Document:

EX-10.1

 Exhibit 10.1 
  

 
 October 28, 2014             

PROMOTION LETTER 

Cassandra Hudson 
 Dear Cassandra: 

It is our pleasure to offer you a promotion! This Promotion Letter serves to confirm the details of your promotion as follows: 

 

			
	Position:	  	Chief Accounting Officer; Vice President of Finance; Assistant Treasurer
		
	Status:	  	Full-time, Regular, Exempt
		
	Reporting to:	  	Chief Financial Officer
		
	Effective Date:	  	October 28, 2014
		
	Compensation:	  	 Base salary of $200,000 annually, which is the equivalent of $8,333.34 semi-monthly, paid in accordance with the
Company’s normal payroll procedures.
  
 All forms of compensation which are referred
to in this promotion letter are subject to reduction to reflect applicable withholding, payroll and other required taxes and deductions. Please note that Carbonite may modify salaries and benefits from time to time as it deems
necessary.

		
	Bonus:	  	You will be eligible for an incentive bonus of 30% of your base salary. The timing and amount of any bonus is subject to the discretion and approval of the Compensation Committee of the Board of Directors.
		
	Stock Options:	  	Options on 25,000 shares of Carbonite common stock vesting in equal quarterly installments commencing upon the date of the grant. The option exercise price will be equal to the fair market value of Carbonite’s common stock
as of the date of grant, as determined by our Board of Directors. All option grants described in this Section are subject to approval by Carbonite’s Board of Directors and the specific terms of the options will be governed by Carbonite’s
stock incentive plan and a separate option agreement to be signed by you and Carbonite.
		
	Acceleration of Options:	  	If during the first twelve months after a Change of Control (as defined in the 2011 Equity Award Plan) you are terminated without cause or if you voluntarily resign from Carbonite due to “Constructive Termination” (as
defined in your existing option agreements), then all of your then-unvested options shall vest immediately prior to the termination date.
		
	Severance:	  	If you are terminated without Cause (as defined below) or are Constructively Terminated (as defined in your existing option or restricted stock unit agreements), you will be entitled to receive a payment amount equal to (i) three
times your then current monthly base salary and (ii) three times the monthly amount that the Company paid for your participation in the Company’s health insurance plan during the month immediately preceding your termination date, subject to any
and all additional conditions and qualifications contained in this letter.

  
 1 

			
		  	 In addition to the provision of three months’ severance benefits, your severance benefits shall be increased so that if you are
terminated without Cause or are Constructively Terminated, in each case within one year after the consummation of a Change of Control of the Company (as defined in the 2011 Equity Award Plan), you will be entitled to receive an additional payment
amount equal to (i) three times your then current monthly base salary and (ii) three times the monthly amount that the Company paid for your participation in the Company’s health insurance plan during the month immediately preceding your
termination date, subject to any and all additional conditions and qualifications contained in this letter.
  

“Cause” shall mean (1) willful misconduct in connection with your employment or willful failure to perform your responsibilities in the best
interests of the Company, as determined by the Company; (2) conviction of, or plea of nolo contendre or guilty to, a felony under the laws of the United States or any State; (3) any act of fraud, theft, embezzlement or other material dishonesty by
you which harmed the Company; (4) intentional violation of a federal or state law or regulation applicable to the Company’s business which violation was or is reasonably likely to be injurious to the Company, or (5) repeated failure to perform
your duties and obligations of your position with the Company which failure is not cured within 30 days after notice of such failure from the Company to you.
  

The foregoing amounts shall be made in accordance with the Company’s normal payroll practices; provided, however, that the Company shall not make any
severance payments unless and until (x) you execute and deliver to the Company a general release in substantially the form of Exhibit A attached hereto (the “Release”), (y) such Release is executed and delivered to the Company
within twenty-one (21) days after your termination date and (z) all time periods for revoking the Release have lapsed. If you are terminated during the month of December of any calendar year and are owed severance hereunder, no severance payments
shall be made prior to January 1st of the next calendar year and any amount that would have otherwise been payable to you in December of the preceding calendar year will be paid to you on the
first date in January on which you would otherwise be entitled to any payment.
  

Following your termination date, all benefits offered by the Company, including health insurance benefits, shall cease. From and after such date, you may elect
to continue your participation in the Company’s health insurance benefits at your expense pursuant to COBRA by notifying the Company in the time specified in the COBRA notice you will be provided and paying the monthly premium yourself.
Notwithstanding the above, if you are a “specified employee” within the meaning of Section 409A of the Internal Revenue Code of 1986, as amended (the “Code”), then any amounts payable to you during the first six months and one
day following the date of your termination that constitute nonqualified deferred compensation within the meaning of Section 409A of the Code (as determined by the Company in its sole discretion) shall not be paid to you until the date that is six
months and one day following such termination to the extent necessary to avoid adverse tax consequences under Section 409A of the Code.

		
	At-Will Employment:	  	Your employment with Carbonite is for no specified period of time and constitutes “at-will” employment. As a result, you are free to resign at any time, for any reason or for no reason, with or without notice.
Similarly, Carbonite is free to conclude its employment relationship with you at any time, with or without cause, and with or without notice.

  
 2 

			
	Other Agreements:	  	As a condition of your promotion, you continue to remain obligated under the Company’s Confidentiality, Invention Assignment and Non-Competition Agreement dated February 22, 2008.
		
	 Expiration
 and
Modification
	  	This Promotion Letter may not be modified or amended except by a written agreement, signed by the Chief Executive Officer or Chief Financial Officer of Carbonite and by you. This offer will expire at 5pm, EST on October 29,
2014.

  

	
	Sincerely,
	
	 /s/ Anthony Folger

	 Anthony Folger
 CFO

  
  

ACCEPTANCE AND ACKNOWLEDGMENT 

I accept the promotion offer from Carbonite as set forth in the Promotion Letter dated October 28, 2014. I understand and acknowledge
that my employment with Carbonite is at-will, for no particular term or duration and that I, or Carbonite, may terminate the employment relationship at any time, with or without cause and with or without prior notice. I acknowledge that the Company
reserves the right to conduct background investigations and/or reference checks on all of its potential employees, and that my job offer, therefore, is contingent upon a clearance of such a background investigation and/or reference check, if any.

 I understand that the terms and conditions described in this Promotion Letter, along with the Carbonite Confidentiality, Invention
Assignment and Non-Competition Agreement are the terms and conditions of my employment. No one other than Carbonite’s Chief Executive Officer or Chief Financial Officer is authorized to sign any employment or other agreement which modifies the
terms of the Promotion Letter and Carbonite’s Carbonite Confidentiality, Invention Assignment and Non-Competition Agreement, and any such modification must be in writing and signed by either such executive. 

 

			
	Signature:	 	 /s/ Cassandra Hudson

	Name:	 	Cassandra Hudson
	Date:	 	October 28, 2014

  
 3 

 Exhibit A 

Release 

  
 4exv4wa

EXHIBIT (4)(a)

American General Life Insurance Company

A STOCK COMPANY

	 	 	 

	CONTRACT NUMBER

	 	[P9999999999]
	 
	 	 
	OWNER

	 	[JOHN DOE]

	 	 	 

	[STATUTORY HOME OFFICE
	 	[ANNUITY SERVICE CENTER
	2727-A ALLEN PARKWAY
	 	P. O. BOX 15570
	HOUSTON, TX 77019]
	 	AMARILLO, TX 79105-5570]

THIS IS A LEGAL DOCUMENT. READ IT CAREFULLY.

AMERICAN GENERAL LIFE INSURANCE COMPANY agrees to provide benefits to the Owner in accordance with
the provisions set forth in this Contract and in consideration of the Application and Purchase
Payments We receive.

The value of amounts allocated to the Separate Account during the accumulation and annuity income
periods is not guaranteed, and will increase or decrease based upon the investment experience of
the Variable Portfolios You choose.

The Fixed Account Options, Dollar Cost Averaging (DCA) Fixed Account Option(s) or one or more fixed
account Guarantee Periods may not be available on the Contract Date. Please check with Your
registered representative for availability of these options.

This Contract may include one or more endorsement(s) or rider(s) as part of the Entire Contract
containing definitions and additional terms affecting how this Contract may work. You should
carefully read the Entire Contract.

RIGHT TO EXAMINE CONTRACT – You may return this Contract within [ten (10)]* days after You receive
it if you are not satisfied with it for any reason. This Contract may be returned to Us at Our
Annuity Service Center or to the agent through whom it was purchased. The Company will void the
Contract and process the refund of the Contract Value on the Business Day during which the notice
of cancellation is received.

*If this Contract replaces any existing Contract, the number of days is [thirty (30)] days.

F-001 (9/13)

If a refund of the Purchase Payment(s) is required, We reserve the right to allocate Your
Purchase Payment(s) to the [Cash Management Portfolio] until the end of the Right To Examine
period.

Signed at the Home Office on the Contract Date.

	 	 	 

	
	 	

For Inquiries Call: [1-800-445-7862]

[www.aig.com/annuities]

FLEXIBLE PAYMENT FIXED AND VARIABLE DEFERRED ANNUITY CONTRACT

Nonparticipating

	 	 	 	 	 

	AG-803 (7/13)
	 	1
	 	 

 

 

TABLE OF CONTENTS

 

	 	 	 	 	 

	Contract Data Page
	 	Pages 3-4
	 
	 	 	 	 
	Definitions
	 	Page 5
	 
	 	 	 	 
	Purchase Payment Provisions
	 	Page 8
	 
	 	 	 	 
	Accumulation Provisions
	 	Page 8
	 
	 	 	 	 
	Charges and Deductions
	 	Page 10
	 
	 	 	 	 
	Transfer Provisions
	 	Page 10
	 
	 	 	 	 
	Withdrawal Provisions
	 	Page 11
	 
	 	 	 	 
	Death Benefit Provisions
	 	Page 12
	 
	 	 	 	 
	Annuity Provisions
	 	Page 13
	 
	 	 	 	 
	General Provisions
	 	Page 15
	 
	 	 	 	 
	Annuity Income Payment Options
	 	Page 18
	 
	 	 	 	 
	Fixed Annuity Income Payment Options Table
	 	Page 19
	 
	 	 	 	 
	Variable Annuity Income Payment Options Table
	 	Page 22

	 	 	 	 	 

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CONTRACT DATA PAGE

Contract Number:  [P9999999999]     Contract Date: [May 2, 2014]

	 	 	 	 	 

	Owner: [JOHN DOE]

	 	[Date of Birth: [March 1, 1976]
	 	Age at Issue: [38]]
	 
	 	 	 	 
	[Owner: [JANE DOE]

	 	Date of Birth: [June 10, 1976]
	 	Age at Issue: [37]]
	 
	 	 	 	 
	Annuitant: [JOHN DOE]

	 	Date of Birth: [March 1, 1976]
	 	Age at Issue: [38]
	 
	 	 	 	 
	[Annuitant: [JANE DOE]

	 	Date of Birth: [June 10, 1976]
	 	Age at Issue: [37]]

Beneficiary: As named by You

Initial Purchase Payment: [$25,000.00]

Maximum Purchase Payment Without Our Approval: [$1,000,000]

Purchase Payment Age Limit: [Prior to the 86th birthday]

Minimum Subsequent Purchase Payment: [$500]

Fixed Account Option(s) Minimum Guaranteed Interest Rate: [1.0% - 3.0%]

Minimum Partial Withdrawal Amount: [$1,000]

Maximum Penalty-Free Withdrawal Percentage: [10%]

Minimum Systematic Withdrawal Amount: [$100]

Minimum Amount Remaining After Any Partial Withdrawal: [$2,500]

Withdrawal Charge Schedule:

See Page [11] for Withdrawal Provisions.

	 	 	 	 	 

	AG-803-P5 (7/13)
	 	3
	 	IOVA

 

CONTRACT DATA PAGE (Cont’d.)

[Premium Tax: None]

Minimum Transfer Amount: [$100]

Separate Account Charge [(including guaranteed death benefit risk charge of [0.10%])]: [1.10%]

Annual Contract Maintenance Fee: [$50]

Transfer Fee: [$25]

Earliest Annuity Date After the Contract Date: [Two years]

Latest Annuity Date: [1st day of the month following Your 95th Birthday]

Separate Account: [Variable Separate Account]

	 	 	 

	
	 	

	 	 	 	 	 

	AG-803-P5 (7/13)
	 	4
	 	IOVA

 

DEFINITIONS

Defined in this section are some of the words and phrases used in this Contract. These terms are
capitalized when used in the Contract with the meaning set forth below.

ACCUMULATION UNIT

An Accumulation Unit is a unit of measure used to compute the Contract Value in a Variable
Portfolio before the Annuity Date.

AGE

The Age of a person is the attained age as of a person’s last birthday. Unless otherwise defined
in an endorsement or rider to this Contract, in the case of Joint Owners/Annuitants, the age of the
[older] person will be used to determine any age-driven benefit.

ANNUITANT

The Annuitant is the natural person(s) (collectively, “Joint Annuitants”) whose life/lives are used
to determine the Annuity Income Payments under the Contract. If the Contract is in force and the
Annuitant is alive on the date Annuity Income Payments begin, We will begin Annuity Income Payments
to the [Payee]. This Contract cannot have Joint Annuitants if it is issued in connection with a
tax-qualified retirement plan.

ANNUITIZATION

Annuitization is a series of periodic Annuity Income Payments. If You select Variable
Annuitization, these periodic Annuity Income Payments vary in amount according to investment
experience of one or more Variable Portfolios, as selected by You and such payments are made from
the Company’s Separate Account. If You select Fixed Annuitization, these periodic Annuity Income
Payments do not vary with investment experience and such payments are made from the Company’s
general asset account.

ANNUITY DATE

The Annuity Date is the date on which Annuity Income Payments to the Payee begin. This date cannot
be later than the Latest Annuity Date.

ANNUITY SERVICE CENTER

The Annuity Service Center is the address shown on Page 1 of this Contract where all Purchase
Payments and requests regarding this Contract are to be sent.

ANNUITY UNIT

An Annuity Unit is a unit of measure determined on or after the Annuity Date and is used to compute
Annuity Income Payments from the Variable Portfolio(s) if Variable Annuitization is selected.

BENEFICIARY

The Beneficiary is selected by You in Writing and will receive the Death Benefit under this
Contract upon Your death.

BUSINESS DAY

Business Day is any day that We are open and the [New York Stock Exchange (“NYSE”)] is open for
trading and generally ends at 4:00 p.m. Eastern Time. The Business Day is the day in which all
financial transactions and requests are deemed to occur when received by Us.

CONTINUATION DATE

The Continuation Date is the date on which We receive, at Our Annuity Service Center: (a) the
Spousal Beneficiary’s Written request to continue the Contract in a form satisfactory to Us; and
(b) Due Proof of Death of the Owner. If We receive (a) and (b) on different dates, the
Continuation Date will be the later date.

	 	 	 	 	 

	AG-803 (7/13)
	 	5
	 	 

 

 

CONTRACT ANNIVERSARY

The date that occurs on the same month and date as the Contract Date for each Contract Year. The
first Contract Anniversary is one (1) year after the Contract Date on the same month and date of
the following Contract Year.

CONTRACT DATE

The Contract Date is the date Your Contract is issued, as shown on the Contract Data Page. It is
the date from which Contract Years and Contract Anniversaries are measured.

CONTRACT VALUE

The Contract Value is the sum of: (1) Your share of the Variable Portfolios’ Accumulation Unit
Values; and (2) the value of amounts if any, allocated to any available Fixed Account Option(s).

CONTRACT YEAR

The one (1) year period starting from the Contract Date in one (1) calendar year and ending on the
date preceding the Contract Anniversary in the following calendar year, and every year thereafter.

DOLLAR COST AVERAGING (DCA)

Dollar Cost Averaging is an optional program under which You authorize the systematic transfer of
specified amounts or percentages from any Variable Portfolio(s) [or any available Fixed Account
Option] into any Variable Portfolio(s) other than the source account.

FIXED ACCOUNT OPTION(S)

The Fixed Account Option(s) are investment options, if available under this Contract, that become
part of the Company’s general asset account and are credited with a fixed rate of interest declared
by the Company. The amount You have in any Fixed Account Option at a given time is a result of
Purchase Payment(s) You have allocated to it or any part of Your Contract Value You have
transferred to it.

GUARANTEE PERIOD

The Guarantee Period is the period for which interest is credited to amounts allocated to any
available Fixed Account Option(s). We determine in Our sole discretion the periods, if any, that
will be offered.

IRC

IRC refers to the Internal Revenue Code of 1986, as amended, or as it may be amended or superseded.

JOINT OWNER

A Joint Owner is any person named as Joint Owner on the Application for a non-qualified contract
and listed on the Contract Data Page, unless subsequently changed. The Joint Owner, if any,
possesses an undivided interest in this Contract in conjunction with the Owner. All references
within this Contract to Owner will also apply to the Joint Owner.

LATEST ANNUITY DATE

The Latest Annuity Date is the [first day of the month following Your] [95th Birthday]
of the Owner, shown on the Contract Data Page. If the Contract is owned by Joint Owners, the
Latest Annuity Date is based on the older Owner’s date of birth. If the Owner is a non-natural
person, the Latest Annuity Date is the [first day of the month following the] [95th
Birthday] of the Annuitant. If the Contract is owned by a non-natural person and has Joint
Annuitants, the Latest Annuity Date is based on the older Annuitant’s date of birth. The Latest
Annuity Date is the date upon which Annuity Income Payments must begin or the Contract must be
surrendered.

OWNER

The Owner is the natural person or entity named in the Contract who is entitled to exercise all
rights and privileges of ownership under the Contract. Owner means both Joint Owners, if
applicable. If there are Joint Owners, the authorizations of both Joint Owners are required In
Writing for all Contract changes and the exercise of any other rights of ownership.

	 	 	 	 	 

	AG-803 (7/13)
	 	6
	 	 

 

 

PAYEE

The Payee is the person receiving Annuity Income Payments under this Contract.

PURCHASE PAYMENT(S)

Purchase Payment(s) are payment(s) in [U.S.] currency made by or on behalf of the Owner to the
Company to purchase the Contract.

REQUIRED DOCUMENTATION

Required Documentation must be received by Us at Our Annuity Service Center and is: (a) Due Proof
of Death of the Owner [before the Annuity Date]; (b) an election form specifying the Annuity Income
Payment options; and (c) any other documentation We may require.

SEPARATE ACCOUNT

The Separate Account is a segregated asset account shown on the Contract Data Page. The Separate
Account consists of Variable Portfolios, each investing in shares of the Underlying Fund(s). The
assets of the Separate Account are not commingled with the general assets and liabilities of the
Company. The value of amounts allocated to the Variable Portfolios of the Separate Account is not
guaranteed.

SPOUSAL BENEFICIARY

The Spousal Beneficiary is the surviving spouse of the original deceased Owner. The Spousal
Beneficiary is designated as the primary Beneficiary at the time of the Owner’s death and may
continue the Contract as the Owner on the Continuation Date.

SUBSEQUENT PURCHASE PAYMENTS

Subsequent Purchase Payments are Purchase Payments made after the initial Purchase Payment.

UNDERLYING FUND

The Underlying Fund is the underlying investment portfolios in which the Variable Portfolio(s)
invest.

VARIABLE PORTFOLIO

A Variable Portfolio is one or more divisions of the Separate Account which provides for the
variable investment options available under this Contract. Each Variable Portfolio has its own
investment objective and is invested in the Underlying Fund(s). A Variable Portfolio is not
chargeable with liabilities arising out of any other Variable Portfolio.

WE, OUR, US, THE COMPANY

We, Our, Us, The Company refers to the American General Life Insurance Company.

WITHDRAWAL(S)

Withdrawals are any amount(s) withdrawn by the Owner from the Contract Value, including any charges
that include but are not limited to Withdrawal Charges, applicable to each such Withdrawal.

WRITTEN, IN WRITING

Written or In Writing refers to a written request or notice in acceptable form and content to Us,
which is signed and
 dated and is received at Our Annuity Service Center.

YOU, YOUR

You, Your refers to the [Owner].

	 	 	 	 	 

	AG-803 (7/13)
	 	7
	 	 

 

 

PURCHASE PAYMENT PROVISIONS

PURCHASE PAYMENTS

Purchase Payments are flexible. This means that, subject to Company disclosed restrictions, You
may change the amounts, frequency and/or timing of Purchase Payments. Purchase Payments can be
made at any time after the Contract Date, but must be received at Our Annuity Service Center before
the Purchase Payment Age Limit, as shown on the Contract Data Page. With instructions from You,
Purchase Payments will be allocated to the Variable Portfolio(s) and/or Fixed Account Option(s), if
available. We reserve the right, upon advance notice to You, to: 1) limit the maximum amount of
Purchase Payments; and 2) discontinue acceptance of any subsequent Purchase Payment(s).

DOLLAR COST AVERAGING (DCA) FIXED ACCOUNT OPTION(S)

Any portion of a Purchase Payment allocated to a DCA Fixed Account Option(s), if available, must be
transferred out to the Variable Portfolio(s) within the specified DCA Fixed Account Option period.
Upon termination of the DCA program, any amounts remaining in the DCA Fixed Account Option(s) will
be transferred to the DCA target allocation(s) for the program being terminated. We reserve the
right to impose a minimum or maximum contribution level on Purchase Payments allocated to a DCA
Fixed Account Option(s) and/or change the terms and conditions of the DCA program at any time. We
reserve the right to cease offering DCA Fixed Account Option(s).

CHANGES TO VARIABLE PORTFOLIO OFFERINGS

If the shares of an Underlying Fund should no longer be available for investment by the Separate
Account, then We may substitute shares of another Underlying Fund, for shares already purchased, or
to be purchased in the future. At any given time, some Variable Portfolios may not be available
for receipt of Purchase Payment(s) or transfer(s). Substitutions may be necessary and will be
carried out in accordance with any applicable state and/or federal laws or regulations.

MINIMUM CONTRACT VALUE

If Your Contract Value falls below the Minimum Amount Remaining After Any Partial Withdrawal, as
shown on the Contract Data Page, as a result of taking partial Withdrawals, subject to applicable
state and federal laws, rules and regulations, We may treat Your partial Withdrawal request as a
request for a total Withdrawal and terminate Your Contract.

ACCUMULATION PROVISIONS

Your Contract provides for an accumulation phase and an income phase. During the accumulation
phase, Your Purchase Payment(s) received prior to the Annuity Date are allocated among any
available Fixed Account Options(s) and/or one or more of the Variable Portfolio(s) in Your
Contract. During the income phase, payments under an Annuity Payment Option selected by You are
made to You or Your designated Payee.

SEPARATE ACCOUNT ACCUMULATION VALUE

The Separate Account Accumulation Value under the Contract is the sum of the Accumulation Unit
Values held in the Variable Portfolios for You.

NUMBER OF ACCUMULATION UNITS

Your Contract is credited with Accumulation Units of the Separate Account when amounts are
allocated to the Variable Portfolio(s). For that portion of each Purchase Payment and/or transfer
amount allocated to a Variable Portfolio, the number of Accumulation Units credited is equal to:

The sum of each Purchase Payment and/or transfer amount allocated to the Variable Portfolio
reduced by any applicable premium taxes:

Divided by

	 	 	 	 	 

	AG-803 (7/13)
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	 	 	The Accumulation Unit Value for that Variable Portfolio for the Business Day in which the
Purchase Payment or transfer amount is allocated to the Variable
Portfolio.

The number of Accumulation Units will be reduced for Withdrawals, Annuitization, amounts
transferred out of a Variable Portfolio, the Contract Maintenance Fee, if applicable, and
applicable charges for any elected features as set forth in endorsements or riders to this
Contract. Any reduction to the Contract Value will be made as of the Business Day in which We
receive all requirements In Writing for the transaction, as appropriate.

ACCUMULATION UNIT VALUE (AUV)

The AUV of a Variable Portfolio for any Business Day is determined as follows:

	 	1.	 	We calculate the Net Investment Rate by dividing (a) by (b) minus (c) where:

	 	(a)	 	is the Variable Portfolio’s income and capital gains and losses (whether
realized or unrealized) on the current Business Day;
	 
	 	(b)	 	is the value of the Variable Portfolio for the immediately preceding
Business Day; and
	 
	 	(c)	 	is the daily Separate Account charge.

	 	2.	 	We calculate the AUV by multiplying (d) by [1+(e)] where:

	 	(d)	 	is the AUV of the immediately preceding Business Day; and

	 	(e)	 	is the Net Investment Rate of the current Business Day.

FIXED ACCOUNT ACCUMULATION VALUE

The Fixed Account Accumulation Value, if any, is the sum of all amounts allocated or transferred to
the Fixed Account Option(s), if available, reduced by any applicable premium taxes, plus all
interest credited to the Fixed Account Option(s) during the period that You have Contract Value
allocated to the Fixed Account Option(s). This amount will be adjusted for Withdrawals,
Annuitization, transfers, the Contract Maintenance Fee, if applicable and allowed by Your state,
and applicable charges for any elected features as set forth in endorsements/riders to this
Contract. The Fixed Account Accumulation Value will not be less than the minimum values required
by law in the state where this Contract is issued.

FIXED ACCOUNT GUARANTEE PERIOD OPTIONS AND INTEREST CREDITING

The portion of Your Contract Value within the Fixed Account Option(s), if available, is credited
with interest at rates guaranteed by Us for the Guarantee Period(s) selected. Interest is credited
on a daily basis at the then applicable effective interest rate for the applicable Guarantee
Period. You may select from one or more Guarantee Periods which We may offer at any particular
time. We reserve the right at any time to add or discontinue Guarantee Periods. If You have
allocated any part of Your Initial Purchase Payment to a Guarantee Period, the percentage
allocated, as well as the duration of the Guarantee Period, is shown on the Application or
administrative election form as completed by You.

The interest rate applicable to the allocation of a Purchase Payment or transfer of Contract Value
to a Fixed Account Option is the rate in effect for the applicable Guarantee Period at the time of
the allocation or transfer. If You have allocated or transferred amounts at different times to any
available Fixed Account Option(s), each allocation or transfer may have a unique effective interest
rate associated with that amount. We guarantee that the effective annual rate of interest for any
available Fixed Account Option(s), including any of the available Guarantee Periods, will not be
less than the Minimum Guaranteed Rate as mandated by Your state, and shown on the Contract Data
Page.

	 	 	 	 	 

	AG-803 (7/13)
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CHARGES AND DEDUCTIONS

We will deduct the following charges from the Contract:

CONTRACT MAINTENANCE FEE

The charge, as shown on the Contract Data Page, if applicable, will be deducted on each Contract
Anniversary on or prior to the Annuity Date. It will also be deducted when the Contract Value is
withdrawn in full if the Withdrawal is not on the Contract Anniversary. [We reserve the right to
waive the fee for Contract Values [of $75,000.00 and up]].

WITHDRAWAL CHARGE

The charge, as shown on the Contract Data Page, if any, may be deducted upon Withdrawal of any
portion of the Contract Value that is not considered a Penalty-Free Withdrawal. See WITHDRAWAL
PROVISIONS below.

SEPARATE ACCOUNT CHARGE

This charge, as shown on the Contract Data Page, on an annualized basis equals a percentage of the
average daily ending value of the assets attributable to the Accumulation Units of the Variable
Portfolio(s) to which all or part of the Contract Value is allocated. This charge compensates Us
for the mortality and expense risk and the costs of contract distribution assumed by Us. We
subtract this charge daily from the Separate Account.

TRANSFER FEE

We permit [15] free transfers between Variable Portfolios and/or available Fixed Account Option(s)
each Contract Year. We may charge You a fee, as shown on the Contract Data Page, for each
additional transfer in that Contract Year, except for transfers made as part of an automated
transfer program.

TRANSFER PROVISIONS

Subject to applicable restrictions, You may transfer all or part of Your Contract Value amongst the
Variable Portfolios and/or available Fixed Account Option(s) (unless otherwise noted). The minimum
amount that can be transferred is subject to the Minimum Transfer Amount, as shown on the Contract
Data Page. The amount that can remain in a Variable Portfolio and/or available Fixed Account
Option is subject to Company limits. We reserve the right to restrict Your transfer privileges,
including but not limited to possible termination of those privileges.

Due to the risks that frequent transfers impose upon Owners and other investors in the Variable
Portfolio(s) and/or Underlying Funds, We or the manager of an Underlying Fund may limit transfer
activity and impose other requirements to minimize these risks, including but not limited to,
requiring a minimum amount that can be transferred, and an amount that can remain in a Variable
Portfolio and/or available Fixed Account Option after a transfer.

TRANSFERS BEFORE THE ANNUITY DATE

Before the Annuity Date, transfers are subject to certain restrictions. You may transfer all or a
portion of Your Contract Value from one Variable Portfolio to another Variable Portfolio(s) or any
available Fixed Account Option(s) other than the DCA Fixed Account Option(s). You may also
transfer all or a portion of Your Contract Value from any available Fixed Account Option(s) to the
Variable Portfolio(s) and/or any available Fixed Account Option(s) other than the DCA Fixed Account
Options of the Contract. A transfer to a Variable Portfolio will result in the redemption of
Accumulation Units in a Variable Portfolio and the purchase of Accumulation Units in the other
Variable Portfolio. Transfers will be effective at the end of the Business Day on which We receive
Your completed Written transfer request.

Unless You instruct Us to make a transfer, Your allocation to any available Fixed Account Option(s)
and Variable Portfolio(s) will remain unchanged, subject to the terms of the Contract. We reserve
the right to terminate Your ability to transfer to any discontinued Fixed Account Option(s) and/or
Variable Portfolio(s). A written notification will be provided to You at Your last known address
prior to any such termination of Your ability to transfer.

	 	 	 	 	 

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TRANSFERS AFTER THE ANNUITY DATE

On and after the Annuity Date, transfers into and out of any available Fixed Account Option(s) are
not allowed. You may transfer all or a portion of Your Annuity Units from one Variable Portfolio
to another Variable Portfolio(s). A transfer will result in the redemption of Annuity Units in a
Variable Portfolio and the purchase of Annuity Units in the other Variable Portfolio. Transfers
will be effective on the last Business Day of the month on which We receive Your Written request
for the transfer.

Unless You instruct Us to make a transfer, Your allocation to the Variable Portfolio(s) will remain
unchanged, subject to the terms of the Contract. We reserve the right to terminate Your ability to
transfer to any discontinued Variable Portfolio(s). A written notification will be provided to You
at Your last known address prior to any such termination of Your ability to transfer.

WITHDRAWAL PROVISIONS

On or before the Annuity Date and while You are living, You may withdraw all (“total Withdrawal”)
or part of Your Contract Value under this Contract by informing Us In Writing. The Minimum Partial
Withdrawal Amount is shown on the Contract Data Page.

Unless You tell Us otherwise In Writing, Withdrawals will be deducted from the Contract Value in
proportion to their allocation among any available Fixed Account Option(s) and the Variable
Portfolio(s). Withdrawals will be based on values for the Business Day on which the Written
request for Withdrawal is received by Us. In the case of a total Withdrawal, the Withdrawal will
be based on values for the Business Day on which the Written request for Withdrawal is received by
Us. Payment of the total Withdrawal will terminate this Contract and We will have no further
obligations under the Contract. Unless the SUSPENSION OF PAYMENTS or DEFERMENT OF PAYMENTS
provisions are in effect, payment of Withdrawals will be made within seven calendar days.

WITHDRAWAL CHARGE

Withdrawals of all or a portion of the Contract Value may be subject to a Withdrawal Charge, as
shown on the Contract Data Page. The Withdrawal Charge percentage applied to any Withdrawal will
depend on how long the Purchase Payment to which the Withdrawal is attributed has been in the
Contract. No Withdrawal Charge is deducted on an amount which is considered a Penalty-Free
Withdrawal or a Purchase Payment no longer subject to a Withdrawal Charge.

For the purpose of determining the Withdrawal Charge applicable to a partial Withdrawal, the
Withdrawal will be attributed to amounts in the following order: (1) any remaining Penalty-Free
Withdrawal amount (except in the case of a total Withdrawal); (2) Purchase Payments not yet
withdrawn and no longer subject to Withdrawal Charges; (3) Purchase Payments not yet withdrawn and
still subject to Withdrawal Charges; and (4) any remaining Contract Value.
 A Purchase Payment, or portion thereof, is considered withdrawn when the Withdrawal incurs a
Withdrawal Charge, and is assumed to be withdrawn on a first-in-first-out (FIFO) basis. The
Withdrawal Charge will be assessed against the Variable Portfolio(s) and the available Fixed
Account Option(s) in the same proportion that the remaining Contract Value is allocated unless You
request that the Withdrawal come from a particular Variable Portfolio or available Fixed Account
Option.

PENALTY-FREE WITHDRAWALS

On any day in a Contract Year before the Annuity Date, You may make a partial Withdrawal of up to
the Penalty-Free Withdrawal amount as of that day without incurring a Withdrawal Charge. The
Maximum Penalty-Free Withdrawal Percentage is shown on the Contract Data Page.

Each Contract Year, the Penalty-Free Withdrawal amount is calculated as the Maximum Penalty-Free
Withdrawal Percentage multiplied by the remaining Purchase Payments not yet withdrawn and still
subject to Withdrawal Charges.

Although amounts withdrawn as Penalty-Free Withdrawals reduce the Contract Value, they do not
reduce the remaining Purchase Payments for purposes of calculating future Penalty-Free Withdrawal
amounts and Withdrawal Charges. Partial Withdrawals in a Contract Year that are in excess of the
Penalty-Free Withdrawal amount incur a Withdrawal Charge applicable to the remaining Purchase
Payments and reduce those Purchase Payments on a first-in-first-out (FIFO) basis.

	 	 	 	 	 

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If You choose to take less than the Penalty-Free Withdrawal amount during a Contract Year, You may
not carry over the unused Penalty-Free Withdrawal amount in any subsequent Contract Years. If Your
Contract Value is subject to Withdrawal Charges, a Penalty-Free Withdrawal is not available to You
if You take a total Withdrawal.

SYSTEMATIC WITHDRAWAL PROGRAM

Prior to the Annuity Date, You may elect to participate in a Systematic Withdrawal Program by
informing Us at Our Annuity Service Center. The Systematic Withdrawal Program allows You to make
automatic Withdrawals from Your Contract monthly, quarterly, semiannually or annually. The Minimum
Systematic Withdrawal Amount is shown on the Contract Data Page. Any amount withdrawn through the
Systematic Withdrawal Program may be subject to a Withdrawal Charge as discussed in the WITHDRAWAL
CHARGE and PENALTY-FREE WITHDRAWALS provisions. You may terminate Your participation in the
Systematic Withdrawal Program at any time by sending Us a Written request.

DEATH PROVISIONS

Notwithstanding any provision of this Contract to the contrary, all payments of Death Benefits
under this Contract will be made in a manner that satisfies the requirements of IRC Section 72(s),
as amended from time to time. If the Contract is owned by a trust or other non-natural person, We
will treat the death of any Annuitant as the death of the “Primary Annuitant” and as the death of
any Owner.

DUE PROOF OF DEATH

Due Proof of Death means any Written proof, which may include but is not limited to:

	 	1.	 	a certified copy of a death certificate; or
	 
	 	2.	 	a certified copy of a decree of a court of competent jurisdiction as to the finding of
death; or

	 
	 	3.	 	a written statement by a medical doctor who attended the deceased Owner at the time of
death.

DEATH OF OWNER BEFORE THE ANNUITY DATE

Upon Your death, We will pay a Death Benefit to the Beneficiary upon Our receiving all Required
Documentation. Unless You have previously designated a payment option on behalf of the Beneficiary,
the Beneficiary must select one of the following options:

	 	1.	 	Immediately collect the Death Benefit in a lump sum payment. If a lump
sum payment is elected, payment will be in accordance with any applicable laws and
regulations governing payments on death; or

	 
	 	2.	 	Collect the Death Benefit in the form of one of the Annuity Income
Payment Options. If an Annuity Income Payment Option is desired, an option must be
elected within 60 days of Our receipt of all Required Documentation. The Annuity
Income Payments must be over the life of the Beneficiary or over a period not
extending beyond the life expectancy of the Beneficiary. Consistent with applicable
tax rules, payments under this option generally must begin within one year after the
Owner’s death, otherwise, the Death Benefit will be paid in accordance with option 1
above; or

	 
	 	3.	 	If eligible and You are the Spousal Beneficiary, You may continue the
Contract (“Continuing Spouse”). If this option is elected, no Death Benefit is paid
out to the Continuing Spouse on the Continuation Date; or

	 
	 	4.	 	A payment option that is mutually
agreeable between You and Us.

	 	 	 	 	 

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The entire interest in the Contract will be distributed within the five year period specified under
applicable laws and regulations, commencing with the date of death of the Owner unless option 2, 3
or 4 was selected under DEATH OF OWNER BEFORE THE ANNUITY DATE.

Upon the Continuing Spouse’s death, the entire interest of the Contract must be distributed
immediately under option 1, 2 or 4 as provided under DEATH OF OWNER BEFORE THE ANNUITY DATE.

AMOUNT OF DEATH BENEFIT

The amount of the Death Benefit is the Contract Value on the Business Day during which We receive
all Required Documentation.

SPOUSAL BENEFICIARY CONTINUATION

If the Spousal Beneficiary continues the Contract on the Continuation Date (“Continuing Spouse”),
the amount continued is the Death Benefit, which is the Contract Value on the Business Day during
which We receive all Required Documentation.

DEATH OF OWNER OR ANNUITANT ON OR AFTER THE ANNUITY DATE

If any Owner or Annuitant dies on or after the Annuity Date and before the entire interest in the
Contract has been distributed, We will continue to make payments of any remaining portion of the
Annuity Income Payment(s) to the Beneficiary under the existing Annuity Income Payments, if a
specified term was elected, upon Our receipt of all Required Documentation. For further
information pertaining to death of the Annuitant, see ANNUITY INCOME PAYMENT OPTIONS.

BENEFICIARY

The Beneficiary is selected by the Owner. While the Owner is living and before the Annuity Date,
the Owner may change the Beneficiary by Written notice. A change in Beneficiary will take effect
on the date We receive the Written notice. If two or more persons are named as Beneficiaries under
the Contract, those surviving the Owner will share equally unless otherwise specified by the Owner
and each must elect to receive their respective portions of the Death Benefit according to the
options listed under DEATH OF OWNER BEFORE THE ANNUITY DATE. Joint Owners, if applicable, shall be
each other’s primary Beneficiary. Any other Beneficiary designation will be treated as a
contingent Beneficiary.

If the Annuitant survives the Owner, and there are no surviving Beneficiaries, the Annuitant will
be deemed the Beneficiary. Joint Annuitants, if any, when the Owner is a trust or other non-natural
person, shall be each other’s primary Beneficiary. Any other Beneficiary designation will be
treated as a contingent Beneficiary.

If the Owner is also the Annuitant and there are no surviving Beneficiaries, upon Our receipt of
all Required Documentation, We will pay the Death Benefit to the estate of the Owner in accordance
with option 1, under DEATH OF OWNER BEFORE THE ANNUITY DATE.

ANNUITY PROVISIONS

ANNUITY DATE

You may specify an Annuity Date. You may change the Annuity Date at any time, at least [thirty
(30) days] prior to the Annuity Date, by Written notice. The Annuity Date must always be the first
day of the calendar month. The Earliest Annuity Date After the Contract Date is shown on the
Contract Data Page. The Annuity Date must not be beyond the Latest Annuity Date shown on the
Contract Data Page. If no Annuity Date is specified by You, the Annuity Date will be the Latest
Annuity Date.

PAYMENTS TO OWNER

Unless You request otherwise, We will make Annuity Income Payments to You. If You want the Annuity
Income Payments under an Annuity Payment Option selected by You to be made to some other Payee, We
will make such Annuity Income Payments subject to receipt of a Written request no later than thirty
(30) days before the due date of the first Annuity Income Payment or subsequent Annuity Income
Payment.

	 	 	 	 	 

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Any such request is subject to the rights of any assignee. No Annuity Income Payments available to
or being paid to the Payee while the Annuitant is alive can be transferred, commuted, anticipated
or encumbered.

FIXED ANNUITIZATION

If a Fixed Annuitization has been elected, the proceeds payable under this Contract less any
applicable premium taxes, shall be applied to the payment of the fixed Annuity Income Payment
option elected at rates which are at least equal to the annuity rates based upon the applicable
tables in the Contract. Upon Annuitization, any amounts remaining in the DCA Fixed Account
Option(s), if applicable, will be applied to a Fixed Annuitization. The unit values credited and
applied to Your Contract are determined on each date of transfer.

AMOUNT OF FIXED ANNUITY INCOME PAYMENTS

The amount of each fixed Annuity Income Payment will be determined by applying the portion of the
Contract Value allocated by You for Fixed Annuitization on the Annuity Date, less any applicable
premium taxes, to the annuity factor applicable to the fixed Annuity Income Payment option chosen.
In no event will the Fixed Annuitization be changed once it begins.

AMOUNT OF VARIABLE ANNUITY INCOME PAYMENTS

	(a)	 	FIRST VARIABLE ANNUITY INCOME PAYMENT: The dollar amount of the first Variable Annuitization
payment will be determined by applying the portion of the Contract Value allocated to the
Variable Portfolio(s) on the Annuity Date, less any applicable premium taxes, to the annuity
factor applicable to the variable Annuity Income Payment option chosen. If the Contract Value
is allocated to more than one Variable Portfolio, the value of Your allocation in each
Variable Portfolio is applied separately to the variable Annuity Income Payment option factor
to determine the amount of the first Annuity Income Payment attributable to each Variable
Portfolio.

	 
	(b)	 	NUMBER OF VARIABLE ANNUITY UNITS: The number of Annuity Units for each applicable Variable
Portfolio is the amount of the first Annuity Income Payment attributable to that Variable
Portfolio divided by the value of the applicable Annuity Unit for that Variable Portfolio as
of the Annuity Date. The number of Annuity Units will not change as a result of investment
experience.

	 
	(c)	 	VALUE OF EACH VARIABLE ANNUITY UNIT: The value of an Annuity Unit may increase or decrease
from one month to the next. For any month, the value of an Annuity Unit of a particular
Variable Portfolio is the value of that Annuity Unit as of the last Business Day of the
preceding month, multiplied by the Net Investment Factor for that Variable Portfolio for the
last Business Day of the current month.

The Net Investment Factor for any Variable Portfolio for a certain month is determined by dividing
(1) by (2) and multiplying by (3) where:

	 	(1)	 	is the Accumulation Unit Value of the Variable Portfolio
determined as of the last Business Day at the end of that month;
and

	 
	 	(2)	 	is the Accumulation Unit Value of the Variable Portfolio
determined as of the last Business Day at the end of the preceding
month; and

	 
	 	(3)	 	is a monthly discount factor of an assumed annualized
investment rate of [3.50%].

	(d)	 	SUBSEQUENT VARIABLE ANNUITY INCOME PAYMENTS: After the first Variable Annuitization payment,
subsequent Variable Annuitization payments will vary in amount according to the investment
performance of the applicable Variable Portfolio(s) in which You are invested. The amount may
change from month to month. The amount of each subsequent payment for each Variable Portfolio
is (1) multiplied by (2) where:

	 	(1)	 	is the number of Annuity Units for each Variable Portfolio
as determined for the first Annuity Income Payment; and

	 	 	 	 	 

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	 	(2)	 	is the value of an Annuity Unit for that Variable Portfolio
determined as of the last Business Day at the end of the month immediately
preceding the month in which the Annuity Income Payment is due.

We guarantee that the amount of each Variable Annuitization payments will not be affected by
variations in expenses or mortality experience.

GENERAL PROVISIONS

ENTIRE CONTRACT

The Entire Contract between You and Us consists of this Contract, the Application for this
Contract, and any attached endorsement(s) and/or rider(s). An agent cannot change the terms or
conditions of this Contract. Any change must be In Writing and approved by Us. Only Our
President, Secretary, or one of Our Vice-Presidents can give Our approval. All statements made by
the applicant for the issuance of the Contract shall, in the absence of fraud, be deemed
representations and not warranties.

CHANGE OF ANNUITANT

If the Owner is an individual, the Owner may change the Annuitant(s) at any time prior to the
Annuity Date, subject to Our approval. To request such a change, the Owner must send a request In
Writing at least thirty (30) days before the Annuity Date. If the Owner is a trust or other
non-natural person, the Owner may not change the Annuitant. Any change of the Annuitant may have
income tax consequences.

DEATH OF ANNUITANT

If the Owner is an individual, the Owner and Annuitant are different persons, and the Annuitant
dies before the Annuity Date, the Owner becomes the Annuitant until the Owner elects a new
Annuitant. If there are Joint Annuitants, upon the death of any Annuitant prior to the Annuity
Date, the Owner may elect a new Joint Annuitant, subject to Our approval. However, if the Owner is
a trust or other non-natural person, We will treat the death of any Annuitant as the death of the
“Primary Annuitant” as defined in the IRC, and as the death of the Owner, as explained in the DEATH
PROVISIONS.

MISSTATEMENT OF AGE OR SEX

You must, upon Our request, provide proof of the Annuitant’s birth date and sex. If the Age or sex
of any Annuitant is misstated, We will adjust future Annuity Income Payments. The amount remaining
to be paid will be the amount that should have been paid with the correct information. We will
credit or charge the amount of any underpayment or overpayment against the next succeeding Annuity
Income Payment(s), if any remain. We reserve the right to collect any overpayment directly from
the Payee.

With respect to Contract issue Age and other age driven features in the Contract, should We
discover a misstatement of Age such that You would not otherwise qualify for an Age-driven benefit,
We may fully pursue Our remedies including possible revocation of any Age-driven benefits. A
written notification will be provided to the Owner at least ten (10) days prior to the revocation
of the Contract.

PROOF OF AGE, SEX, OR SURVIVAL

We may require satisfactory proof of correct Age or sex at any time. If any payment under this
Contract depends on the Annuitant being alive, We may require satisfactory proof of survival.

DEFERMENT OF PAYMENTS

We may defer making payments, subject to Your state regulatory approval from the available Fixed
Account Option(s) for up to six (6) months. Interest, subject to state requirements, will be
credited during the deferral period.

	 	 	 	 	 

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SUSPENSION OF PAYMENTS

We may suspend or postpone any payments from the Variable Portfolios if any of the following occur:

	(a)	 	the [NYSE] is closed (other than customary weekend and holiday closings);
	 
	(b)	 	trading on the [NYSE] is restricted;
	 
	(c)	 	an emergency exists such that it is not reasonably practical to dispose of securities in the
Variable Portfolios or to determine the value of its assets;
	 
	(d)	 	the United States Securities and Exchange Commission, by order, so permits for the protection
of Owners; or
	 
	(e)	 	We are on notice that this Contract is the subject of a court proceeding, an arbitration, a
regulatory matter or other legal action.

Conditions in (b) and (c) will be decided by or in accordance with rules of the United States
Securities and Exchange Commission.

CONFORMITY WITH STATE LAWS

The provisions of this Contract will be interpreted by the laws of the state in which the
Application was signed or such other state as is required by law. Any provision which, on the
Contract Date, is in conflict with the law of such state is amended to conform to the minimum
requirements of such law.

CHANGES IN LAW

If the laws governing this Contract or the taxation of benefits under the Contract change, We
reserve the right to amend this Contract to comply with these changes.

ASSIGNMENT / CHANGE OF OWNER

Unless restricted by federal tax law, this Contract can be assigned before the Annuity Date, but We
will not be bound by an assignment or change of Owner unless the request for assignment is In
Writing and is recorded. Your rights and those of any other person referred to in this Contract
will be subject to the assignment. Certain assignments may be taxable. We do not assume any
responsibility for the validity or tax consequences of any assignment. The assignment, unless
otherwise specified by You, will take effect on the date that You signed the notice of assignment,
subject to any payments made or actions taken by Us prior to Us receiving such assignment In
Writing. We reserve the right to not recognize assignments or change of Owner if it changes the
risk profile of the Owner of the Contract as determined in Our sole discretion.

INSURABLE INTEREST

Evidence must exist that the Owner(s), Annuitant(s) or Beneficiary(ies) will suffer a financial
loss at the death of the life that triggers the Death Benefit. Generally, We consider an interest
insurable if a familial relationship and/or economic interest exists. A familial relationship
generally includes those persons related by blood or by law. An economic interest exists when the
Owner has a lawful and substantial economic interest in having the life, health or bodily safety of
the insured life preserved.

CLAIMS OF CREDITORS

To the extent permitted by law, no right or proceeds payable under this Contract will be subject to
claims of creditors or legal process.

PREMIUM TAXES OR OTHER TAXES

We may deduct from Your Contract Value any premium tax or other taxes payable to a state or other
government entity, if applicable. Should We advance any amount so due, We are not waiving any
right to collect such amount at a later date. We will deduct any withholding taxes required by
applicable law.

WRITTEN NOTICE

Any notice We send to You will be sent to Your address shown in the Application unless You request
otherwise.

	 	 	 	 	 

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PERIODIC REPORTS

At least once during each Contract Year, We will send You a statement of the account activity of
the Contract. The statement will include all transactions which have occurred during the
accounting period shown on the statement.

INCONTESTABILITY

This Contract will be incontestable after it has been in force for a period of two years or less
depending on Your state law from the Contract Date during the lifetime of any Owner who is required
to provide Us with information concerning such Owner’s identity. Accurate statements as to any
Owner’s identity are required as a condition of issuing this Contract. The Incontestability of
this Contract applies to any statements any Owner makes, except as otherwise stated in the
Misstatement of Age or Sex Provision.

WAIVER

Our waiver of any of the terms and conditions under this Contract will not be deemed to constitute
waiver of the right to enforce strict compliance.

NONPARTICIPATING

This Contract does not share in Our surplus.

	 	 	 	 	 

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ANNUITY INCOME PAYMENT OPTIONS

During the Annuitant’s life, upon Written election, the Contract Value may be applied to provide
one of the following Annuity Income Payment options or any Annuity Income Payment option that is
mutually agreeable. Prior to the Annuity Date but not before the Earliest Annuity Date After the
Contract Date shown on the Contract Data Page, You can choose one of the options described below.
If no option has been selected by the Annuity Date, You will automatically receive option 4, below,
with 120 monthly payments guaranteed; for Joint Owners, You will automatically receive Option 3,
below, with 120 monthly payments guaranteed.

OPTIONS 1 & 1v - LIFE ANNUITY, LIFETIME PAYMENTS GUARANTEED

Payments payable to a Payee during the lifetime of the Annuitant. No further Annuity Income
Payments are payable after the death of the Annuitant.

OPTIONS 2 & 2v - JOINT AND SURVIVOR LIFE ANNUITY

Payments payable to the Payee during the lifetime of the Annuitant and during the lifetime of a
designated second person. No further Annuity Income Payments are payable after the deaths of both
the Annuitant and the designated second person.

OPTIONS 3 & 3v - JOINT AND SURVIVOR LIFE ANNUITY - WITH 120 OR 240 MONTHLY PAYMENTS GUARANTEED

Payments payable to the Payee during the lifetime of the Annuitant and during the lifetime of a
designated second person. If, at the death of the survivor, Annuity Income Payments have been made
for less than 120 or 240 monthly periods, the remaining guaranteed Annuity Income Payments will be
continued to the Beneficiary. If, at the death of the survivor, Annuity Income Payments have been
made for at least 120 or 240 monthly periods, as selected at the time of Annuitization, no further
Annuity Income Payments will be made.

OPTIONS 4 & 4v - LIFE ANNUITY WITH - 120 OR 240 MONTHLY PAYMENTS GUARANTEED

Payments payable to the Payee during the lifetime of the Annuitant. If, at the death of the
Annuitant, Annuity Income Payments have been made for less than the 120 or 240 monthly periods, as
selected at the time of Annuitization, the remaining guaranteed Annuity Income Payments will be
continued to the Beneficiary. If, at death of the Annuitant, Annuity Income Payments have been
made for at least 120 or 240 monthly periods, no further payments will be made.

OPTIONS 5 & 5v - FIXED PAYMENTS FOR A SPECIFIED PERIOD CERTAIN

Payments payable to the Payee for any specified period of time for five (5) years or more, but not
exceeding thirty (30) years, as selected at the time of Annuitization. The selection must be made
for full twelve month periods. In the event of death of the Annuitant during the specified period
of time, any remaining Annuity Income Payments will be continued to the Beneficiary. If the
Annuitant dies after the end of the specific period of time, no further Annuity Income Payments
will be made. If Variable Annuity Income Payments are elected under this Annuity Income Payment
Option, any remaining guaranteed Variable Annuity Income Payments may be redeemed for a discounted
value determined by Us. Any applicable Withdrawal Charges will be deducted from the discounted
value as if Your Contract was fully withdrawn.

	 	 	 	 	 

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FIXED ANNUITY INCOME PAYMENT OPTIONS TABLE

BASIS OF COMPUTATION

The actuarial basis for the Table of Annuity Rates is the Annuity 2000 Mortality Table with a
guaranteed interest rate of [1.50%], with quinquennial age setbacks. In order to determine the
applicable factors at the time of Annuitization, the Annuitant’s age will be set back by one year
for every five year period after the Contract Date. The Fixed Annuity Income Payment Options Table
does not include any applicable premium tax.

	 	 	 	 	 

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	AG-803 (7/13)

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VARIABLE ANNUITY INCOME PAYMENT OPTIONS TABLE

BASIS OF COMPUTATION

The actuarial basis for the Table of Annuity Rates is the Annuity 2000 Mortality Table with an
effective annual Assumed Investment Rate of [3.50%], with quinquennial age setbacks. In order to
determine the applicable factors at the time of Annuitization, the Annuitant’s age will be set back
by one year for every five year period after the Contract Date. The Variable Annuity
Income Payment Options Table does not include any applicable premium tax.

	 	 	 	 	 

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	AG-803 (7/13)

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	AG-803 (7/13)

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American General Life Insurance Company

A STOCK COMPANY

FLEXIBLE PAYMENT FIXED AND VARIABLE DEFERRED ANNUITY CONTRACT

Nonparticipating

Copyright © 2014 American International Group, Inc. All rights reserved.

	 	 	 	 	 

	AG-803 (7/13)
	 	25

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