7 and 10] year(s). We reserve
the right to offer Guarantee Periods of durations other than those available on
the Contract Date. We also reserve the right to cease offering a particular
Guarantee Period or Periods.

Index Rate
The Index Rate is the average of the Ask Yields for the U.S. Treasury Strips as
reported by a national quoting service for the applicable maturity. The average
is based on the period from the 22nd day of the calendar month two months prior
to the calendar month of Index Rate determination to the 21st day of the
calendar month immediately prior to the month of determination. The applicable
maturity date for these U.S. Treasury Strips is on or next following the last
day of the Guarantee Period. If the Ask Yields are no longer available, the
Index Rate will be determined using a suitable replacement method.

We currently set the Index Rate once each calendar month. However, we reserve
the right to set the Index Rate more frequently than monthly, but in no event
will such Index Rate be based on a period less than 28 days.

GA-IA-1082                             3D4

<PAGE>

                                  THE SCHEDULE
                                CHARGES AND FEES
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

DEDUCTIONS FROM PREMIUMS

None

DEDUCTIONS FROM ACCUMULATION VALUE

Initial Administrative Charge

None

Administrative Charge
We charge a maximum of $30 to cover a portion of our ongoing administrative
expenses for each Contract Processing Period. The charge is incurred at the
beginning of the Contract Processing Period and deducted on the Contract
Processing Date at the end of the period.

At the time of deduction, this charge will be waived if: (1) The Accumulation
Value is at least $100,000; or (2) The sum of premiums paid to date is at least
$100,000.

Excess Allocation Charge
Currently none, however, we reserve the right to charge $25 for a change if you
make more than twelve allocation changes per Contract Year. Any charge will be
deducted in proportion to the amount being transferred from each Division.

Surrender Charge
A Surrender Charge is imposed as a percentage of unliquidated premium if the
Contract is surrendered or an Excess Partial Withdrawal is taken. The
percentage imposed at time of surrender or Excess Partial Withdrawal
depends on the number of complete years that have elapsed since a Premium
Payment was made. The Surrender Charge expressed as a percentage of each
Premium Payment is as follows:

          Complete Years Elapsed                     Surrender
           Since Premium Payment                      Charges
           ---------------------                     ---------
                     [0                                  6%
                     1                                   5%
                     2                                   4%
                     3                                   3%
                     4+                                 0%]

Surrender of the Contract is permitted at or before the commencement of Annuity
Payments.

GA-IA-1082                             3E1

<PAGE>

                                  THE SCHEDULE
                                CHARGES AND FEES
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

Premium Taxes
We deduct the amount of any premium or other state and local taxes levied by
any state or governmental entity when such taxes are incurred.

We reserve the right to defer collection of Premium Taxes until surrender or
until application of Accumulation Value to an Annuity Option. An Excess Partial
Withdrawal will result in the deduction of any Premium Tax then due us on such
amount. We reserve the right to change the amount we charge for Premium Tax
charges on future Premium Payments to conform with changes in the law or if the
Owner changes state of residence.

Deductions from the Divisions
Mortality and Expense Risk Charge - We deduct a charge from the assets in each
---------------------------------
Variable Separate Account Division on a daily basis of not more that [0.004280]
% (equivalent to an annual maximum rate of [1.55]%) for mortality and expense
risks. This charge is not deducted from the Fixed Account or General Account
Accumulation Values.

Asset Based Administrative Charge - We deduct a charge of not more than
---------------------------------
[0.000411]% of the assets in each Variable Separate Account Division on a daily
basis (equivalent to an annual maximum rate of [0.15]%) to compensate us for a
portion of our ongoing administrative expenses. This charge is not deducted
from the Fixed Account or General Account Accumulation Values.

CHARGE DEDUCTION DIVISION

If elected by you, all charges against the Accumulation Value in this Contract
will be deducted from the [Liquid Asset Division].

GA-IA-1082                             3E2

<PAGE>

                                  THE SCHEDULE
                                INCOME PLAN FACTORS
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

Values for other payment periods, ages or joint life combinations are available
on request. Monthly payments are shown for each $1,000 applied.

                       TABLE FOR INCOME FOR A FIXED PERIOD

  Fixed Period  Monthly    Fixed Period   Monthly   Fixed Period     Monthly
      of Years   Income        of Years    Income       of Years      Income

    [5           17.95           14        7.28           23           5.00
    6            15.18           15        6.89           24           4.85
    7            13.20           16        6.54           25           4.72
    8            11.71           17        6.24           26           4.60
    9            10.56           18        5.98           27           4.49
    10            9.64           19        5.74           28           4.38
    11            8.88           20        5.53           29           4.28
    12            8.26           21        5.33           30          4.19]
    13            7.73           22        5.16

                            TABLE FOR INCOME FOR LIFE

                   Male/Female             Male/Female             Male/Female
  Age         10 Years Certain        20 Years Certain          Refund Certain

[50               $4.06/3.83              $3.96/3.77              $3.93/3.75
55                 4.43/4.14               4.25/4.05               4.25/4.03
60                 4.90/4.56               4.57/4.37               4.66/4.40
65                 5.51/5.10               4.90/4.73               5.12/4.83
70                 6.26/5.81               5.18/5.07               5.76/5.42
75                 7.11/6.70               5.38/5.33               6.58/6.19
80                 7.99/7.70               5.48/5.46               7.69/7.21
85                 8.72/8.59               5.52/5.51               8.72/8.59
90                 9.23/9.18               5.53/5.53            10.63/10.53]

GA-IA-1082                             3F

<PAGE>

                                 THE SCHEDULE (COMBO DB)
                                 CONTRACT FACTS
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|
CONTRACT FACTS

Contract Processing Date
The Contract Processing Date for your Contract is [April 1] of each year.

Specially Designated Division
When a distribution is made from an investment portfolio underlying a Separate
Account Division in which reinvestment is not available, we will allocate the
amount of the distribution to the [Liquid Asset Division] unless you specify
otherwise.

PARTIAL WITHDRAWALS

The maximum amount that can be withdrawn each Contract Year without being
considered an Excess Partial Withdrawal is described below. We will collect a
Surrender Charge for Excess Partial Withdrawals and a charge for any
unrecovered Premium Taxes. In no event may a Partial Withdrawal be greater
than 90% of the Cash Surrender Value. After a Partial Withdrawal,
the remaining Accumulation Value must be at least $100 to keep the
Contract in force.

Systematic Partial Withdrawals and Conventional Partial Withdrawals may not be
taken in the same Contract Year.

To determine the Surrender Charge on Excess Partial Withdrawals, the
withdrawals will occur in the following order:
     (1) Earnings;
     (2) The Free Amount;
     (3) Premium Payments made [four] or more years prior to the
         withdrawal; and
     (4) Premium Payments made less than [four] years prior
         to withdrawal.

Earnings and Free Amounts are not treated as withdrawals of Premium Payments
for purposes of calculating any Surrender Charge.

Conventional Partial Withdrawals
Minimum Withdrawal Amount:      $100

The maximum amount that can be taken as a Conventional Partial Withdrawal each
Contract Year without being considered an Excess Partial Withdrawal is the
greater of:

   (1) Earnings (defined below) not previously withdrawn, but not less than
       zero; and
   (2) The Free Amount, equal to 10% of Premium Payments not previously
       withdrawn, which were received within [four] years prior to the date
       of withdrawal.

Earnings are equal to the Accumulation Value, less Premium Payments, plus prior
withdrawals.

Any Conventional Partial Withdrawal is subject to a Market Value Adjustment
unless withdrawn from a Fixed Allocation within 30 days prior to the Maturity
Date.

GA-IA-1082                             3D1

<PAGE>

                                  THE SCHEDULE
                           CONTRACT FACTS (continued)
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

Systematic Partial Withdrawals
Systematic Partial Withdrawals may be elected to commence after 28 days from
the Contract Issue Date and may be taken on a monthly, quarterly or annual
basis. You select the day withdrawals will be made, but no later than the
28th day of the month. If you do not elect a day, the Contract Date will be
used.

Maximum Withdrawal Amounts:

  Variable Separate Account Divisions:   .833% of Premium Payments monthly,
                                          2.5% of Premium Payments
                                          quarterly or 10% of Premium Payments
                                          annually.
  Fixed Allocations and
  Guaranteed Interest Divisions:         Interest earned on a Fixed Allocation
                                         or Guaranteed Interest Division
                                         for the prior month, quarter or year
                                         (depending on the frequency
                                         selected).

The Maximum Withdrawal Amount available as a Systematic Partial Withdrawal
is 10% of Premium Payments not previously withdrawn. Systematic Partial
Withdrawals from Fixed Allocations are not subject to a Market Value
Adjustment. A Systematic Partial Withdrawal in excess of Earnings and
the Free Amount may be subject to a Surrender Charge.

IRA Partial Withdrawals for Qualified Plans Only
Partial Withdrawals may be taken from a Contract issued as an IRA on a monthly,
quarterly or annual basis. A minimum withdrawal of $100.00 is required. You
select the day the withdrawals will be made, but no later than the 28th day of
the month. If you do not elect a day, the Contract Date will be used.
Systematic Partial Withdrawals and Conventional Partial Withdrawals are
not allowed when IRA Partial Withdrawals are being taken. An IRA Partial
Withdrawal in excess of the maximum amount allowed under the Systematic
Partial Withdrawal option may be subject to a Market Value Adjustment.

DEATH BENEFIT

The Death Benefit is the greatest of (i), (ii), (iii), (iv) and (v)
below, where:
   (i)      is the Accumulation Value;
   (ii)     is the lesser of (a) and (b) where (a) is the Guaranteed
            Death Benefit, and (b) is the Maximum Guaranteed Death Benefit;
   (iii)    is the Cash Surrender Value;
   (iv)     is the Minimum Death Benefit; and
   (v)      the Alternate Guaranteed Death Benefit.

MINIMUM DEATH BENEFIT

The Minimum Death Benefit shall be the sum of the following:

    1.   The Accumulation Value allocated to Special Funds; and
    2.   Adjusted Premium for non-Special Funds.

GA-IA-1082                             3D2

<PAGE>

                                  THE SCHEDULE
                           CONTRACT FACTS (continued)
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

Adjusted Premium for non-Special Funds shall mean all premium allocated to
non-Special Funds, plus an adjustment for any amounts transferred to
non-Special Funds, less a prorata adjustment for any amounts transferred or
withdrawn from non-Special Funds. The amount of the prorata adjustment will
equal (a) times (b) divided by (c), where: (a) is the Adjusted Premium for
non-Special Funds prior to the transfer or withdrawal; (b) is the Accumulation
Value of the transfer or withdrawal; and (c) is the Accumulation Value
allocated to non-Special Funds before the transfer or withdrawal. Adjusted
Premium for Special Funds has the same definition, but with respect to
amounts allocated to Special Funds.

Transfers from Special Funds increase the Adjusted Premium for non-Special
Funds by the lesser of the reduction of the Adjusted Premium for Special Funds
and net Accumulation Value transferred. Transfers from non-Special Funds
increase the Adjusted Premium for Special Funds by the reduction in the
Adjusted Premium for non-Special Funds.

GUARANTEED DEATH BENEFIT

The Guaranteed Death Benefit for the Contract is equal to the sum of I and
II below.
    I.   The Guaranteed Death Benefit Base for non-Special Funds.
   II.   The Accumulation Value allocated to Special Funds.

On the Contract Date, the Guaranteed Death Benefit Base for non-Special Funds
is the initial premium, if applicable, allocated to non-Special Funds. On
subsequent Valuation Dates, the Guaranteed Death Benefit Base for non-Special
Funds is calculated as follows:

   (1)  Start with the Guaranteed Death Benefit Base for non-Special Funds
        on the prior Valuation Date.
   (2)  Calculate interest on (1) for the current Valuation Period at the
        Guaranteed Death Benefit Interest Rate for non-Special Funds.
   (3)  Add (1) and (2).
   (4)  Add to (3) any additional premiums allocated to non-Special Funds
        during the current Valuation Period.
   (5)  Add to (or subtract from) (4) adjustments for transfers from (to)
        Special Funds made during the Valuation Period.
   (6)  Subtract from (5) the amount of any Special Partial Withdrawal
         Adjustments and Prorata Partial Withdrawal Adjustments for any partial
         withdrawals made from non-Special Funds during the current Valuation
         Period.

The Guaranteed Death Benefit Base for Special Funds has a corresponding
definition, but with respect to amounts allocated to Special Funds.

Transfers from Special Funds to non-Special Funds will reduce the
Guaranteed Death Benefit Base for Special Funds on a prorata basis.
The resulting increase in the Guaranteed Death Benefit Base for
non-Special Funds will equal the lesser of the reduction in the
Guaranteed Death Benefit Base for Special Funds and the
net Accumulation Value transferred.

GA-IA-1082                             3D3

<PAGE>

                                  THE SCHEDULE
                           CONTRACT FACTS (continued)
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

Transfers from non-Special Funds to Special Funds will reduce the Guaranteed
Death Benefit Base for non-Special Funds on a prorata basis. The resulting
increase in the Guaranteed Death Benefit Base for Special Funds will equal the
reduction in Guaranteed Death Benefit Base for non-Special Funds.

GUARANTEED DEATH BENEFIT INTEREST RATE

The Guaranteed Death Benefit Interest Rate is [7%] compounded annually, except:

   (a)  For any portion of the Guaranteed Death Benefit Base for Special
        Funds, the Guaranteed Death Benefit Interest
        Rate is [7%] (compounded annually); and
   (b)  For any valuation period ending after the Contract Anniversary on
        which the Owner attains age [80], or after the Maximum Guaranteed
        Death Benefit has been reached, the Guaranteed Death Benefit
        Interest Rate is [0%].

SPECIAL FUNDS

Where used in this Contract, Special Funds are [the Liquid Asset Division, the
Limited Maturity Bond Division, the Fixed Allocations and the Guaranteed
Interest Division]. We may add newly available Divisions as Special Funds. We
may also reclassify an existing Division as a Special Fund or remove such
designation upon 30 days notice to you. Such reclassification will apply to
amounts transferred or otherwise added to such Division after the date of
change. We may reduce the Mortality and Expense Risk Charge (if applicable) for
that portion of the Contract invested in a Special Fund.

MAXIMUM GUARANTEED DEATH BENEFIT

The Maximum Guaranteed Death Benefit is equal to [three] times premium paid,
reduced by the amount of any Partial Withdrawal Adjustments. The Maximum
Guaranteed Death Benefit is allocated proportionally based on the Contract's
allocation to Special and non-Special funds. Transfers and withdrawals will
affect the allocation of the Maximum Guaranteed Death Benefit at the same
proportion among the Special and non-Special Funds that they bear to the
Accumulation Value transferred or withdrawn. Any addition due to spousal
continuation will not affect the Maximum Guaranteed Death Benefit or the
Guaranteed Death Benefit Base.

SPECIAL AND PRORATA PARTIAL WITHDRAWAL ADJUSTMENTS

For any partial withdrawal, the Death Benefit components will be reduced by
Prorata Partial Withdrawal Adjustments. A Prorata Partial Withdrawal Adjustment
will be made unless a Special Partial Withdrawal Adjustment applies to the
component for the withdrawal. Special Partial Withdrawal Adjustments are made
when partial withdrawals in any Contract Year do not exceed [7%] of the sum of
cumulative premiums, but only if partial withdrawals in each prior year did not
exceed [7%] of the sum of premiums paid prior to that year. The Special Partial
Withdrawal Adjustment is equal to the amount of the Accumulation Value
withdrawn.

GA-IA-1082                             3D4

<PAGE>

                                  THE SCHEDULE
                           CONTRACT FACTS (continued)
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

Special Partial Withdrawal Adjustments are applicable only in the calculation
of the Maximum Guaranteed Death Benefit and the Guaranteed Death Benefit Base,
and in all other cases withdrawals are treated as Prorata Partial Withdrawal
Adjustments.

The Prorata Partial Withdrawal Adjustment to a Death Benefit component is equal
to (1) divided by (2), multiplied by (3), where: (1) is the Accumulation Value
withdrawn; (2) is the Accumulation Value immediately prior to withdrawal; and
(3) is the amount of the applicable Death Benefit component immediately prior
to the withdrawal. Separate adjustments will apply to the amounts in the
Special and non-Special Funds.

ALTERNATE GUARANTEED DEATH BENEFIT

The Alternate Guaranteed Death Benefit for the Contact is equal to the
sum of I and II below.
     I.  The Alternate Guaranteed Death Benefit Base for non-Special Funds.
     II. The Accumulation Value allocated to Special Funds.

On the Contract Date, the Alternate Guaranteed Death Benefit Base for
non-Special Funds is the initial premium allocated to non-Special Funds. On
subsequent Valuation Dates, the Alternate Guaranteed Death Benefit Base for
non-Special Funds is calculated as follows:

   (1)  Start with the Alternate Guaranteed Death Benefit Base for non-Special
        Funds from the prior Valuation Date.
   (2)  Add to (1) any additional premium allocated to the non-Special Funds
        during the current Valuation Period and
        adjustments for transfers from Special Funds during the current
        Valuation Period and subtract from (1) any adjustment for transfers to
        Special Funds during the current Valuation Period and any Prorata
        Partial Withdrawal Adjustments for any Partial Withdrawals taken from
        non-Special Funds during the current Valuation Period.
   (3)  On a Valuation Date that occurs on or prior to the Owner's Attained
        Age [90], which is also a Contract Anniversary, we set the Alternate
        Guaranteed Death Benefit Base for non-Special Funds equal to the
        greater of (2) or the Accumulation Value as of such date. On all other
        Valuation Dates, the Alternate Guaranteed Death Benefit Base for
        non-Special Funds is equal to (2).

The Alternate Guaranteed Death Benefit Base for Special Funds has a
corresponding definition, but with respect to amounts allocated to Special
Funds.

Transfers from Special Funds to non-Special Funds will reduce the Alternate
Guaranteed Death Benefit Base for Special Funds on a prorata basis. The
resulting increase in the Alternate Guaranteed Death Benefit Base for
non-Special Funds will equal the lesser of the reduction in the Alternate
Guaranteed Death Benefit Base for Special Funds and the net Accumulation Value
transferred.

GA-IA-1082                             3D5

<PAGE>

                                  THE SCHEDULE
                           CONTRACT FACTS (continued)
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

Transfers from non-Special Funds to Special Funds will reduce the Alternate
Guaranteed Death Benefit Base for non-Special Funds on a prorata basis. The
resulting increase in the Alternate Guaranteed Death Benefit Base for Special
Funds will equal the reduction in Alternate Guaranteed Death Benefit Base for
non-Special Funds.

CHANGE OF OWNER

A change of Owner from a sole Owner to a sole Owner (where there have never
been multiple Owners designated) will result in recalculation of the Death
Benefit, the Guaranteed Death Benefit, the Alternate Guaranteed Death Benefit
and the Maximum Guaranteed Death Benefit. If the new Owner's Attained Age at
the time of the change is less than [80], the Guaranteed Death Benefit,
the Alternate Guaranteed Death Benefit and the Maximum Guaranteed Death
Benefit in effect prior to the change will remain in effect and the Death
Benefit provision shall apply. If the new Owner's Attained Age at the time
of the change is [80] or greater, but not greater than [85]:
     (a) The Guaranteed Death Benefit, the Alternate Guaranteed Death
         Benefit and the Maximum Guaranteed Death Benefit
         following the change will be zero; and
     (b) The Death Benefit will then be the greatest of:
         1) the Cash Surrender Value;
         2) the Accumulation Value; and
         3) the Minimum Death Benefit.

If ownership changes result in multiple Owners or if there has ever been
multiple Owners, the Guaranteed Death Benefit, the Alternate Guaranteed Death
Benefit and the Maximum Guaranteed Death Benefit shall be set to zero. If the
oldest Owner is age [85] or younger at the time of the change, the Death
Benefit will then be the greatest of (b) 1, (b) 2 or (b) 3 above.

If any Owner's or oldest multiple Owner's Attained Age is [86] or greater at
the time of the change, the Guaranteed Death Benefit, the Minimum Death
Benefit, the Alternate Guaranteed Death Benefit and the Maximum Guaranteed
Death Benefit will be zero, and the Death Benefit will then be the Cash
Surrender Value.

When a change of Owner reduces the Guaranteed Death Benefit, the Alternate
Guaranteed Death Benefit and the Maximum Guaranteed Death Benefit to zero,
there will be a reduction in the Mortality and Expense Risk Charge.

GA-IA-1082                             3D6

<PAGE>

                                  THE SCHEDULE
                           CONTRACT FACTS (continued)
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

SPOUSAL CONTINUATION UPON DEATH OF OWNER

If at the Owner's death, the surviving spouse of the deceased Owner is the
Beneficiary and such surviving spouse elects to continue the Contract as their
own pursuant to Internal Revenue Code Section 72(s) or the equivalent
provisions of U.S. Treasury Department rules for qualified plans, the
following will apply:
    (a)  If the greater of (ii), (iv), and (v) in the Death Benefit provision
         as of the date we receive due proof of death of the Owner, minus the
         Accumulation Value, also as of that date, is greater than zero, we
         will add such difference to the Accumulation Value. Such addition
         will be allocated to the Divisions of the Separate Account in the
         same proportion as the Accumulation Value in each Division bears to
         the Accumulation Value in the Separate Account. If there is no
         Accumulation Value in the Separate Account, the addition will be
         allocated to the Liquid Asset Division, or its successor.
    (b)  The Guaranteed Death Benefit, the Alternate Guaranteed Death Benefit,
         the Minimum Death Benefit, and the Maximum Guaranteed Death Benefit
         will continue to apply, with all age criteria using the surviving
         spouse's age as the determining age.
    (c)  At subsequent surrender, any Surrender Charge applicable to premiums
         paid prior to the date we receive due proof of death of the Owner will
         be waived. Any premiums paid later will be subject to any applicable
         Surrender Charge.

This addition to Accumulation Value is available only to the spouse of the
Owner as of the date of death of the Owner if such spouse under the
provisions of this Contract elects to continue the Contract as their own.

CHOOSING AN INCOME PLAN

Required Date of Annuity Commencement
Distributions from a Contract funding a qualified plan must commence no later
than April 1st of the calendar year following the calendar year in which the
Owner attains age 70 1/2. Otherwise, the Annuity Commencement Date may be no
later than the same date as the Contract Processing Date in the month following
the Annuitant's 90th birthday. In applying the Accumulation Value, we may first
collect any Premium Taxes due us. If, on the Annuity Commencement Date, a
Surrender Charge remains, your elected Annuity Option must include a period
certain of at least five years duration.

Minimum Annuity Income Payment
The minimum monthly annuity income payment that we will make is [$20].

GA-IA-1082                             3D7

<PAGE>

                                  THE SCHEDULE
                           CONTRACT FACTS (continued)
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

OPTIONAL BENEFIT RIDERS - [None.]

ATTAINED AGE

The Issue Age of the Annuitant or Owner plus the number of full years elapsed
since the Contract Date.

RESTRICTED FUNDS - [None]

FIXED ACCOUNT

Minimum Fixed Allocation
The minimum allocation to the Fixed Account in any one Fixed Allocation is
[$250.00].

Minimum Guaranteed Interest Rate - [3%.]

Guarantee Periods
We currently offer Guarantee Periods of [1, 3, 5, 7 and 10] year(s). We reserve
the right to offer Guarantee Periods of durations other than those available on
the Contract Date. We also reserve the right to cease offering a particular
Guarantee Period or Periods.

Index Rate
The Index Rate is the average of the Ask Yields for the U.S. Treasury Strips as
reported by a national quoting service for the applicable maturity. The average
is based on the period from the 22nd day of the calendar month two months prior
to the calendar month of Index Rate determination to the 21st day of the
calendar month immediately prior to the month of determination. The applicable
maturity date for these U.S. Treasury Strips is on or next following the last
day of the Guarantee Period. If the Ask Yields are no longer available, the
Index Rate will be determined using a suitable replacement method.

We currently set the Index Rate once each calendar month. However, we reserve
the right to set the Index Rate more frequently than monthly, but in no event
will such Index Rate be based on a period less than 28 days.

GA-IA-1082                             3D8

<PAGE>

                                  THE SCHEDULE
                                CONTRACT FEES
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|
DEDUCTIONS FROM PREMIUMS

None

DEDUCTIONS FROM ACCUMULATION VALUE

Initial Administrative Charge
None

Administrative Charge
We charge a maximum of $30 to cover a portion of our ongoing administrative
expenses for each Contract Processing Period. The charge is incurred at the
beginning of the Contract Processing Period and deducted on the Contract
Processing Date at the end of the period.

At the time of deduction, this charge will be waived if: (1) The Accumulation
Value is at least $100,000; or (2) The sum of premiums paid to date is at least
$100,000.

Excess Allocation Charge
Currently none, however, we reserve the right to charge $25 for a change if
you make more than twelve allocation changes per Contract Year. Any charge
will be deducted in proportion to the amount being transferred from each
Division.

Surrender Charge
A Surrender Charge is imposed as a percentage of unliquidated premium if the
Contract is surrendered or an Excess Partial Withdrawal is taken. The
percentage imposed at time of surrender or Excess Partial Withdrawal depends
on the number of complete years that have elapsed since a Premium Payment
was made. The Surrender Charge expressed as a percentage of each Premium
Payment is as follows:

       Complete Years Elapsed                     Surrender
       Since Premium Payment                       Charges
       ---------------------                      --------
                 [0                                  6%
                  1                                  5%
                  2                                  4%
                  3                                  3%
                 4+                                  0%]

Surrender of the Contract is permitted at or before the commencement of Annuity
Payments.

GA-IA-1082                             3E1

<PAGE>

                                  THE SCHEDULE
                                 CHARGES AND FEES (continued)
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

Premium Taxes
We deduct the amount of any premium or other state and local taxes levied by
any state or governmental entity when such taxes are incurred.

We reserve the right to defer collection of Premium Taxes until surrender or
until application of Accumulation Value to an Annuity Option. An Excess Partial
Withdrawal will result in the deduction of any Premium Tax then due us on such
amount. We reserve the right to change the amount we charge for Premium Tax
charges on future Premium Payments to conform with changes in the law or if the
Owner changes state of residence.

Deductions from the Divisions

Mortality and Expense Risk Charge - We deduct a charge from the assets in each
---------------------------------
Variable Separate Account Division on a daily basis of not more than
[0.005815]% (equivalent to an annual maximum rate of [2.10]%) for mortality
and expense risks. The charge is not deducted from the Fixed Account or
General Account Accumulation Values.

Asset Based Administrative Charge - We deduct a charge of not more than
---------------------------------
[0.000411]% of the assets in each Variable Separate Account Division on a
daily basis (equivalent to an annual maximum rate of [0.15]%) to compensate
us for a portion of our ongoing administrative expenses. This charge is not
deducted from the Fixed Account or General Account Accumulation Values.

CHARGE DEDUCTION DIVISION

If elected by you, all charges against the Accumulation Value in this Contract
will be deducted from the [Liquid Asset Division].

GA-IA-1082                             3E2

<PAGE>

                                  THE SCHEDULE
                                 INCOME PLAN FACTORS
------------------------------------------------------------------------------

|-----------------------------------------------------------------------------|
|Annuitant                Owner                                               |
|[THOMAS J. DOE]          [JOHN Q. DOE]                                       |
|                                                                             |
|-----------------------------------------------------------------------------|
|Initial Premium           Annuity Option            Annuity Commencement Date|
|[$10,000]                 [LIFE 10-YEAR CERTAIN]    [JANUARY 1, 2026]        |
|-----------------------------------------------------------------------------|
|Separate Account(s)                                 Contract Number          |
|[SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]          [123456]                 |
|-----------------------------------------------------------------------------|

Values for other payment periods, ages or joint life combinations are available
on request. Monthly payments are shown for each $1,000 applied.

                       TABLE FOR INCOME FOR A FIXED PERIOD

  Fixed Period   Monthly     Fixed Period    Monthly   Fixed Period    Monthly
      of Years    Income         of Years     Income       of Years     Income

    [5             17.95            14         7.28           23          5.00
    6              15.18            15         6.89           24          4.85
    7              13.20            16         6.54           25          4.72
    8              11.71            17         6.24           26          4.60
    9              10.56            18         5.98           27          4.49
    10              9.64            19         5.74           28          4.38
    11              8.88            20         5.53           29          4.28
    12              8.26            21         5.33           30          4.19]
    13              7.73            22         5.16

                            TABLE FOR INCOME FOR LIFE

                    Male/Female           Male/Female            Male/Female
  Age          10 Years Certain      20 Years Certain         Refund Certain

[50                $4.06/3.83            $3.96/3.77             $3.93/3.75
55                  4.43/4.14             4.25/4.05              4.25/4.03
60                  4.90/4.56             4.57/4.37              4.66/4.40
65                  5.51/5.10             4.90/4.73              5.12/4.83
70                  6.26/5.81             5.18/5.07              5.76/5.42
75                  7.11/6.70             5.38/5.33              6.58/6.19
80                  7.99/7.70             5.48/5.46              7.69/7.21
85                  8.72/8.59             5.52/5.51              8.72/8.59
90                  9.23/9.18             5.53/5.53           10.63/10.53]

GA-IA-1082                             3F1Exhibit 4(c)

     ||||GOLDEN                        FLEXIBLE PREMIUM
   ||||||AMERICAN                      DEFERRED COMBINATION
  |||||||LIFE INSURANCE                VARIABLE AND FIXED
    |||||COMPANY                       ANNUITY CERTIFICATE

Golden American is a stock company domiciled in Delaware.
-------------------------------------------------------------------------------
|------------------------------------------------------------------------------|
|                                                                              |
|------------------------------------------------------------------------------|
|         Contractholder                               Group Contract Number   |
|         [GOLDEN INVESTORS TRUST]                     [G000021-OE]            |
|------------------------------------------------------------------------------|
|         Annuitant                           Owner                            |
|         [THOMAS J. DOE]                    [JOHN Q. DOE]                     |
|                                                                              |
|------------------------------------------------------------------------------|
|         Initial Premium     Annuity Option          Annuity Commencement Date|
|         [$10,000]           [LIFE 10-YEAR CERTAIN]  [JANUARY 1, 2026]        |
|------------------------------------------------------------------------------|
|         Separate Account(s)                          Certificate Number      |
|         [SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]   [123456]                |
|------------------------------------------------------------------------------|

In this Certificate you or your refers to the Owner shown above. We, our or us
refers to Golden American Life Insurance Company. You may allocate this
Certificate's Accumulation Value among the Variable Separate Account, the
General Account and the Fixed Account shown in the Schedule.

This Certificate describes the benefits and provisions of the group contract.
The group contract, as issued to the Contractholder by us with any Riders or
Endorsements, alone makes up the agreement under which benefits are paid. The
group contract may be inspected at the office of the Contractholder. In
consideration of any application for this Certificate and the payment of
premiums, we agree, subject to the terms and conditions of the group contract,
to provide the benefits described in this Certificate to the Owner. The
Annuitant under this Certificate must be eligible under the terms of the group
contract. If the group contract and this Certificate are in force, we will make
income payments to the Owner starting on the Annuity Commencement Date as shown
in the Schedule. If the Owner dies prior to the Annuity Commencement Date, we
will pay a death benefit to the Beneficiary. The amount of such benefit is
subject to the terms of this Certificate.

The benefits of the Certificate will be paid according to the provisions of the
Certificate and group contract.

ALL PAYMENTS AND VALUES, WHEN BASED ON THE INVESTMENT EXPERIENCE OF A VARIABLE
SEPARATE ACCOUNT DIVISION, MAY INCREASE OR DECREASE, DEPENDING ON THE
CERTIFICATE'S INVESTMENT RESULTS. ALL PAYMENTS AND VALUES BASED ON THE FIXED
ACCOUNT MAY BE SUBJECT TO A MARKET VALUE ADJUSTMENT, THE OPERATION OF WHICH MAY
CAUSE SUCH PAYMENTS AND VALUES TO INCREASE OR DECREASE.

RIGHT TO EXAMINE THIS CERTIFICATE: YOU MAY RETURN THIS CERTIFICATE TO US OR THE
AGENT THROUGH WHOM YOU PURCHASED IT WITHIN 10 DAYS AFTER YOU RECEIVE IT. IF SO
RETURNED, WE WILL TREAT THE CERTIFICATE AS THOUGH IT WERE NEVER ISSUED. UPON
RECEIPT WE WILL PROMPTLY REFUND THE ACCUMULATION VALUE, ADJUSTED FOR ANY MARKET
VALUE ADJUSTMENT, PLUS ANY CHARGES WE HAVE DEDUCTED AS OF THE DATE THE RETURNED
CERTIFICATE IS RECEIVED BY US.

Customer Service Center                  Secretary: /s/ Myles R. Tashman
1475 Dunwoody Drive
West Chester, PA  19380                  President: /s/ Barnett Chernow
1-800-366-0066
-------------------------------------------------------------------------------
FLEXIBLE PREMIUM DEFERRED COMBINATION VARIABLE AND FIXED ANNUITY
CERTIFICATE - NO DIVIDENDS
  Variable Cash Surrender Values while the Annuitant and Owner are living and
  prior to the Annuity Commencement Date.  Death Benefit subject to guaranteed
  minimum.  Partial Withdrawal Option.  Non-participating.  Investment results
  reflected in values.

GA-CA-1082

<PAGE>

                              CERTIFICATE CONTENTS
-------------------------------------------------------------------------------

THE SCHEDULE                                     YOUR CERTIFICATE BENEFITS....16
Payment and Investment Information...........3A   Cash Value Benefit
The Variable Separate Accounts...............3B   Partial Withdrawal Option
The General Account..........................3C   Proceeds Payable to the
Certificate Facts............................3D    Beneficiary
Charges and Fees.............................3E  CHOOSING AN INCOME PLAN......18
Income Plan Factors..........................3F   Annuity Benefits
                                                  Annuity Commencement
                                                   Date Selection
IMPORTANT TERMS.............................. 4   Frequency Selection
                                                  The Income Plan
INTRODUCTION TO THIS CERTIFICATE............. 6   The Annuity Options
The Certificate                                   Payment When Named Person Dies
The Owner
The Annuitant                                    OTHER IMPORTANT INFORMATION..20
The Beneficiary                                   Entire Contract
Change of Owner or Beneficiary                    Sending Notice to Us
                                                  Reports to Owner

PREMIUM PAYMENTS AND ALLOCATION CHANGES...... 8   Assignment - Using this
                                                   Certificate as
                                                    Collateral Security

Initial Premium Payment                            Changing this Certificate
Additional Premium Payments                        Certificate Changes -
                                                    Applicable Tax Law
Your Right to Change Allocation of                 Misstatement of Age or Sex
 Accumulation Value                                Non-Participating
What Happens if a Variable Separate Account        Contestability
 Division is Not Available                         Payments We May Defer
Restricted Funds                                   Authority to Make Agreements
Thresholds                                         Required Note on Our
                                                    Computations
Dollar Cap
Premium Threshold
Allocation Threshold
Thresholds - Effect on Withdrawals
Threshold Processing

HOW WE MEASURE THE CERTIFICATE'S

ACCUMULATION VALUE.......................... 11
The Variable Separate Accounts
The General Account
Valuation Period
Accumulation Value
Accumulation Value in each Division and
 Fixed Allocation
Fixed Account
Measurement of Investment Experience
Charges Deducted from Accumulation Value on each Certificate Processing Date

Copies of any additional Riders and Endorsements are at the back
of this Certificate.

THE SCHEDULE

The Schedule gives specific facts about this Certificate and its
coverage. Please refer to the Schedule while reading this Certificate.

GA-CA-1082                          2

<PAGE>

                                  THE SCHEDULE

                       PAYMENT AND INVESTMENT INFORMATION

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

|------------------------------------------------------------------------------|
|   Annuitant              Owner                                               |
|   [THOMAS J. DOE]        [JOHN Q. DOE]                                       |
|------------------------------------------------------------------------------|
|   Annuitant's Issue Age  Annuitant's Sex          Owner's Issue Age          |
|   [55]                   [MALE]                   [35]                       |
|------------------------------------------------------------------------------|
|   Initial Premium        Annuity Option           Annuity Commencement Date  |
|   [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]          |
|------------------------------------------------------------------------------|
|   Certificate Date       Issue Date               Residence Status           |
|   [JANUARY 1, 1996]      [JANUARY 1, 1996]        [DELAWARE]                 |
|------------------------------------------------------------------------------|
|   Separate Account(s)                             Certificate Number         |
|   [SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]      [123456]                   |
|------------------------------------------------------------------------------|

INITIAL INVESTMENT

Initial Premium Payment received:                    [$10,000]

Your initial Accumulation Value has been invested as follows:

                                                           Percentage of
               Divisions                               Accumulation Value
               ---------                               ------------------
            [Equity Income                                    10%
             Fully Managed                                    10%
         Capital Appreciation                                 10%
           Rising Dividends                                   10%
                Growth                                        10%
              Real Estate                                     10%
             Value Equity                                      5%
              Hard Assets                                      5%
           Emerging Markets                                    5%
            Managed Global                                     5%
         Limited Maturity Bond                                 5%
             Liquid Asset                                      5%
           Strategic Equity                                    5%
       Fixed Allocation - 1 Year                               5%]
----------------------------------------   ------------------------------------
                 Total                                        100%
                 =====                                        ====

GA-CA-1082                            3A1

<PAGE>

                                  THE SCHEDULE

                 PAYMENT AND INVESTMENT INFORMATION (continued)
-------------------------------------------------------------------------------

|------------------------------------------------------------------------------|
|   Annuitant              Owner                                               |
|   [THOMAS J. DOE]        [JOHN Q. DOE]                                       |
|------------------------------------------------------------------------------|
|   Annuitant's Issue Age  Annuitant's Sex          Owner's Issue Age          |
|   [55]                   [MALE]                   [35]                       |
|------------------------------------------------------------------------------|
|   Initial Premium        Annuity Option           Annuity Commencement Date  |
|   [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]          |
|------------------------------------------------------------------------------|
|   Certificate Date       Issue Date               Residence Status           |
|   [JANUARY 1, 1996]      [JANUARY 1, 1996]        [DELAWARE]                 |
|------------------------------------------------------------------------------|
|   Separate Account(s)                             Certificate Number         |
|   [SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]      [123456]                   |
|------------------------------------------------------------------------------|
ADDITIONAL PREMIUM PAYMENT INFORMATION

Except in the case of a Certificate issued as an IRA, we will accept additional
Premium Payments until either the Annuitant or Owner reaches the Attained Age of
[86]. The minimum additional payment which may be made is $[500.00].

If this Certificate is issued as an IRA, no contributions may be made for the
taxable year in which you attain age 70 1/2 and thereafter (except for rollover
contributions). The minimum additional payment which may be made to a
Certificate issued as an IRA is $250.00.

ACCUMULATION VALUE ALLOCATION RULES

We reserve the right to impose a charge for any allocation change in excess of
twelve per Certificate Year. The Excess Allocation Charge is shown in the
Schedule. Allocations into and out of the Guaranteed Interest Divisions are
subject to restrictions (see General Account).

ALLOCATION CHANGES BY TELEPHONE

You may request allocation changes by telephone during our telephone request
business hours. You may call our Customer Service Center at 1-800-366-0066 to
make allocation changes by using the personal identification number you will
receive. You may also mail any notice or request for allocation changes to our
Customer Service Center at the address shown on the cover page.

GA-CA-1082                           3A2

<PAGE>

                                  THE SCHEDULE

                         THE VARIABLE SEPARATE ACCOUNTS

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

|------------------------------------------------------------------------------|
|   Annuitant              Owner                                               |
|   [THOMAS J. DOE]        [JOHN Q. DOE]                                       |
|------------------------------------------------------------------------------|
|   Initial Premium        Annuity Option           Annuity Commencement Date  |
|   [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]          |
|------------------------------------------------------------------------------|
|   Separate Account(s)                             Certificate Number         |
|   [SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]      [123456]                   |
|------------------------------------------------------------------------------|

DIVISIONS INVESTING IN SHARES OF A MUTUAL FUND

Separate Account B (the "Account") is a unit investment trust Separate Account,
organized in and governed by the laws of the State of Delaware, our state of
domicile. The Account is divided into Divisions. Each Division listed below
invests in shares of the mutual fund portfolio (the "Series") designated. Each
portfolio is a part of The GCG Trust managed by Directed Services, Inc.

   SERIES                       SERIES                      SERIES
   ------                       ------                      ------
   [All Cap                     Capital Growth              Liquid Asset
   Equity Income                Managed Global              Strategic Equity
   Fully Managed                Asset Allocation Growth     Research
   Value Equity                 Diversified Mid-Cap         Growth
   Small Cap                    Investors                   Global Fixed Income
   Capital Appreciation         Large Cap Value             Developing World
   Rising Dividends             Real Estate                 Equity Income
   Mid-Cap Growth               Hard Assets                 Growth and Income
   Total Return                 Limited Maturity Bond       Special Situations

     The Division listed below invests in shares of the mutual fund portfolio
     (the "Portfolio") designated. The portfolio is a part of the ING Variable
     Insurance Trust managed by ING Investment Management.

         PORTFOLIO
         ---------
         ING Global Brand Names Fund

     The Division listed below invests in shares of the mutual fund portfolio
     (the "Portfolio") designated. The portfolios are a part of the Prudential
     Series Fund, Inc. managed by Jennison Associates, LLC.

         PORTFOLIO
         ---------
         Prudential Jennison

     The Division listed below invests in shares of the mutual fund portfolio
     (the "Portfolio") designated. The portfolio is a part of the Warburg Pincus
     Trust managed by Credit Suisse Asset Management, LLC.

         PORTFOLIO
         ---------
         International Equity
         International Growth

     The Division listed below invests in shares of the mutual fund portfolio
     (the "Portfolio") designated. The portfolios are a part of the PIMCO Trust
     managed by Pacific Investment Management Company.

         PORTFOLIO
         ---------
         PIMCO High Yield Bond
         PIMCO StocksPlus Growth & Income]

GA-CA-1082                            3B

<PAGE>

                                  THE SCHEDULE

                               THE GENERAL ACCOUNT

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

|------------------------------------------------------------------------------|
|   Annuitant              Owner                                               |
|   [THOMAS J. DOE]        [JOHN Q. DOE]                                       |
|------------------------------------------------------------------------------|
|   Initial Premium        Annuity Option           Annuity Commencement Date  |
|   [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]          |
|------------------------------------------------------------------------------|
|   Separate Account(s)                             Certificate Number         |
|   [SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]      [123456]                   |
|------------------------------------------------------------------------------|

GENERAL ACCOUNT

[Guaranteed Interest Division

A Guaranteed Interest Division provides an annual minimum interest rate of 3%.
At our sole discretion, we may periodically declare higher interest rates for
specific Guarantee Periods. Such rates will apply to periods following the date
of declaration. Any declaration will be by class and will be based on our future
expectations.

Limitations of Allocations

We reserve the right to restrict allocations into and out of the General
Account. Such limits may be dollar restrictions on allocations into the General
Account or we may restrict reallocations into the General Account.

Transfers from a Guaranteed Interest Division

We currently require that an amount allocated to a Guarantee Period not be
transferred until the Maturity Date, except pursuant to our published rules. We
reserve the right not to allow amounts previously transferred from a Guaranteed
Interest Division to the Variable Separate Account Divisions or to a Fixed
Allocation to be transferred back to a Guaranteed Interest Division for a period
of at least six months from the date of transfer.]

GA-CA-1082                        3C

<PAGE>

                             THE SCHEDULE (STANDARD)

                                CERTIFICATE FACTS
-------------------------------------------------------------------------------
|------------------------------------------------------------------------------|
|   Annuitant              Owner                                               |
|   [THOMAS J. DOE]        [JOHN Q. DOE]                                       |
|------------------------------------------------------------------------------|
|   Initial Premium        Annuity Option           Annuity Commencement Date  |
|   [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]          |
|------------------------------------------------------------------------------|
|   Separate Account(s)                             Certificate Number         |
|   [SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]      [123456]                   |
|------------------------------------------------------------------------------|
CERTIFICATE FACTS

Certificate Processing Date

The Certificate Processing Date for your Certificate is [April 1] of each year.

Specially Designated Division

When a distribution is made from an investment portfolio underlying a Separate
Account Division in which reinvestment is not available, we will allocate the
amount of the distribution to the [Liquid Asset Division] unless you specify
otherwise.

PARTIAL WITHDRAWALS

The maximum amount that can be withdrawn each Certificate Year without being
considered an Excess Partial Withdrawal is described below. We will collect a
Surrender Charge for Excess Partial Withdrawals and a charge for any unrecovered
Premium Taxes. In no event may a Partial Withdrawal be greater than 90% of the
Cash Surrender Value. After a Partial Withdrawal, the remaining Accumulation
Value must be at least $100 to keep the Certificate in force.

Systematic Partial Withdrawals and Conventional Partial Withdrawals may not be
taken in the same Certificate Year.

To   determine the Surrender Charge on Excess Partial Withdrawals, the
     withdrawals will occur in the following order: (1) Earnings; (2) The Free
     Amount; (3) Premium Payments made [four] or more years prior to the
     withdrawal; and (4) Premium Payments made less than [four] years prior to
     withdrawal.

Earnings and Free Amounts are not treated as withdrawals of Premium Payments for
purposes of calculating any Surrender Charge.

Conventional Partial Withdrawals
Minimum Withdrawal Amount: $100.

The maximum amount that can be taken as a Conventional Partial Withdrawal each
Certificate Year without being considered an Excess Partial Withdrawal is the
greater of:

     (1) Earnings (defined below) not previously withdrawn, but not less than
         zero; and
     (2) The Free Amount, equal to 10% of Premium Payments not previously
         withdrawn, which were received within [four] years prior to the date of
         withdrawal.

Earnings are equal to the Accumulation Value, less Premium Payments, plus prior
withdrawals.

Any Conventional Partial Withdrawal is subject to a Market Value Adjustment
unless withdrawn from a Fixed Allocation within 30 days prior to the Maturity
Date.

GA-CA-1082                              3D1

<PAGE>

                                  THE SCHEDULE

                          CERTIFICATE FACTS (continued)
-------------------------------------------------------------------------------

|------------------------------------------------------------------------------|
|   Annuitant              Owner                                               |
|   [THOMAS J. DOE]        [JOHN Q. DOE]                                       |
|------------------------------------------------------------------------------|
|   Initial Premium        Annuity Option           Annuity Commencement Date  |
|   [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]          |
|------------------------------------------------------------------------------|
|   Separate Account(s)                             Certificate Number         |
|   [SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]      [123456]                   |
|------------------------------------------------------------------------------|

Systematic Partial Withdrawals
Systematic Partial Withdrawals may be elected to commence after 28 days from the
Certificate Issue Date and may be taken on a monthly, quarterly or annual basis.
You select the day withdrawals will be made, but no later than the 28th day of
the month. If you do not elect a day, the Certificate Date will be used.

Maximum Withdrawal Amounts:

     Variable Separate Account Divisions:  .833% of Premium Payments monthly,
                                            2.5% of Premium Payments quarterly
                                            or 10% of Premium Payments annually.

     Fixed Allocations and
     Guaranteed Interest Divisions:        Interest earned on a Fixed Allocation
                                           or Guaranteed Interest Division for
                                           the prior month, quarter or year
                                           (depending on the frequency
                                           selected).

The Maximum Withdrawal Amount available as a Systematic Partial Withdrawal is
10% of Premium Payments not previously withdrawn. Systematic Partial Withdrawals
from Fixed Allocations are not subject to a Market Value Adjustment. A
Systematic Partial Withdrawal in excess of Earnings and the Free Amount may be
subject to a Surrender Charge.

IRA Partial Withdrawals for Qualified Plans Only

Partial Withdrawals may be taken from a Certificate issued as an IRA on a
monthly, quarterly or annual basis. A minimum withdrawal of $100.00 is required.
You select the day the withdrawals will be made, but no later than the 28th day
of the month. If you do not elect a day, the Certificate Date will be used.
Systematic Partial Withdrawals and Conventional Partial Withdrawals are not
allowed when IRA Partial Withdrawals are being taken. An IRA Partial Withdrawal
in excess of the maximum amount allowed under the Systematic Partial Withdrawal
option may be subject to a Market Value Adjustment.

DEATH BENEFIT

The Death Benefit is the greatest of (i), (ii) and (iii) below, where:
     (i)   is the Accumulation Value;
     (ii)  is the Guaranteed Death Benefit;
     (iii) is the Cash Surrender Value.

GA-CA-1082                            3D2

<PAGE>

                                  THE SCHEDULE

                          CERTIFICATE FACTS (continued)
-------------------------------------------------------------------------------

|------------------------------------------------------------------------------|
|   Annuitant              Owner                                               |
|   [THOMAS J. DOE]        [JOHN Q. DOE]                                       |
|------------------------------------------------------------------------------|
|   Initial Premium        Annuity Option           Annuity Commencement Date  |
|   [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]          |
|------------------------------------------------------------------------------|
|   Separate Account(s)                             Certificate Number         |
|   [SEPARATE ACCOUNT B AND THE FIXED ACCOUNT]      [123456]                   |
|------------------------------------------------------------------------------|

GUARANTEED DEATH BENEFIT

The Guaranteed Death Benefit for the Certificate is equal to the sum of I and II
below.
     I.  The Guaranteed Death Benefit Base for non-Special Funds
     II. The Accumulation Value allocated to Special Funds

On the Certificate Date, the Guaranteed Death Benefit Base for non-Special Funds
is the initial premium allocated to non-Special Funds. On subsequent Valuation
Dates, the Guaranteed Death Benefit Base for non-Special Funds is calculated as
follows:
     (1)  Start with the  Guaranteed  Death Benefit Base for  non-Special  Funds
          from the prior Valuation Date.
     (2)  Add any additional  premiums paid and allocated to  non-Special  Funds
          during the current Valuation Period to (1).
     (3)  Adjust (2) for any  transfers to or from  Special  Funds during the
          current Valuation Period.
     (4)  Subtract from (3) any Prorata Partial  Withdrawal  Adjustments for any
          Partial  Withdrawal  made from  non-Special  Funds  during the current
          Valuation Period.

The Guaranteed Death Benefit Base for Special Funds has a corresponding
definition, but with respect to amounts allocated to Special Funds.

Transfers from Special Funds to non-Special Funds will reduce the Guaranteed
Death Benefit Base for Special Funds on a prorata basis. The resulting increase
in the Guaranteed Death Benefit Base for non-Special Funds will equal the lesser
of the reduction in the Guaranteed Death Benefit Base for Special Funds and the
net Accumulation Value transferred.

Transfers from non-Special Funds to Special Funds will reduce the Guaranteed
Death Benefit Base for non-Special Funds on a prorata basis. The resulting
increase in the Guaranteed Death Benefit Base for Special Funds will equal the
reduction in Guaranteed Death Benefit Base for non-Special Funds.

GA-CA-1082                         3D3

<PAGE>

                                  THE SCHEDULE

                         CERTIFICATE FACTS (continued)
   ----------------------------------------------------------------------------
    Annuitant              Owner
    [THOMAS J. DOE]        [JOHN Q. DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
   ----------------------------------------------------------------------------
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
    Separate Account(s)    Certificate Number
   ----------------------------------------------------------------------------
    [SEPARATE ACCOUNT B AND THE FIXED ACC[123456]
   ----------------------------------------------------------------------------

SPECIAL FUNDS

Where used in this Certificate, Special Funds are [the Liquid Asset Division,
the Limited Maturity Bond Division, the Fixed Allocations and the Guaranteed
Interest Division]. We may add newly available Divisions as Special Funds. We
may also reclassify an existing Division as a Special Fund or remove such
designation upon 30 days notice to you. Such reclassification will apply to
amounts transferred or otherwise added to such Division after the date of
change. We may reduce the Mortality and Expense Risk Charge (if applicable) for
that portion of the Certificate invested in a Special Fund.

PRORATA PARTIAL WITHDRAWAL ADJUSTMENTS

For any partial withdrawal, the Death Benefit components will be reduced by
Prorata Partial Withdrawal Adjustments. The Prorata Partial Withdrawal
Adjustment to a Death Benefit component for a partial withdrawal is equal to (1)
divided by (2) multiplied by (3), where: (1) is the Accumulation Value
withdrawn; (2) is the Accumulation Value immediately prior to withdrawal; and
(3) is the amount of the applicable Death Benefit component immediately prior to
the withdrawal. Separate adjustments will apply to amounts in the Special and
non-Special Funds.

CHANGE OF OWNER

A change of Owner will result in recalculation of the Death Benefit and the
Guaranteed Death Benefit. If the Owner's or the oldest of multiple Owners'
Attained Age at the time of the change is less than [86], the Guaranteed Death
Benefit in effect prior to the change will remain in effect and the Death
Benefit provision shall apply.

If any Owner's or oldest multiple Owners' Attained Age is [86] or greater at the
time of the change, the Guaranteed Death Benefit will be zero, and the Death
Benefit will then be the Cash Surrender Value.

GA-CA-1082                         3D4
<PAGE>

                                  THE SCHEDULE

                          CERTIFICATE FACTS (continued)
   ----------------------------------------------------------------------------
    Annuitant              Owner
    [THOMAS J. DOE]        [JOHN Q. DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
   ----------------------------------------------------------------------------
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
    Separate Account(s)    Certificate Number
   ----------------------------------------------------------------------------
    [SEPARATE ACCOUNT B AND THE FIXED ACC[123456]
   ----------------------------------------------------------------------------

SPOUSAL CONTINUATION UPON DEATH OF OWNER

If at the Owner's death, the surviving spouse of the deceased Owner is the
Beneficiary and such surviving spouse elects to continue the Certificate as
their own pursuant to Internal Revenue Code Section 72(s) or the equivalent
provisions of U.S. Treasury Department rules for qualified plans, the following
will apply:
     (i)  If the Guaranteed Death Benefit as of the date we receive due proof of
          death of the  Owner,  minus the  Accumulation  Value,  also as of that
          date,  is  greater  than  zero,  we will  add such  difference  to the
          Accumulation  Value.  Such addition will be allocated to the Divisions
          of the Separate  Account in the same  proportion  as the  Accumulation
          Value in each Division bears to the Accumulation Value in the Separate
          Account.  If there is no Accumulation  Value in the Separate  Account,
          the addition  will be allocated to the Liquid Asset  Division,  or its
          successor.
     (ii) The  Guaranteed  Death  Benefit will  continue to apply,  with all age
          criteria using the surviving spouse's age as the determining age.
     (iii)At subsequent  surrender,  any Surrender Charge applicable to premiums
          paid prior to the date we receive due proof of death of the Owner will
          be waived.  Any premiums paid later will be subject to any  applicable
          Surrender Charge.

This addition to Accumulation Value is available only to the spouse of the Owner
as of the date of death of the Owner if such spouse under the provisions if this
Certificate elects to continue the Certificate as their own.

CHOOSING AN INCOME PLAN

Required Date of Annuity Commencement

Distributions from a Certificate funding a qualified plan must commence no later
than April 1st of the calendar year following the calendar year in which the
Owner attains age 70 1/2. Otherwise, the Annuity Commencement Date may be no
later than the same date as the Certificate Processing Date in the month
following the Annuitant's 90th birthday. In applying the Accumulation Value, we
may first collect any Premium Taxes due us. If, on the Annuity Commencement
Date, a Surrender Charge remains, your elected Annuity Option must include a
period certain of at least five years duration.

Minimum Annuity Income Payment

The minimum monthly annuity income payment that we will make is [$20].

GA-CA-1082                         3D5
<PAGE>

                                  THE SCHEDULE

                          CERTIFICATE FACTS (continued)
   ----------------------------------------------------------------------------
    Annuitant              Owner
    [THOMAS J. DOE]        [JOHN Q. DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
   ----------------------------------------------------------------------------
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
    Separate Account(s)    Certificate Number
   ----------------------------------------------------------------------------
    [SEPARATE ACCOUNT B AND THE FIXED ACC[123456]
   ----------------------------------------------------------------------------

OPTIONAL BENEFIT RIDERS - [None]

ATTAINED AGE

The Issue Age of the Annuitant or Owner plus the number of full years elapsed
since the Certificate Date.

RESTRICTED FUNDS - [None]

FIXED ACCOUNT

     Minimum Fixed Allocation
     The minimum  allocation to the Fixed Account in any one Fixed Allocation is
     [$250.00].

     Minimum Guaranteed Interest Rate - [3%]

     Guarantee Periods
     We currently  offer  Guarantee  Periods of [1, 3, 5, 7 and 10] year(s).  We
     reserve the right to offer Guarantee  Periods of durations other than those
     available  on the  Certificate  Date.  We also  reserve  the right to cease
     offering a particular Guarantee Period or Periods.

     Index Rate
     The Index  Rate is the  average  of the Ask  Yields  for the U.S.  Treasury
     Strips  as  reported  by a  national  quoting  service  for the  applicable
     maturity.  The  average  is  based on the  period  from the 22nd day of the
     calendar  month  two  months  prior to the  calendar  month  of Index  Rate
     determination  to the 21st day of the calendar month  immediately  prior to
     the month of  determination.  The  applicable  maturity date for these U.S.
     Treasury  Strips  is on or next  following  the last  day of the  Guarantee
     Period. If the Ask Yields are no longer  available,  the Index Rate will be
     determined using a suitable replacement method.

     We  currently  set the Index Rate once each  calendar  month.  However,  we
     reserve the right to set the Index Rate more frequently  than monthly,  but
     in no event will such Index Rate be based on a period less than 28 days.

GA-CA-1082                         3D6
<PAGE>

                                  THE SCHEDULE

                                CHARGES AND FEES
   ----------------------------------------------------------------------------
    Annuitant              Owner
    [THOMAS J. DOE]        [JOHN Q. DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
   ----------------------------------------------------------------------------
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
    Separate Account(s)    Certificate Number
   ----------------------------------------------------------------------------
    [SEPARATE ACCOUNT B AND THE FIXED ACC[123456]
   ----------------------------------------------------------------------------

DEDUCTIONS FROM PREMIUMS

     None

DEDUCTIONS FROM ACCUMULATION VALUE

     Initial Administrative Charge
     None

     Administrative Charge
     We charge a maximum of $30 to cover a portion of our ongoing administrative
     expenses for each Certificate  Processing Period. The charge is incurred at
     the  beginning  of the  Certificate  Processing  Period and deducted on the
     Certificate Processing Date at the end of the period.

     At the  time of deduction, this charge will be waived  if:
       (1) The Accumulation  Value is at least  $100,000;  or
       (2) The sum of premiums paid to date is at least $100,000

     Excess Allocation Charge
     Currently none, however, we reserve the right to charge $25 for a change if
     you make more than twelve  allocation  changes per  Certificate  Year.  Any
     charge will be deducted in proportion to the amount being  transferred from
     each Division.

     Surrender Charge
     A Surrender  Charge is imposed as a percentage of  unliquidated  premium if
     the  Certificate is  surrendered or an Excess Partial  Withdrawal is taken.
     The percentage  imposed at time of surrender or Excess  Partial  Withdrawal
     depends on the number of complete  years that have elapsed  since a Premium
     Payment was made.  The Surrender  Charge  expressed as a percentage of each
     Premium Payment is as follows:

       Complete Years Elapsed                     Surrender
        Since Premium Payment                      Charges
        ---------------------                      -------

                 [0                                  6%
                  1                                  5%
                  2                                  4%
                  3                                  3%
                 4+                                  0%]

     Surrender of the Certificate is permitted at or before the  commencement of
     Annuity Payments.

GA-CA-1082                         3E1

<PAGE>

                                  THE SCHEDULE

                                CHARGES AND FEES
   ----------------------------------------------------------------------------
    Annuitant              Owner
    [THOMAS J. DOE]        [JOHN Q. DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
   ----------------------------------------------------------------------------
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
    Separate Account(s)    Certificate Number
   ----------------------------------------------------------------------------
    [SEPARATE ACCOUNT B AND THE FIXED ACC[123456]
   ----------------------------------------------------------------------------

     Premium Taxes
     We deduct the amount of any premium or other  state and local taxes  levied
     by any state or governmental entity when such taxes are incurred.

     We reserve the right to defer  collection of Premium Taxes until  surrender
     or until application of Accumulation  Value to an Annuity Option. An Excess
     Partial Withdrawal will result in the deduction of any Premium Tax then due
     us on such amount.  We reserve the right to change the amount we charge for
     Premium Tax charges on future  Premium  Payments to conform with changes in
     the law or if the Owner changes state of residence.

     Deductions from the Divisions
     Mortality  and Expense  Risk Charge - We deduct a charge from the assets in
     -----------------------------------
     each Variable  Separate  Account Division on a daily basis of not more than
     [0.004558]% (equivalent to an annual maximum rate of [1.65]%) for mortality
     and expense  risks.  The charge is not deducted  from the Fixed  Account or
     General Account Accumulation Values.

     Asset  Based  Administrative  Charge - We  deduct a charge of not more than
     ------------------------------------
     [0.000411]% of the assets in each Variable  Separate  Account Division on a
     daily basis (equivalent to an annual maximum rate of [0.15]%) to compensate
     us for a portion of our ongoing administrative expenses. This charge is not
     deducted from the Fixed Account or General Account Accumulation Values.

CHARGE DEDUCTION DIVISION

If elected by you, all charges against the Accumulation Value in this
Certificate will be deducted from the [Liquid Asset Division].

GA-CA-1082                         3E2
<PAGE>

                                  THE SCHEDULE

                               INCOME PLAN FACTORS
   ----------------------------------------------------------------------------
     Annuitant                                                        Owner
    [THOMAS J. DOE]        [JOHN Q. DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
   ----------------------------------------------------------------------------
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
    Separate Account(s)    Certificate Number
   ----------------------------------------------------------------------------
    [SEPARATE ACCOUNT B AND THE FIXED ACC[123456]
   ----------------------------------------------------------------------------

Values for other payment periods, ages or joint life combinations are available
on request. Monthly payments are shown for each $1,000 applied.

                       TABLE FOR INCOME FOR A FIXED PERIOD
<TABLE>
<CAPTION>

      Fixed Period            Monthly           Fixed Period             Monthly          Fixed Period             Monthly
          of Years             Income               of Years              Income              of Years              Income
       <S>                  <C>                    <C>                 <C>                   <C>

        [5                  17.95                  14                  7.28                  23                   5.00
        6                   15.18                  15                  6.89                  24                   4.85
        7                   13.20                  16                  6.54                  25                   4.72
        8                   11.71                  17                  6.24                  26                   4.60
        9                   10.56                  18                  5.98                  27                   4.49
        10                   9.64                  19                  5.74                  28                   4.38
        11                   8.88                  20                  5.53                  29                   4.28
        12                   8.26                  21                  5.33                  30                  4.19]
        13                   7.73                  22                  5.16

</TABLE>

                            TABLE FOR INCOME FOR LIFE
<TABLE>
<CAPTION>

                                        Male/Female                         Male/Female                        Male/Female
      Age                          10 Years Certain                    20 Years Certain                     Refund Certain
<S>                                      <C>                                 <C>                                <C>
[50                                      $4.06/3.83                          $3.96/3.77                         $3.93/3.75
55                                        4.43/4.14                           4.25/4.05                          4.25/4.03
60                                        4.90/4.56                           4.57/4.37                          4.66/4.40
65                                        5.51/5.10                           4.90/4.73                          5.12/4.83
70                                        6.26/5.81                           5.18/5.07                          5.76/5.42
75                                        7.11/6.70                           5.38/5.33                          6.58/6.19
80                                        7.99/7.70                           5.48/5.46                          7.69/7.21
85                                        8.72/8.59                           5.52/5.51                          8.72/8.59
90                                        9.23/9.18                           5.53/5.53                       10.63/10.53]

</TABLE>

GA-CA-1082                         3F
<PAGE>

                                 IMPORTANT TERMS

-------------------------------------------------------------------------------
ACCUMULATION VALUE - The amount that a Certificate provides for investment at
     any time. Initially, this amount is equal to the premium paid.

ANNUITANT - The person designated by the Owner to be the measuring life in
     determining Annuity Payments.

ANNUITY COMMENCEMENT DATE - For each Certificate, the date on which Annuity
     Payments begin.

ANNUITY OPTIONS - Options the Owner selects that determine the form and amount
     of Annuity Payments.

ANNUITY PAYMENT - The periodic payment an Owner receives.

ATTAINED AGE - The Issue Age of the Annuitant or Owner plus the number of full
     years elapsed since the Certificate Date.

BENEFICIARY - The person designated to receive benefits in the case of the death
     of the Owner.

BUSINESS DAY - Any day the New York Stock Exchange ("NYSE") is open for trading,
     exclusive of federal holidays, or any day on which the Securities and
     Exchange Commission ("SEC") requires that mutual funds, unit investment
     trusts or other investment portfolios be valued.

CASH SURRENDER VALUE - The amount the Owner receives upon surrender of the
     Certificate.

CERTIFICATE ANNIVERSARY - The anniversary of the Certificate Date.

CERTIFICATE DATE - The date we received the initial premium and upon which we
     begin determining the Certificate values. It may not be the same as the
     Certificate Issue Date. This date is used to determine Certificate months,
     processing dates, years, and anniversaries.

CERTIFICATE ISSUE DATE - The date the Certificate is issued at our Customer
     Service Center.

CERTIFICATE PROCESSING DATES - The days when we deduct certain charges from the
     Accumulation Value. If the Certificate Processing Date is not a Valuation
     Date, it will be on the next succeeding Valuation Date. The Certificate
     Processing Date will be on the Certificate Anniversary of each year.

CERTIFICATE PROCESSING PERIOD - The period between successive Certificate
     Processing Dates unless it is the first Certificate Processing Period. In
     that case, it is the period from the Certificate Date to the first
     Certificate Processing Date.

CERTIFICATE YEAR - The period between Certificate Anniversaries.

CHARGE DEDUCTION DIVISION - The Division from which all charges are deducted if
     so designated or elected by the Owner.

CONTINGENT ANNUITANT - The person designated by the Owner who, upon the
     Annuitant's death prior to the Annuity Commencement Date, becomes the
     Annuitant.

CONTRACT ISSUE DATE - The date the group contract is issued at our Customer
     Service Center.

CONTRACTHOLDER - The entity to whom the group contract is issued.

GA-CA-1082                         4
<PAGE>

                           IMPORTANT TERMS (continued)
-------------------------------------------------------------------------------

EXPERIENCE FACTOR - The factor which reflects the investment experience of the
     portfolio in which a Variable Separate Account Division invests and also
     reflects the charges assessed against the Division for a Valuation Period.

FIXED ACCOUNT - This is the Separate Account established to support Fixed
     Allocations.

FIXEDALLOCATION - An amount allocated to the Fixed Account that is credited
     with a Guaranteed Interest Rate for a specified Guarantee Period.

GUARANTEE PERIOD - The period of years a rate of interest is guaranteed to be
     credited to a Fixed Allocation or allocations to a Guaranteed Interest
     Division.

GUARANTEED INTEREST DIVISION - An investment option available in the General
     Account, an account which contains all of our assets other than those held
     in our Separate Accounts.

GUARANTEED INTEREST RATE - The effective annual interest rate which we will
     credit for a specified Guarantee Period.

GUARANTEED MINIMUM INTEREST RATE - The minimum interest rate which can be
     declared by us for Fixed Allocations or Guaranteed Interest Divisions.

INDEX OF INVESTMENT EXPERIENCE - The index that measures the performance of a
     Variable Separate Account Division.

INITIAL PREMIUM - The payment amount required to put each Certificate in effect.

ISSUE AGE - The Annuitant's or Owner's age on the last birthday on or before the
     Certificate Date.

MARKET VALUE ADJUSTMENT - A positive or negative adjustment to a Fixed
     Allocation. It may apply if all or part of a Fixed Allocation is withdrawn,
     transferred, or applied to an Annuity Option prior to the end of the
     Guarantee Period.

MATURITY DATE - The date on which a Guarantee Period matures.

OWNER- The person who owns a Certificate and is entitled to exercise all rights
     of the Certificate. This person's death also initiates payment of the Death
     Benefit.

RIDERS - Riders add provisions or change the terms of the Certificate.

SPECIALLY DESIGNATED DIVISION - Distributions from a portfolio underlying a
     Division in which reinvestment is not available will be allocated to this
     Division unless you specify otherwise.

VALUATION DATE - The day at the end of a Valuation Period when each Division is
     valued.

VALUATION PERIOD - Each business day together with any non-business days before
     it.

VARIABLE SEPARATE ACCOUNT DIVISION - An investment option available in the
     Variable Separate Account shown in the Schedule.

GA-CA-1082                         5
<PAGE>

                        INTRODUCTION TO THIS CERTIFICATE
-------------------------------------------------------------------------------

THE CERTIFICATE

     This is a legal Certificate between you and us. We provide benefits as
     stated in this Certificate. In return, you supply us with the Initial
     Premium Payment required to put this Certificate in effect.

     This Certificate, together with any attached enrollment form, Riders or
     Endorsements, constitutes the entire Certificate. Riders and Endorsements
     add provisions or change the terms of the basic Certificate.

THE OWNER

     You are the Owner of this Certificate. You are also the Annuitant unless
     another Annuitant has been named by you and is shown in the Schedule. You
     have the rights and options described in this Certificate, including but
     not limited to the right to receive the Annuity Benefits on the Annuity
     Commencement Date.

     One or more people may own this Certificate. If there are multiple Owners
     named, the age of the oldest Owner will be used to determine the applicable
     Death Benefit. In the case of a sole Owner who dies prior to the Annuity
     Commencement Date, we will pay the Beneficiary the Death Benefit then due.
     If the sole Owner is not an individual, we will treat the Annuitant as
     Owner for the purpose of determining when the Owner dies under the Death
     Benefit provision (if there is no Contingent Annuitant), and the
     Annuitant's age will determine the applicable Death Benefit payable to the
     Beneficiary. The sole Owner's estate will be the Beneficiary if no
     Beneficiary designation is in effect, or if the designated Beneficiary has
     predeceased the Owner. In the case of a joint Owner of the Certificate
     dying prior to the Annuity Commencement Date, the surviving Owner(s) will
     be deemed as the Beneficiary(ies).

THE ANNUITANT

     The Annuitant is the measuring life of the Annuity Benefits provided under
     this Certificate. You may name a Contingent Annuitant. The Annuitant may
     not be changed during the Annuitant's lifetime.

     If the Annuitant dies before the Annuity Commencement Date, the Contingent
     Annuitant becomes the Annuitant. You will be the Contingent Annuitant
     unless you name someone else. The Annuitant must be a natural person. If
     the Annuitant dies and no Contingent Annuitant has been named, we will
     allow you sixty days to designate someone other than yourself as an
     Annuitant. If all Owners are not individuals and, through the operation of
     this provision, an Owner becomes Annuitant, we will pay the death proceeds
     to the Beneficiary. If there are joint Owners, we will treat the youngest
     of the Owners as the Contingent Annuitant designated, unless you elect
     otherwise.

THE BENEFICIARY

     The Beneficiary is the person to whom we pay death proceeds if any Owner
     dies prior to the Annuity Commencement Date. See Proceeds Payable to the
     Beneficiary for more information. We pay death proceeds to the primary
     Beneficiary (unless there are joint Owners in which case the Death Benefit
     proceeds are payable to the surviving Owner). If the primary Beneficiary
     dies before the Owner, the death proceeds are paid to the Contingent
     Beneficiary, if any. If there is no surviving Beneficiary, we pay the death
     proceeds to the Owner's estate.

GA-CA-1082                         6
<PAGE>

                  INTRODUCTION TO THIS CERTIFICATE (continued)
-------------------------------------------------------------------------------

     One or more persons may be named as primary Beneficiary or contingent
     Beneficiary. In the case of more than one Beneficiary, we will assume any
     death proceeds are to be paid in equal shares to the surviving
     Beneficiaries. You can specify other than equal shares.

     You have the right to change Beneficiaries, unless you designate the
     primary Beneficiary irrevocable. When an irrevocable Beneficiary has been
     designated, you and the irrevocable Beneficiary may have to act together to
     exercise the rights and options under this Certificate.

CHANGE OF OWNER OR BENEFICIARY

     During your lifetime and while this Certificate is in effect you can
     transfer ownership of this Certificate or change the Beneficiary. To make
     any of these changes, you must send us written notice of the change in a
     form satisfactory to us. The change will take effect as of the day the
     notice is signed. The change will not affect any payment made or action
     taken by us before recording the change at our Customer Service Center. A
     Change of Owner may affect the amount of Death Benefit payable under this
     Certificate. See Proceeds Payable to Beneficiary.

GA-CA-1082                         7
<PAGE>

                     PREMIUM PAYMENTS AND ALLOCATION CHANGES
-------------------------------------------------------------------------------

INITIAL PREMIUM PAYMENT

     The Initial Premium Payment is required to put this Certificate in effect.
     The amount of the Initial Premium Payment is shown in the Schedule.

ADDITIONAL PREMIUM PAYMENTS

     You may make additional Premium Payments under this Certificate after the
     end of the Right to Examine period. Restrictions on additional Premium
     Payments, such as the Attained Age of the Annuitant or Owner and the timing
     and amount of each payment, are shown in the Schedule. We reserve the right
     to defer acceptance of or to return any additional Premium Payments.

     As of the date we receive and accept your additional Premium Payment:

          (1)  The Accumulation Value will increase by the amount of the Premium
               Payment less any premium deductions as shown in the Schedule.

          (2)  The increase in the Accumulation Value will be allocated among
               the Divisions of the Variable Separate Account and General
               Account and allocations to the Fixed Account in accordance with
               your instructions. If you do not provide such instructions,
               allocation will be among the Divisions of the Variable Separate
               Account and General Account and allocations to the Fixed Account
               in proportion to the amount of Accumulation Value in each
               Division or Fixed Allocation.

     Where to Make Payments
     Remit the Premium Payments to our Customer Service
     Center at the address shown on the cover page. On request we will give you
     a receipt signed by our treasurer.

YOUR RIGHT TO CHANGE ALLOCATION OF ACCUMULATION VALUE

     You may change the allocation of the Accumulation Value among the Divisions
     and Fixed Allocations after the end of the Right to Examine period.
     Allocation changes in excess of twelve in any Certificate Year are subject
     to the Excess Allocation Charge as stated in the Schedule. To make an
     allocation change, you must provide us with satisfactory notice at our
     Customer Service Center. The change will take effect when we receive the
     notice. Restrictions for reallocation into and out of Divisions of the
     Variable Separate Account and General Account and allocations to the Fixed
     Account are shown in the Schedule. An allocation from the Fixed Account may
     be subject to a Market Value Adjustment. See the Schedule.

WHAT HAPPENS IF A VARIABLE SEPARATE ACCOUNT DIVISION IS NOT AVAILABLE

     When a distribution is made from an investment portfolio supporting a unit
     investment trust Separate Account Division in which reinvestment is not
     available, we will allocate the distribution to the Specially Designated
     Division shown in the Schedule unless you specify otherwise.

     Such a distribution may occur when an investment portfolio or Division
     matures, when distribution from a portfolio or Division cannot be
     reinvested in the portfolio or Division due to the unavailability of
     securities, or for other reasons. When this occurs because of maturity, we
     will send written notice to you thirty days in advance of such date. To
     elect an allocation to other than the Specially Designated Division shown
     in the Schedule, you must provide satisfactory notice to us at least seven
     days prior to the date the investment matures. Such allocations will not be
     counted as an allocation change of the Accumulation Value for purposes of
     the number of free allocations permitted.

GA-CA-1082                         8
<PAGE>

               PREMIUM PAYMENTS AND ALLOCATION CHANGES (continued)
-------------------------------------------------------------------------------

RESTRICTED FUNDS

     Restricted Funds are subject to limits as to amounts which may be invested
     or transferred into such Divisions. The designation of a Division as a
     Restricted Fund may be changed upon 30 days notice to the Owner with regard
     to future transfers and Premium Payments into such Division. When a new
     Division is made available it may be designated as a Restricted Fund. If so
     designated, the rules regarding its restrictions will be sent to the Owner.
     Restricted Funds available under this Certificate, if any, as well as
     applicable total Certificate limits, are shown in the Schedule.

THRESHOLDS

     Each Restricted Fund has one or more thresholds at which point no further
     amounts may be allocated to that Division. Compliance with a threshold is
     verified whenever there is a transaction initiated which is subject to such
     threshold (Premium Payments, transfers, withdrawals). A threshold is
     applied to the total Accumulation Value of each Restricted Fund. Thresholds
     may be changed by the Company for new premiums, transfers or withdrawals by
     Restricted Fund upon 30 day notice.

DOLLAR CAP

     The Dollar Cap is the dollar amount at which no further Accumulation Value
     may be added to Restricted Funds.

PREMIUM THRESHOLD

     The threshold for premium by Restricted Fund limits the amount of any
     premium which may be allocated to that Division. Should a request for
     allocation to a Restricted Fund exceed the limit in effect for that
     Division or for the Certificate, any excess over that amount shall be
     allocated prorata to any non-Restricted Fund(s) in which the Certificate is
     then invested. Should the Certificate not be invested in other
     non-Restricted Funds, the excess will be invested in the Specially
     Designated Division unless we receive written instructions to do otherwise.
     Premium allocations must also satisfy the Allocation Threshold.

ALLOCATION THRESHOLD

     Allocations into a Restricted Fund are limited to that amount such that the
     Accumulation Value in that Restricted Fund after such allocation does not
     exceed the threshold for that Division and does not cause the Certificate's
     total limit on allocation to Restricted Funds to be exceeded. If the amount
     of an allocation would cause either limit to be exceeded, the allocation
     will only be executed to the extent the lower limit would allow.

     Allocations from a Restricted Fund will be allowed even if the amount
     remaining in the Restricted Fund after an allocation exceeds the Allocation
     Threshold. If a program of allocations over time is authorized by us,
     verification of the threshold will be performed at the initiation of such
     program. If such program is modified at a later date, a testing of
     thresholds will be done at that time.

GA-CA-1082                         9
<PAGE>

               PREMIUM PAYMENTS AND ALLOCATION CHANGES (continued)
-------------------------------------------------------------------------------

THRESHOLDS - EFFECT ON WITHDRAWALS

     If a withdrawal is requested while any Accumulation Value is allocated to
     Restricted Funds and the Allocation Threshold percentage is currently
     exceeded, the percentage for funds invested in Restricted Funds for the
     total Certificate, after taking into account the withdrawal, may not be
     higher than prior to the withdrawal. Should the calculated effect of a
     withdrawal result in the total Certificate threshold being exceeded, the
     excess portion of the withdrawal will be processed prorata from all
     Variable Divisions. Systematic withdrawals, while the Certificate has
     investments in Restricted Funds, if not withdrawn prorata from all
     Divisions, shall be monitored annually to assure threshold compliance.
     Should the effect of such withdrawals cause a Restricted Fund to exceed its
     threshold, the Divisions from which the withdrawals are processed may be
     adjusted to assure that the percentage of Accumulation Value in the
     Restricted Funds does not increase.

THRESHOLD PROCESSING

     For the purpose of calculating any thresholds, the values for the Divisions
     will be determined using the prior day's closing Index of Investment
     Experience.

GA-CA-1082                         10
<PAGE>

                HOW WE MEASURE THE CERTIFICATE'S ACCUMULATION VALUE
-------------------------------------------------------------------------------

     The variable Annuity Benefits under this Certificate are provided through
     investments which may be made in our Separate Accounts.

THE VARIABLE SEPARATE ACCOUNTS

     These accounts, which are designated in the Schedule, are kept separate
     from our General Account and any other Separate Accounts we may have. They
     are used to support Variable Annuity Certificates and may be used for other
     purposes permitted by applicable laws and regulations. We own the assets in
     the Separate Accounts. Assets equal to the reserves and other liabilities
     of the accounts will not be charged with liabilities that arise from any
     other business we conduct; but, we may transfer to our General Account
     assets which exceed the reserves and other liabilities of the Variable
     Separate Accounts. Income and realized and unrealized gains or losses from
     assets in these Variable Separate Accounts are credited to or charged
     against the account without regard to other income, gains or losses in our
     other investment accounts.

     The Variable Separate Account will invest in mutual funds, unit investment
     trusts and other investment portfolios which we determine to be suitable
     for this Certificate's purposes. The Variable Separate Account is treated
     as a unit investment trust under Federal securities laws. It is registered
     with the Securities and Exchange Commission ("SEC") under the Investment
     Company Act of 1940. The Variable Separate Account is also governed by
     state law as designated in the Schedule. The trusts may offer
     non-registered series.

Variable Separate Account Divisions

     A unit investment trust Separate Account includes Divisions, each investing
     in a designated investment portfolio. The Divisions and the investment
     portfolios designated may be managed by a separate investment adviser. Such
     adviser may be registered under the Investment Advisers Act of 1940.

Changes within the Variable Separate Accounts

     We may, from time to time, make additional Variable Separate Account
     Divisions available to you. These Divisions will invest in investment
     portfolios we find suitable for the group contract. We also have the right
     to eliminate Divisions from a Variable Separate Account, to combine two or
     more Divisions or to substitute a new portfolio for the portfolio in which
     a Division invests. A substitution may become necessary if, in our
     judgment, a portfolio or Division no longer suits the purpose of the group
     contract. This may happen due to a change in laws or regulations, or a
     change in a portfolio's investment objectives or restrictions, or because
     the portfolio or Division is no longer available for investment, or for
     some other reason. We will obtain any required regulatory approvals before
     making such a substitution.

     Subject to any required regulatory approvals, we reserve the right to
     transfer assets of the Variable Separate Account which we determine to be
     associated with the class of contracts to which the group contract belongs,
     to another Variable Separate Account or Division.

When permitted by law, we reserve the right to:

     (1) deregister a Variable Separate Account under the Investment Company Act
         of 1940;
     (2) operate a Variable Separate Account as a management company under the
         Investment Company Act of 1940, if it is operating as a unit investment
         trust;

     (3) operate a Variable Separate Account as a unit investment trust under
         the Investment Company Act of 1940, if it is operating as a managed
         Variable Separate Account;

     (4) restrict or eliminate any voting rights of Owners, or other persons who
         have voting rights to a Variable Separate Account; and

     (5) combine a Variable Separate Account with other Variable Separate
         Accounts.

GA-CA-1082                         11
<PAGE>

         HOW WE MEASURE THE CERTIFICATE'S ACCUMULATION VALUE (continued)
-------------------------------------------------------------------------------
THE GENERAL ACCOUNT

     The General Account contains all assets of the Company other than those in
     the Separate Accounts we establish. The Guaranteed Interest Divisions
     available for investment are shown in the Schedule. We may, from time to
     time, offer other Divisions where assets are held in our General Account.

VALUATION PERIOD

     Each Division and Fixed Allocation will be valued at the end of each
     Valuation Period on a Valuation Date. A Valuation Period is each Business
     Day together with any non-Business Days before it. A Business Day is any
     day the New York Stock Exchange (NYSE) is open for trading, and the SEC
     requires mutual funds, unit investment trusts, or other investment
     portfolios to value their securities.

ACCUMULATION VALUE

     The Accumulation Value of this Certificate is the sum of the amounts in
     each of the Divisions of the Variable Separate Account and General Account
     and allocations to the Fixed Account. You select the Divisions of the
     Variable Separate Account and General Account and the Fixed Allocations of
     the Fixed Account to which to allocate the Accumulation Value.

ACCUMULATION VALUE IN EACH DIVISION AND FIXED ALLOCATION

     On the Certificate Date

     On the Certificate Date, the Accumulation Value is allocated to each
     Division and Fixed Allocation as elected by you, subject to certain terms
     and conditions imposed by us. We reserve the right to allocate premium to
     the Specially Designated Division during any Right to Examine period. After
     such time, allocation will be made proportionately in accordance with the
     initial allocation(s) as elected by you.

     On each Valuation Date

     At the end of each subsequent Valuation Period, the amount of Accumulation
     Value in each Division and Fixed Allocation will be calculated as follows:

          (1)  We take the Accumulation Value in the Division or Fixed
               Allocation at the end of the preceding Valuation Period.

          (2)  We multiply (1) by the Variable Separate Account Division's Net
               Rate of Return for the current Valuation Period or we calculate
               the interest to be credited to a Fixed Allocation or to a
               Guaranteed Interest Division for the current Valuation Period.

          (3)  We add (1) and (2).

          (4)  We add to (3) any additional Premium Payments (less any premium
               deductions as shown in the Schedule) allocated to the Division or
               Fixed Allocation during the current Valuation Period.

          (5)  We add or subtract allocations to or from that Division or Fixed
               Allocation during the current Valuation Period.

          (6)  We subtract from (5) any Partial Withdrawals which are allocated
               to the Division or Fixed Allocation during the current Valuation
               Period.

          (7)  We subtract from (6) the amounts allocated to that Division or
               Fixed Allocation for:

               (a)  any charges due for the Optional Benefit Riders as shown in
                    the Schedule;

               (b)  any deductions from Accumulation Value as shown in the
                    Schedule.

     All amounts in (7) are allocated to each Division or Fixed Allocation in
     the proportion that (6) bears to the Accumulation Value unless the Charge
     Deduction Division has been specified (see the Schedule).

GA-CA-1082                         12
<PAGE>

         HOW WE MEASURE THE CERTIFICATE'S ACCUMULATION VALUE (continued)
-------------------------------------------------------------------------------

FIXED ACCOUNT

     The Fixed Account is a Separate Account under state insurance law and is
     not required to be registered with the Securities and Exchange Commission
     under the Investment Company Act of 1940. The Fixed Account includes
     various Fixed Allocations which we credit with fixed rates of interest for
     the Guarantee Period or Periods you select. We reset the interest rates for
     new Fixed Allocations periodically based on our sole discretion.

     Guarantee Periods

     Each Fixed Allocation is guaranteed an interest rate or rates for a
     Guarantee Period. The Guaranteed Interest Rates for a Fixed Allocation are
     effective for the entire period. The Maturity Date of a Guarantee Period
     will be on the last day of the calendar month in which the Guarantee Period
     ends. Withdrawals and transfers made during a Guarantee Period may be
     subject to a Market Value Adjustment unless made within thirty days prior
     to the Maturity Date.

     Upon the expiry of a Guarantee Period, we will transfer the Accumulation
     Value of the expiring Fixed Allocation to a Fixed Allocation with a
     Guarantee Period equal in length to the expiring Guarantee Period, unless
     you select another period prior to a Maturity Date. We will notify you at
     least thirty days prior to a Maturity Date of your options for renewal. If
     the period remaining from the expiry of the previous Guarantee Period to
     the Annuity Commencement Date is less than the period you have elected or
     the period expiring, the next shortest period then available that will not
     extend beyond the Annuity Commencement Date will be offered to you. If a
     period is not available, the Accumulation Value will be transferred to the
     Specially Designated Division.

     We will declare Guaranteed Interest Rates for the then available Fixed
     Allocation Guarantee Periods. These interest rates are based solely on our
     expectation as to our future earnings. Declared Guaranteed Interest Rates
     are subject to change at any time prior to application to specific Fixed
     Allocations, although in no event will the rates be less than the Minimum
     Guaranteed Interest Rate (see the Schedule).

     Market Value Adjustments

     A Market Value Adjustment will be applied to a Fixed Allocation upon
     withdrawal, transfer or application to an Income Plan if made more than
     thirty days prior to such Fixed Allocation's Maturity Date, except on
     Systematic Partial Withdrawals and IRA Partial Withdrawals. The Market
     Value Adjustment is applied to each Fixed Allocation separately.

     The Market Value Adjustment is determined by multiplying the amount of the
     Accumulation Value withdrawn, transferred or applied to an Income Plan by
     the following factor:

                                            N/365
                         ((1+I)/(1+J+.0050))      -1

     Where I is the Index Rate for a Fixed Allocation on the first day of the
     applicable Guarantee Period: J is the Index Rate for new Fixed Allocations
     with Guarantee Periods equal to the number of years (fractional years
     rounded up to the next full year) remaining in the Guarantee Period at the
     time of calculation; and N is the remaining number of days in the Guarantee
     Period at the time of calculation. (The Index Rate is described in the
     Schedule.)

     Market Value Adjustments will be applied as follows:

          (1)  The Market Value Adjustment will be applied to the amount
               withdrawn before deduction of any applicable Surrender Charge.

          (2)  For a Partial Withdrawal, partial transfer or in the case where a
               portion of an allocation is applied to an Income Plan, the Market
               Value Adjustment will be calculated on the total amount that must
               be withdrawn, transferred or applied to an Income Plan in order
               to provide the amount requested.

GA-CA-1082                         13
<PAGE>

         HOW WE MEASURE THE CERTIFICATE'S ACCUMULATION VALUE (continued)
-------------------------------------------------------------------------------

          (3)  If the Market Value Adjustment is negative, it will be assessed
               first against any remaining Accumulation Value in the particular
               Fixed Allocation. Any remaining Market Value Adjustment will be
               applied against the amount withdrawn, transferred or applied to
               an Income Plan.

          (4)  If the Market Value Adjustment is positive, it will be credited
               to any remaining Accumulation Value in the particular Fixed
               Allocation. If a cash surrender, full transfer or full
               application to an Income Plan has been requested, the Market
               Value Adjustment is added to the amount withdrawn, transferred or
               applied to an Income Plan.

MEASUREMENT OF INVESTMENT EXPERIENCE

     Index of Investment Experience

     The Investment Experience of a Variable Separate Account Division is
     determined on each Valuation Date. We use an Index to measure changes in
     each Division's experience during a Valuation Period. We set the Index at
     $10 when the first investments in a Division are made. The Index for a
     current Valuation Period equals the Index for the preceding Valuation
     Period multiplied by the Experience Factor for the current Valuation
     Period.

     How We Determine the Experience Factor

     For Divisions of a unit investment trust Separate Account, the Experience
     Factor reflects the Investment Experience of the portfolio in which the
     Division invests as well as the charges assessed against the Division for a
     Valuation Period. The factor is calculated as follows:

          (1)  We take the net asset value of the portfolio in which the
               Division invests at the end of the current Valuation Period.

          (2)  We add to (1) the amount of any dividend or capital gains
               distribution declared for the investment portfolio and reinvested
               in such portfolio during the current Valuation Period. We
               subtract from that amount a charge for our taxes, if any.

          (3)  We divide (2) by the net asset value of the portfolio at the end
               of the preceding Valuation Period.

          (4)  We subtract the daily Mortality and Expense Risk Charge for each
               Division described in the Schedule for each day in the Valuation
               Period.

          (5)  We subtract the daily Asset Based Administrative Charge described
               in the Schedule for each day in the Valuation Period.

     Calculations for Divisions investing in unit investment trusts are on a per
     unit basis.

     Net Rate of Return for a Variable Separate Account Division

     The Net Rate of Return for a Variable Separate Account Division during a
     Valuation Period is the Experience Factor for that Valuation Period minus
     one.

     Interest Credited to a Guaranteed Interest Division

     Accumulation Value allocated to a Guaranteed Interest Division will be
     credited with the Guaranteed Interest Rate for the Guarantee Period in
     effect on the date the premium or reallocation is applied. Once applied,
     such rate will be guaranteed until the Maturity Date of that Guarantee
     Period. Interest will be credited daily at a rate to yield the declared
     annual Guaranteed Interest Rate. No Guaranteed Interest Rate will be less
     than the Minimum Interest Rate shown in the Schedule.

GA-CA-1082                         14
<PAGE>

         HOW WE MEASURE THE CERTIFICATE'S ACCUMULATION VALUE (continued)
-------------------------------------------------------------------------------

     Interest Credited to a Fixed Allocation

     A Fixed Allocation will be credited with the Guaranteed Interest Rate for
     the Guarantee Period in effect on the date the premium or reallocation is
     applied. Once applied, such rate will be guaranteed until that Fixed
     Allocation's Maturity Date. Interest will be credited daily at a rate to
     yield the declared annual Guaranteed Interest Rate.

     We periodically declare Guaranteed Interest Rates for then available
     Guarantee Periods. No Guaranteed Interest Rate will be less than the
     Minimum Interest Rate shown in the Schedule.

CHARGES DEDUCTED FROM ACCUMULATION VALUE ON EACH CERTIFICATE PROCESSING DATE

     Expense charges and fees are shown in the Schedule.

     Charge Deduction Division Option

     We will deduct all charges against the Accumulation Value of this
     Certificate from the Charge Deduction Division if you elected this option
     on the application (see the Schedule). If you did not elect this Option or
     if the charges are greater than the amount in the Charge Deduction
     Division, the charges against the Accumulation Value will be deducted as
     follows:

          (1)  If these charges are less than the Accumulation Value in the
               Variable Separate Account Divisions, they will be deducted
               proportionately from all Divisions.

          (2)  If these charges exceed the Accumulation Value in the Variable
               Separate Account Divisions, any excess over such value will be
               deducted proportionately from any Fixed Allocations and
               Guaranteed Interest Divisions.

     Any charges taken from the Fixed Account or the General Account will be
     taken from the Fixed Allocations or the Guaranteed Interest Divisions
     starting with the Guarantee Period nearest its Maturity Date until such
     charges have been paid.

     At any time while this Certificate is in effect, you may change your
     election of this Option. To do this you must send us a written request to
     our Customer Service Center. Any change will take effect within seven days
     of the date we receive your request.

GA-CA-1082                         15
<PAGE>

                            YOUR CERTIFICATE BENEFITS
-------------------------------------------------------------------------------

     While this Certificate is in effect, there are important rights and
     benefits that are available to you. We discuss these rights and benefits in
     this section.

CASH VALUE BENEFIT

     Cash Surrender Value

     The Cash Surrender Value, while the Annuitant is living and before the
     Annuity Commencement Date, is determined as follows:

          (1)  We take the Certificate's Accumulation Value;

          (2)  We adjust for any applicable Market Value Adjustment;

          (3)  We deduct any Surrender Charges;

          (4)  We deduct any charges shown in the Schedule that have been
               incurred but not yet deducted, including:

               (a)  any administrative charge that has not yet been deducted;

               (b)  the pro rata part of any charges for Optional Benefit
                    Riders; and

               (c)  any applicable premium or other tax.

     Cancelling to Receive the Cash Surrender Value

     At any time while the Annuitant is living and before the Annuity
     Commencement Date, you may surrender this Certificate to us. To do this,
     you must return this Certificate with a signed request for cancellation to
     our Customer Service Center.

     The Cash Surrender Value will vary daily. We will determine the Cash
     Surrender Value as of the date we receive the Certificate and your signed
     request in our Customer Service Center. All benefits under this Certificate
     will then end.

     We will usually pay the Cash Surrender Value within seven days; but, we may
     delay payment as described in the Payments We May Defer provision.

PARTIAL WITHDRAWAL OPTION

     After the Certificate Date, you may make Partial Withdrawals. Partial
     Withdrawals may be subject to a Partial Withdrawal Charge (see the
     Schedule). The minimum amount that may be withdrawn is shown in the
     Schedule. The maximum amount that may be withdrawn without Surrender Charge
     is shown in the Schedule. To take a Partial Withdrawal, you must provide us
     satisfactory notice at our Customer Service Center.

PROCEEDS PAYABLE TO THE BENEFICIARY

     Prior to the Annuity Commencement Date

     If the sole Owner dies prior to the Annuity Commencement Date, we will pay
     the Beneficiary the Death Benefit. If there are joint Owners and any Owner
     dies, we will pay the surviving Owners the Death Benefit. We will pay the
     amount on receipt of due proof of the Owner's death at our Customer Service
     Center. Such amount may be received in a single lump sum or applied to any
     of the Annuity Options (see Choosing an Income Plan). When the Owner (or
     all Owners where there are joint Owners) is not an individual, the Death
     Benefit will become payable on the death of the Annuitant prior to the
     Annuity Commencement Date (unless a Contingent Annuitant survived the
     Annuitant). Only one Death Benefit is payable under this Certificate. In
     all events, distributions under the Certificate must be made as required by
     applicable law.

GA-CA-1082                         16
<PAGE>

                      YOUR CERTIFICATE BENEFITS (continued)
-------------------------------------------------------------------------------

     How to Claim Payments to Beneficiary

     We must receive proof of the Owner's (or the Annuitant's) death before we
     will make any payments to the Beneficiary. We will calculate the Death
     Benefit as of the date we receive due proof of death. The Beneficiary
     should contact our Customer Service Center for instructions.

GA-CA-1082                         17
<PAGE>

                             CHOOSING AN INCOME PLAN
-------------------------------------------------------------------------------
ANNUITY BENEFITS

     If the Annuitant and Owner are living on the Annuity Commencement Date, we
     will begin making payments to the Owner. We will make these payments under
     the Annuity Option (or Options) as chosen in the application or as
     subsequently selected. You may choose or change an Annuity Option by making
     a written request at least 30 days prior to the Annuity Commencement Date.
     Unless you have chosen otherwise, Option 2 on a 10-year period certain
     basis will become effective. The amounts of the payments will be determined
     by applying the Accumulation Value on the Annuity Commencement Date in
     accordance with the Annuity Options section below (see Payments We May
     Defer). Before we pay any Annuity Benefits, we require the return of this
     Certificate. If this Certificate has been lost, we require the applicable
     lost Certificate form.

ANNUITY COMMENCEMENT DATE SELECTION

     You select the Annuity Commencement Date. You may select any date following
     the fifth Certificate Anniversary but before the required date of Annuity
     Commencement as shown in the Schedule. If you do not select a date, the
     Annuity Commencement Date will be in the month following the required date
     of Annuity Commencement.

FREQUENCY SELECTION

     You may choose the frequency of the Annuity Payments. They may be monthly,
     quarterly, semi-annually or annually. If we do not receive written notice
     from you, the payments will be made monthly.

THE INCOME PLAN

     While this Certificate is in effect and before the Annuity Commencement
     Date, you may choose one or more Annuity Options for the payment of Death
     Benefit proceeds. If, at the time of the Owner's death, no Option has been
     chosen for paying the Death Benefit proceeds, the Beneficiary may choose an
     Option within one year. You may also elect an Annuity Option on surrender
     of the Certificate for its Cash Surrender Value. For each Option we will
     issue a separate written agreement putting the Option into effect.

     Our approval is needed for any Option where:

          (1)  the person named to receive payment is other than the Owner or
               Beneficiary; or

          (2)  the person named is not a natural person, such as a corporation;
               or

          (3)  any income payment would be less than the minimum annuity income
               payment shown in the Schedule.

THE ANNUITY OPTIONS

     There are four Options to choose from. They are:

     Option 1. Income for a Fixed Period

     Payment is made in equal installments for a fixed number of years. We
     guarantee each monthly payment will be at least the Income for Fixed Period
     amount shown in the Schedule. Values for annual, semiannual or quarterly
     payments are available on request.

GA-CA-1082                         18
<PAGE>

                       CHOOSING AN INCOME PLAN (continued)
-------------------------------------------------------------------------------

     Option 2. Income for Life

     Payment is made to the person named in equal monthly installments and
     guaranteed for at least a period certain. The period certain can be 10 or
     20 years. Other periods certain are available on request. A refund certain
     may be chosen instead. Under this arrangement, income is guaranteed until
     payments equal the amount applied. If the person named lives beyond the
     guaranteed period, payments continue until his or her death.

     We guarantee each payment will be at least the amount shown in the
     Schedule. By age, we mean the named person's age on his or her nearest
     birthday before the Option's effective date. Amounts for ages not shown are
     available on request.

     Option 3. Joint Life Income

     This Option is available if there are two persons named to receive
     payments. At least one of the persons named must be either the Owner or
     Beneficiary of this Certificate. Monthly payments are guaranteed and are
     made as long as at least one of the named persons is living. The monthly
     payment amounts are available upon request. Such amounts are guaranteed and
     will be calculated on the same basis as the Table for Income for Life,
     however, the amounts will be based on two lives.

     Option 4. Annuity Plan

     Payment may be made under any other method mutually agreed upon by you and
     us.

     The minimum rates for Option 1 are based on 3% interest, compounded
     annually. The minimum rates for Options 2 and 3 are based on 3% interest,
     compounded annually, and the Annuity 2000 Mortality Table. We may pay a
     higher rate at our discretion.

PAYMENT WHEN NAMED PERSON DIES

     When the person named to receive payment dies, we will pay any amounts
     still due as provided by the Option agreement. The amounts still due are
     determined as follows:

          (1)  For Option 1 or for any remaining guaranteed payments in Option
               2, payments will be continued.

          (2)  For Option 3, no amounts are payable after both named persons
               have died.

          (3)  For Option 4, the annuity agreement will state the amount due, if
               any.

GA-CA-1082                         19
<PAGE>

                           OTHER IMPORTANT INFORMATION
-------------------------------------------------------------------------------

ENTIRE CONTRACT

     The group contract, including any attached Rider, endorsement, amendment
     and the application of the Contractholder, constitute the entire contract
     between the Contractholder and us. All statements made by the
     Contractholder, any Owner or any Annuitant will be deemed representations
     and not warranties. No such statement will be used in any contest unless it
     is contained in the application signed by the Owner, a copy of which has
     been furnished to the Owner, the Beneficiary or to the Contractholder.

SENDING NOTICE TO US

     Whenever written notice is required, send it to our Customer Service
     Center. The address of our Customer Service Center is shown on the cover
     page. Please include your Certificate number in all correspondence.

REPORTS TO OWNER

     We will send you a report at least once during each Certificate Year. The
     report will show the Accumulation Value and the Cash Surrender Value as of
     the end of the Certificate Processing Period. The report will also show the
     allocation of the Accumulation Value as of such date and the amounts
     deducted from or added to the Accumulation Value since the last report. The
     report will also include any information that may be currently required by
     the insurance supervisory official of the jurisdiction in which the
     Certificate is delivered.

     We will also send you copies of any shareholder reports of the portfolios
     in which the Divisions of the Variable Separate Account invest, as well as
     any other reports, notices or documents required by law to be furnished to
     Owners.

ASSIGNMENT - USING THIS CERTIFICATE AS COLLATERAL SECURITY

     You can assign this Certificate as collateral security for a loan or other
     obligation. This does not change the ownership. Your rights and any
     Beneficiary's right are subject to the terms of the assignment. To make or
     release an assignment, we must receive written notice satisfactory to us,
     at our Customer Service Center. We are not responsible for the validity of
     any assignment.

CHANGING THIS CERTIFICATE

     This Certificate or any additional benefit riders may be changed to another
     annuity plan according to our rules at the time of the change.

CERTIFICATE CHANGES - APPLICABLE TAX LAW

     We reserve the right to make changes in this Certificate or its Riders to
     the extent we deem it necessary to continue to qualify this Certificate as
     an annuity. Any such changes will apply uniformly to all Certificates that
     are affected. You will be given advance written notice of such changes.

MISSTATEMENT OF AGE OR SEX

     If an age or sex has been misstated, the amounts payable or benefits
     provided by this Certificate will be those that the Premium Payment made
     would have bought at the correct age or sex.

NON-PARTICIPATING

     This Certificate does not participate in the divisible surplus of Golden
     American Life Insurance Company.

GA-CA-1082                         20
<PAGE>

                     OTHER IMPORTANT INFORMATION (continued)
-------------------------------------------------------------------------------

CONTESTABILITY

     This Certificate is incontestable from its date of issue.

PAYMENTS WE MAY DEFER

     We may not be able to determine the value of the assets of the Variable
     Separate Account Divisions because: (1) The NYSE is closed for trading; (2)
     the SEC determines that a state of emergency exists; (3) an order or
     pronouncement of the SEC permits a delay for the protection of Owners; or
     (4) the check used to pay the premium has not cleared through the banking
     system. This may take up to 15 days.

     During such times, as to amounts allocated to the Divisions of the Variable
     Separate Account, we may delay:

          (1)  determination and payment of the Cash Surrender Value;

          (2)  determination and payment of any Death Benefit if death occurs
               before the Annuity Commencement Date;

          (3)  allocation changes of the Accumulation Value; or

          (4)  application of the Accumulation Value under an income plan.

     As to the amounts allocated to a Guaranteed Interest Division in the
     General Account and as to amounts allocated to Fixed Allocations of the
     Fixed Account, we may, at any time, defer payment of the Cash Surrender
     Value for up to six months after we receive a request for it. We will allow
     interest of at least 3.00% a year on any Cash Surrender Value payment
     derived from the Fixed Allocations or Guaranteed Interest Divisions that we
     defer 30 days or more.

AUTHORITY TO MAKE AGREEMENTS

     All agreements made by us must be signed by one of our officers. No other
     person, including an insurance agent or broker, can: (1) change any of this
     Certificate's terms; (2) extend the time for Premium Payments; or (3) make
     any agreement binding on us.

REQUIRED NOTE ON OUR COMPUTATIONS

     We have filed a detailed statement of our computations with the insurance
     supervisory official in the jurisdiction where this Certificate is
     delivered. The values are not less than those required by the law of that
     state or jurisdiction. Any benefit provided by an attached Optional Benefit
     Rider will not increase these values unless otherwise stated in that Rider.

GA-CA-1082                         21
<PAGE>

FLEXIBLE PREMIUM DEFERRED COMBINATION VARIABLE AND FIXED ANNUITY CERTIFICATE
- NO DIVIDENDS
-------------------------------------------------------------------------------

Variable Cash Surrender Values while the Annuitant and Owner are living and
prior to the Annuity Commencement Date. Death Benefit subject to guaranteed
minimum. Partial Withdrawal Option. Non-participating. Investment results
reflected in values.

GA-CA-1082
<PAGE>

                              THE SCHEDULE (7% DB)

                                CERTIFICATE FACTS

   ----------------------------------------------------------------------------
    Annuitant              Owner
    [THOMAS J. DOE]        [JOHN Q. DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
   ----------------------------------------------------------------------------
    Separate Account(s)                             Certificate Number
    [SEPARATE ACCOUNT B AND THE FIXED ACCONT        [123456]
   ----------------------------------------------------------------------------

CERTIFICATE FACTS

     Certificate Processing Date

     The Certificate Processing Date for your Certificate is [April 1] of each
     year.

     Specially Designated Division

     When a distribution is made from an investment portfolio underlying a
     Separate Account Division in which reinvestment is not available, we will
     allocate the amount of the distribution to the [Liquid Asset Division]
     unless you specify otherwise.

PARTIAL WITHDRAWALS

     The maximum amount that can be withdrawn each Certificate Year without
     being considered an Excess Partial Withdrawal is described below. We will
     collect a Surrender Charge for Excess Partial Withdrawals and a charge for
     any unrecovered Premium Taxes. In no event may a Partial Withdrawal be
     greater than 90% of the Cash Surrender Value. After a Partial Withdrawal,
     the remaining Accumulation Value must be at least $100 to keep the
     Certificate in force.

     Systematic Partial Withdrawals and Conventional Partial Withdrawals may not
     be taken in the same Certificate Year.

     To determine the Surrender Charge on Excess Partial Withdrawals, the
     withdrawals will occur in the following order:

          (1)  Earnings;

          (2)  The Free Amount;

          (3)  Premium Payments made [four] or more prior to the withdrawal;

          (4)  Premium Payments made less than [four] years prior to withdrawal.

     Earnings and Free Amounts are not treated as withdrawals of Premium
     Payments for purposes of calculating any Surrender Charge.

     Conventional Partial Withdrawals

     Minimum Withdrawal Amount: $100.

     The maximum amount that can be taken as a Conventional Partial Withdrawal
     each Certificate Year without being considered an Excess Partial Withdrawal
     is the greater of:

          (1)  Earnings (defined below) not previously withdrawn, but not less
               than zero; and

          (2)  The Free Amount, equal to 10% of Premium Payments not previously
               withdrawn, which were received within [four] years prior to the
               date of withdrawal.

Earnings are equal to the Accumulation Value, less Premium Payments, plus prior
withdrawals.

Any Conventional Partial Withdrawal is subject to a Market Value Adjustment
unless withdrawn from a Fixed Allocation within 30 days prior to the Maturity
Date.

GA-CA-1082                         3D1
<PAGE>

                                  THE SCHEDULE

                          CERTIFICATE FACTS (continued)
   ----------------------------------------------------------------------------
    Annuitant              Owner
    [THOMAS J. DOE]        [JOHN Q. DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
   ----------------------------------------------------------------------------
    Separate Account(s)                             Certificate Number
    [SEPARATE ACCOUNT B AND FIXED ACCOUNT]          [123456]
   ----------------------------------------------------------------------------

     Systematic Partial Withdrawals

     Systematic Partial Withdrawals may be elected to commence after 28 days
     from the Certificate Issue Date and may be taken on a monthly, quarterly or
     annual basis. You select the day withdrawals will be made, but no later
     than the 28th day of the month. If you do not elect a day, the Certificate
     Date will be used.

     Maximum Withdrawal Amounts:

     Variable Separate Account Divisions:   .833% of Premium Payments monthly,
                                            2.5% of Premium Payments quarterly
                                            or 10% of Premium Payments annually.

     Fixed Allocations and
     Guaranteed Interest Divisions:         Interest earned on a Fixed
                                            Allocation or Guaranteed Interest
                                            Division for the prior month,
                                            quarter or year (depending on the
                                            frequency selected).

     The Maximum Withdrawal Amount available as a Systematic Partial Withdrawal
     is 10% of Premium Payments not previously withdrawn. Systematic Partial
     Withdrawals from Fixed Allocations are not subject to a Market Value
     Adjustment. A Systematic Partial Withdrawal in excess of Earnings and the
     Free Amount may be subject to a Surrender Charge.

     IRA Partial Withdrawals for Qualified Plans Only

     Partial Withdrawals may be taken from a Certificate issued as an IRA on a
     monthly, quarterly or annual basis. A minimum withdrawal of $100.00 is
     required. You select the day the withdrawals will be made, but no later
     than the 28th day of the month. If you do not elect a day, the Certificate
     Date will be used. Systematic Partial Withdrawals and Conventional Partial
     Withdrawals are not allowed when IRA Partial Withdrawals are being taken.
     An IRA Partial Withdrawal in excess of the maximum amount allowed under the
     Systematic Partial Withdrawal option may be subject to a Market Value
     Adjustment.

DEATH BENEFIT

     The Death Benefit is the greatest of (i), (ii), (iii) and (iv) below,
     where:

          (i)  is the Accumulation Value;

          (ii) is the lesser of (a) and (b), where (a) is the Guaranteed Death
               Benefit and (b) is the Maximum Guaranteed Death Benefit;

          (iii) is the Cash Surrender Value; and

          (iv) is the Minimum Death Benefit.

MINIMUM DEATH BENEFIT

     The Minimum Death Benefit shall be the sum of the following:

          1. The Accumulation Value allocated to Special Funds; and

          2. Adjusted Premium for non-Special Funds.

GA-CA-1082                         3D2
<PAGE>

                                  THE SCHEDULE

                          CERTIFICATE FACTS (continued)
   ----------------------------------------------------------------------------
    Annuitant              Owner
    [THOMAS J. DOE]        [JOHN Q. DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
   ----------------------------------------------------------------------------
    Separate Account(s)                             Certificate Number
    [SEPARATE ACCOUNT B AND FIXED ACCOUNT]          [123456]
    ---------------------------------------------------------------------------

     Adjusted Premium for non-Special Funds shall mean all premium allocated to
     non-Special Funds, plus an adjustment for any amounts transferred to
     non-Special Funds, less a prorata adjustment for any amounts transferred or
     withdrawn from non-Special Funds. The amount of the prorata adjustment will
     equal (a) times (b) divided by (c), where: (a) is the Adjusted Premium for
     non-Special Funds prior to the transfer or withdrawal; (b) is the
     Accumulation Value of the transfer or withdrawal; and (c) is the
     Accumulation Value allocated to non-Special Funds before the transfer or
     withdrawal. Adjusted Premium for Special Funds has the same definition, but
     with respect to amounts allocated to Special Funds.

     Transfers from Special Funds increase the Adjusted Premium for non-Special
     Funds by the lesser of the reduction of the Adjusted Premium for Special
     Funds and net Accumulation Value transferred. Transfers from non-Special
     Funds increase the Adjusted Premium for Special Funds by the reduction in
     the Adjusted Premium for non-Special Funds.

GUARANTEED DEATH BENEFIT

     The Guaranteed Death Benefit for the Certificate is equal to the sum of I
     and II below.

          I.  The Guaranteed Death Benefit Base for non-Special Funds

          II. The Accumulation Value allocated to Special Funds

     On the Certificate Date, the Guaranteed Death Benefit Base for non-Special
     Funds is the initial premium, if applicable, allocated to non-Special
     Funds. On subsequent Valuation Dates, the Guaranteed Death Benefit Base for
     non-Special Funds is calculated as follows:

               (1)  Start with the Guaranteed Death Benefit Base for non-Special
                    Funds on the prior Valuation Date.

               (2)  Calculate interest on (1) for the current Valuation Period
                    at the Guaranteed Death Benefit Interest Rate for
                    non-Special Funds.

               (3)  Add (1) and (2).

               (4)  Add to (3) any additional premiums allocated to non-Special
                    Funds during the current Valuation Period.

               (5)  Add to (or subtract from) (4) adjustments for transfers from
                    (to) Special Funds made during the Valuation Period.

               (6)  Subtract from (5) the amount of any Special Partial
                    Withdrawal Adjustments and Prorata Partial Withdrawal
                    Adjustments for any partial withdrawals made from
                    non-Special Funds during the current Valuation Period.

     The Guaranteed Death Benefit Base for Special Funds has a corresponding
     definition, but with respect to amounts allocated to Special Funds.

     Transfers from Special Funds to non-Special Funds will reduce the
     Guaranteed Death Benefit Base for Special Funds on a prorata basis. The
     resulting increase in the Guaranteed Death Benefit Base for non-Special
     Funds will equal the lesser of the reduction in the Guaranteed Death
     Benefit Base for Special Funds and the net Accumulation Value transferred.

GA-CA-1082                         3D3
<PAGE>

                                  THE SCHEDULE

                          CERTIFICATE FACTS (continued)
   ----------------------------------------------------------------------------
    Annuitant              Owner
    [THOMAS J. DOE]        [JOHN Q DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
   ----------------------------------------------------------------------------
    Separate Account(s)                             Certificate Number
    [SEPARATE ACCOUNT B AND FIXED ACCOUNT]          [123456]
    ---------------------------------------------------------------------------

     Transfers from non-Special Funds to Special Funds will reduce the
     Guaranteed Death Benefit Base for non-Special Funds on a prorata basis. The
     resulting increase in the Guaranteed Death Benefit Base for Special Funds
     will equal the reduction in Guaranteed Death Benefit Base for non-Special
     Funds.

GUARANTEED DEATH BENEFIT INTEREST RATE

     The Guaranteed Death Benefit Interest Rate is [7%] compounded annually,
     except:

          (a)  For any portion of the Guaranteed Death Benefit Base for Special
               Funds, the Guaranteed Death Benefit Interest Rate is [7%]
               (compounded annually); and

          (b)  For any valuation period ending after the Certificate Anniversary
               on which the Owner attains age [80], or after the Maximum
               Guaranteed Death Benefit has been reached, the Guaranteed Death
               Benefit Interest Rate is [0%].

SPECIAL FUNDS

     Where used in this Certificate, Special Funds are [the Liquid Asset
     Division, the Limited Maturity Bond Division, the Fixed Allocations and the
     Guaranteed Interest Division]. We may add newly available Divisions as
     Special Funds. We may also reclassify an existing Division as a Special
     Fund or remove such designation upon 30 days notice to you. Such
     reclassification will apply to amounts transferred or otherwise added to
     such Division after the date of change. We may reduce the Mortality and
     Expense Risk Charge (if applicable) for that portion of the Certificate
     invested in a Special Fund.

MAXIMUM GUARANTEED DEATH BENEFIT

     The Maximum Guaranteed Death Benefit is equal to [three] times premium
     paid, reduced by the amount of any Partial Withdrawal Adjustments. The
     Maximum Guaranteed Death Benefit is allocated proportionally based on the
     Certificate's allocation to Special and non-Special funds. Transfers and
     withdrawals will affect the allocation of the Maximum Guaranteed Death
     Benefit at the same proportion among the Special and non-Special Funds that
     they bear to the Accumulation Value transferred or withdrawn. Any addition
     due to spousal continuation will not affect the Maximum Guaranteed Death
     Benefit or the Guaranteed Death Benefit Base.

SPECIAL AND PRORATA PARTIAL WITHDRAWAL ADJUSTMENTS

     For any partial withdrawal, the Death Benefit components will be reduced by
     Prorata Partial Withdrawal Adjustments. A Prorata Partial Withdrawal
     Adjustment will be made unless a Special Partial Withdrawal Adjustment
     applies to the component for the withdrawal. Special Partial Withdrawal
     Adjustments are made when partial withdrawals in any Certificate Year do
     not exceed [7%] of the sum of cumulative premiums, but only if partial
     withdrawals in each prior year did not exceed [7%] of the sum of premiums
     paid prior to that year. The Special Partial Withdrawal Adjustment is equal
     to the amount of the Accumulation Value withdrawn.

GA-CA-1082                         3D4
<PAGE>

                                  THE SCHEDULE

                          CERTIFICATE FACTS (continued)
   ----------------------------------------------------------------------------
    Annuitant              Owner
    [THOMAS J. DOE]        [JOHN Q. DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
   ----------------------------------------------------------------------------
    Separate Account(s)                             Certificate Number
    [SEPARATE ACCOUNT B AND FIXED ACCOUNT]          [123456]
    ---------------------------------------------------------------------------

     Special Partial Withdrawal Adjustments are applicable only in the
     calculation of the Maximum Guaranteed Death Benefit and the Guaranteed
     Death Benefit Base, and in all other cases withdrawals are treated as
     Prorata Partial Withdrawal Adjustments.

     The Prorata Partial Withdrawal Adjustment to a Death Benefit component is
     equal to (1) divided by (2), multiplied by (3), where: (1) is the
     Accumulation Value withdrawn; (2) is the Accumulation Value immediately
     prior to withdrawal; and (3) is the amount of the applicable Death Benefit
     component immediately prior to the withdrawal. Separate adjustments will
     apply to the amounts in the Special and non-Special Funds.

CHANGE OF OWNER

     A change of Owner from a sole Owner to a sole Owner (where there have never
     been multiple Owners designated) will result in recalculation of the Death
     Benefit, the Guaranteed Death Benefit, and the Maximum Guaranteed Death
     Benefit. If the new Owner's Attained Age at the time of the change is less
     than [80], the Guaranteed Death Benefit and the Maximum Guaranteed Death
     Benefit in effect prior to the change will remain in effect and the Death
     Benefit provision shall apply. If the new Owner's Attained Age at the time
     of the change is [80] or greater, but not greater than [85]:

          (a)  The Guaranteed Death Benefit and the Maximum Guaranteed Death
               Benefit following the change will be zero; and

          (b)  The Death Benefit will then be the greatest of:

               (1)  the Cash Surrender Value;

               (2)  the Accumulation Value; and

               (3)  the Minimum Death Benefit.

     If ownership changes result in multiple Owners or if there has ever been
     multiple Owners, the Guaranteed Death Benefit and the Maximum Guaranteed
     Death Benefit shall be set to zero. If the oldest Owner is age [85] or
     younger at the time of the change, the Death Benefit will then be the
     greatest of (b) 1, (b) 2 or (b) 3 above.

     If any Owner's or oldest multiple Owners' Attained Age is [86] or greater
     at the time of the change, the Guaranteed Death Benefit, the Minimum Death
     Benefit, and the Maximum Guaranteed Death Benefit will be zero, and the
     Death Benefit will then be the Cash Surrender Value.

     When a change of Owner reduces the Guaranteed Death Benefit and the Maximum
     Guaranteed Death Benefit to zero, there will be a reduction in the
     Mortality and Expense Risk Charge.

GA-CA-1082                         3D5
<PAGE>

                                  THE SCHEDULE

                          CERTIFICATE FACTS (continued)
   ----------------------------------------------------------------------------
    Annuitant              Owner
    [THOMAS J. DOE]        [JOHN Q. DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
   ----------------------------------------------------------------------------
    Separate Account(s)                             Certificate Number
    [SEPARATE ACCOUNT B AND FIXED ACCOUNT]          [123456]
   ----------------------------------------------------------------------------

SPOUSAL CONTINUATION UPON DEATH OF OWNER

     If at the Owner's death, the surviving spouse of the deceased Owner is the
     Beneficiary and such surviving spouse elects to continue the Certificate as
     their own pursuant to Internal Revenue Code Section 72(s) or the equivalent
     provisions of U.S. Treasury Department rules for qualified plans, the
     following will apply:

     (a)  If the greater of (ii) and (iv) in the Death Benefit provision as of
          the date we receive due proof of death of the Owner minus the
          Accumulation Value, also as of that date, is greater than zero, we
          will add such difference to the Accumulation Value. Such addition will
          be allocated to the Divisions of the Separate Account in the same
          proportion as the Accumulation Value in each Division bears to the
          Accumulation Value in the Separate Account. If there is no
          Accumulation Value in the Separate Account, the addition will be
          allocated to the Liquid Asset Division, or its successor.

     (b)  The Guaranteed Death Benefit and the Maximum Guaranteed Death Benefit
          will continue to apply, using the surviving spouse's age as the
          determining age.

     (c)  At subsequent surrender, any Surrender Charge applicable to premiums
          paid prior to the date we receive due proof of death of the Owner will
          be waived. Any premiums paid later will be subject to any applicable
          Surrender Charge.

     This addition to Accumulation Value is available only to the spouse of the
     Owner as of the date of death of the Owner if such spouse under the
     provisions of this Certificate elects to continue the Certificate as their
     own.

CHOOSING AN INCOME PLAN

     Required Date of Annuity Commencement

     Distributions from a Certificate funding a qualified plan must commence no
     later than April 1st of the calendar year following the calendar year in
     which the Owner attains age 70 1/2. Otherwise, the Annuity Commencement
     Date may be no later than the same date as the Certificate Processing Date
     in the month following the Annuitant's 90th birthday. In applying the
     Accumulation Value, we may first collect any Premium Taxes due us. If, on
     the Annuity Commencement Date, a Surrender Charge remains, your elected
     Annuity Option must include a period certain of at least five years
     duration.

     Minimum Annuity Income Payment

     The minimum monthly annuity income payment that we will make is [$20].

GA-CA-1082                         3D6
<PAGE>

                                  THE SCHEDULE

                          CERTIFICATE FACTS (continued)
   ----------------------------------------------------------------------------
    Annuitant              Owner
    [THOMAS J. DOE]        [JOHN Q. DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
   ----------------------------------------------------------------------------
    Separate Account(s)                             Certificate Number
    [SEPARATE ACCOUNT B AND FIXED ACCOUNT]          [123456]
    ---------------------------------------------------------------------------

OPTIONAL BENEFIT RIDERS - [None].

ATTAINED AGE

     The Issue Age of the Annuitant or Owner plus the number of full years
     elapsed since the Certificate Date.

RESTRICTED FUNDS - [None]

FIXED ACCOUNT

     Minimum Fixed Allocation

     The minimum allocation to the Fixed Account in any one Fixed Allocation is
     [$250.00].

     Minimum Guaranteed Interest Rate - [3%].

     Guarantee Periods

     We currently offer Guarantee Periods of [1, 3, 5, 7 and 10] year(s). We
     reserve the right to offer Guarantee Periods of durations other than those
     available on the Certificate Date. We also reserve the right to cease
     offering a particular Guarantee Period or Periods.

     Index Rate

     The Index Rate is the average of the Ask Yields for the U.S. Treasury
     Strips as reported by a national quoting service for the applicable
     maturity. The average is based on the period from the 22nd day of the
     calendar month two months prior to the calendar month of Index Rate
     determination to the 21st day of the calendar month immediately prior to
     the month of determination. The applicable maturity date for these U.S.
     Treasury Strips is on or next following the last day of the Guarantee
     Period. If the Ask Yields are no longer available, the Index Rate will be
     determined using a suitable replacement method.

     We currently set the Index Rate once each calendar month. However, we
     reserve the right to set the Index Rate more frequently than monthly, but
     in no event will such Index Rate be based on a period less than 28 days.

GA-CA-1082                         3D7
<PAGE>

                                  THE SCHEDULE

                                CHARGES AND FEES
   ----------------------------------------------------------------------------
    Annuitant              Owner
    [THOMAS J. DOE]        [JOHN Q. DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
   ----------------------------------------------------------------------------
    Separate Account(s)                             Certificate Number
    [SEPARATE ACCOUNT B AND FIXED ACCOUNT]          [123456]
   ----------------------------------------------------------------------------

DEDUCTIONS FROM PREMIUMS

     None

DEDUCTIONS FROM ACCUMULATION VALUE

     Initial Administrative Charge

     None

     Administrative Charge

     We charge a maximum of $30 to cover a portion of our ongoing administrative
     expenses for each Certificate Processing Period. The charge is incurred at
     the beginning of the Certificate Processing Period and deducted on the
     Certificate Processing Date at the end of the period.

     At the time of deduction, this charge will be waived if:

          1. The Accumulation Value is at least $100,000; or

          2. The sum of premiums paid to date is at least $100,000 Excess
             Allocation Charge

     Currently none, however, we reserve the right to charge $25 for a change if
     you make more than twelve allocation changes per Certificate Year. Any
     charge will be deducted in proportion to the amount being transferred from
     each Division.

     Surrender Charge

     A Surrender Charge is imposed as a percentage of unliquidated premium if
     the Certificate is surrendered or an Excess Partial Withdrawal is taken.
     The percentage imposed at time of surrender or Excess Partial Withdrawal
     depends on the number of complete years that have elapsed since a Premium
     Payment was made. The Surrender Charge expressed as a percentage of each
     Premium Payment is as follows:

       Complete Years Elapsed                     Surrender
       Since Premium Payment                       Charges
       ----------------------                     ---------
                 [0                                  6%
                  1                                  5%
                  2                                  4%
                  3                                  3%
                 4+                                  0%]

     Surrender of the Certificate is permitted at or before the commencement of
     Annuity Payments.

GA-CA-1082                         3E1
<PAGE>

                                  THE SCHEDULE

                         CHARGES AND FEES (continued)
   ----------------------------------------------------------------------------
    Annuitant              Owner
    [THOMAS J. DOE]        [JOHN Q. DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
    ---------------------------------------------------------------------------
    Separate Account(s)                             Certificate Number
    [SEPARATE ACCOUNT B AND FIXED ACCOUNT]          [123456]
    ---------------------------------------------------------------------------

     Premium Taxes

     We deduct the amount of any premium or other state and local taxes levied
     by any state or governmental entity when such taxes are incurred.

     We reserve the right to defer collection of Premium Taxes until surrender
     or until application of Accumulation Value to an Annuity Option. An Excess
     Partial Withdrawal will result in the deduction of any Premium Tax then due
     us on such amount. We reserve the right to change the amount we charge for
     Premium Tax charges on future Premium Payments to conform with changes in
     the law or if the Owner changes state of residence.

     Deductions from the Divisions

     Mortality and Expense Risk Charge - We deduct a charge from the assets in
     each Variable Separate Account Division on a daily basis of not more than
     [0.005535]%(equivalent to an annual maximum rate of [2.00]%) for mortality
     and expense risks. The charge is not deducted from the Fixed Account or
     General Account Accumulation Values.

     Asset Based Administrative Charge - We deduct a charge of not more than
     [0.000411]% of the assets in each Variable Separate Account Division on a
     daily basis (equivalent to an annual maximum rate of [0.15]%) to compensate
     us for a portion of our ongoing administrative expenses. This charge is not
     deducted from the Fixed Account or General Account Accumulation Values.

CHARGE DEDUCTION DIVISION

     If elected by you, all charges against the Accumulation Value in this
     Certificate will be deducted from the [Liquid Asset Division].

GA-CA-1082                         3E2
<PAGE>

                                  THE SCHEDULE

                               INCOME PLAN FACTORS
   ----------------------------------------------------------------------------
    Annuitant              Owner
    [THOMAS J. DOE]        [JOHN Q. DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
   ----------------------------------------------------------------------------
    Separate Account(s)                             Certificate Number
    [SEPARATE ACCOUNT B AND FIXED ACCOUNT]          [123456]
    ---------------------------------------------------------------------------

Values for other payment periods, ages or joint life combinations are available
on request. Monthly payments are shown for each $1,000 applied.

                       TABLE FOR INCOME FOR A FIXED PERIOD

<TABLE>
<CAPTION>
      Fixed Period            Monthly           Fixed Period             Monthly          Fixed Period            Monthly
          of Years             Income               of Years              Income              of Years            Income

        <S>                  <C>                   <C>                 <C>                   <C>                  <C>
        [5                   17.95                 14                  7.28                  23                   5.00
         6                   15.18                 15                  6.89                  24                   4.85
         7                   13.20                 16                  6.54                  25                   4.72
         8                   11.71                 17                  6.24                  26                   4.60
         9                   10.56                 18                  5.98                  27                   4.49
        10                    9.64                 19                  5.74                  28                   4.38
        11                    8.88                 20                  5.53                  29                   4.28
        12                    8.26                 21                  5.33                  30                  4.19]
        13                    7.73                 22                  5.16

</TABLE>

                            TABLE FOR INCOME FOR LIFE

                      Male/Female           Male/Female           Male/Female
      Age        10 Years Certain      20 Years Certain        Refund Certain

     [50               $4.06/3.83            $3.96/3.77            $3.93/3.75
      55                4.43/4.14             4.25/4.05             4.25/4.03
      60                4.90/4.56             4.57/4.37             4.66/4.40
      65                5.51/5.10             4.90/4.73             5.12/4.83
      70                6.26/5.81             5.18/5.07             5.76/5.42
      75                7.11/6.70             5.38/5.33             6.58/6.19
      80                7.99/7.70             5.48/5.46             7.69/7.21
      85                8.72/8.59             5.52/5.51             8.72/8.59
      90                9.23/9.18             5.53/5.53          10.63/10.53]

GA-CA-1082                         3F
<PAGE>

                             THE SCHEDULE (RATCHET)

                                CERTIFICATE FACTS
   ----------------------------------------------------------------------------
    Annuitant              Owner
    [THOMAS J. DOE]        [JOHN Q. DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
   ----------------------------------------------------------------------------
    Separate Account(s)                             Certificate Number
    [SEPARATE ACCOUNT B AND FIXED ACCOUNT]          [123456]
   ----------------------------------------------------------------------------

CERTIFICATE FACTS

     Certificate Processing Date

     The Certificate Processing Date for your Certificate is [April 1] of each
     year.

     Specially Designated Division

     When a distribution is made from an investment portfolio underlying a
     Separate Account Division in which reinvestment is not available, we will
     allocate the amount of the distribution to the [Liquid Asset Division]
     unless you specify otherwise.

PARTIAL WITHDRAWALS

     The maximum amount that can be withdrawn each Certificate Year without
     being considered an Excess Partial Withdrawal is described below. We will
     collect a Surrender Charge for Excess Partial Withdrawals and a charge for
     any unrecovered Premium Taxes. In no event may a Partial Withdrawal be
     greater than 90% of the Cash Surrender Value. After a Partial Withdrawal,
     the remaining Accumulation Value must be at least $100 to keep the
     Certificate in force.

     Systematic Partial Withdrawals and Conventional Partial Withdrawals may not
     be taken in the same Certificate Year.

     To determine the Surrender Charge on Excess Partial Withdrawals, the
     withdrawals will occur in the following order:

          (1)  Earnings;

          (2)  The Free Amount;

          (3)  Premium Payments made [four] or more years prior to the
               withdrawal; and,

          (4)  Premium Payments made less than [four] years prior to withdrawal.

     Earnings and Free Amounts are not treated as withdrawals of Premium
     Payments for purposes of calculating any Surrender Charge.

     Conventional Partial Withdrawals
     Minimum Withdrawal Amount: $100.

     The maximum amount that can be taken as a Conventional Partial Withdrawal
     each Certificate Year without being considered an Excess Partial Withdrawal
     is the greater of:

          (1)  Earnings (defined below) not previously withdrawn, but not less
               than zero; and

          (2)  The Free Amount, equal to 10% of Premium Payments not previously
               withdrawn, which were received within [four] years prior to the
               date of withdrawal.

     Earnings are equal to the Accumulation Value, less Premium Payments, plus
     prior withdrawals.

     Any Conventional Partial Withdrawal is subject to a Market Value Adjustment
     unless withdrawn from a Fixed Allocation within 30 days prior to the
     Maturity Date.

GA-CA-1082                         3D1
<PAGE>

                                  THE SCHEDULE

                          CERTIFICATE FACTS (continued)
   ----------------------------------------------------------------------------
    Annuitant              Owner
    [THOMAS J. DOE]        [JOHN Q. DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
   ----------------------------------------------------------------------------
    Separate Account(s)                             Certificate Number
    [SEPARATE ACCOUNT B AND FIXED ACCOUNT]          [123456]
   ----------------------------------------------------------------------------

     Systematic Partial Withdrawals

     Systematic Partial Withdrawals may be elected to commence after 28 days
     from the Certificate Issue Date and may be taken on a monthly, quarterly or
     annual basis. You select the day withdrawals will be made, but no later
     than the 28th day of the month. If you do not elect a day, the Certificate
     Date will be used.

     Maximum Withdrawal Amounts:

     Variable Separate Account Divisions:   .833% of Premium Payments monthly,
                                            2.5% of Premium Payments quarterly
                                            or 10% of Premium Payments annually.

     Fixed Allocations and
     Guaranteed Interest Divisions:         Interest earned on a Fixed
                                            Allocation or Guaranteed Interest
                                            Division for the prior month,
                                            quarter or year (depending on the
                                            frequency selected).

     The Maximum Withdrawal Amount available as a Systematic Partial Withdrawal
     is 10% of Premium Payments not previously withdrawn. Systematic Partial
     Withdrawals from Fixed Allocations are not subject to a Market Value
     Adjustment. A Systematic Partial Withdrawal in excess of Earnings and the
     Free Amount may be subject to a Surrender Charge.

     IRA Partial Withdrawals for Qualified Plans Only

     Partial Withdrawals may be taken from a Certificate issued as an IRA on a
     monthly, quarterly or annual basis. A minimum withdrawal of $100.00 is
     required. You select the day the withdrawals will be made, but no later
     than the 28th day of the month. If you do not elect a day, the Certificate
     Date will be used. Systematic Partial Withdrawals and Conventional Partial
     Withdrawals are not allowed when IRA Partial Withdrawals are being taken.
     An IRA Partial Withdrawal in excess of the maximum amount allowed under the
     Systematic Partial Withdrawal option may be subject to a Market Value
     Adjustment.

DEATH BENEFIT

     The Death Benefit is the greatest of (i), (ii), (iii) and (iv) below,
     where:

          (i)  is the Accumulation Value;

          (ii) is the Guaranteed Death Benefit;

          (iii) is the Cash Surrender Value; and

          (iv) is the Minimum Death Benefit.

GA-CA-1082                         3D2
<PAGE>

                                  THE SCHEDULE

                          CERTIFICATE FACTS (continued)
   ----------------------------------------------------------------------------
    Annuitant              Owner
    [THOMAS J. DOE]        [JOHN Q. DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
   ----------------------------------------------------------------------------
    Separate Account(s)                             Certificate Number
    [SEPARATE ACCOUNT B AND FIXED ACCOUNT]          [123456]
   ----------------------------------------------------------------------------

MINIMUM DEATH BENEFIT

     The Minimum Death Benefit shall be the sum of the following:

          1. The Accumulation Value allocated to Special Funds; and

          2. Adjusted Premium for non-Special Funds.

     Adjusted Premium for non-Special Funds shall mean all premium allocated to
     non-Special Funds, plus an adjustment for any amounts transferred to
     non-Special Funds, less a prorata adjustment for any amounts transferred or
     withdrawn from non-Special Funds. The amount of the prorata adjustment will
     equal (a) times (b) divided by (c), where (a) is the Adjusted Premium for
     non-Special Funds prior to the transfer or withdrawal; (b) is the
     Accumulation Value of the transfer or withdrawal; and (c) is the
     Accumulation Value allocated to non-Special Funds before the transfer or
     withdrawal. Adjusted Premium for Special Funds has the same definition, but
     with respect to amounts allocated to Special Funds.

     Transfers from Special Funds increase the Adjusted Premium for non-Special
     Funds by the lesser of the reduction of the Adjusted Premium for Special
     Funds and net Accumulation Value transferred. Transfers from non-Special
     Funds increase the Adjusted Premium for Special Funds by the reduction in
     the Adjusted Premium for non-Special Funds.

GUARANTEED DEATH BENEFIT

     The Guaranteed Death Benefit for the Certificate is equal to the sum of I
     and II below.

          I.  The Guaranteed Death Benefit Base for non-Special Funds

          II. The Accumulation Value allocated to Special Funds

     On the Certificate Date, the Guaranteed Death Benefit Base for non-Special
     Funds is the initial premium allocated to non-Special Funds. On subsequent
     Valuation Dates, the Guaranteed Death Benefit Base for non-Special Funds is
     calculated as follows:

          (1)  Start with the Guaranteed Death Benefit Base for non-Special
               Funds on the prior Valuation Date.

          (2)  Add to (1) any additional premium allocated to the non-Special
               Funds during the current Valuation Period and adjustments for
               transfers from Special Funds during the current Valuation Period
               and subtract from (1) any adjustment for transfers to Special
               Funds during the current Valuation Period and any Prorata Partial
               Withdrawal Adjustments for any Partial Withdrawals taken from
               non-Special Funds during the current Valuation Period.

          (3)  On a Valuation Date that occurs on or prior to the Owner's
               Attained Age [90], which is also a Certificate Anniversary, we
               set the Guaranteed Death Benefit Base for non-Special Funds equal
               to the greater of (2) or the Accumulation Value allocated to
               non-Special Funds as of such date. On all other Valuation Dates,
               the Guaranteed Death Benefit Base for non-Special Funds is equal
               to (2).

     The Guaranteed Death Benefit Base for Special Funds has a corresponding
     definition, but with respect to amounts allocated to Special Funds.

GA-CA-1082                         3D3
<PAGE>

                                  THE SCHEDULE

                          CERTIFICATE FACTS (continued)
   ----------------------------------------------------------------------------
    Annuitant              Owner
    [THOMAS J. DOE]        [JOHN Q. DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
   ----------------------------------------------------------------------------
    Separate Account(s)                             Certificate Number
    [SEPARATE ACCOUNT B AND FIXED ACCOUNT]          [123456]
   ----------------------------------------------------------------------------

     Transfers from Special Funds to non-Special Funds will reduce the
     Guaranteed Death Benefit Base for Special Funds on a prorata basis. The
     resulting increase in the Guaranteed Death Benefit Base for non-Special
     Funds will equal the lesser of the reduction in the Guaranteed Death
     Benefit Base for Special Funds and the net Accumulation Value transferred.

     Transfers from non-Special Funds to Special Funds will reduce the
     Guaranteed Death Benefit Base for non-Special Funds on a prorata basis. The
     resulting increase in the Guaranteed Death Benefit Base for Special Funds
     will equal the reduction in Guaranteed Death Benefit Base for non-Special
     Funds.

SPECIAL FUNDS

     Where used in this Certificate, Special Funds are [the Liquid Asset
     Division, the Limited Maturity Bond Division, the Fixed Allocations and the
     Guaranteed Interest Division]. We may add newly available Divisions as
     Special Funds. We may also reclassify an existing Division as a Special
     Fund or remove such designation upon 30 days notice to you. Such
     reclassification will apply to amounts transferred or otherwise added to
     such Division after the date of change. We may reduce the Mortality and
     Expense Risk Charge (if applicable) for that portion of the Certificate
     invested in a Special Fund.

PRORATA PARTIAL WITHDRAWAL ADJUSTMENTS

     For any partial withdrawal, the Death Benefit components will be reduced by
     Prorata Partial Withdrawal Adjustments. The Prorata Partial Withdrawal
     Adjustment to a Death Benefit component for a partial withdrawal is equal
     to (1) divided by (2) multiplied by (3), where: (1) is the Accumulation
     Value withdrawn; (2) is the Accumulation Value immediately prior to
     withdrawal; and (3) is the amount of the applicable Death Benefit component
     immediately prior to the withdrawal. Separate adjustments will apply to
     amounts in the Special and non-Special Funds.

CHANGE OF OWNER

     A change of Owner from a sole Owner to a sole Owner (where there have never
     been multiple Owners designated) will result in recalculation of the Death
     Benefit and the Guaranteed Death Benefit. If the new Owner's Attained Age
     at the time of the change is less than [80], the Guaranteed Death Benefit
     in effect prior to the change will remain in effect and the Death Benefit
     provision will apply. If the new Owner's Attained Age at the time of the
     change is [80] or greater, but not greater than [85]:

          (a)  The Guaranteed Death Benefit following the change will be zero;
               and

          (b)  The Death Benefit will then be the greatest of:

               (1)  the Cash Surrender Value;

               (2)  the Accumulation Value; and

               (3)  the Minimum Death Benefit.

GA-CA-1082                         3D4
<PAGE>

                                  THE SCHEDULE

                          CERTIFICATE FACTS (continued)
   ----------------------------------------------------------------------------
    Annuitant              Owner
    [THOMAS J. DOE]        [JOHN Q. DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
   -----------------------------------------------------------------------------
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
   ----------------------------------------------------------------------------
    Separate Account(s)                             Certificate Number
    [SEPARATE ACCOUNT B AND FIXED ACCOUNT]          [123456]
   ----------------------------------------------------------------------------

     If ownership changes result in multiple Owners or if there has ever been
     multiple Owners, the Guaranteed Death Benefit shall be set to zero. If the
     oldest Owner is age [85] or younger at the time of the change, the Death
     Benefit will then be the greatest of (b) 1, (b) 2 or (b) 3 above.

     If any Owner's or oldest multiple Owners' Attained Age is [86] or greater
     at the time of the change, the Guaranteed Death Benefit will be zero, and
     the Death Benefit will then be the Cash Surrender Value.

     When a change of Owner reduces the Guaranteed Death Benefit to zero, there
     will be a reduction in the Mortality and Expense Risk Charge.

SPOUSAL CONTINUATION UPON DEATH OF OWNER

     If at the Owner's death, the surviving spouse of the deceased Owner is the
     Beneficiary and such surviving spouse elects to continue the Certificate as
     their own pursuant to Internal Revenue Code Section 72(s) or the equivalent
     provisions of U.S. Treasury Department rules for qualified plans, the
     following will apply:

     (a)  If the greater of (ii) and (iv) in the Death Benefit provision as of
          the date we receive due proof of death of the Owner minus the
          Accumulation Value, also as of that date, is greater than zero, we
          will add such difference to the Accumulation Value. Such addition will
          be allocated to the Divisions of the Separate Account in the same
          proportion as the Accumulation Value in each Division bears to the
          Accumulation Value in the Separate Account. If there is no
          Accumulation Value in the Separate Account, the addition will be
          allocated to the Liquid Asset Division, or its successor.

     (b)  The Guaranteed Death Benefit and the Maximum Guaranteed Death Benefit
          will continue to apply, using the surviving spouse's age as the
          determining age.

     (c)  At subsequent surrender, any Surrender Charge applicable to premiums
          paid prior to the date we receive due proof of death of the Owner will
          be waived. Any premiums paid later will be subject to any applicable
          Surrender Charge.

     This addition to Accumulation Value is available only to the spouse of the
     Owner as of the date of death of the Owner if such spouse under the
     provisions of this Certificate elects to continue the Certificate as their
     own.

CHOOSING AN INCOME PLAN

     Required Date of Annuity Commencement

     Distributions from a Certificate funding a qualified plan must commence no
     later than April 1st of the calendar year following the calendar year in
     which the Owner attains age 70 1/2. Otherwise, the Annuity Commencement
     Date may be no later than the same date as the Certificate Processing Date
     in the month following the Annuitant's 90th birthday. In applying the
     Accumulation Value, we may first collect any Premium Taxes due us. If, on
     the Annuity Commencement Date, a Surrender Charge remains, your elected
     Annuity Option must include a period certain of at least five years
     duration.

     Minimum Annuity Income Payment

     The minimum monthly annuity income payment that we will make is [$20].

GA-CA-1082                         3D5
<PAGE>

                                  THE SCHEDULE

                          CERTIFICATE FACTS (continued)
   ----------------------------------------------------------------------------
    Annuitant              Owner
    [THOMAS J. DOE]        [JOHN Q. DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
   ----------------------------------------------------------------------------
    Separate Account(s)                             Certificate Number
    [SEPARATE ACCOUNT B AND FIXED ACCOUNT]          [123456]
   ----------------------------------------------------------------------------

OPTIONAL BENEFIT RIDERS - [None]

ATTAINED AGE

     The Issue Age of the Annuitant or Owner plus the number of full years
     elapsed since the Certificate Date.

RESTRICTED FUNDS - [None]

FIXED ACCOUNT

     Minimum Fixed Allocation

     The minimum allocation to the Fixed Account in any one Fixed Allocation is
     [$250.00].

     Minimum Guaranteed Interest Rate - [3%]

     Guarantee Periods

     We currently offer Guarantee Periods of [1, 3, 5, 7 and 10] year(s). We
     reserve the right to offer Guarantee Periods of durations other than those
     available on the Certificate Date. We also reserve the right to cease
     offering a particular Guarantee Period or Periods.

     Index Rate

     The Index Rate is the average of the Ask Yields for the U.S. Treasury
     Strips as reported by a national quoting service for the applicable
     maturity. The average is based on the period from the 22nd day of the
     calendar month two months prior to the calendar month of Index Rate
     determination to the 21st day of the calendar month immediately prior to
     the month of determination. The applicable maturity date for these U.S.
     Treasury Strips is on or next following the last day of the Guarantee
     Period. If the Ask Yields are no longer available, the Index Rate will be
     determined using a suitable replacement method.

     We currently set the Index Rate once each calendar month. However, we
     reserve the right to set the Index Rate more frequently than monthly, but
     in no event will such Index Rate be based on a period less than 28 days.

GA-CA-1082                         3D6
<PAGE>

                                  THE SCHEDULE

                                CHARGES AND FEES
   ----------------------------------------------------------------------------
    Annuitant              Owner
    [THOMAS J. DOE]        [JOHN Q. DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
   ----------------------------------------------------------------------------
    Separate Account(s)                             Certificate Number
    [SEPARATE ACCOUNT B AND FIXED ACCOUNT]          [123456]
   ----------------------------------------------------------------------------

DEDUCTIONS FROM PREMIUMS

     None

DEDUCTIONS FROM ACCUMULATION VALUE

     Initial Administrative Charge

     None

     Administrative Charge

     We charge a maximum of $30 to cover a portion of our ongoing administrative
     expenses for each Certificate Processing Period. The charge is incurred at
     the beginning of the Certificate Processing Period and deducted on the
     Certificate Processing Date at the end of the period.

     At the time of deduction, this charge will be waived if:

          (1)  The Accumulation Value is at least $100,000; or

          (2)  The sum of premiums paid to date is at least $100,000.

     Excess Allocation Charge

     Currently none, however, we reserve the right to charge $25 for a change if
     you make more than twelve allocation changes per Certificate Year. Any
     charge will be deducted in proportion to the amount being transferred from
     each Division.

     Surrender Charge

     A Surrender Charge is imposed as a percentage of unliquidated premium if
     the Certificate is surrendered or an Excess Partial Withdrawal is taken.
     The percentage imposed at time of surrender or Excess Partial Withdrawal
     depends on the number of complete years that have elapsed since a Premium
     Payment was made. The Surrender Charge expressed as a percentage of each
     Premium Payment is as follows:

       Complete Years Elapsed                     Surrender
       Since Premium Payment                       Charges
       ----------------------                     ---------
                 [0                                  6%
                  1                                  5%
                  2                                  4%
                  3                                  3%
                 4+                                  0%]

     Surrender of the Certificate is permitted at or before the commencement of
     Annuity Payments.

GA-CA-1082                         3E1
<PAGE>

                                  THE SCHEDULE

                          CHARGES AND FEES (continued)
   ----------------------------------------------------------------------------
    Annuitant              Owner
    [THOMAS J. DOE]        [JOHN Q. DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
   ----------------------------------------------------------------------------
    Separate Account(s)                             Certificate Number
    [SEPARATE ACCOUNT B AND FIXED ACCOUNT]          [123456]
   ----------------------------------------------------------------------------

     Premium Taxes

     We deduct the amount of any premium or other state and local taxes levied
     by any state or governmental entity when such taxes are incurred.

     We reserve the right to defer collection of Premium Taxes until surrender
     or until application of Accumulation Value to an Annuity Option. An Excess
     Partial Withdrawal will result in the deduction of any Premium Tax then due
     us on such amount. We reserve the right to change the amount we charge for
     Premium Tax charges on future Premium Payments to conform with changes in
     the law or if the Owner changes state of residence.

     Deductions from the Divisions

     Mortality and Expense Risk Charge - We deduct a charge from the assets in
     each Variable Separate Account Division on a daily basis of not more than
     [0.005255]% (equivalent to an annual maximum rate of [1.90]%) for mortality
     and expense risks. The charge is not deducted from the Fixed Account or
     General Account Accumulation Values.

     Asset Based Administrative Charge - We deduct a charge of not more than
     [0.000411]% of the assets in each Variable Separate Account Division on a
     daily basis (equivalent to an annual maximum rate of [0.15]%) to compensate
     us for a portion of our ongoing administrative expenses. This charge is not
     deducted from the Fixed Account or General Account Accumulation Values.

CHARGE DEDUCTION DIVISION

     If elected by you, all charges against the Accumulation Value in this
     Certificate will be deducted from the [Liquid Asset Division].

GA-CA-1082                         3E2
<PAGE>

                                  THE SCHEDULE

                               INCOME PLAN FACTORS
   ----------------------------------------------------------------------------
    Annuitant              Owner
    [THOMAS J. DOE]        [JOHN Q. DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
   ----------------------------------------------------------------------------
    Separate Account(s)                             Certificate Number
    [SEPARATE ACCOUNT B AND FIXED ACCOUNT]          [123456]
   ----------------------------------------------------------------------------

     Values for other payment periods, ages or joint life combinations are
     available on request. Monthly payments are shown for each $1,000 applied.

                       TABLE FOR INCOME FOR A FIXED PERIOD

<TABLE>
<CAPTION>
      Fixed Period        Monthly     Fixed Period        Monthly    Fixed Period        Monthly
          of Years         Income         of Years         Income        of Years         Income

        <S>              <C>             <C>            <C>             <C>             <C>
        [5               17.95           14             7.28            23              5.00
         6               15.18           15             6.89            24              4.85
         7               13.20           16             6.54            25              4.72
         8               11.71           17             6.24            26              4.60
         9               10.56           18             5.98            27              4.49
        10                9.64           19             5.74            28              4.38
        11                8.88           20             5.53            29              4.28
        12                8.26           21             5.33            30             4.19]
        13                7.73           22             5.16

</TABLE>

                            TABLE FOR INCOME FOR LIFE

                   Male/Female         Male/Female           Male/Female
        Age        10 Years Certain    20 Years Certain        Refund Certain

        [50        $4.06/3.83          $3.96/3.77            $3.93/3.75
        55          4.43/4.14           4.25/4.05             4.25/4.03
        60          4.90/4.56           4.57/4.37             4.66/4.40
        65          5.51/5.10           4.90/4.73             5.12/4.83
        70          6.26/5.81           5.18/5.07             5.76/5.42
        75          7.11/6.70           5.38/5.33             6.58/6.19
        80          7.99/7.70           5.48/5.46             7.69/7.21
        85          8.72/8.59           5.52/5.51             8.72/8.59
        90          9.23/9.18           5.53/5.53           10.63/10.53]

GA-CA-1082                         3F
<PAGE>

                             THE SCHEDULE (COMBO DB)

                                CERTIFICATE FACTS
   ----------------------------------------------------------------------------
    Annuitant              Owner
    [THOMAS J. DOE]        [JOHN Q. DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
   ----------------------------------------------------------------------------
    Separate Account(s)                             Certificate Number
    [SEPARATE ACCOUNT B AND FIXED ACCOUNT]          [123456]
   ----------------------------------------------------------------------------

CERTIFICATE FACTS

     Certificate Processing Date

     The Certificate Processing Date for your Certificate is [April 1] of each
     year.

     Specially Designated Division

     When a distribution is made from an investment portfolio underlying a
     Separate Account Division in which reinvestment is not available, we will
     allocate the amount of the distribution to the [Liquid Asset Division]
     unless you specify otherwise.

PARTIAL WITHDRAWALS

     The maximum amount that can be withdrawn each Certificate Year without
     being considered an Excess Partial Withdrawal is described below. We will
     collect a Surrender Charge for Excess Partial Withdrawals and a charge for
     any unrecovered Premium Taxes. In no event may a Partial Withdrawal be
     greater than 90% of the Cash Surrender Value. After a Partial Withdrawal,
     the remaining Accumulation Value must be at least $100 to keep the
     Certificate in force.

     Systematic Partial Withdrawals and Conventional Partial Withdrawals may not
     be taken in the same Certificate Year.

     To determine the Surrender Charge on Excess Partial Withdrawals, the
     withdrawals will occur in the following order:

          (1)  Earnings;

          (2)  The Free Amount;

          (3)  Premium Payments made [four] or more years prior to the
               withdrawal; and,

          (4)  Premium Payments which made less than [four] years prior to
               withdrawal.

     Earnings and Free Amounts are not treated as withdrawals of Premium
     Payments for purposes of calculating any Surrender Charge.

     Conventional Partial Withdrawals
     Minimum Withdrawal Amount: $100.

     The maximum amount that can be taken as a Conventional Partial Withdrawal
     each Certificate Year without being considered an Excess Partial Withdrawal
     is the greater of:

          (1)  Earnings (defined below) not previously withdrawn, but not less
               than zero; and

          (2)  The Free Amount, equal to 10% of Premium Payments not previously
               withdrawn, which were received within [four] years prior to the
               date of withdrawal.

     Earnings are equal to the Accumulation Value, less Premium Payments, plus
     prior withdrawals.

     Any Conventional Partial Withdrawal is subject to a Market Value Adjustment
     unless withdrawn from a Fixed Allocation within 30 days prior to the
     Maturity Date.

GA-CA-1082                         3D1
<PAGE>

                                  THE SCHEDULE

                          CERTIFICATE FACTS (continued)
   ----------------------------------------------------------------------------
    Annuitant              Owner
    [THOMAS J. DOE]        [JOHN Q. DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
   ----------------------------------------------------------------------------
    Separate Account(s)                             Certificate Number
    [SEPARATE ACCOUNT B AND FIXED ACCOUNT]          [123456]
   ----------------------------------------------------------------------------

     Systematic Partial Withdrawals

     Systematic Partial Withdrawals may be elected to commence after 28 days
     from the Certificate Issue Date and may be taken on a monthly, quarterly or
     annual basis. You select the day withdrawals will be made, but no later
     than the 28th day of the month. If you do not elect a day, the Certificate
     Date will be used.

     Maximum Withdrawal Amounts:

     Variable Separate Account Divisions:   .833% of Premium Payments monthly,
                                            2.5% of Premium Payments quarterly
                                            or 10% of Premium Payments annually.

     Fixed Allocations and
     Guaranteed Interest Divisions:         Interest earned on a Fixed
                                            Allocation or Guaranteed Interest
                                            Division for the prior month,
                                            quarter or year (depending on the
                                            frequency selected).

     The Maximum Withdrawal Amount available as a Systematic Partial Withdrawal
     is 10% of Premium Payments not previously withdrawn. Systematic Partial
     Withdrawals from Fixed Allocations are not subject to a Market Value
     Adjustment. A Systematic Partial Withdrawal in excess of Earnings and the
     Free Amount may be subject to a Surrender Charge.

     IRA Partial Withdrawals for Qualified Plans Only

     Partial Withdrawals may be taken from a Certificate issued as an IRA on a
     monthly, quarterly or annual basis. A minimum withdrawal of $100.00 is
     required. You select the day the withdrawals will be made, but no later
     than the 28th day of the month. If you do not elect a day, the Certificate
     Date will be used. Systematic Partial Withdrawals and Conventional Partial
     Withdrawals are not allowed when IRA Partial Withdrawals are being taken.
     An IRA Partial Withdrawal in excess of the maximum amount allowed under the
     Systematic Partial Withdrawal option may be subject to a Market Value
     Adjustment.

DEATH BENEFIT

     The Death Benefit is the greatest of (i), (ii), (iii), (iv) and (v) below,
     where:

          (i)  is the Accumulation Value;

          (ii) is the lesser of (a) and (b) where (a) is the Guaranteed Death
               Benefit, and (b) is the Maximum Guaranteed Death Benefit;

          (iii) is the Cash Surrender Value;

          (iv) is the Minimum Death Benefit; and

          (v)  the Alternate Guaranteed Death Benefit.

MINIMUM DEATH BENEFIT

The Minimum Death Benefit shall be the sum of the following:

          1. The Accumulation Value allocated to Special Funds; and

          2. Adjusted Premium for non-Special Funds.

GA-CA-1082                         3D2
<PAGE>

                                  THE SCHEDULE

                          CERTIFICATE FACTS (continued)
   ----------------------------------------------------------------------------
    Annuitant              Owner
    [THOMAS J. DOE]        [JOHN Q. DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
   ----------------------------------------------------------------------------
    Separate Account(s)                             Certificate Number
    [SEPARATE ACCOUNT B AND FIXED ACCOUNT]          [123456]
   ----------------------------------------------------------------------------

     Adjusted Premium for non-Special Funds shall mean all premium allocated to
     non-Special Funds, plus an adjustment for any amounts transferred to
     non-Special Funds, less a prorata adjustment for any amounts transferred or
     withdrawn from non-Special Funds. The amount of the prorata adjustment will
     equal (a) times (b) divided by (c), where: (a) is the Adjusted Premium for
     non-Special Funds prior to the transfer or withdrawal; (b) is the
     Accumulation Value of the transfer or withdrawal; and (c) is the
     Accumulation Value allocated to non-Special Funds before the transfer or
     withdrawal. Adjusted Premium for Special Funds has the same definition, but
     with respect to amounts allocated to Special Funds.

     Transfers from Special Funds increase the Adjusted Premium for non-Special
     Funds by the lesser of the reduction of the Adjusted Premium for Special
     Funds and net Accumulation Value transferred. Transfers from non-Special
     Funds increase the Adjusted Premium for Special Funds by the reduction in
     the Adjusted Premium for non-Special Funds.

GUARANTEED DEATH BENEFIT

     The Guaranteed Death Benefit for the Certificate is equal to the sum of I
     and II below.

          I. The Guaranteed Death Benefit Base for non-Special Funds

          II.The Accumulation Value allocated to Special Funds

     On the Certificate Date, the Guaranteed Death Benefit Base for non-Special
     Funds is the initial premium, if applicable, allocated to non-Special
     Funds. On subsequent Valuation Dates, the Guaranteed Death Benefit Base for
     non-Special Funds is calculated as follows:

          (1)  Start with the Guaranteed Death Benefit Base for non-Special
               Funds on the prior Valuation Date.

          (2)  Calculate interest on (1) for the current Valuation Period at the
               Guaranteed Death Benefit Interest Rate for non-Special Funds.

          (3)  Add (1) and (2).

          (4)  Add to (3) any additional premiums allocated to non-Special Funds
               during the current Valuation Period.

          (5)  Add to (or subtract from) (4) adjustments for transfers from (to)
               Special Funds made during the Valuation Period.

          (6)  Subtract from (5) the amount of any Special Partial Withdrawal
               Adjustments and Prorata Partial Withdrawal Adjustments for any
               partial withdrawals made from non-Special Funds during the
               current Valuation Period.

     The Guaranteed Death Benefit Base for Special Funds has a corresponding
     definition, but with respect to amounts allocated to Special Funds.

     Transfers from Special Funds to non-Special Funds will reduce the
     Guaranteed Death Benefit Base for Special Funds on a prorata basis. The
     resulting increase in the Guaranteed Death Benefit Base for non-Special
     Funds will equal the lesser of the reduction in the Guaranteed Death
     Benefit Base for Special Funds and the net Accumulation Value transferred.

GA-CA-1082                         3D3
<PAGE>

                                  THE SCHEDULE

                          CERTIFICATE FACTS (continued)
   ----------------------------------------------------------------------------
    Annuitant              Owner
    [THOMAS J. DOE]        [JOHN Q. DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
   ----------------------------------------------------------------------------
    Separate Account(s)                             Certificate Number
    [SEPARATE ACCOUNT B AND FIXED ACCOUNT]          [123456]
   ----------------------------------------------------------------------------

     Transfers from non-Special Funds to Special Funds will reduce the
     Guaranteed Death Benefit Base for non-Special Funds on a prorata basis. The
     resulting increase in the Guaranteed Death Benefit Base for Special Funds
     will equal the reduction in Guaranteed Death Benefit Base for non-Special
     Funds.

GUARANTEED DEATH BENEFIT INTEREST RATE

     The Guaranteed Death Benefit Interest Rate is [7%] compounded annually,
     except:

          (a)  For any portion of the Guaranteed Death Benefit Base for Special
               Funds, the Guaranteed Death Benefit Interest Rate is [7%]
               (compounded annually); and

          (b)  For any valuation period ending after the Certificate Anniversary
               on which the Owner attains age [80], or after the Maximum
               Guaranteed Death Benefit has been reached, the Guaranteed Death
               Benefit Interest Rate is [0%].

SPECIAL FUNDS

     Where used in this Certificate, Special Funds are [the Liquid Asset
     Division, the Limited Maturity Bond Division, the Fixed Allocations and the
     Guaranteed Interest Division]. We may add newly available Divisions as
     Special Funds. We may also reclassify an existing Division as a Special
     Fund or remove such designation upon 30 days notice to you. Such
     reclassification will apply to amounts transferred or otherwise added to
     such Division after the date of change. We may reduce the Mortality and
     Expense Risk Charge (if applicable) for that portion of the Certificate
     invested in a Special Fund.

MAXIMUM GUARANTEED DEATH BENEFIT

     The Maximum Guaranteed Death Benefit is equal to [three] times premium
     paid, reduced by the amount of any Partial Withdrawal Adjustments. The
     Maximum Guaranteed Death Benefit is allocated proportionally based on the
     Certificate's allocation to Special and non-Special funds. Transfers and
     withdrawals will affect the allocation of the Maximum Guaranteed Death
     Benefit at the same proportion among the Special and non-Special Funds that
     they bear to the Accumulation Value transferred or withdrawn. Any addition
     due to spousal continuation will not affect the Maximum Guaranteed Death
     Benefit or the Guaranteed Death Benefit Base.

SPECIAL AND PRORATA PARTIAL WITHDRAWAL ADJUSTMENTS

     For any partial withdrawal, the Death Benefit components will be reduced by
     Prorata Partial Withdrawal Adjustments. A Prorata Partial Withdrawal
     Adjustment will be made unless a Special Partial Withdrawal Adjustment
     applies to the component for the withdrawal. Special Partial Withdrawal
     Adjustments are made when partial withdrawals in any Certificate Year do
     not exceed [7%] of the sum of cumulative premiums, but only if partial
     withdrawals in each prior year did not exceed [7%] of the sum of premiums
     paid prior to that year. The Special Partial Withdrawal Adjustment is equal
     to the amount of the Accumulation Value withdrawn.

GA-CA-1082                         3D4
<PAGE>

                                  THE SCHEDULE

                          CERTIFICATE FACTS (continued)
   ----------------------------------------------------------------------------
    Annuitant              Owner
    [THOMAS J. DOE]        [JOHN Q. DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
   ----------------------------------------------------------------------------
    Separate Account(s)                             Certificate Number
    [SEPARATE ACCOUNT B AND FIXED ACCOUNT]          [123456]
   ----------------------------------------------------------------------------

     Special Partial Withdrawal Adjustments are applicable only in the
     calculation of the Maximum Guaranteed Death Benefit and the Guaranteed
     Death Benefit Base, and in all other cases withdrawals are treated as
     Prorata Partial Withdrawal Adjustments.

     The Prorata Partial Withdrawal Adjustment to a Death Benefit component is
     equal to (1) divided by (2), multiplied by (3), where: (1) is the
     Accumulation Value withdrawn; (2) is the Accumulation Value immediately
     prior to withdrawal; and (3) is the amount of the applicable Death Benefit
     component immediately prior to the withdrawal. Separate adjustments will
     apply to the amounts in the Special and non-Special Funds.

ALTERNATE GUARANTEED DEATH BENEFIT

     The Alternate Guaranteed Death Benefit for the Certificate is equal to the
     sum of I and II below.

          I.  The Alternate Guaranteed Death Benefit Base for non-Special Funds

          II. The Accumulation Value allocated to Special Funds

     On the Certificate Date, the Alternate Guaranteed Death Benefit Base for
     non-Special Funds is the initial premium allocated to non-Special Funds. On
     subsequent Valuation Dates, the Alternate Guaranteed Death Benefit Base for
     non-Special Funds is calculated as follows:

          (1)  Start with the Alternate Guaranteed Death Benefit Base for
               non-Special Funds from the prior Valuation Date.

          (2)  Add to (1) any additional premium allocated to the non-Special
               Funds during the current Valuation Period and adjustments for
               transfers from Special Funds during the current Valuation Period
               and subtract from (1) any adjustment for transfers to Special
               Funds during the current Valuation Period and any Prorata Partial
               Withdrawal Adjustments for any Partial Withdrawals taken from
               non-Special Funds during the current Valuation Period.

          (3)  On a Valuation Date that occurs on or prior to the Owner's
               Attained Age [90], which is also a Certificate Anniversary, we
               set the Alternate Guaranteed Death Benefit Base for non-Special
               Funds equal to the greater of (2) or the Accumulation Value as of
               such date. On all other Valuation Dates, the Alternate Guaranteed
               Death Benefit Base for non-Special Funds is equal to (2).

     The Alternate Guaranteed Death Benefit Base for Special Funds has a
     corresponding definition, but with respect to amounts allocated to Special
     Funds.

     Transfers from Special Funds to non-Special Funds will reduce the Alternate
     Guaranteed Death Benefit Base for Special Funds on a prorata basis. The
     resulting increase in the Alternate Guaranteed Death Benefit Base for
     non-Special Funds will equal the lesser of the reduction in the Alternate
     Guaranteed Death Benefit Base for Special Funds and the net Accumulation
     Value transferred.

GA-CA-1082                         3D5
<PAGE>

                                  THE SCHEDULE

                          CERTIFICATE FACTS (continued)
   ----------------------------------------------------------------------------
    Annuitant              Owner
    [THOMAS J. DOE]        [JOHN Q. DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
   ----------------------------------------------------------------------------
    Separate Account(s)                             Certificate Number
    [SEPARATE ACCOUNT B AND FIXED ACCOUNT]          [123456]
   ----------------------------------------------------------------------------

     Transfers from non-Special Funds to Special Funds will reduce the Alternate
     Guaranteed Death Benefit Base for non-Special Funds on a prorata basis. The
     resulting increase in the Alternate Guaranteed Death Benefit Base for
     Special Funds will equal the reduction in Alternate Guaranteed Death
     Benefit Base for non-Special Funds.

CHANGE OF OWNER

     A change of Owner from a sole Owner to a sole Owner (where there have never
     been multiple Owners designated) will result in recalculation of the Death
     Benefit, the Guaranteed Death Benefit, the Alternate Guaranteed Death
     Benefit, and the Maximum Guaranteed Death Benefit. If the new Owner's
     Attained Age at the time of the change is less than [80], the Guaranteed
     Death Benefit, the Alternate Guaranteed Death Benefit and the Maximum
     Guaranteed Death Benefit in effect prior to the change will remain in
     effect and the Death Benefit provision shall apply. If the new Owner's
     Attained Age at the time of the change is [80] or greater, but not greater
     than [85]:

          (a)  The Guaranteed Death Benefit, the Alternate Guaranteed Death
               Benefit, and the Maximum Guaranteed Death Benefit following the
               change will be zero; and

          (b)  The Death Benefit will then be the greatest of:

               1)  the Cash Surrender Value;

               2)  the Accumulation Value; and

               3)  the Minimum Death Benefit.

     If ownership changes result in multiple Owners or if there has ever been
     multiple Owners, the Guaranteed Death Benefit, the Alternate Guaranteed
     Death Benefit and the Maximum Guaranteed Death Benefit shall be set to
     zero. If the oldest Owner is age [85] or younger at the time of the change,
     the Death Benefit will then be the greatest of (b) 1, (b) 2 or (b) 3 above.

     If any Owner's or oldest multiple Owner's Attained Age is [86] or greater
     at the time of the change, the Guaranteed Death Benefit, the Minimum Death
     Benefit, the Alternate Guaranteed Death Benefit and the Maximum Guaranteed
     Death Benefit will be zero, and the Death Benefit will then be the Cash
     Surrender Value.

     When a change of Owner reduces the Guaranteed Death Benefit, the Alternate
     Guaranteed Death Benefit and the Maximum Guaranteed Death Benefit to zero,
     there will be a reduction in the Mortality and Expense Risk Charge.

GA-CA-1082                         3D6
<PAGE>

                                  THE SCHEDULE

                          CERTIFICATE FACTS (continued)
   ----------------------------------------------------------------------------
    Annuitant              Owner
    [THOMAS J. DOE]        [JOHN Q. DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
   ----------------------------------------------------------------------------
    Separate Account(s)                             Certificate Number
    [SEPARATE ACCOUNT B AND FIXED ACCOUNT]          [123456]
   ----------------------------------------------------------------------------

SPOUSAL CONTINUATION UPON DEATH OF OWNER

     If at the Owner's death, the surviving spouse of the deceased Owner is the
     Beneficiary and such surviving spouse elects to continue the Certificate as
     their own pursuant to Internal Revenue Code Section 72(s) or the equivalent
     provisions of U.S. Treasury Department rules for qualified plans, the
     following will apply:

     (a)  If the greater of (ii), (iv) and (v) in the Death Benefit provision as
          of the date we receive due proof of death of the Owner, minus the
          Accumulation Value, also as of that date, is greater than zero, we
          will add such difference to the Accumulation Value. Such addition will
          be allocated to the Divisions of the Separate Account in the same
          proportion as the Accumulation Value in each Division bears to the
          Accumulation Value in the Separate Account. If there is no
          Accumulation Value in the Separate Account, the addition will be
          allocated to the Liquid Asset Division, or its successor.

     (b)  The Guaranteed Death Benefit, the Alternate Guaranteed Death Benefit,
          the Minimum Death Benefit, and the Maximum Guaranteed Death Benefit
          will continue to apply, with all age criteria using the surviving
          spouse's age as the determining age.

     (c)  At subsequent surrender, any Surrender Charge applicable to premiums
          paid prior to the date we receive due proof of death of the Owner will
          be waived. Any premiums paid later will be subject to any applicable
          Surrender Charge.

     This addition to Accumulation Value is available only to the spouse of the
     Owner as of the date of death of the Owner if such spouse under the
     provisions of this Certificate elects to continue the Certificate as their
     own.

CHOOSING AN INCOME PLAN

     Required Date of Annuity Commencement

     Distributions from a Certificate funding a qualified plan must commence no
     later than April 1st of the calendar year following the calendar year in
     which the Owner attains age 70 1/2. Otherwise, the Annuity Commencement
     Date may be no later than the same date as the Certificate Processing Date
     in the month following the Annuitant's 90th birthday. In applying the
     Accumulation Value, we may first collect any Premium Taxes due us. If, on
     the Annuity Commencement Date, a Surrender Charge remains, your elected
     Annuity Option must include a period certain of at least five years
     duration.

     Minimum Annuity Income Payment

     The minimum monthly annuity income payment that we will make is [$20].

GA-CA-1082                         3D7
<PAGE>

                                  THE SCHEDULE

                          CERTIFICATE FACTS (continued)
   ----------------------------------------------------------------------------
    Annuitant              Owner
    [THOMAS J. DOE]        [JOHN Q. DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
   ----------------------------------------------------------------------------
    Separate Account(s)                             Certificate Number
    [SEPARATE ACCOUNT B AND FIXED ACCOUNT]          [123456]
   ----------------------------------------------------------------------------

OPTIONAL BENEFIT RIDERS - [None]

ATTAINED AGE

     The Issue Age of the Annuitant or Owner plus the number of full years
     elapsed since the Certificate Date.

RESTRICTED FUNDS - [None]

FIXED ACCOUNT

     Minimum Fixed Allocation

     The minimum allocation to the Fixed Account in any one Fixed Allocation is
     [$250.00].

     Minimum Guaranteed Interest Rate - [3%]

     Guarantee Periods

     We currently offer Guarantee Periods of [1, 3, 5, 7 and 10] year(s). We
     reserve the right to offer Guarantee Periods of durations other than those
     available on the Certificate Date. We also reserve the right to cease
     offering a particular Guarantee Period or Periods.

     Index Rate

     The Index Rate is the average of the Ask Yields for the U.S. Treasury
     Strips as reported by a national quoting service for the applicable
     maturity. The average is based on the period from the 22nd day of the
     calendar month two months prior to the calendar month of Index Rate
     determination to the 21st day of the calendar month immediately prior to
     the month of determination. The applicable maturity date for these U.S.
     Treasury Strips is on or next following the last day of the Guarantee
     Period. If the Ask Yields are no longer available, the Index Rate will be
     determined using a suitable replacement method.

     We currently set the Index Rate once each calendar month. However, we
     reserve the right to set the Index Rate more frequently than monthly, but
     in no event will such Index Rate be based on a period less than 28 days.

GA-CA-1082                         3D8
<PAGE>

                                  THE SCHEDULE

                                CHARGES AND FEES
   ----------------------------------------------------------------------------
    Annuitant              Owner
    [THOMAS J. DOE]        [JOHN Q. DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
   ----------------------------------------------------------------------------
    Separate Account(s)                             Certificate Number
    [SEPARATE ACCOUNT B AND FIXED ACCOUNT]          [123456]
   ----------------------------------------------------------------------------

DEDUCTIONS FROM PREMIUMS

     None

DEDUCTIONS FROM ACCUMULATION VALUE

     Initial Administrative Charge

     None

     Administrative Charge

     We charge a maximum of $30 to cover a portion of our ongoing administrative
     expenses for each Certificate Processing Period. The charge is incurred at
     the beginning of the Certificate Processing Period and deducted on the
     Certificate Processing Date at the end of the period.

     At the time of deduction, this charge will be waived if:

          (1)  The Accumulation Value is at least $100,000; or

          (2)  The sum of premiums paid to date is at least $100,000

     Excess Allocation Charge

     Currently none, however, we reserve the right to charge $25 for a change if
     you make more than twelve allocation changes per Certificate Year. Any
     charge will be deducted in proportion to the amount being transferred from
     each Division.

     Surrender Charge

     A Surrender Charge is imposed as a percentage of unliquidated premium if
     the Certificate is surrendered or an Excess Partial Withdrawal is taken.
     The percentage imposed at time of surrender or Excess Partial Withdrawal
     depends on the number of complete years that have elapsed since a Premium
     Payment was made. The Surrender Charge expressed as a percentage of each
     Premium Payment is as follows:

       Complete Years Elapsed                     Surrender
       Since Premium Payment                       Charges
       ----------------------                     ---------
                 [0                                  6%
                  1                                  5%
                  2                                  4%
                  3                                  3%
                 4+                                  0%]

     Surrender of the Certificate is permitted at or before the commencement of
     Annuity Payments.

GA-CA-1082                         3E1
<PAGE>

                                  THE SCHEDULE

                          CHARGES AND FEES (continued)
   ----------------------------------------------------------------------------
    Annuitant              Owner
    [THOMAS J. DOE]        [JOHN Q. DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
   ----------------------------------------------------------------------------
    Separate Account(s)                             Certificate Number
    [SEPARATE ACCOUNT B AND FIXED ACCOUNT]          [123456]
   ----------------------------------------------------------------------------

     Premium Taxes

     We deduct the amount of any premium or other state and local taxes levied
     by any state or governmental entity when such taxes are incurred.

     We reserve the right to defer collection of Premium Taxes until surrender
     or until application of Accumulation Value to an Annuity Option. An Excess
     Partial Withdrawal will result in the deduction of any Premium Tax then due
     us on such amount. We reserve the right to change the amount we charge for
     Premium Tax charges on future Premium Payments to conform with changes in
     the law or if the Owner changes state of residence.

     Deductions from the Divisions

     Mortality and Expense Risk Charge - We deduct a charge from the assets in
     each Variable Separate Account Division on a daily basis of not more than
     [0.005815]% (equivalent to an annual maximum rate of [2.10]%) for mortality
     and expense risks. The charge is not deducted from the Fixed Account or
     General Account Accumulation Values.

     Asset Based Administrative Charge - We deduct a charge of not more than
     [0.000411]% of the assets in each Variable Separate Account Division on a
     daily basis (equivalent to an annual maximum rate of [0.15]%) to compensate
     us for a portion of our ongoing administrative expenses. This charge is not
     deducted from the Fixed Account or General Account Accumulation Values.

CHARGE DEDUCTION DIVISION

     If elected by you, all charges against the Accumulation Value in this
     Certificate will be deducted from the [Liquid Asset Division].

GA-CA-1082                         3E2
<PAGE>

                                  THE SCHEDULE

                               INCOME PLAN FACTORS
   ----------------------------------------------------------------------------
    Annuitant              Owner
    [THOMAS J. DOE]        [JOHN Q. DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
   ----------------------------------------------------------------------------
    Separate Account(s)                             Certificate Number
    [SEPARATE ACCOUNT B AND FIXED ACCOUNT]          [123456]
   ----------------------------------------------------------------------------

Values for other payment periods, ages or joint life combinations are available
on request. Monthly payments are shown for each $1,000 applied.

                       TABLE FOR INCOME FOR A FIXED PERIOD

  Fixed Period    Monthly    Fixed Period    Monthly    Fixed Period    Monthly
      of Years     Income        of Years     Income        of Years     Income

        [5           17.95          14         7.28            23          5.00
         6           15.18          15         6.89            24          4.85
         7           13.20          16         6.54            25          4.72
         8           11.71          17         6.24            26          4.60
         9           10.56          18         5.98            27          4.49
        10            9.64          19         5.74            28          4.38
        11            8.88          20         5.53            29          4.28
        12            8.26          21         5.33            30         4.19]
        13            7.73          22         5.16

                            TABLE FOR INCOME FOR LIFE

            Male/Female           Male/Female           Male/Female
Age         10 Years Certain      20 Years Certain        Refund Certain

[50         $4.06/3.83            $3.96/3.77            $3.93/3.75
55           4.43/4.14             4.25/4.05             4.25/4.03
60           4.90/4.56             4.57/4.37             4.66/4.40
65           5.51/5.10             4.90/4.73             5.12/4.83
70           6.26/5.81             5.18/5.07             5.76/5.42
75           7.11/6.70             5.38/5.33             6.58/6.19
80           7.99/7.70             5.48/5.46             7.69/7.21
85           8.72/8.59             5.52/5.51             8.72/8.59
90           9.23/9.18             5.53/5.53           10.63/10.53]

GA-CA-1082                         3F
<PAGE>

                               THE SCHEDULE (BASE)

                                CERTIFICATE FACTS
   ----------------------------------------------------------------------------
    Annuitant              Owner
    [THOMAS J. DOE]        [JOHN Q. DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
   ----------------------------------------------------------------------------
    Separate Account(s)                             Certificate Number
    [SEPARATE ACCOUNT B AND FIXED ACCOUNT]          [123456]
   ----------------------------------------------------------------------------

CERTIFICATE FACTS

     Certificate Processing Date

     The Certificate Processing Date for your Certificate is [April 1] of each
     year.

     Specially Designated Division

     When a distribution is made from an investment portfolio underlying a
     Separate Account Division in which reinvestment is not available, we will
     allocate the amount of the distribution to the [Liquid Asset Division]
     unless you specify otherwise.

PARTIAL WITHDRAWALS

     The maximum amount that can be withdrawn each Certificate Year without
     being considered an Excess Partial Withdrawal is described below. We will
     collect a Surrender Charge for Excess Partial Withdrawals and a charge for
     any unrecovered Premium Taxes. In no event may a Partial Withdrawal be
     greater than 90% of the Cash Surrender Value. After a Partial Withdrawal,
     the remaining Accumulation Value must be at least $100 to keep the
     Certificate in force.

     Systematic Partial Withdrawals and Conventional Partial Withdrawals may not
     be taken in the same Certificate Year.

     To determine the Surrender Charge on Excess Partial Withdrawals, the
     withdrawals will occur in the following order:

          (1)  Earnings;

          (2)  The Free Amount;

          (3)  Premium Payments made [four] or more years prior to the
               withdrawal; and

          (4)  Premium Payments made less than [four] years prior to withdrawal.

     Earnings and Free Amounts are not treated as withdrawals of Premium
     Payments for purposes of calculating any Surrender Charge.

     Conventional Partial Withdrawals
     Minimum Withdrawal Amount: $100.

     The maximum amount that can be taken as a Conventional Partial Withdrawal
     each Certificate Year without being considered an Excess Partial Withdrawal
     is the greater of:

          (1)  Earnings (defined below) not previously withdrawn, but not less
               than zero; and

          (2)  The Free Amount, equal to 10% of Premium Payments not previously
               withdrawn, which were received within [four] years prior to the
               date of withdrawal.

     Earnings are equal to the Accumulation Value, less Premium Payments, plus
     prior withdrawals.

     Any Conventional Partial Withdrawal is subject to a Market Value Adjustment
     unless withdrawn from a Fixed Allocation within 30 days prior to the
     Maturity Date.

GA-CA-1082                         3D1
<PAGE>

                                  THE SCHEDULE

                          CERTIFICATE FACTS (continued)
   ----------------------------------------------------------------------------
    Annuitant              Owner
    [THOMAS J. DOE]        [JOHN Q. DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
   ----------------------------------------------------------------------------
    Separate Account(s)                             Certificate Number
    [SEPARATE ACCOUNT B AND FIXED ACCOUNT]          [123456]
   ----------------------------------------------------------------------------

Systematic Partial Withdrawals

     Systematic Partial Withdrawals may be elected to commence after 28 days
     from the Certificate Issue Date and may be taken on a monthly, quarterly or
     annual basis. You select the day withdrawals will be made, but no later
     than the 28th day of the month. If you do not elect a day, the Certificate
     Date will be used.

     Maximum Withdrawal Amounts:

     Variable Separate Account Divisions:   .833% of Premium Payments monthly,
                                            2.5% of Premium Payments quarterly
                                            or 10% of Premium Payments annually.

     Fixed Allocations and
     Guaranteed Interest Divisions:         Interest earned on a Fixed
                                            Allocation or Guaranteed Interest
                                            Division for the prior month,
                                            quarter or year (depending on the
                                            frequency selected).

     The Maximum Withdrawal Amount available as a Systematic Partial Withdrawal
     is 10% of Premium Payments not previously withdrawn. Systematic Partial
     Withdrawals from Fixed Allocations are not subject to a Market Value
     Adjustment. A Systematic Partial Withdrawal in excess of Earnings and the
     Free Amount may be subject to a Surrender Charge.

     IRA Partial Withdrawals for Qualified Plans Only

     Partial Withdrawals may be taken from a Certificate issued as an IRA on a
     monthly, quarterly or annual basis. A minimum withdrawal of $100.00 is
     required. You select the day the withdrawals will be made, but no later
     than the 28th day of the month. If you do not elect a day, the Certificate
     Date will be used. Systematic Partial Withdrawals and Conventional Partial
     Withdrawals are not allowed when IRA Partial Withdrawals are being taken.
     An IRA Partial Withdrawal in excess of the maximum amount allowed under the
     Systematic Partial Withdrawal option may be subject to a Market Value
     Adjustment.

DEATH BENEFIT

     The Death Benefit is the greatest of (i) and (ii) below, where:

          (i)  is the Accumulation Value; and

          (ii) is the Cash Surrender Value.

GA-CA-1082                         3D2
<PAGE>

                                  THE SCHEDULE

                          CERTIFICATE FACTS (continued)
   ----------------------------------------------------------------------------
    Annuitant              Owner
    [THOMAS J. DOE]        [JOHN Q. DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
   ----------------------------------------------------------------------------
    Separate Account(s)                             Certificate Number
    [SEPARATE ACCOUNT B AND FIXED ACCOUNT]          [123456]
   ----------------------------------------------------------------------------

SPOUSAL CONTINUATION UPON DEATH OF OWNER

     If at the Owner's death, the surviving spouse of the deceased Owner is the
     Beneficiary and such surviving spouse elects to continue the Certificate as
     their own pursuant to Internal Revenue Code Section 72(s) or the equivalent
     provisions of U.S. Treasury Department rules for qualified plans, on any
     subsequent surrender, Surrender Charges applicable to premiums paid prior
     to the date we receive due proof of death of the Owner will be waived. Any
     premiums paid later will be subject to any applicable Surrender Charge.

CHOOSING AN INCOME PLAN

     Required Date of Annuity Commencement

     Distributions from a Certificate funding a qualified plan must commence no
     later than April 1st of the calendar year following the calendar year in
     which the Owner attains age 70 1/2. Otherwise, the Annuity Commencement
     Date may be no later than the same date as the Certificate Processing Date
     in the month following the Annuitant's 90th birthday. In applying the
     Accumulation Value, we may first collect any Premium Taxes due us. If, on
     the Annuity Commencement Date, a Surrender Charge remains, your elected
     Annuity Option must include a period certain of at least five years
     duration.

     Minimum Annuity Income Payment

     The minimum monthly annuity income payment that we will make is [$20].

GA-CA-1082                         3D3
<PAGE>

                                  THE SCHEDULE

                          CERTIFICATE FACTS (continued)
   ----------------------------------------------------------------------------
    Annuitant              Owner
    [THOMAS J. DOE]        [JOHN Q. DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
   ----------------------------------------------------------------------------
    Separate Account(s)                             Certificate Number
    [SEPARATE ACCOUNT B AND FIXED ACCOUNT]          [123456]
   ----------------------------------------------------------------------------

OPTIONAL BENEFIT RIDERS - [None]

ATTAINED AGE

     The Issue Age of the Annuitant or Owner plus the number of full years
     elapsed since the Certificate Date.

RESTRICTED FUNDS - [None]

FIXED ACCOUNT

     Minimum Fixed Allocation

     The minimum allocation to the Fixed Account in any one Fixed Allocation is
     [$250.00].

     Minimum Guaranteed Interest Rate - [3%].

     Guarantee Periods

     We currently offer Guarantee Periods of [1, 3, 5, 7 and 10] year(s). We
     reserve the right to offer Guarantee Periods of durations other than those
     available on the Certificate Date. We also reserve the right to cease
     offering a particular Guarantee Period or Periods.

     Index Rate

     The Index Rate is the average of the Ask Yields for the U.S. Treasury
     Strips as reported by a national quoting service for the applicable
     maturity. The average is based on the period from the 22nd day of the
     calendar month two months prior to the calendar month of Index Rate
     determination to the 21st day of the calendar month immediately prior to
     the month of determination. The applicable maturity date for these U.S.
     Treasury Strips is on or next following the last day of the Guarantee
     Period. If the Ask Yields are no longer available, the Index Rate will be
     determined using a suitable replacement method.

     We currently set the Index Rate once each calendar month. However, we
     reserve the right to set the Index Rate more frequently than monthly, but
     in no event will such Index Rate be based on a period less than 28 days.

GA-CA-1082                         3D4
<PAGE>

                                  THE SCHEDULE

                                CHARGES AND FEES
   ----------------------------------------------------------------------------
    Annuitant              Owner
    [THOMAS J. DOE]        [JOHN Q. DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
   ----------------------------------------------------------------------------
    Separate Account(s)                             Certificate Number
    [SEPARATE ACCOUNT B AND FIXED ACCOUNT]          [123456]
   ----------------------------------------------------------------------------

DEDUCTIONS FROM PREMIUMS

     None

DEDUCTIONS FROM ACCUMULATION VALUE

     Initial Administrative Charge

     None

     Administrative Charge

     We charge a maximum of $30 to cover a portion of our ongoing administrative
     expenses for each Certificate Processing Period. The charge is incurred at
     the beginning of the Certificate Processing Period and deducted on the
     Certificate Processing Date at the end of the period.

     At the time of deduction, this charge will be waived if:

          (1)  The Accumulation Value is at least $100,000; or

          (2)  The sum of premiums paid to date is at least $100,000

     Excess Allocation Charge

     Currently none, however, we reserve the right to charge $25 for a change if
     you make more than twelve allocation changes per Certificate Year. Any
     charge will be deducted in proportion to the amount being transferred from
     each Division.

     Surrender Charge

     A Surrender Charge is imposed as a percentage of unliquidated premium if
     the Certificate is surrendered or an Excess Partial Withdrawal is taken.
     The percentage imposed at time of surrender or Excess Partial Withdrawal
     depends on the number of complete years that have elapsed since a Premium
     Payment was made. The Surrender Charge expressed as a percentage of each
     Premium Payment is as follows:

       Complete Years Elapsed                     Surrender
       Since Premium Payment                       Charges
       ----------------------                     ---------
                 [0                                  6%
                  1                                  5%
                  2                                  4%
                  3                                  3%
                 4+                                  0%]

     Surrender of the Certificate is permitted at or before the commencement of
     Annuity Payments.

GA-CA-1082                         3E1
<PAGE>

                                  THE SCHEDULE

                          CHARGES AND FEES (continued)
   ----------------------------------------------------------------------------
    Annuitant              Owner
    [THOMAS J. DOE]        [JOHN Q. DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
   ----------------------------------------------------------------------------
    Separate Account(s)                             Certificate Number
    [SEPARATE ACCOUNT B AND FIXED ACCOUNT]          [123456]
   ----------------------------------------------------------------------------

     Premium Taxes

     We deduct the amount of any premium or other state and local taxes levied
     by any state or governmental entity when such taxes are incurred.

     We reserve the right to defer collection of Premium Taxes until surrender
     or until application of Accumulation Value to an Annuity Option. An Excess
     Partial Withdrawal will result in the deduction of any Premium Tax then due
     us on such amount. We reserve the right to change the amount we charge for
     Premium Tax charges on future Premium Payments to conform with changes in
     the law or if the Owner changes state of residence.

     Deductions from the Divisions

     Mortality and Expense Risk Charge - We deduct a charge from the assets in
     ---------------------------------
     each Variable Separate Account Division on a daily basis of not more than
     [0.004280]% (equivalent to an annual maximum rate of [1.55]%) for mortality
     and expense risks. The charge is not deducted from the Fixed Account or
     General Account Accumulation Values.

     Asset Based Administrative Charge - We deduct a charge of not more than
     ---------------------------------
     [0.000411]% of the assets in each Variable Separate Account Division on a
     daily basis (equivalent to an annual maximum rate of [0.15]%) to compensate
     us for a portion of our ongoing administrative expenses. This charge is not
     deducted from the Fixed Account or General Account Accumulation Values.

CHARGE DEDUCTION DIVISION

     If elected by you, all charges against the Accumulation Value in this
     Certificate will be deducted from the [Liquid Asset Division].

GA-CA-1082                         3E2
<PAGE>

                                  THE SCHEDULE

                               INCOME PLAN FACTORS
   ----------------------------------------------------------------------------
    Annuitant              Owner
    [THOMAS J. DOE]        [JOHN Q. DOE]
   ----------------------------------------------------------------------------
    Initial Premium        Annuity Option           Annuity Commencement Date
    [$10,000]              [LIFE 10-YEAR CERTAIN]   [JANUARY 1, 2026]
   ----------------------------------------------------------------------------
    Separate Account(s)                             Certificate Number
    [SEPARATE ACCOUNT B AND FIXED ACCOUNT]          [123456]
   ----------------------------------------------------------------------------

Values for other payment periods, ages or joint life combinations are available
on request. Monthly payments are shown for each $1,000 applied.

                       TABLE FOR INCOME FOR A FIXED PERIOD

  Fixed Period    Monthly   Fixed Period    Monthly   Fixed Period    Monthly
      of Years     Income       of Years     Income       of Years     Income

        [5           17.95         14         7.28           23          5.00
         6           15.18         15         6.89           24          4.85
         7           13.20         16         6.54           25          4.72
         8           11.71         17         6.24           26          4.60
         9           10.56         18         5.98           27          4.49
        10            9.64         19         5.74           28          4.38
        11            8.88         20         5.53           29          4.28
        12            8.26         21         5.33           30         4.19]
        13            7.73         22         5.16

                            TABLE FOR INCOME FOR LIFE

                 Male/Female          Male/Female           Male/Female
        Age      10 Years Certain     20 Years Certain        Refund Certain

        [50      $4.06/3.83           $3.96/3.77            $3.93/3.75
        55        4.43/4.14            4.25/4.05             4.25/4.03
        60        4.90/4.56            4.57/4.37             4.66/4.40
        65        5.51/5.10            4.90/4.73             5.12/4.83
        70        6.26/5.81            5.18/5.07             5.76/5.42
        75        7.11/6.70            5.38/5.33             6.58/6.19
        80        7.99/7.70            5.48/5.46             7.69/7.21
        85        8.72/8.59            5.52/5.51             8.72/8.59
        90        9.23/9.18            5.53/5.53           10.63/10.53]

Source: [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00024-of-00352.parquet"}, [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00024-of-00352.parquet"}]]