Document:

Exhibit 10.3

  

   

  

  
    EXECUTION VERSION

    

    

    FOURTH AMENDMENT TO CREDIT AGREEMENT

     

    

    This FOURTH AMENDMENT TO CREDIT AGREEMENT (this “Amendment”), dated as of October 14, 2019, is made between GALAXY GAMING, INC., a Nevada corporation (the “Borrower”), and ZIONS BANCORPORATION, N.A. dba
      NEVADA STATE BANK, a Nevada state banking corporation (the “Lender”).

     

    RECITALS

     

    A.          The Lender and the Borrower entered into a Credit Agreement, dated as of April 24, 2018, as amended by the First Amendment to Credit Agreement, dated as of April 22, 2019, as further amended by the Waiver and
      Second Amendment to Credit Agreement, dated as of May 6, 2019, and as further amended by the Third Amendment to Credit Agreement, dated as of August 16, 2019 (as further amended, restated, or otherwise modified, the “Credit Agreement”),
      pursuant to which the Lender agreed to extend credit to the Borrower.

     

    B.          The parties desire to amend certain provisions of the Credit Agreement, subject to the terms of this Amendment.

     

    AGREEMENT

     

    NOW, THEREFORE, for good and valuable consideration, the receipt and adequacy of which are hereby acknowledged,
        the parties agree as follows.

     

    Section 1.            Capitalized Terms. Capitalized terms not defined shall have the meanings assigned to them in the Credit
      Agreement, unless the context shall otherwise require.

     

    Section 2.            Amendments to Credit Agreement.

     

    
      
        
          2.1         Definitions. Article I of the Credit Agreement is amended by:

        

      

    

     

    
      
        
          (a)          Adding the following definitions in the appropriate alphabetical order.

        

      

    

     

    “Fourth Amendment”: Fourth Amendment to Credit Agreement, dated as of the Fourth Amendment Date.

     

    “Fourth Amendment Date”: October 14, 2019. “Index”: As defined in Section 2.12.

     

    

    “Pre-Substitute Rate”: As defined in Section 2.12.

     

    “Subordinated Debt (Triangulum)”: That certain Unsecured Promissory Note, dated as of May 6, 2019, made by the Borrower in favor of Triangulum Partners, LLC, a New Mexico limited liability
      company, in an original principal amount of $39,096,401, which Indebtedness provides that, upon a Default or Event of Default under this Agreement, the Borrower shall cease making all payments under the Subordinated Debt (Triangulum).

     

    
      
        

    

    
    “Substitute Index Rate”: As defined in Section 2.12.

     

    (b)          Amending and restating the following definitions as follows. 

     

    

    “Applicable Margin”: When the Borrower’s Leverage Ratio as set forth in the most recent Compliance Certificate received by the Lender pursuant to Section 5.1(c) is (a) greater than or equal to
      4.00 to 1.00, 4.00% and (b) less than 4.00 to 1.00, 3.50%.

    

    

    “Commitments”: The Revolving Commitment and the Term Loan A Commitment.

     

    “Senior Leverage Ratio”: As of the last day of any fiscal quarter for the 12 consecutive fiscal months ending on such date, the ratio of Total Funded Debt, excluding the Subordinated Debt
      (Triangulum), to EBITDA for the four fiscal quarters ending on such date, in each case calculated for the Borrower and its Subsidiaries in accordance with GAAP.

    

    

    “Term Loan”: A Term Loan A.

    

    

    “Total Funded Debt”: At the time of any determination, without duplication, (a) all Indebtedness for borrowed money, (b) Capitalized Lease Obligations, (c) notes payable and draws against
      extensions of credit, (d) any obligations owed for all or any part of the deferred purchase price of property or services (excluding trade payables incurred in the ordinary course of business and insurance premiums paid over time), (e) all
      Indebtedness secured by any Lien on any property of any Loan Party even though such Loan Party has not assumed or become liable for the payment of such Indebtedness, provided that for purposes of this clause (e) the amount of such Indebtedness shall
      be limited to the greater of (i) the amount of such Indebtedness as to which there is recourse to the Borrower and (ii) the fair market value of the property subject to the Liens, and (f) Contingent Obligations.

     

    “Total Liabilities”: At the time of any determination, the amount, on a consolidated basis, of all items of Indebtedness of any Loan Party referred to that would constitute “liabilities” for
      balance sheet purposes in accordance with GAAP.

     

    (c)          Deleting the following definitions. 

     

    

    “Restructuring Period”

     

    

    “Subordinated Debt (Restructuring)” 

     

    

    “Subordinated Debt (Take-Out)”

     

    

    
      2

      
        

    

    “Subordination Agreement” 

     

    

    “Term Loan B”

     

    

    “Term Loan B Borrowing Date”

     

     

    

    “Term Loan B Commitment”

     

    

    “Term Loan B Commitment Amount”

     

     

    

    “Term Loan B Maturity Date”

     

    

    
      
        
          2.2         Term Loan B.

        

      

    

     

    
      
        
          (a)          Section 2.1(c) of the Credit Agreement is deleted in its entirety.

        

      

    

     

    
      
        
          (b)         Section 2.2(c) of the Credit Agreement is deleted in its entirety.

        

      

    

    

    

    (c)         Section 2.3 of the Credit Agreement is amended to delete the sentence, “The Term Loan B shall be evidenced by a Term Note payable to the order of the Lender in the principal amount equal to the Term Loan B
      Commitment Amount.”

     

    (d)         Section 2.4(c) of the Credit Agreement is amended to delete the phrase, “or the Term Loan B Maturity Date, as applicable.”

     

    (e)         Section 2.5(b) of the Credit Agreement is amended to delete both instances of the phrase, “or the Term Loan B Maturity Date, as applicable.”

     

    (f)          The first sentence of Section 2.11(b) of the Credit Agreement is amended and restated to read as follows.

     

    “The proceeds of the Term Loan shall be used to (a) refinance outstanding Indebtedness of the Borrower and redeem the associated outstanding warrants, and (b) pay transaction and closing costs
      associated with the Loan Documents.”

     

    
      
        
          (g)         Section 3.3 of the Credit Agreement is deleted in its entirety.

        

      

    

     

    (h)         Section 8.13 of the Credit Agreement is amended to delete the phrases (i) “the later of” and (ii) “or the Term Loan B Maturity Date, as applicable.”

     

    2.3         Fees. Section 2.8 of the Credit Agreement is amended and restated in its entirety to read as follows.

     

    “Fees. The Borrower shall pay to the Lender on the Closing Date an origination fee in an amount equal to 0.75% of the Revolving Commitment and the Term Loan A Commitment.
      Such origination fee shall be fully earned when paid and nonrefundable. Commencing with the fiscal quarter ending on June 30, 2019, and retroactive to April 22, 2019, an unused fee in the amount of 0.25% of the difference between the Revolving
      Commitment Amount and the average daily balance of the Revolving Loan during such fiscal quarter shall be due and payable on the last day of each fiscal quarter. The Borrower shall pay to the Lender on the Fourth Amendment Date an amendment fee in an
      amount equal to $25,102.50.”

     

    
      3

      
        

    

    2.4          LIBOR Replacement. Section 2.12 of the Credit Agreement is amended and restated in its entirety to read as follows.

     

    “Interest Rate Not Ascertainable, Etc. If Lender determines, in its sole discretion, that the LIBOR Rate base rate (“Index”) (i) has been or imminently will be discontinued, (ii) is no
      longer an industry-accepted reference rate for loans of a similar type to the Loans and/or has been superseded by an alternative reference rate, or (iii) is no longer representative or may not be used pursuant to a public statement by the
      administrator of the Index or other regulatory authority (e.g., the Federal Reserve), in each case with respect to any type of loan or transaction, then Lender may select an alternative reference rate, which
      may reflect adjustments to the related spread or margin (collectively, the “Substitute Index Rate”), to be used in lieu of the LIBOR Rate-based interest rate set forth in the Note and/or this Agreement (the “Pre-Substitute Rate”).

     

    Lender and Borrower acknowledge that the discontinuation of the Index is a future event over which neither Lender nor Borrower has influence but which will necessarily affect the Pre-Substitute Rate.
      Accordingly, Lender shall use reasonable efforts to select a Substitute Index Rate that Lender in good faith believes is a practical means of preserving the parties’ intent relative to the economics of the Pre-Substitute Rate. Notwithstanding the
      foregoing, the parties acknowledge that, initially and/or over time, the Substitute Index Rate will differ from the Pre-Substitute Rate. In selecting the Substitute Index Rate, Lender shall consider to what extent and the manner in which
      industry-accepted substitutes for the Index have been established, and the parties acknowledge that different Substitute Index Rates may be selected for different types of loans and transactions. Borrower agrees that Lender shall not be liable in any
      manner for its selection of a Substitute Index Rate, provided that Lender makes such selection in good faith.

     

    The Substitute Index Rate shall be used in lieu of the Pre-Substitute Rate, and all references in this Agreement to the Pre-Substitute Rate shall be deemed to refer to the Substitute Index Rate,
      effective as of the date specified by Lender in a written notice given by Lender to Borrower. To the extent practicable, such notice shall be given at least 30 days prior to the effective date. The Substitute Index Rate shall remain in effect from
      the effective date set forth in such notice until the later of the Revolving Loan Maturity Date and the Term Loan A Maturity Date, as such may be extended, unless such an instance occurs where the Substitute Index Rate is no longer available, in
      which case the provisions of this section will again apply for purposes of replacing the Substitute Index Rate.”

     

    
      4

      
        

    

    
      
        
          2.5         Indebtedness.

        

      

    

    

    

    (a)         Section 6.12(f) is amended and restated in its entirety to read: “the Subordinated Debt (Triangulum);”.

     

    (b)         Section 6.12(g) is amended and restated in its entirety to read: “(Reserved); and”.

     

    2.6         Senior Leverage Ratio. Section 6.16(a) of the Credit Agreement is amended and restated in its entirety to read as
      follows.

     

    “Commencing with the fiscal quarter ending December 31, 2019, the Borrower will not permit the Senior Leverage Ratio to be greater than 2.00 to 1.00.”

     

    2.7         Total Leverage Ratio. The table in Section 6.16(b) of the Credit Agreement is amended and restated in its entirety to
      read as follows.

     

    	
            Fiscal Quarter Ending

          	
            Total Leverage Ratio

          
	
            December 31, 2019 and March 31, 2020

          	
            7.25 to 1.00

          
	
            June 30, 2020 and September 30, 2020

          	
            7.00 to 1.00

          
	
            December 31, 2020 and March 31, 2021

          	
            6.75 to 1.00

          
	
            June 30, 2021 and September 30, 2021

          	
            6.50 to 1.00

          
	
            December 31, 2021 and March 31, 2022

          	
            6.25 to 1.00

          
	
            June 30, 2022 and September 30, 2022

          	
            6.00 to 1.00

          
	
            December 31, 2022 and thereafter

          	
            5.75 to 1.00

          

     

    2.8         Exhibit A. Exhibit A is amended to delete the phrase “Term Loan [A][B]” with “Term Loan A.”

     

    2.9         Exhibit D. Section 3 of the “Attachment to Compliance Certificate” following Exhibit D is amended and restated in its
      entirety to read as follows.

     

    Senior Leverage Ratio (Section 6.16(a))

     

    
      	
              (a)

            	
              Total Funded Debt

            	 	
              $

            	 	 
	
              (b)

            	
              Subordinated Debt (Triangulum)

            	 	
              $

            	 	 
	
              (c)

            	
              (a), minus (b)

            	 	
              $

            	 	 
	
              (d)

            	
              EBITDA

            	 	
              $

            	 	 

    

     

    

    Ratio of (c) to (d):          to 1.00

    

    

    Section 3.            Effectiveness of Amendments. This Amendment shall become effective upon delivery by the Borrower of, and
      compliance by the Borrower with, the following:

     

    3.1         Documents. The Lender shall have received this Amendment
      executed by a duly authorized officer of the Borrower.

     

    
      5

      
        

    

    
      
        
          3.2         Fees and Expenses. The Lender shall have received all fees and other amounts due and payable
            by the Borrower on or prior to the date hereof, including the reasonable fees and expenses of counsel to the Lender payable pursuant to Section 8.2 of the Credit Agreement.

        

      

    

     

    3.3         Other Matters. All corporate and legal proceedings relating
      to the Borrower and all instruments and agreements in connection with the transactions contemplated by this Amendment shall be satisfactory in scope, form and substance to the Lender and its counsel, and the Lender shall have received all information
      and copies of all documents including records of corporate proceedings, as the Lender or its counsel may reasonably have requested in connection therewith, such documents where appropriate to be certified by proper corporate or governmental
      authorities.

     

    Section 4.            Representations, Warranties, Authority.

     

    4.1         Reassertion of Representations and Warranties, No Default. The Borrower hereby represents that on and
      as of the date hereof and after giving effect to this Amendment all of the representations and warranties contained in the Credit Agreement and the other Loan Documents are true, correct and complete in all material respects as of the date hereof as
      though made on and as of such date, except (i) for changes permitted by the terms of the Credit Agreement as amended by this Amendment and (ii) to the extent such representation or warranty relates to an earlier specified date, in which case such
      representation or warranty is reaffirmed as true and correct in all material respects as to such date and there will exist no Default or Event of Default under the Credit Agreement as amended by this Amendment on such date which has not been cured or
      waived by the Lender.

     

    4.2         Authority, No Conflict, No Consent Required, Enforceability. The Borrower represents and warrants
      that the Borrower has the power and legal right and authority to enter into this Amendment and has duly authorized as appropriate the execution and delivery of the Amendment by proper corporate action, and neither the Amendment nor the agreements
      contained herein or therein contravenes or constitutes a default under any agreement, instrument or indenture to which the Borrower is a party or a signatory or a provision of the Borrower’s Articles of Incorporation, Bylaws or any other agreement or
      requirement of law, or results in the imposition of any lien on any of its property under any agreement binding on or applicable to the Borrower or any of its property except, if any, in favor of the Lender. The Borrower represents and warrants that
      no consent, approval or authorization of or registration or declaration with any Person, including but not limited to any governmental authority, is required in connection with the execution and delivery by the Borrower of the Amendment or other
      agreements and documents executed and delivered by the Borrower in connection therewith or the performance of obligations of the Borrower therein described, except (a) for those which the Borrower has obtained or provided and as to which the Borrower
      has delivered certified copies of documents evidencing each such action to the Lender and (b) for those which the Borrower will make, obtain or provide upon the consummation of this Amendment and as to which the Borrower will promptly deliver
      certified copies of documents evidencing each such action to the Lender. The Borrower represents and warrants that the Amendment constitutes the legal, valid and binding obligations of the Borrower, enforceable against the Borrower in accordance with
      their terms, subject to limitations as to enforceability which might result from bankruptcy, insolvency, moratorium and other similar laws affecting creditors’ rights generally and subject to limitations on the availability of equitable remedies.

     

    
      6

      
        

    

    4.3         No Adverse Claim. The Borrower warrants, acknowledges and agrees that no events have taken place and
      no circumstances exist at the date hereof which would give the Borrower a basis to assert a defense, offset or counterclaim to any claim of the Lender with respect to the obligations.

     

    Section 5.            Affirmation of Credit Agreement, Further References, Affirmation of Security Interest. The Lender and the Borrower each acknowledge and affirm that the Credit Agreement, as amended hereby, is hereby ratified and confirmed in all respects and all terms, conditions and
      provisions of the Credit Agreement and the other Loan Documents, except as amended by this Amendment, shall remain unmodified and in full force and effect. All references in any document or instrument to the Credit Agreement are hereby amended and
      shall refer to the Credit Agreement as amended hereby. The Borrower confirms to the Lender that the Obligations are and continue to be secured by the security interest granted by the Borrower in favor of the Lender under the Security Agreement and
      all of the terms, conditions, provisions, agreements, requirements, promises, obligations, duties, covenants and representations of the Borrower under such document and any and all other documents and agreements entered into with respect to the
      obligations under the Credit Agreement are incorporated herein by reference and are hereby ratified and affirmed in all respects by the Borrower.

     

    Section 6.            Merger and Integration, Superseding Effect. This Amendment, from and after the date hereof, embodies the
      entire agreement and understanding between the parties hereto and supersedes and has merged into this Amendment all prior oral and written agreements on the same subjects by and between the parties hereto with the effect that this Amendment shall
      control with respect to the specific subjects hereof and thereof.

     

    Section 7.            Severability. Whenever possible, each provision of this Amendment and any other statement, instrument or
      transaction contemplated hereby or thereby or relating hereto or thereto shall be interpreted in such manner as to be effective, valid and enforceable under the applicable law of any jurisdiction, but, if any provision of this Amendment or any other
      statement, instrument or transaction contemplated hereby or thereby or relating hereto or thereto shall be held to be prohibited, invalid or unenforceable under the applicable law, such provision shall be ineffective in such jurisdiction only to the
      extent of such prohibition, invalidity or unenforceability, without invalidating or rendering unenforceable the remainder of such provision or the remaining provisions of this Amendment or any other statement, instrument or transaction contemplated
      hereby or thereby or relating hereto or thereto in such jurisdiction, or affecting the effectiveness, validity or enforceability of such provision in any other jurisdiction.

     

    Section 8.            Successors. This Amendment shall be binding upon the Borrower, the Lender and their respective successors and
      assigns, and shall inure to the benefit of the Borrower, and the Lender and their successors and assigns.

    

    

    
      7

      
        

    

    Section 9.            Legal Expenses. As provided in Section 8.2 of the Credit Agreement, the Borrower agrees to reimburse the
      Lender upon demand for all reasonable out-of-pocket expenses (including filing and recording costs and fees, charges and disbursements of outside counsel to the Lender) incurred in connection with the negotiation, preparation, enforcement and
      collection of this Amendment and all other documents negotiated and prepared in connection with this Amendment.

     

    Section 10.          Headings. The headings of various sections of this Amendment have been inserted for reference only and shall not
      be deemed to be a part of this Amendment.

    

    

    Section 11.          Counterparts. This Amendment may be executed in several counterparts as deemed necessary or convenient, each of
      which, when so executed, shall be deemed an original, provided that all such counterparts shall be regarded as one and the same document, and any party to this Amendment may execute any such agreement by executing a counterpart of such agreement.

     

    Section 12.          Governing Law. THE AMENDMENT SHALL BE GOVERNED BY THE INTERNAL LAWS OF THE STATE OF NEVADA, WITHOUT GIVING EFFECT TO CONFLICT OF LAW PRINCIPLES THEREOF.

     

    Section 13.          Acknowledgement and Release. IN ORDER TO INDUCE THE LENDER TO ENTER INTO THIS AMENDMENT, THE BORROWER: (A)
      REPRESENTS AND WARRANTS TO THE LENDER THAT NO EVENTS HAVE TAKEN PLACE AND NO CIRCUMSTANCES EXIST AT THE DATE HEREOF WHICH WOULD GIVE THE BORROWER THE RIGHT TO ASSERT A DEFENSE, OFFSET OR COUNTERCLAIM TO ANY CLAIM BY THE LENDER FOR PAYMENT OF THE
      OBLIGATIONS; AND (B) HEREBY RELEASES AND FOREVER DISCHARGES THE LENDER AND ITS SUCCESSORS, ASSIGNS, DIRECTORS, OFFICERS, AGENTS, EMPLOYEES AND PARTICIPANTS FROM ANY AND ALL ACTIONS, CAUSES OF ACTION, SUITS, PROCEEDINGS, DEBTS, SUMS OF MONEY,
      COVENANTS, CONTRACTS, CONTROVERSIES, CLAIMS AND DEMANDS, AT LAW OR IN EQUITY, WHICH THE BORROWER EVER HAD OR NOW HAS AGAINST THE LENDER OR ANY OF ITS SUCCESSORS, ASSIGNS, DIRECTORS, OFFICERS, AGENTS, EMPLOYEES OR PARTICIPANTS BY VIRTUE OF THEIR
      RELATIONSHIP TO THE BORROWER IN CONNECTION WITH THIS AMENDMENT, THE CREDIT AGREEMENT, THE LOAN DOCUMENTS AND TRANSACTIONS RELATED THERETO.

     

    ***

    

    

    
      8

      
        

    

    IN WITNESS WHEREOF, the parties hereto have caused this Amendment to be executed as of the date and year first above written.

    

    

    
      	
               

            	
              BORROWER:

            
	
               

            	
               

            
	
               

            	
              GALAXY GAMING, INC.

            
	
               

            	
               

            
	
               

            	By:

            	/s/ Harry Hagerty
	
               

            	Name: Harry Hagerty

            
	
               

            	
              Title: Chief Financial Officer

            

    

    

    

    Fourth Amendment to Credit Agreement

    

    
      
        

    

    
      
        	
                 

              	
                LENDER:

              
	
                 

              	
                 

              
	
                 

              	
                
                  ZIONS BANCORPORATION, N.A. DBA NEVADA STATE BANK

                

              
	
                 

              	
                 

              
	
                 

              	By:

              	/s/ Jamie Gazza
	
                 

              	Name: Jamie Gazza
	
                 

              	
                
                  Title: Senior Gaming Director

                

              

         

        

      

    

    Fourth Amendment to Credit AgreementInsured:

Owner:

	 	
[JOHN DOE]

[JANE DOE]

	 	 
	
Initial Specified Amount:

	 	
$

	
[100,000

	
]

	
Policy Date:

	
[MAY 1, 2015]

	
Minimum Specified Amount:

	 	
$

	
[100,000

	
]

	
Date of Issue:

	
[MAY 1, 2015]

	
Monthly Anniversary Day:

	 	 	
[01

	
]

	
Issue Age and Sex:

	
[35 MALE]

Premium Class:                                                        [STANDARD TOBACCO]

Plan of Insurance:                                                  FLEXIBLE PREMIUM VARIABLE LIFE INSURANCE

[Benefit Selection Option:

Death Benefit Option:

Death Benefit Option 2 Factor:

[20]%. If the Insured is still living and this policy is still In Force at Attained Age 121, the Specified Amount will automatically be reduced by [20]%.]

Death Benefit Option [1 (Level)] [Death Benefit Option 3 Limit: [$ ]]

(Applicable if Death Benefit Option 2 is elected): [115.00]%

Premium Payments:                                                  Planned Premium: $[782.00]

Premiums payable until Attained Age 121. Additional premium payments may vary by frequency or amount.

[Risk Factor: [1.500] to Age [40] ([JOHN DOE])]

[Flat Extra: $[5.00] Per $1000 to Age [40] ([JOHN DOE])]

Minimum Additional Premium Payment Amount:

Planned                      Payment Mode:

$[200.00] [ANNUALLY]

No-Lapse Provision:                                                  No-Lapse Premium: $[47.58] monthly

No-Lapse Period: [20] Policy Years

Beneficiary:                                                        As named in the application for this policy, unless later changed by You.

Guaranteed Minimum Fixed

Account Interest Rate:                                                        1.0% annual effective rate (0.00272616%% daily)

Persistency Bonus Rate:                                                                [0.35]% annual effective rate ([0. 02911998]% monthly) in Policy Year

[16] and thereafter.

Minimum Specified Amount Increase:

Maximum Number of Specified Amount Increases per Policy Year:

Maximum Number of Specified Amount Decreases per Policy Year:

$[1000]

Increases to Specified Amount not allowed after Attained Age [85].

[Unlimited] in Policy Year [1]; and

[1] in Policy Year [2] and thereafter.

[Decreases not allowed] in Policy Year [1]; and

[1] in Policy Year [2] and thereafter.

Paid-up nonforfeiture benefits are based on the Ultimate 2017 CSO Age Nearest Birthday, Male/Female, Composite mortality table and interest at the annual rate of 4.00%.

Fixed Policy Loan Interest Rate Charged:

Interest Credited to Loan Account Value:

Participating Policy Loan Interest Rate Charged:

Minimum Policy Loan Amount:

Minimum Policy Loan Repayment:

Separate Account:

Minimum Transfer Amount:

Minimum Remaining Value of the Fixed Account or any Sub-Account(s) After a Transfer:

4.0% annual effective rate in Policy Years 1-10; and

3.0% annual effective rate in Policy Years 11 and thereafter.

3.0% annual effective rate (0.00809863% daily) in all Policy Years. 6.0% annual effective rate in Policy Years 1-10;

5.0% annual effective rate in Policy Years 11 and before Attained Age 121; and

3.0% after Attained Age 121.

$[500]

$[25]

[Lincoln Life & Annuity Flexible Premium Variable Life Account M]

$[50] or the entire value of the Fixed Account or Sub-Account being transferred, whichever is less.

$100.00 unless the entire value of the Fixed Account or Sub-Account(s) is being transferred

Limitation on Transfers from the Fixed Account:

Account(s) available from which to transfer funds for Dollar Cost Averaging:

Cannot exceed the greater of [25.0]% of the Fixed Account Value as of the immediately preceding Policy Anniversary; or the total dollar amount transferred from the Fixed Account in the immediately preceding Policy Year.

[money market Sub-Account

Fixed Account (may be elected at policy issue only)]

Amount of Partial Surrenders:

Must be at least $500.00; and/or not more than 90.0% of the Surrender Value of this policy as of the end of the Valuation Period ending on the Valuation Day on which the request is received in a form acceptable to Us.

This policy may Lapse before the Insured reaches Age 121 even if planned premiums are paid when due. This might be due to:

	
a.

	
changes in current Cost of Insurance rates, interest credited to the Fixed Account, Indexed Credits, or expense loads;

	
b.

	
policy loans or partial surrenders (i.e. withdrawals);

	
c.

	
changes in Death Benefit Option or Specified Amount; or

	
d.

	
performance of the Variable Sub-Accounts. Any of these events may require that more premium be paid.

AN ADDITIONAL LUMP SUM PAYMENT MAY BE REQUIRED TO KEEP THE POLICY IN FORCE AT THE END OF THE NO-LAPSE PERIOD.

ADDITIONAL AMOUNTS ARE NOT GUARANTEED AND WE HAVE THE RIGHT TO CHANGE THE AMOUNT OF INTEREST CREDITED TO THIS POLICY AND THE AMOUNT OF COST OF INSURANCE OR OTHER EXPENSE CHARGES DEDUCTED UNDER THIS POLICY WHICH MAY REQUIRE MORE PREMIUM TO BE PAID THAN WAS ILLUSTRATED OR THE CASH VALUES MAY BE LESS THAN THOSE ILLUSTRATED.

EXCEPT AS PROVIDED UNDER THE NO-LAPSE PROVISION, IF APPLICABLE, AN ADDITIONAL PREMIUM PAYMENT MAY BE REQUIRED TO KEEP THIS POLICY IN FORCE SHOULD THE ACCUMULATION VALUE, MINUS INDEBTEDNESS, BE INSUFFICIENT TO COVER THE RESPECTIVE MONTHLY DEDUCTIONS. MONTHLY DEDUCTIONS WILL NOT CONTINUE DURING THE TIME THE NO-LAPSE PROVISION IS PREVENTING THE POLICY FROM ENTERING THE GRACE PERIOD OR LAPSING. A NEGATIVE ACCUMULATION VALUE WILL NOT BE ACCUMULATED DURING THE NO-LAPSE PERIOD AND UNPAID MONTHLY DEDUCTIONS WILL NOT NEED TO BE REPAID AT THE END OF THE NO-LAPSE PERIOD. YOU SHOULD CONTACT US TO OBTAIN ADDITIONAL INFORMATION ABOUT THIS.

UNDER FEDERAL LAW, THIS POLICY MAY NOT QUALIFY AS LIFE INSURANCE AFTER THE INSURED REACHES AGE 121 AND MAY BE SUBJECT TO ADVERSE TAX CONSEQUENCES. A TAX ADVISOR SHOULD BE CONSULTED PRIOR TO THE CONTINUATION OF THIS POLICY AFTER THE INSURED REACHES AGE 121.

	
[Overloan Protection Rider

	 
	
Minimum Value Threshold:

	
[93.00]%

	
Maximum Value Threshold:

	
[99.00]%

	
Election Charge:

	
[3.00]%

	
Minimum Policy Years In Force:

	
[15]

	
Minimum Attained Age:

	
[75]]

[Waiver of Monthly Deduction Benefit Rider]

[Change of Insured Benefit Rider

Effective Date:                                                            [MAY 1, 2015]

Date of Expiry:                                                            [MAY 1, 2045]]

[Exec Enhanced Surrender Value Rider Enhanced Surrender Value Per

Thousand Adjustment Rate:                                                                                [0.00] in Policy Years [1 – 5]; and

[0.00] in Policy Years [6] and thereafter until the end of the Surrender Charge period shown on Policy Specifications page 3b.]

Monthly Charge Per $1,000:                                                                                [0.05000]]

[Accelerated Death Benefits Rider for Chronic Illness and Terminal Illness

Premium Class:                                                  [STANDARD TOBACCO]

[Risk Factor: [2.000] for [30] Policy Years] [Flat Extra: $[5.00] for [5] Policy Year(s)]

Minimum Monthly Benefit (for Chronic Illness only): $ [250.00] Maximum Monthly Benefit (for Chronic Illness only) will be the lesser of:

	
1.

	
[2.00]% of the Original Benefit Amount; or

	
2.

	
The monthly equivalent of the Per Diem Limit. If the Maximum Monthly Benefit is determined by the Per Diem Limit, the Monthly Benefit Amount will vary by the number of days in each Policy Month. You may contact Us at any time, at the address or phone number shown on the cover page of Your policy, to obtain the current Per Diem Limit established by the Internal Revenue Service.

Specified Amount Limit: $[5,000,000]

If the Policy's Specified Amount is increased at the Insured's Attained Age 70 or later, the Specified Amount Limit shown above will be $[2,000,000].]

[Accelerated Death Benefits Rider for Chronic Illness and Terminal Illness

Table of Cost of Insurance Rates Per $1,000 of Policy Net Amount at Risk or Rider Net Amount at Risk, as applicable

The monthly Cost of Insurance Rates below are based on the Insured's sex (if applicable), Issue Age, Premium Class and Policy Year. If the Insured is in a Rated Premium Class, the Cost of Insurance Rate will be equal to (1) multiplied by (2), plus (3), where:

	
(1)

	
is the applicable monthly rate from the table below;

	
(2)

	
is the Risk Factor, if any, shown on this rider's Policy Specifications; and

	
(3)

	
is the Flat Extra charge, if any, shown on this rider's Policy Specifications divided by 12 to convert to a monthly rate.

Please refer to the rider's Cost of Insurance provision for details concerning which net amount at risk will be used to determine the rider's Cost of Insurance and how the net amount at risk is calculated.

Monthly Rates

The applicable Cost of Insurance Rate is determined as either i. or ii. noted below:

	
i.

	
For any Policy Month prior to acceleration of the death benefit, the rate applicable to the amount of the Policy's current Specified Amount; or

	
ii.

	
Following acceleration of the death benefit, for any Policy Month in which benefits are not payable, the rate applicable to the amount of this rider's current Remaining Benefit Amount.

	
Policy

Year

	 	 	
Less than

$250,000

	 	 	
$250,000

to

	 	 	
$500,000

to

	 	 	
$1,000,000

to

	 	 	
$2,000,000

to

	 	 	
$3,000,000

to

	 	 	
$4,000,000

to

	 
	 	 	 	 	 	 	
$

	
499,999

	 	 	
$

	
999,999

	 	 	
$

	
1,999,999

	 	 	
$

	
2,999,999

	 	 	
$

	
3,999,999

	 	 	
$

	
5,000,000

	 
	 	
[1

	 	 	 	
0.09084

	 	 	 	
0.08667

	 	 	 	
0.08667

	 	 	 	
0.08251

	 	 	 	
0.07834

	 	 	 	
0.07000

	 	 	 	
0.06167

	 
	 	
2

	 	 	 	
0.09168

	 	 	 	
0.08751

	 	 	 	
0.08751

	 	 	 	
0.08334

	 	 	 	
0.07917

	 	 	 	
0.07084

	 	 	 	
0.06250

	 
	 	
3

	 	 	 	
0.09251

	 	 	 	
0.08834

	 	 	 	
0.08834

	 	 	 	
0.08417

	 	 	 	
0.08001

	 	 	 	
0.07167

	 	 	 	
0.06334

	 
	 	
4

	 	 	 	
0.09334

	 	 	 	
0.08917

	 	 	 	
0.08917

	 	 	 	
0.08501

	 	 	 	
0.08084

	 	 	 	
0.07251

	 	 	 	
0.06417

	 
	 	
5

	 	 	 	
0.09334

	 	 	 	
0.08917

	 	 	 	
0.08917

	 	 	 	
0.08501

	 	 	 	
0.08084

	 	 	 	
0.07251

	 	 	 	
0.06417

	 
	 	
6

	 	 	 	
0.09418

	 	 	 	
0.09001

	 	 	 	
0.09001

	 	 	 	
0.08584

	 	 	 	
0.08167

	 	 	 	
0.07334

	 	 	 	
0.06417

	 
	 	
7

	 	 	 	
0.09501

	 	 	 	
0.09084

	 	 	 	
0.09084

	 	 	 	
0.08667

	 	 	 	
0.08251

	 	 	 	
0.07334

	 	 	 	
0.06500

	 
	 	
8

	 	 	 	
0.09668

	 	 	 	
0.09168

	 	 	 	
0.09168

	 	 	 	
0.08751

	 	 	 	
0.08334

	 	 	 	
0.07417

	 	 	 	
0.06584

	 
	 	
9

	 	 	 	
0.09751

	 	 	 	
0.09251

	 	 	 	
0.09251

	 	 	 	
0.08834

	 	 	 	
0.08417

	 	 	 	
0.07501

	 	 	 	
0.06667

	 
	 	
10

	 	 	 	
0.09751

	 	 	 	
0.09251

	 	 	 	
0.09251

	 	 	 	
0.08834

	 	 	 	
0.08417

	 	 	 	
0.07501

	 	 	 	
0.06667

	 
	 	
11

	 	 	 	
0.09834

	 	 	 	
0.09334

	 	 	 	
0.09334

	 	 	 	
0.08917

	 	 	 	
0.08501

	 	 	 	
0.07584

	 	 	 	
0.06667

	 
	 	
12

	 	 	 	
0.09918

	 	 	 	
0.09418

	 	 	 	
0.09418

	 	 	 	
0.09001

	 	 	 	
0.08584

	 	 	 	
0.07667

	 	 	 	
0.06750

	 
	 	
13

	 	 	 	
0.10001

	 	 	 	
0.09501

	 	 	 	
0.09501

	 	 	 	
0.09084

	 	 	 	
0.08667

	 	 	 	
0.07751

	 	 	 	
0.06834

	 
	 	
14

	 	 	 	
0.10001

	 	 	 	
0.09501

	 	 	 	
0.09501

	 	 	 	
0.09084

	 	 	 	
0.08667

	 	 	 	
0.07751

	 	 	 	
0.06834

	 
	 	
15

	 	 	 	
0.10084

	 	 	 	
0.09668

	 	 	 	
0.09668

	 	 	 	
0.09168

	 	 	 	
0.08751

	 	 	 	
0.07834

	 	 	 	
0.06917

	 
	 	
16

	 	 	 	
0.10168

	 	 	 	
0.09751

	 	 	 	
0.09751

	 	 	 	
0.09251

	 	 	 	
0.08751

	 	 	 	
0.07834

	 	 	 	
0.06917

	 
	 	
17

	 	 	 	
0.10251

	 	 	 	
0.09834

	 	 	 	
0.09834

	 	 	 	
0.09334

	 	 	 	
0.08834

	 	 	 	
0.07917

	 	 	 	
0.07000

	 
	 	
18

	 	 	 	
0.10334

	 	 	 	
0.09918

	 	 	 	
0.09918

	 	 	 	
0.09418

	 	 	 	
0.08917

	 	 	 	
0.08001

	 	 	 	
0.07084

	 
	 	
19

	 	 	 	
0.10334

	 	 	 	
0.09918

	 	 	 	
0.09918

	 	 	 	
0.09418

	 	 	 	
0.08917

	 	 	 	
0.08001

	 	 	 	
0.07084

	 
	 	
20

	 	 	 	
0.10418

	 	 	 	
0.10001

	 	 	 	
0.10001

	 	 	 	
0.09501

	 	 	 	
0.09001

	 	 	 	
0.08084

	 	 	 	
0.07167

	
]

	
Policy

Year

	 	 	
Less than

$250,000

	 	 	
$250,000

to

	 	 	
$500,000

to

	 	 	
$1,000,000

to

	 	 	
$2,000,000

to

	 	 	
$3,000,000

to

	 	 	
$4,000,000

to

	 
	 	 	 	 	 	 	
$

	
499,999

	 	 	
$

	
999,999

	 	 	
$

	
1,999,999

	 	 	
$

	
2,999,999

	 	 	
$

	
3,999,999

	 	 	
$

	
5,000,000

	 
	 	
[21

	 	 	 	
0.10584

	 	 	 	
0.10084

	 	 	 	
0.10084

	 	 	 	
0.09584

	 	 	 	
0.09084

	 	 	 	
0.08167

	 	 	 	
0.07167

	 
	 	
22

	 	 	 	
0.10668

	 	 	 	
0.10168

	 	 	 	
0.10168

	 	 	 	
0.09668

	 	 	 	
0.09168

	 	 	 	
0.08251

	 	 	 	
0.07251

	 
	 	
23

	 	 	 	
0.10668

	 	 	 	
0.10168

	 	 	 	
0.10168

	 	 	 	
0.09668

	 	 	 	
0.09168

	 	 	 	
0.08251

	 	 	 	
0.07251

	 
	 	
24

	 	 	 	
0.10751

	 	 	 	
0.10251

	 	 	 	
0.10251

	 	 	 	
0.09751

	 	 	 	
0.09251

	 	 	 	
0.08251

	 	 	 	
0.07334

	 
	 	
25

	 	 	 	
0.10835

	 	 	 	
0.10334

	 	 	 	
0.10334

	 	 	 	
0.09834

	 	 	 	
0.09334

	 	 	 	
0.08334

	 	 	 	
0.07417

	 
	 	
26

	 	 	 	
0.10918

	 	 	 	
0.10418

	 	 	 	
0.10418

	 	 	 	
0.09918

	 	 	 	
0.09418

	 	 	 	
0.08417

	 	 	 	
0.07417

	 
	 	
27

	 	 	 	
0.11001

	 	 	 	
0.10501

	 	 	 	
0.10501

	 	 	 	
0.10001

	 	 	 	
0.09501

	 	 	 	
0.08501

	 	 	 	
0.07501

	 
	 	
28

	 	 	 	
0.11001

	 	 	 	
0.10501

	 	 	 	
0.10501

	 	 	 	
0.10001

	 	 	 	
0.09501

	 	 	 	
0.08501

	 	 	 	
0.07501

	 
	 	
29

	 	 	 	
0.11085

	 	 	 	
0.10584

	 	 	 	
0.10584

	 	 	 	
0.10084

	 	 	 	
0.09584

	 	 	 	
0.08584

	 	 	 	
0.07584

	 
	 	
30

	 	 	 	
0.11168

	 	 	 	
0.10668

	 	 	 	
0.10668

	 	 	 	
0.10168

	 	 	 	
0.09668

	 	 	 	
0.08667

	 	 	 	
0.07667

	 
	 	
31

	 	 	 	
0.11251

	 	 	 	
0.10751

	 	 	 	
0.10751

	 	 	 	
0.10251

	 	 	 	
0.09751

	 	 	 	
0.08751

	 	 	 	
0.07667

	 
	 	
32

	 	 	 	
0.11251

	 	 	 	
0.10751

	 	 	 	
0.10751

	 	 	 	
0.10251

	 	 	 	
0.09751

	 	 	 	
0.08751

	 	 	 	
0.07667

	 
	 	
33

	 	 	 	
0.11335

	 	 	 	
0.10835

	 	 	 	
0.10835

	 	 	 	
0.10334

	 	 	 	
0.09834

	 	 	 	
0.08751

	 	 	 	
0.07751

	 
	 	
34

	 	 	 	
0.11501

	 	 	 	
0.10918

	 	 	 	
0.10918

	 	 	 	
0.10418

	 	 	 	
0.09918

	 	 	 	
0.08834

	 	 	 	
0.07834

	 
	 	
35

	 	 	 	
0.11585

	 	 	 	
0.11001

	 	 	 	
0.11001

	 	 	 	
0.10501

	 	 	 	
0.10001

	 	 	 	
0.08917

	 	 	 	
0.07917

	 
	 	
36

	 	 	 	
0.11668

	 	 	 	
0.11085

	 	 	 	
0.11085

	 	 	 	
0.10584

	 	 	 	
0.10084

	 	 	 	
0.09001

	 	 	 	
0.07917

	 
	 	
37

	 	 	 	
0.11668

	 	 	 	
0.11085

	 	 	 	
0.11085

	 	 	 	
0.10584

	 	 	 	
0.10084

	 	 	 	
0.09001

	 	 	 	
0.07917

	 
	 	
38

	 	 	 	
0.11751

	 	 	 	
0.11168

	 	 	 	
0.11168

	 	 	 	
0.10668

	 	 	 	
0.10168

	 	 	 	
0.09084

	 	 	 	
0.08001

	 
	 	
39

	 	 	 	
0.11835

	 	 	 	
0.11251

	 	 	 	
0.11251

	 	 	 	
0.10751

	 	 	 	
0.10251

	 	 	 	
0.09168

	 	 	 	
0.08084

	 
	 	
40

	 	 	 	
0.11918

	 	 	 	
0.11418

	 	 	 	
0.11418

	 	 	 	
0.10835

	 	 	 	
0.10334

	 	 	 	
0.09251

	 	 	 	
0.08167

	 
	 	
41

	 	 	 	
0.12001

	 	 	 	
0.11501

	 	 	 	
0.11501

	 	 	 	
0.10918

	 	 	 	
0.10334

	 	 	 	
0.09251

	 	 	 	
0.08167

	 
	 	
42

	 	 	 	
0.12001

	 	 	 	
0.11501

	 	 	 	
0.11501

	 	 	 	
0.10918

	 	 	 	
0.10334

	 	 	 	
0.09251

	 	 	 	
0.08167

	 
	 	
43

	 	 	 	
0.12085

	 	 	 	
0.11585

	 	 	 	
0.11585

	 	 	 	
0.11001

	 	 	 	
0.10418

	 	 	 	
0.09334

	 	 	 	
0.08251

	 
	 	
44

	 	 	 	
0.12168

	 	 	 	
0.11668

	 	 	 	
0.11668

	 	 	 	
0.11085

	 	 	 	
0.10501

	 	 	 	
0.09418

	 	 	 	
0.08334

	 
	 	
45

	 	 	 	
0.12252

	 	 	 	
0.11751

	 	 	 	
0.11751

	 	 	 	
0.11168

	 	 	 	
0.10584

	 	 	 	
0.09501

	 	 	 	
0.08417

	 
	 	
46

	 	 	 	
0.12252

	 	 	 	
0.11751

	 	 	 	
0.11751

	 	 	 	
0.11168

	 	 	 	
0.10584

	 	 	 	
0.09501

	 	 	 	
0.08417

	 
	 	
47

	 	 	 	
0.12418

	 	 	 	
0.11835

	 	 	 	
0.11835

	 	 	 	
0.11251

	 	 	 	
0.10668

	 	 	 	
0.09584

	 	 	 	
0.08417

	 
	 	
48

	 	 	 	
0.12502

	 	 	 	
0.11918

	 	 	 	
0.11918

	 	 	 	
0.11335

	 	 	 	
0.10751

	 	 	 	
0.09668

	 	 	 	
0.08501

	 
	 	
49

	 	 	 	
0.12585

	 	 	 	
0.12001

	 	 	 	
0.12001

	 	 	 	
0.11418

	 	 	 	
0.10835

	 	 	 	
0.09668

	 	 	 	
0.08584

	 
	 	
50

	 	 	 	
0.12668

	 	 	 	
0.12085

	 	 	 	
0.12085

	 	 	 	
0.11501

	 	 	 	
0.10918

	 	 	 	
0.09751

	 	 	 	
0.08667

	 
	 	
51

	 	 	 	
0.12668

	 	 	 	
0.12085

	 	 	 	
0.12085

	 	 	 	
0.11501

	 	 	 	
0.10918

	 	 	 	
0.09751

	 	 	 	
0.08667

	 
	 	
52

	 	 	 	
0.12752

	 	 	 	
0.12168

	 	 	 	
0.12168

	 	 	 	
0.11585

	 	 	 	
0.11001

	 	 	 	
0.09834

	 	 	 	
0.08667

	 
	 	
53

	 	 	 	
0.12835

	 	 	 	
0.12252

	 	 	 	
0.12252

	 	 	 	
0.11668

	 	 	 	
0.11085

	 	 	 	
0.09918

	 	 	 	
0.08751

	 
	 	
54

	 	 	 	
0.12918

	 	 	 	
0.12335

	 	 	 	
0.12335

	 	 	 	
0.11751

	 	 	 	
0.11168

	 	 	 	
0.10001

	 	 	 	
0.08834

	 
	 	
55

	 	 	 	
0.12918

	 	 	 	
0.12335

	 	 	 	
0.12335

	 	 	 	
0.11751

	 	 	 	
0.11168

	 	 	 	
0.10001

	 	 	 	
0.08834

	 
	 	
56

	 	 	 	
0.13002

	 	 	 	
0.12418

	 	 	 	
0.12418

	 	 	 	
0.11835

	 	 	 	
0.11251

	 	 	 	
0.10084

	 	 	 	
0.08917

	 
	 	
57

	 	 	 	
0.13085

	 	 	 	
0.12502

	 	 	 	
0.12502

	 	 	 	
0.11918

	 	 	 	
0.11335

	 	 	 	
0.10168

	 	 	 	
0.08917

	 
	 	
58

	 	 	 	
0.13168

	 	 	 	
0.12585

	 	 	 	
0.12585

	 	 	 	
0.12001

	 	 	 	
0.11418

	 	 	 	
0.10168

	 	 	 	
0.09001

	 
	 	
59

	 	 	 	
0.13335

	 	 	 	
0.12668

	 	 	 	
0.12668

	 	 	 	
0.12085

	 	 	 	
0.11501

	 	 	 	
0.10251

	 	 	 	
0.09084

	 
	 	
60

	 	 	 	
0.13335

	 	 	 	
0.12668

	 	 	 	
0.12668

	 	 	 	
0.12085

	 	 	 	
0.11501

	 	 	 	
0.10251

	 	 	 	
0.09084

	
]

	
Policy

Year

	 	 	
Less than

$250,000

	 	 	
$250,000

to

	 	 	
$500,000

to

	 	 	
$1,000,000

to

	 	 	
$2,000,000

to

	 	 	
$3,000,000

to

	 	 	
$4,000,000

to

	 
	 	 	 	 	 	 	
$

	
499,999

	 	 	
$

	
999,999

	 	 	
$

	
1,999,999

	 	 	
$

	
2,999,999

	 	 	
$

	
3,999,999

	 	 	
$

	
5,000,000

	 
	 	
[61

	 	 	 	
0.13418

	 	 	 	
0.12752

	 	 	 	
0.12752

	 	 	 	
0.12168

	 	 	 	
0.11585

	 	 	 	
0.10334

	 	 	 	
0.09168

	 
	 	
62

	 	 	 	
0.13502

	 	 	 	
0.12835

	 	 	 	
0.12835

	 	 	 	
0.12252

	 	 	 	
0.11668

	 	 	 	
0.10418

	 	 	 	
0.09168

	 
	 	
63

	 	 	 	
0.13585

	 	 	 	
0.12918

	 	 	 	
0.12918

	 	 	 	
0.12335

	 	 	 	
0.11751

	 	 	 	
0.10501

	 	 	 	
0.09251

	 
	 	
64

	 	 	 	
0.13585

	 	 	 	
0.12918

	 	 	 	
0.12918

	 	 	 	
0.12335

	 	 	 	
0.11751

	 	 	 	
0.10501

	 	 	 	
0.09251

	 
	 	
65

	 	 	 	
0.13669

	 	 	 	
0.13002

	 	 	 	
0.13002

	 	 	 	
0.12418

	 	 	 	
0.11835

	 	 	 	
0.10584

	 	 	 	
0.09334

	
]]

Table of Surrender Charges

See Surrender Provisions for an example of when this table will be used.

	

Policy Year

	 	 	
Surrender Charge as of

Beginning of Policy Year

	 
	 	
[1

	 	 	
$ 

	
[1,853.00

	 
	 	
2

	 	 	
$

	
1,786.00

	 
	 	
3

	 	 	
$

	
1,717.00

	 
	 	
4

	 	 	
$

	
1,645.00

	 
	 	
5

	 	 	
$

	
1,571.00

	 
	 	
6

	 	 	
$

	
1,493.00

	 
	 	
7

	 	 	
$

	
1,412.00

	 
	 	
8

	 	 	
$

	
1,329.00

	 
	 	
9

	 	 	
$

	
1,241.00

	 
	 	
10

	 	 	
$

	
1,150.00

	 
	 	
11

	 	 	
$

	
915.00

	 
	 	
12

	 	 	
$

	
683.00

	 
	 	
13

	 	 	
$

	
479.00

	 
	 	
14

	 	 	
$

	
304.00

	 
	 	
15

	 	 	
$

	
162.00

	 
	
16] and thereafter

	 	 	
$

	
0.00

	
]

The maximum allowable surrender charges are based on the Ultimate 2017 CSO Age Nearest Birthday, Male/Female, Composite mortality table and interest at the annual rate of 4.00%.

Calculation of Charge for Decrease in Specified Amount

For decreases in Specified Amount, excluding full surrender of this policy, the charge will be calculated as (1) divided by (2), then multiplied by (3), where:

	
(1)

	
is the amount of the decrease;

	
(2)

	
is the Initial Specified Amount; and

	
(3)

	
is the then applicable surrender charge from the Table of Surrender Charges shown above.

However, no charge will be applied under the following circumstances:

	
a.

	
where the decrease occurs after the [10th] Policy Anniversary of the Initial Specified Amount; or

	
b.

	
where the decrease is caused by a partial surrender.

Table of Expense Charges and Fees

The following expenses and fees are charged under this policy:

Premium Load

We will deduct a Premium Load not to exceed [6.0]% from each premium payment in [all] policy years.

Cost of Insurance

See the Cost of Insurance provision. The Net Amount at Risk Discount Factor used in that provision is [1.00082954].

Guaranteed Maximum Monthly Administrative Fee

The Monthly Administrative Fee equals (1) plus (2) plus (3) plus (4), where:

	
(1)

	
is a fee of $[10] per month during each Policy Year;

	
(2)

	
is a monthly charge of [0.19966] per $1,000 of Initial Specified Amount for the first [120] months from the Policy Date; and

	
(3)

	
is a monthly charge per $1,000 for any increase in Specified Amount for the [120] months following the date of increase. The rate used to calculate this charge will be based on the Insured's sex,

Premium Class, and Attained Age on the date of the increase; and

	
(4)

	
is the Indexed Account Asset Charge which is a monthly charged rate of [0.00012491] for the first

[180] months from the Policy Date and is multiplied by the sum of the value in the Holding Account and the Indexed Account.

Guaranteed Maximum Mortality and Expense Risk ("M&E") Charge Rate

[0.0005550]% daily [(0.20)]% annually [in all] Policy Years.

Transfer Fee

$[25] per each transfer request in excess of 24 during any Policy Year.

Table of Guaranteed Maximum Cost of Insurance Rates

The monthly Cost of Insurance rates are based on the Insured's sex, Issue Age, and the Policy Year, but will not exceed the rates shown in the table below in accordance with the Ultimate 2017 CSO Age Nearest Birthday, Male/Female, Composite. If the Insured is in a rated Premium Class, the Guaranteed Maximum Cost of Insurance Rates shown in the table below will be adjusted to reflect the applicable Risk Factor and/or Flat Extra Monthly Insurance Cost, if any, shown in the Policy Specifications as described in the "Cost of Insurance Rates" provision.

Policy                    Monthly                                        Policy                        Monthly                                  Policy                      Monthly

    YearRate          YearRate    YearRate

[1                    [0.11425                                    2                          0.12510                                3                        0.13511

4                    0.14680                                    5                          0.15849                                6                        0.17185

7                    0.18438                                    8                          0.19524                                9                        0.20026

10                    0.20610                                    11                          0.21195                                12                        0.21780

13                    0.22282                                    14                          0.22867                                15                        0.23452

16                    0.24455                                    17                          0.25793                                18                        0.27382

19                    0.29222                                    20                          0.31313                                21                        0.33824

22                    0.36670                                    23                          0.39936                                24                        0.43623

25                    0.47982                                    26                          0.52931                                27                        0.58723

28                    0.65192                                    29                          0.72507                                30                        0.80587

31                    0.89181                                    32                          0.98376                                33                        1.08088

34                    1.18660                                    35                          1.30517                                36                        1.44345

37                    1.60750                                    38                          1.79919                                39                        2.02130

40                    2.27151                                    41                          2.54665                                42                        2.84439

43                    3.16586                                    44                          3.51657                                45                        3.91184

46                    4.36379                                    47                          4.88763                                48                        5.46690

49                    6.19129                                    50                          7.03014                                51                        8.00749

52                    9.14350                                    53                          10.44600                                54                        11.92318

55                    13.53010                                    56                          15.25398                                57                        17.04273

58                    18.84889                                    59                          20.66178                                60                        22.38628

61                    23.93836                                    62                          26.00183                                63                        28.28101

64                    30.86253                                    65                          33.72178                                66                        36.82893

67                    39.87065                                    68                          43.02541                                69                        46.23878

70                    49.44991                                    71                          52.58615                                72                        55.57224

73                    60.05144                                    74                          65.05535                                75                        70.68603

76                    77.06844                                    77                          83.33333                                78                        83.33333

79                    83.33333                                    80                          83.33333                                81                        83.33333

82                    83.33333                                    83                          83.33333                                84                        83.33333

85                    83.33333                                    86]                          83.33333]

Corridor Percentages Table

Death Benefit Qualification Test: [Guideline Premium Test]

See the Death Benefit Qualification Test and Death Benefit Proceeds provisions for an explanation of how this table will be used.

	
 

    Age

	
Corridor

   Percentage

	
 

    Age

	
Corridor

   Percentage

	
[16-40

	
[250%

	
70

	
115%

	
41

	
243

	
71

	
113

	
42

	
236

	
72

	
111

	
43

	
229

	
73

	
109

	
      44

	
      222

	
      74

	
      107

	
45

	
215

	
75

	
105

	
46

	
209

	
76

	
105

	
47

	
203

	
77

	
105

	
48

	
197

	
78

	
105

	
      49

	
      191

	
      79

	
      105

	
50

	
185

	
80

	
105

	
51

	
178

	
81

	
105

	
52

	
171

	
82

	
105

	
53

	
164

	
83

	
105

	
      54

	
      157

	
      84

	
      105

	
55

	
150

	
85

	
105

	
56

	
146

	
86

	
105

	
57

	
142

	
87

	
105

	
58

	
138

	
88

	
105

	
      59

	
      134

	
      89

	
      105

	
60

	
130

	
90

	
105

	
61

	
128

	
91

	
104

	
62

	
126

	
92

	
103

	
63

	
124

	
93

	
102

	
      64

	
      122

	
      94

	
      101

	
65

	
120

	
95

	
100

	
66

	
119

	
96

	
100

	
67

	
118

	
97

	
100

	
68

	
117

	
98

	
100

	
69

	
116

	
99

	
100

	 	 	
100 and

    later]

	
100]

                         

Holding Account Specifications

Guaranteed Minimum Holding Account Interest Rate:

	
1.1

	
% annual effective rate (0.00272616% daily)

Indexed Account Option(s) Specifications

Initial Indexed Account Allocation Date:

The 15th day of the calendar month following the date we process payment of the initial premium.

[Monthly] Indexed Account Allocation Date:

[15th ] day of each calendar month.

Index Bonus

If an Index Bonus is credited, the amount will be equal to (A) times (B) where:

	
(A)

	
Is the reduction in the value of any Segment; and

	
(B)

	
Is a rate not less than the minimum guaranteed Index Bonus Rate of [1.000]%.

The Index Bonus will be credited on the Monthly Anniversary Day, after the processing of the Monthly Deduction, to the most recently opened Segment with a value greater than zero. If multiple Segments were opened on the same allocation date, a prorated portion of the Index Bonus will be credited to each of the Segments.

[Name of Indexed Account Option: [1-Year Point-to-Point - Capped]

Index: ["S & P 500®"]

Segment Duration: [1 year]

Minimum Guaranteed Indexed Participation Rate: [100.00]%

Minimum Guaranteed Indexed Growth Cap: [3.00]%

Minimum Guaranteed Annual Interest Rate Credited to a Maturing Segment: 1.00%

Indexed Credits

Indexed Credits are calculated separately for each Segment on the Segment Maturity Date. Indexed Credits are not calculated or credited to a Segment between Segment Maturity Dates. Any amount deducted from a Segment prior to the Segment Maturity Date will not receive any Indexed Credit. The payment of a full surrender prior to the Segment Maturity Date will result in the Minimum Guaranteed Annual Interest Rate Credited to a Maturing Segment being applied on a prorated basis. The Indexed Credit on the Segment Maturity Date is equal to (A) times (B) where:

	
(A)

	
Is the Indexed Growth Rate; and

	
(B)

	
Is the value of the Segment as of its Segment Maturity Date prior to any Indexed Credit being applied.

If the Indexed Credit for a Maturing Segment results in an effective annual rate less than the Minimum Guaranteed Annual Interest Rate Credited to a Maturing Segment as shown above, then additional interest will be credited as required to equal the minimum rate.

Calculation of the Indexed Growth Rate Used in Determining Indexed Credits: We will determine the Indexed Interest Growth Rate in effect on a Segment Maturity Date subject to any guaranteed factors for the Indexed Account Option as shown above.

Indexed Growth Rate:

The Indexed Growth Rate is equal to [(a/b) – 1] x c; not to exceed d where:

A = the closing value of the Index as of the Segment Maturity Date; B = the closing value of the Index as of the Segment Date;

C = the Participation Rate in effect on the Segment Date; and D = the Indexed Growth Cap in effect on the Segment Date.

[The S&P 500 Index is a product of S&P Dow Jones Indices LLC ("SPDJI"), and has been licensed for use by the Lincoln Life & Annuity Company of New York. Standard & Poor's®, S&P® and S&P 500® are registered trademarks of Standard & Poor's Financial Services LLC ("S&P"); Dow Jones® is a registered trademark of Dow Jones Trademark Holdings LLC ("Dow Jones"); and these trademarks have been licensed for use by SPDJI and sublicensed for certain purposes by Lincoln Life & Annuity Company of New York. Lincoln Life & Annuity Company of New York's product is not sponsored, endorsed, sold or promoted by SPDJI, Dow Jones, S&P, their respective affiliates, and none of such parties make any representation regarding the advisability of investing in such product nor do they have any liability for any errors, omissions, or interruptions of the S&P 500 Index.]

Name of Indexed Account Option: [1-Year Point-to-Point - Capped]

Participation Rate

A factor used in calculating the Indexed Growth Rate and the Indexed Credit applicable to a Segment. We will declare the Participation Rate applicable to a Segment at the beginning of the Segment year. We guarantee that the Participation Rate will never be less than the Minimum Guaranteed Indexed Participation Rate shown above.

Indexed Growth Cap

A factor used in calculating the Indexed Growth Rate and the Indexed Credit applicable to a Segment. We will declare the Indexed Growth Cap applicable to a Segment at the beginning of the Segment year. We guarantee that the Indexed Growth Cap will never be less than the Minimum Guaranteed Indexed Growth Cap as shown above.]

[Name of Indexed Account Option: [1-Year Point-to-Point - Uncapped]

Index: ["S & P 500®"]

Segment Duration: [1 year]

Minimum Guaranteed Indexed Participation Rate: [15.00]%

Minimum Guaranteed Annual Interest Rate Credited to a Maturing Segment: 1.00%

Indexed Credits

Indexed Credits are calculated separately for each Segment on the Segment Maturity Date. Indexed Credits are not calculated or credited to a Segment between Segment Maturity Dates. Any amount deducted from a Segment prior to the Segment Maturity Date will not receive any Indexed Credit. The payment of a full surrender prior to the Segment Maturity Date will result in the Minimum Guaranteed Annual Interest Rate Credited to a Maturing Segment being applied on a prorated basis. The Indexed Credit on the Segment Maturity Date is equal to (A) times (B) where:

	
(A)

	
Is the Indexed Growth Rate; and

	
(B)

	
Is the value of the Segment as of its Segment Maturity Date prior to any Indexed Credit being applied.

If the Indexed Credit for a Maturing Segment results in an effective annual rate less than the Minimum Guaranteed Annual Interest Rate Credited to a Maturing Segment as shown above, then additional interest will be credited as required to equal the minimum rate.

Calculation of the Indexed Growth Rate Used in Determining Indexed Credits: We will determine the Indexed Interest Growth Rate in effect on a Segment Maturity Date subject to any guaranteed factors for the Indexed Account Option as shown above.

Indexed Growth Rate:

The Indexed Growth Rate is equal to [(a/b) – 1] x c; where:

A = the closing value of the Index as of the Segment Maturity Date; B = the closing value of the Index as of the Segment Date; and

C = the Participation Rate in effect on the Segment Date.

[The S&P 500 Index is a product of S&P Dow Jones Indices LLC ("SPDJI"), and has been licensed for use by the Lincoln Life & Annuity Company of New York. Standard & Poor's®, S&P® and S&P 500® are registered trademarks of Standard & Poor's Financial Services LLC ("S&P"); Dow Jones® is a registered trademark of Dow Jones Trademark Holdings LLC ("Dow Jones"); and these trademarks have been licensed for use by SPDJI and sublicensed for certain purposes by Lincoln Life & Annuity Company of New York. Lincoln Life & Annuity Company of New York's product is not sponsored, endorsed, sold or promoted by SPDJI, Dow Jones, S&P, their respective affiliates, and none of such parties make any representation regarding the advisability of investing in such product nor do they have any liability for any errors, omissions, or interruptions of the S&P 500 Index.]

Name of Indexed Account Option: [1-Year Point-to-Point - Uncapped] (continued)

Participation Rate

A factor used in calculating the Indexed Growth Rate and the Indexed Credit applicable to a Segment. We will declare the Participation Rate applicable to a Segment at the beginning of the Segment year. We guarantee that the Participation Rate will never be less than the Minimum Guaranteed Indexed Participation Rate shown above.]

[Name of Indexed Account Option: [1-Year Point-to-Point – High Participation]

Index: ["S & P 500®"]

Segment Duration: [1 year]

Minimum Guaranteed Indexed Participation Rate: [140.00]%

Minimum Guaranteed Indexed Growth Cap: [3.00]%

Minimum Guaranteed Annual Interest Rate Credited to a Maturing Segment: 1.00%

Indexed Credits

Indexed Credits are calculated separately for each Segment on the Segment Maturity Date. Indexed Credits are not calculated or credited to a Segment between Segment Maturity Dates. Any amount deducted from a Segment prior to the Segment Maturity Date will not receive any Indexed Credit. The payment of a full surrender prior to the Segment Maturity Date will result in the Minimum Guaranteed Annual Interest Rate Credited to a Maturing Segment being applied on a prorated basis. The Indexed Credit on the Segment Maturity Date is equal to (A) times (B) where:

	
(A)

	
Is the Indexed Growth Rate; and

	
(B)

	
Is the value of the Segment as of its Segment Maturity Date prior to any Indexed Credit being applied.

If the Indexed Credit for a Maturing Segment results in an effective annual rate less than the Minimum Guaranteed Annual Interest Rate Credited to a Maturing Segment as shown above, then additional interest will be credited as required to equal the minimum rate.

Calculation of the Indexed Growth Rate Used in Determining Indexed Credits: We will determine the Indexed Interest Growth Rate in effect on a Segment Maturity Date subject to any guaranteed factors for the Indexed Account Option as shown above.

Indexed Growth Rate:

The Indexed Growth Rate is equal to [(a/b) – 1] x c; not to exceed d where:

A = the closing value of the Index as of the Segment Maturity Date; B = the closing value of the Index as of the Segment Date;

C = the Participation Rate in effect on the Segment Date; and D = the Indexed Growth Cap in effect on the Segment Date.

[The S&P 500 Index is a product of S&P Dow Jones Indices LLC ("SPDJI"), and has been licensed for use by the Lincoln Life & Annuity Company of New York. Standard & Poor's®, S&P® and S&P 500® are registered trademarks of Standard & Poor's Financial Services LLC ("S&P"); Dow Jones® is a registered trademark of Dow Jones Trademark Holdings LLC ("Dow Jones"); and these trademarks have been licensed for use by SPDJI and sublicensed for certain purposes by Lincoln Life & Annuity Company of New York. Lincoln Life & Annuity Company of New York's product is not sponsored, endorsed, sold or promoted by SPDJI, Dow Jones, S&P, their respective affiliates, and none of such parties make any representation regarding the advisability of investing in such product nor do they have any liability for any errors, omissions, or interruptions of the S&P 500 Index.]

Name of Indexed Account Option: [1-Year Point-to-Point – High Participation]

Participation Rate

A factor used in calculating the Indexed Growth Rate and the Indexed Credit applicable to a Segment. We will declare the Participation Rate applicable to a Segment at the beginning of the Segment year. We guarantee that the Participation Rate will never be less than the Minimum Guaranteed Indexed Participation Rate shown above.

Indexed Growth Cap

A factor used in calculating the Indexed Growth Rate and the Indexed Credit applicable to a Segment. We will declare the Indexed Growth Cap applicable to a Segment at the beginning of the Segment year. We guarantee that the Indexed Growth Cap will never be less than the Minimum Guaranteed Indexed Growth Cap as shown above.]

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