Document:

Contract

 Brighthouse Life Insurance Company 

(A Stock Company) 
 1209 Orange Street 

Wilmington, DE 19801 
 NOTICE 

To obtain information about your policy or if you need assistance or need help in resolving a complaint, you may call (800)-638-7732. 

Brighthouse Life Insurance Company (referred to as “we”, “us”, “our”, and the “Company”) will make Income
Payments as described in this Contract beginning on the Annuity Date. 
 This Policy is a legal contract between the policyholder and the Company.

 FREE LOOK PROVISION - RIGHT TO CANCEL 
 This Contract may
be returned for any reason within 10 days after you receive it by mailing or delivering the Contract to either us or the agent who sold it. Return of this Contract by mail is effective on being postmarked, properly addressed and postage prepaid. We
will promptly refund your Account Value as of the Business Day we receive your Contract. Your Account Value may be more or less than your Purchase Payment. 
 Signed
for the Company. 
  

			
	

	  	

		
	Secretary	  	President

 SINGLE PREMIUM DEFERRED ANNUITY CONTRACT 

This Contract contains Shield Options and a Fixed Account. The initial interest rate for the Fixed Account is guaranteed for one year. 

NONPARTICIPATING 
 READ YOUR CONTRACT
CAREFULLY. 
 VALUES AND DETERMINATION OF ANNUITY PAYMENTS PROVIDED BY THIS CONTRACT, WHEN BASED ON THE VALUE OF THE SHIELD OPTION(S), ARE
VARIABLE, MAY INCREASE OR DECREASE, AND ARE NOT GUARANTEED AS TO FIXED DOLLAR AMOUNT. 

  

					
	L-22494 (09/12)-AV	 		 	

 TABLE OF CONTENTS 
  

			
	 	  	PAGE
		
	 CONTRACT SCHEDULE
	  	3
		
	 DEFINITIONS
	  	4
		
	 GENERAL PROVISIONS
	  	5
		
	 ANNUITANT, OWNERSHIP, ASSIGNMENT PROVISIONS
	  	6
		
	 BENEFICIARY PROVISIONS
	  	7
		
	 PURCHASE PAYMENT PROVISIONS
	  	7
		
	 RENEWAL PROVISIONS
	  	8
		
	 ACCOUNT VALUE PROVISIONS
	  	8
		
	 WITHDRAWAL PROVISIONS
	  	11
		
	 DEATH BENEFIT PROVISIONS
	  	11
		
	 ANNUITY PROVISIONS
	  	12

  

					
	L-22494 (09/12)-AV	 		 	

 DEFINITIONS 

Account Value 
 Is the total of the value of the Shield
Option(s) under this Contract, adjusted for any amounts that may be included by rider during the Accumulation Period. Also referred to as “Contract Value.” 

Accumulation Period 
 The period prior to the
Annuity Date. 
 Annuity Service Office 

The office indicated on the Contract Schedule to which notices and requests must be sent, or as otherwise changed by notice from us. 

Annuitant 
 The natural person listed on the
Contract Schedule on whose life Income Payments are based. Any reference to Annuitant shall also include any Joint Annuitant under an Annuity Option. 

Annuity Date 
 A date on which you choose to
begin receiving Income Payments. If we agree, you may change the Annuity Date subject to the requirements shown under the Annuity Option Information section on the Contract Schedule. If you do not choose an Annuity Date, the Annuity Date will be the
Annuity Date described on the Contract Schedule. Also referred to as “Maturity Date.” 
 Attained Age 

The age of any Owner, Beneficiary or Annuitant on his/her last birthday. 

Beneficiary 
 The person(s) or entity(ies) you
name to receive a death benefit payable under this Contract upon the death of the Owner or a Joint Owner, or in certain circumstances, an Annuitant. 

Business Day 
 Any day our Annuity Service
Office, shown on the Contract Schedule, is open for business. For purposes of administrative requests and transactions, a Business Day ends at 4:00PM Eastern Standard Time. 

Code 
 The Internal Revenue Code of 1986, as
amended. 
 Company 
 Brighthouse Life
Insurance Company 
 Contract Anniversary 

An anniversary of the Issue Date of this Contract. 

Contract Year 
 A one-year period starting on
the Issue Date and on each Contract Anniversary thereafter. 
 Income Payments 

A series of payments made by us during an Income Period, which we guarantee as to dollar amount. 

Income Period 
 A period starting on an
Annuity Date during which Income Payments are payable. 
 Investment Amount 

The Investment Amount for each Shield Option is the amount that is allocated to the Shield Option. The Investment Amount will be reduced for any
withdrawal by the same percentage that the withdrawal reduces the Interim Value attributable to that Shield Option. The Investment Amount is adjusted by the Performance Rate at the end of the Term. 

Issue Date 
 The date this Contract was
issued. The Issue Date is shown on the Contract Schedule. 

  

					
	L-22494 (09/12)	 	4	 	

 Joint Owner 

If there is more than one Owner, each Owner shall be a Joint Owner of the Contract. 

Notice 
 Any form of communication providing
information we need, either in a signed writing or another manner that we approve in advance. All Notices to us must be sent to our Annuity Service Office and received in good order. To be effective for a Business Day, a Notice must be received in
good order prior to the end of that Business Day. 
 Owner 

The person(s) entitled to the ownership rights under this Contract. If Joint Owners are named, all references to Owner shall mean Joint Owners. (Referred
to as “you”, “yours” or “policyholder.”) 
 Purchase Payment 

The amount paid to us under this Contract as consideration for the benefits it provides. 

GENERAL PROVISIONS 

The Contract 
 The Contract consists of this
contract and any attached riders or endorsements. We may require this Contract to be returned to us prior to the payment of any benefit. It is important to review any riders or endorsements. In case of conflict with any other provision of this
Contract, the provisions of the Rider or Endorsement will control. 
 Notwithstanding any provision of this Contract to the contrary, this Contract
will be construed and administered in accordance with applicable sections of the Code. To preserve this Contract’s status as an annuity and comply with applicable sections of the Code and applicable Treasury Regulations, we may, if necessary
amend this Contract. We will notify you of any amendments and, when required by law, we will obtain your approval and the approval of the appropriate regulatory authority. 

Non-Participating 
 This Contract will not
share in any distribution by us of Company dividends. 
 Misstatement of Age or Sex 

We may require proof of the age or sex of the Annuitant, Owner and/or Beneficiary before making any payments under this Contract that are measured by the
Annuitant’s, Owner’s or Beneficiary’s life. If the age or sex of the Annuitant, Owner or Beneficiary has been misstated, the amount payable will be the amount that the Account Value would have provided at the correct age and sex. 

Once Income Payments have begun, any underpayments will be made up in one sum with the next Income Payment or in any other manner agreed to by us. Any
overpayments will be deducted first from future Income Payments. No interest will be credited or charged in the event of an underpayment or overpayment. 

Protection of Proceeds 
 The Contract and
payments under it will be exempt from the claims of creditors to the extent permitted by law. 
 Reports 

At least once each calendar year we will furnish you with a report showing the Account Value and any other information as may be required by law. We will
send you confirmations of certain transactions. Reports and confirmations will be sent to your last known address on our records. You will have 60 days from the date you receive your report or confirmation to inform us of any errors in the report or
confirmation, otherwise the report or confirmation will be deemed to be final and correct. 
 Premium and Other Taxes 

We reserve the right to deduct from the Purchase Payment or Account Value any taxes paid by us to any governmental entity relating to this Contract
(including without limitation: premium taxes, federal, state and local withholding of income, estate, inheritance and other taxes required by law, and any new or increased state income taxes that may be enacted into law). 

We may determine when taxes relate to the Contract, including for example when they have resulted from: receipt by us of the Purchase Payment;
commencement of Income Payments, payment of death benefits; or partial and full withdrawals; and any new or increased taxes which become effective that are imposed on us and which relate to the Purchase Payment, or interest earnings.

  

					
	L-22494 (09/12)	 	5	 	

 
We may pay taxes when due and make a deduction from the Account Value at a later date. Payment at an earlier date does not waive any right we may have to deduct amounts at a later date. 

Evidence of Survival 
 We may require proof
that any person(s) on whose life Income Payments are based is alive. We reserve the right to discontinue Income Payments until satisfactory proof is received. 

Modification of Contract 
 This Contract may
be changed by us in order to maintain compliance with applicable state and federal law. This Contract may be changed or altered only in writing signed by our President, Vice-President, or Secretary. 

Deferral of Payments 
 After receipt of a
Notice of withdrawal from you, we reserve the right to defer payment for a withdrawal for the period permitted by law but not for more than six (6) months. 

Suspension of Payments or Transfers 
 We may
be required to suspend or delay the payment of death benefits, the calculation of income payments, withdrawals, and transfers when we cannot obtain an Index Value under the following circumstances: 

 

	 	•	 	 the New York Stock Exchange is closed (other than customary weekend and holiday closings); 

 

	 	•	 	 trading on the New York Stock Exchange is restricted; 

 

	 	•	 	 an emergency exists such that we cannot value Investment Amounts; or 

 

	 	•	 	 during any other period when a regulator by order, so permits. 

ANNUITANT, OWNERSHIP, ASSIGNMENT PROVISIONS 

Owner 
 You, as the Owner, have all the
interest and rights under this Contract. The Owner is the person designated as such on the Issue Date, unless changed. 
 You may change the Owner at
any time. Any change of Owner is subject to our underwriting requirements in effect at the time of the request. A change of Owner will automatically revoke any prior designation of Owner. A request for change must be: 

 

	 	1.	 by Notice; and 

  

	 	2.	 received by us at the Annuity Service Office. 

The change will become effective as of the date the Notice is signed by you. A new designation of Owner will not apply to any payment made or action
taken by us prior to the time the new designation was recorded at our Annuity Service Office. 
 Joint Owner 

A Contract may be owned by Joint Owners, limited to natural persons. Either Joint Owner can exercise all rights under the Contract unless you inform us
otherwise as indicated on the Contract Schedule or in a Notice to us. Upon the death of either Owner, the surviving Joint Owner will be deemed to be the primary Beneficiary unless you inform us otherwise. Any other Beneficiary designation will be
treated as a contingent Beneficiary unless otherwise indicated on the Contract Schedule or in a Notice to us. 
 Annuitant 

The Annuitant is the person designated by you, the events in the life of whom are of primary importance in affecting the timing or amount of the payout
under the contract. Unless the Contract is owned by a non-natural person, you may change the Annuitant at any time prior to an Annuity Date. Any change of Annuitant is subject to our underwriting rules in effect at the time of the request. 

Assignment 
 This Contract may not be assigned
without our consent in writing and is subject to our underwriting requirements. You may not assign your rights under this Contract after the start of Income Payments. In certain tax markets assignment of this Contract is prohibited by the Internal
Revenue Code. If your contract is assigned absolutely, we will treat it as a change of ownership and all rights will be transferred. We are not bound by any assignment request unless it is in writing. We are not responsible for the validity of any
assignment. Assignments, unless otherwise specified by the Owner, shall 

  

					
	L-22494 (09/12)	 	6	 	

 
take effect on the date the notice of assignment is signed, subject to any payments made or actions taken by us before a signed copy of the assignment form is received by us at our Annuity
Service Office. 
 BENEFICIARY PROVISIONS 

Beneficiary 
 The Beneficiary is the person(s) named on the
Contract Schedule or the surviving Joint Owner, unless changed. Unless you provide otherwise, the death benefit will be paid to or in equal shares as follows: 
  

	 	1.	 to the primary Beneficiary(ies) who survive you (or who survive the Annuitant if the Owner is a non-natural person); or
if there are none, then 

  

	 	2.	 to the contingent Beneficiary(ies) who survive you (or who survive the Annuitant if the Owner is a non-natural person);
or if there are none, then 

  

	 	3.	 to your estate. 

Change of Beneficiary 
 Subject to the rights,
including the written consent, of any irrevocable Beneficiary and any applicable laws or regulations, you may change the primary Beneficiary or contingent Beneficiary. A change may be made by filing a Notice with us. The change will take effect as
of the date the Notice is signed, but we will not be liable for any payment made or action taken before we have recorded the change. 
 
PURCHASE PAYMENT PROVISIONS 
 Separate Account 
 The
Purchase Payment made to this Contract is invested in the Separate Account shown on the Contract Schedule. We have exclusive and absolute ownership and control of the assets of the Separate Account. It is a non-unitized separate account. You do not
share in the investment performance of assets allocated to the Separate Account. All investment income, gains and losses, whether or not realized, from assets allocated to the Separate Account are borne by the Company. The obligations under this
Contract are independent of the investment performance of the Separate Account and are the obligations of the Company. 
 We will maintain in the
Separate Account assets with an aggregate value at least equal to the Contract reserves. 
 If the aggregate value of such assets should fall below
such amount, the Company will transfer assets into the Separate Account so that the value of the Separate Account’s assets is at least equal to such amount. Assets supporting reserves for annuity benefits under such contracts, in the course of
payment, shall not be maintained in the Separate Account. 
 Shield Options 

On the Issue Date, you may allocate your Purchase Payment to one or more of the available Shield Options listed on the Contract Schedule. At the end of
each Term, you may transfer the Account Value attributable to the Shield Option(s) to one or more of the available Shield Options subject to the Transfer Requirements shown on the Contract Schedule and the Renewal Provisions. 

Each Shield Option has an associated Index, Term, Shield Rate, and either a Cap Rate or a Step Rate as defined below. 

Term 
 The initial Term(s) begin on the Issue
Date. A Term ends and a subsequent Term begins, on the Contract Anniversary coinciding with the term duration of the then current Term for that Shield Option. 

Index 
 There is a specific Index associated
with each Shield Option. The Index is the price index of certain securities, excluding dividends, or commodities. 
 Index Value 

The Index Value of an Index, on a Business Day, is the published closing value of the Index on that Business Day. We will use consistent sources to
obtain Index Values. If these sources are no longer available for specific indices, we will select an alternative published source(s) for these Index Values. The Index Value on any day that is not a Business Day is the value as of the prior Business
Day. 

  

					
	L-22494 (09/12)	 	7	 	

 Index Performance 

Index Performance is the percentage change in an Index Value measured from the beginning of a Term to any day, including the last day, within the Term.
Index Performance can be positive, negative, or zero. 
 Shield Rate 

The Shield Rate is the amount of any negative Index Performance that is absorbed by us at the end of the Term. Any negative Index Performance beyond the
Shield Rate will reduce the Investment Amount. For example, a -15% Index Performance with a 10% Shield Rate will result in a -5% Performance Rate; or, a -10% Index Performance with a 25% Shield Rate will result in a 0% Performance Rate. 

The Shield Rate may vary between Shield Options, and it is not an annual rate. 

Cap Rate 
 The Cap Rate is the maximum rate
that may be credited at the end of a Term based on Index Performance. A new Cap Rate is declared for each subsequent Term, and such rate will not be less than the Minimum Guaranteed Cap Rate on the Contract Schedule. 

The Cap Rate may vary between Shield Options, and it is not an annual rate. 

Step Rate 
 The Step Rate is the rate credited
at the end of a Term if the Index Performance is greater than or equal to zero. A new Step Rate is declared for each subsequent Term, and such rate will not be less than the Minimum Guaranteed Step Rate on the Contract Schedule. 

The Step Rate may vary between Shield Options, and it is not an annual rate. 

RENEWAL PROVISIONS 

For renewals into the same Shield Option, a new Cap Rate or Step Rate, whichever is applicable, will be declared and will go into effect on the Contract
Anniversary that coincides with the beginning of the new Shield Option. 
 Discontinuation or Substantial Change to an Index 

If any Index is discontinued or, we determine that our use of such Index should be discontinued, or if the calculation of an Index is substantially
changed, we may substitute a comparable index. We will send you a notice in writing before any such substitution is made. Upon substitution of an Index, we will calculate your Index Performance on the existing Index up until the date of substitution
and the new Index from the date of substitution to the end of the Term. A substitute Index will not change the Shield Rate, Cap Rate or Step Rate for an existing Shield Option. 

Addition or Discontinuance of a Shield Option 

We can add or discontinue any Shield Option. When a change is made to the Shield Options or Indices referenced on the Contract Schedule or as changed
subsequent to the Issue Date, we will send notification to you which will describe any changes to the Shield Options then available under the Contract as required by law. This change will take effect upon your Contract as of the next Contract
Anniversary for any allowable transfers into the Shield Option(s). If you are currently invested in a Shield Option which is no longer available, you will remain in that Shield Option until the end of the Term, but that Shield Option will not be
available thereafter. 
 ACCOUNT VALUE PROVISIONS 

The Account Value attributable to each Shield Option is as determined below and will be the Interim Value on any day during the Term and the Investment
Amount as adjusted for the Performance Rate at the end of the Term as defined below subject to any fees as outlined in the Contract Schedule or via any riders or endorsements. 

Charges and Fees 
 We will deduct charges and
fees from your Account Value as described on the Contract Schedule (or any applicable riders or endorsements). 
 Performance Rate 

The Performance Rate is the rate credited at the end of the Term. The Performance Rate at the end of a particular Term is the Index Performance, adjusted
for the applicable Shield Rate, Cap Rate, or Step Rate. The Performance Rate can be positive, negative, or equal to zero. At the end of the Term, any increase or reduction in a particular Shield Option is determined by multiplying the Performance
Rate by the Investment Amount of the Shield Option on the last day of the 

  

					
	L-22494 (09/12)	 	8	 	

 
Term. 
 The Performance Rate is determined as follows: 

Shield 100 Option with a Cap Rate: 
 If Index
Performance is equal to or less than zero, then the Performance Rate will be zero. 
 If Index Performance is greater than zero and less than the Cap
Rate, then the Performance Rate will equal the Index Performance. 
 If the Index Performance is greater than zero and equals or exceeds the Cap Rate,
then the Performance Rate will equal the Cap Rate. 
 Shield 100 Option with a Step Rate: 

If Index Performance is less than zero then the Performance Rate will equal zero. 

If Index Performance is equal to or greater than zero, the Performance Rate will equal the Step Rate. 

Other Shield Options with a Cap Rate: 
 If
Index Performance is equal to or less than zero, then the Performance Rate will equal the lesser of zero, or the Index Performance increased by the Shield Rate. (For example: a -15% Index Performance with a 10% Shield Rate will result in a -5%
Performance Rate.) The Performance Rate can never be greater than zero if the Index Performance is negative. 
 If Index Performance is greater than
zero and less than the Cap Rate, then the Performance Rate will equal the Index Performance. 
 If Index Performance is greater than zero and equals or
exceeds the Cap Rate, then the Performance Rate will equal the Cap Rate. 
 Other Shield Options with a Step Rate: 

If Index Performance is less than zero, then the Performance Rate will equal the lesser of zero or the Index Performance increased by the Shield Rate.
(For example: a -15%Index Performance with a 10% Shield Rate will result in a -5% Performance Rate.) The Performance Rate can never be greater than zero if the Index Performance is negative. 

If Index Performance is equal to or greater than zero, the Performance Rate will equal the Step Rate. 

Interim Value 
 The Interim Value for each
Shield Option is the value we assign on any Business Day prior to the end of the Term. During the Transfer Period set forth in the Contract Schedule, the Interim Value of each Shield Option will equal the Investment Amount in that Shield Option.
After the Transfer Period, the Interim Value of that Shield Option is equal to the Investment Amount in the Shield Option, adjusted for the Index Performance of the associated Index and subject to the applicable Accrued Shield Rate, Accrued Cap
Rate, or Accrued Step Rate, as defined below. 
 On the date of a withdrawal from the Shield Option(s), your Interim Value will be reduced by the
amount withdrawn. 
 Accrued Shield Rate 

The Accrued Shield Rate is the portion of the Shield Rate that has accrued from the beginning of a Term to any day within the Term. This is the amount
that will be applied in calculating the Interim Value on any day prior to the end of the Term if Index Performance is less than zero. The Accrued Shield Rate is equal to the Shield Rate multiplied by the number of days elapsed since the beginning of
the Term, divided by the total number of days in the Term. 
 Accrued Cap Rate 

The Accrued Cap Rate is the portion of the Cap Rate that has accrued from the beginning of a Term to any day within the Term. This is the maximum Index
Performance that may be applied in calculating the Interim Value on any day prior to the end of the Term if Index Performance is greater than zero. The Accrued Cap Rate is equal to the Cap Rate multiplied by the number of days elapsed since the
beginning of the Term, divided by the total number of days in the Term. 
 Accrued Step Rate 

The Accrued Step Rate is the portion of the Step Rate that has accrued from the beginning of a Term to any day within the Term. This is the rate that
will be applied in calculating the Interim Value on any day prior to the end of the Term if Index Performance is equal to or greater than zero. The Accrued Step Rate is equal to the Step Rate multiplied by the number of days elapsed since the
beginning of the Term divided by the total number of days in the Term. 

  

					
	L-22494 (09/12)	 	9	 	

 Performance Rate for Determination of Interim Value 

Except as indicated on the Contract Schedule, the Performance Rate during a particular Term is the Index Performance, adjusted for the applicable Accrued
Shield Rate, Accrued Cap Rate, or Accrued Step Rate. 
 For purposes of determining the Accrued Shield Rate, Accrued Cap Rate, and Accrued Step Rate,
the total number of days in each calendar year of a Term is 365. 
 The following are hypothetical examples that show the determination of the Interim
Value when the Index Performance is greater than zero and less than zero. These hypothetical examples are rounded for illustrative purposes: 

Example #1 – Index Performance is positive – Interim Value calculated 306 days into a Term of 3 Years. 

 

			
	 Issue Date
	 	 March 1, 2013

		
	 Investment Amount
	 	 $100,000

		
	 Shield Option
	 	 XYZ 10

		
	 Term
	 	 3 Years

		
	 Shield Rate
	 	 10%

		
	 Cap Rate
	 	 25%

		
	 Index Value at Beginning of Term
	 	 1000

		
	 Number of Days in Term
	 	 1095 (3 X 365 = 1095)

		
	 Index Value at close of Business Day on January 1, 2014
	 	 1100

		
	 Index Performance
	 	 10%

		
	 Accrued Days
	 	 306

 The Accrued Cap Rate as of January 1, 2014 is 6.986% 306 days into the 3 year term (25%*(306/1095)). The Index
Performance is calculated at 10% (1100/1000 - 1). Since the Index Performance is positive, the Interim Value is then determined by multiplying the Investment Amount by the lesser of the Index Performance or the Accrued Cap Rate and adding that
amount to the Investment Amount. As of the close of the Business Day January 1, 2014, the Interim Value is $106,986 ($100,000+$100,000 * 6.986%). 
 Example
#2 – Index Performance is negative– Interim Value calculated 306 days into a Term of 3 Years. 
  

			
	 Issue Date
	 	 March 1, 2013

		
	 Investment Amount
	 	 $100,000

		
	 Shield Option
	 	 XYZ 10

		
	 Term
	 	 3 Years

		
	 Shield Rate
	 	 10%

		
	 Cap Rate
	 	 25%

		
	 Index Value at Beginning of Term
	 	 1000

		
	 Number of Days in Term
	 	 1095 (3 X 365 = 1095)

		
	 Index Value at close of Business Day on January 1, 2014
	 	 950

		
	 Index Performance
	 	 -5%

		
	 Accrued Days
	 	 306

 The Accrued Shield Rate as of January 1, 2014 is 2.795% 306 days into the 3 year term (10% * (306/1095)). The Index
Performance is calculated at -5% (950/1000 - 1). Since the Index Performance is negative, the Interim Value is then determined by multiplying the Investment Amount by the Index Performance plus the Accrued Shield Rate (-5% + 2.795% = -2.205%) and
adding that amount to the Investment Amount. As of the close of Business Day January 1, 2014, the Interim Value is $97,795 ($100,000+$100,000*-2.205%). 

  

					
	L-22494 (09/12)	 	10	 	

 WITHDRAWAL PROVISIONS 

Withdrawals 
 Prior to the Annuity Date, you
may, upon Notice to us, request a full or a partial withdrawal and we will withdraw that amount from the Account Value (“the amount withdrawn”). A withdrawal will result in a reduction to each Shield Option in the ratio that each Shield
Option bears to the total Account Value, as determined under the Account Value Provisions above, unless otherwise directed by you. The amount payable to you will be a net amount equal to the amount withdrawn adjusted for any applicable Withdrawal
Charge and any other fees shown on the Contract Schedule, Premium and Other Taxes, and any other rider and endorsement fees. 
 The total amount
withdrawn from the Account Value must not be less than the Minimum Partial Withdrawal amount shown on the Contract Schedule. If the withdrawal would result in the remaining Account Value being less than the Minimum Account Value shown on the
Contract Schedule, we will treat the withdrawal request as a request for a full withdrawal. 
 If you request a full or partial withdrawal, the amount
withdrawn after adjustments for any Withdrawal Charge will result in our paying you a net amount. The net amount payable to you is equal to (a)-(b)-(c)-(d), where: 
  

	 	(a)	 is the amount withdrawn from the Account Value, and 

 

	 	(b)	 is the Withdrawal Charge and other fees, if any, as described on the Contract Schedule, and 

 

	 	(c)	 is the Premium and Other Taxes, if any, and 

 

	 	(d)	 is the rider and endorsement fees, if any. 

The amount withdrawn will reduce the Investment Amount, as defined in the Definitions section, for each Shield Option by the percentage reduction in the
Interim Value of such Shield Option. 
 DEATH BENEFIT PROVISIONS 

Death of Owner During the Accumulation Period 

During the Accumulation Period, the death benefit will be paid to your Beneficiary(ies) upon your death, or the first death of a Joint Owner. If the
Contract is owned by a non-natural person, the Annuitant will be deemed the Owner for purposes of determining the death benefit. If there are Joint Owners, the age of the oldest will be used to determine the death benefit where applicable. 

Death Benefit Amount During the Accumulation Period 

The “Death Benefit Amount” is the Account Value, as defined under the Account Value Provisions above, determined as of the end of the Business
Day on which we have received Notice of both due proof of death and the first acceptable election for the payment method. 
 Death Benefit Options
During the Accumulation Period 
 In the event an Owner (or the Annuitant where the Owner is not an individual) dies during the Accumulation
Period, a Beneficiary must choose payment of the death benefit under one of the options below (unless the Owner has previously chosen an option). The death benefit options available under the Contract include the following and any other options
acceptable to you and us: 
 Option 1 - lump sum payment of the death benefit; or 

Option 2 - the payment of the entire death benefit within five years of the date of death of the Owner or the first Joint Owner to die; or

 Option 3 - payment of the death benefit under an Annuity Option or other periodic payment option acceptable to us in substantially equal
periodic payments (made at least annually) over the lifetime of the Beneficiary or over a period not extending beyond the life expectancy of the Beneficiary with distribution beginning within one year of the date of death of the Owner or the first
Joint Owner to die. 
 Any portion of the death benefit not applied under Option 3 within one (1) year of the date of the Owner’s or
Joint Owner’s death must be distributed within five years of the date of death. 
 Beneficiary Continuation Options During Accumulation Period

 We offer two types of Beneficiary Continuation Options during the Accumulation Period: the Spousal Continuation and Non-Spousal Beneficiary
Continuation Options described below. We must receive Notice of the election of one of these Beneficiary Continuation Options by the end of the 90th day after we receive Notice of due proof of death. If the surviving spouse qualifies for Spousal
Continuation and has not chosen one of the death benefit options above by the end of the 90 day period, the Spousal Continuation Option will be automatically applied on the 90th day. If a Non-Spousal Beneficiary

  

					
	L-22494 (09/12)	 	11	 	

 
qualifies for Non-Spousal Beneficiary Continuation and has not chosen one of the death benefit options above by the end of the 90 day period, the Non-Spousal Beneficiary Continuation Option will
be automatically applied on the 90th day. 
 Spousal Continuation During Accumulation Period 

If the Owner dies during the Accumulation Period and the Beneficiary is his or her spouse, the spouse may choose to continue the Contract in his or her
own name and exercise all the Owner’s rights under the Contract. The Death Benefit Amount under the continued contract payable upon the continuing spouse’s death will be computed as described above in the Death Benefit Amount During the
Accumulation Period section. 
 Non-Spousal Beneficiary Continuation During Accumulation Period 

A Beneficiary who is not a spouse can choose to continue the Contract until the fifth anniversary of the Owner’s death. The Contract can be
continued by a Beneficiary only if his or her share of the death benefit is at least equal to our published minimum for this right. If the Beneficiary continues the Contract under this provision his or her share will not be paid. It will instead be
continued in the Contract on the date we determine the Death Benefit Amount. Such Beneficiary will have the right to make partial and full withdrawals of his/her share of the Contract, not subject to Withdrawal Charges. Such Beneficiary will also
have the right to make transfers at the end of a Term as described on the Contract Schedule. 
 During the continuation period the Beneficiary can
choose to receive his/her share of this Contract in a single lump sum payment or apply it to an Annuity Option or other option acceptable to us that must be payable for the life of the Beneficiary or for a term no longer than the life expectancy of
the Beneficiary starting within one year after the death of the Owner. 
 On the fifth anniversary of the Owner’s death any Beneficiary will be
paid his/her share of the Account Value that has not been applied to an Annuity option or other settlement option permissible under the Code, in a single lump sum payment and this Contract will terminate. 

Death of Annuitant During Income Period 
 Upon
the death of the Annuitant during the Income Period, the death benefit, if any, will be as specified in the Annuity Option chosen. Death benefits will be paid at least as rapidly as under the method of distribution in effect at the Annuitant’s
death. 
 Death of Owner During the Income Period 

If the Owner (or a Joint Owner), is not the Annuitant, and dies during the Income Period, any remaining payments under the Annuity Option will continue
at least as rapidly as under the method of distribution in effect at the time of the Owner’s (or Joint Owner’s) death. Upon the death of the Owner (or a Joint Owner) during the Income Period, the Beneficiary becomes entitled to exercise
the rights of the Owner. If an Owner (or Joint Owner) is the Annuitant and dies during the Income Period, the death benefit, if any, will be as specified in the Annuity Option chosen and will continue at least as rapidly as under the method of
distribution in effect at the time of the Owner’s (or Joint Owner’s) death. 
 Death of Annuitant During Accumulation Period 

Upon the death of an Annuitant, who is not the Owner or Joint Owner, during the Accumulation Period, the Owner (or Oldest Joint Owner) automatically
becomes the Annuitant, unless the Owner, subject to our underwriting rules in effect at the time of request, chooses a new Annuitant. If the Owner is a non-natural person, the death of the Annuitant will be treated as the death of an Owner (see
Death of Owner During the Accumulation Period discussed above). 
 Payment of Death Benefit 

We will require Notice of both due proof of death and an acceptable election for the payment method before any death benefit is paid. Our obligations are
subject to all payments made and actions taken by us before our receipt of Notice of due proof of death. 
 Any death benefit will be paid in
accordance with applicable law or regulations governing death benefit payments. 
 ANNUITY PROVISIONS 

Election of Annuity Option 
 The Annuity Option
is chosen by you or your Beneficiary in a form satisfactory to us. We will automatically send you information about Annuity Options before your Annuity Date. If you do not choose an Annuity Option, make a full withdrawal by the Annuity Date, or ask
us to continue the Contract by the Annuity Date, we will automatically pay you under Option 2: Life Annuity with Ten (10) Years of Income Payments Guaranteed. You can make, change, or revoke your Annuity Option choice before the death benefit
becomes payable or the Annuity Date, whichever occurs first. 

  

					
	L-22494 (09/12)	 	12	 	

 Annuity Options 

You may choose to receive Income Payments monthly, quarterly, semi-annually or annually. The following Annuity Options, or any other options acceptable
to you and us, may be chosen: 
 Option 1: Life Annuity 

Income Payments that are paid as long as the Annuitant is living. 

Option 2: Life Annuity with 10 Years of Income Payments Guaranteed 

Income Payments that continue as long as the Annuitant is living but are guaranteed to be paid for ten years. 

Option 3: Joint and Last Survivor Life Annuity 

Income Payments that are paid as long as either of two Annuitants is living. 

Option 4: Joint and Last Survivor Annuity with 10 Years of Income Payments Guaranteed 

Income Payments that continue as long as either of the two Annuitants are living but are guaranteed to be paid for ten years. 

If, as of the Annuity Date, the then current Annuity rates applicable to this class of contracts provide an Income Payment greater than the one
guaranteed under this Contract for the same Annuity Option, then the greater payment will be made. 
 Income Payments 

Income Payments are based upon the Annuity Option chosen, the Account Value, as defined under the Account Value Provisions above, applied to the Annuity
Option, the Annuitant’s Attained Age and sex, and the appropriate Fixed Annuity Table. These payments will be reduced by any applicable charges and fees as described in the Contract Schedule. 

Frequency and Amount of Income Payments 

Income Payments will be paid as monthly installments or at any frequency acceptable to you and us. If the amount of the Account Value to be applied under
an Annuity Option is less than $5,000, we reserve the right to make one lump sum payment equal to the then current Account Value in lieu of Income Payments. If the amount of the Income Payment would be less than $100, we may reduce the frequency of
payments to an interval which will result in the payment being at least $100, but with a frequency of no less than annually. 
 Basis of Payments

 The Annuity Tables are based on the tables defined under the Annuity Option Information described in the Contract Schedule. The amount of each
Income Payment is guaranteed by us. 

  

					
	L-22494 (09/12)	 	13	 	

 [FIXED ANNUITY TABLES 

AMOUNT OF MONTHLY INCOME PAYMENT 
 PER $1000
OF Account Value 
 Annuitant Only 

 

 Option 1: Life Annuity 
  

					
	 Attained Age

of Annuitant
	  	Male	  	Female            
	 55
	  	2.74	  	2.59
	 60
	  	3.07	  	2.89
	 65
	  	3.50	  	3.27
	 70
	  	4.07	  	3.77
	 75
	  	4.84	  	4.45
	 80
	  	5.93	  	5.42
	 85
	  	7.50	  	6.86

 

 Option 2: Life Annuity with 10 

Years of Income Payments Guaranteed 
  

					
	 Attained Age

of Annuitant
	  	Male	  	Female            
	 55
	  	2.73	  	2.59
	 60
	  	3.05	  	2.88
	 65
	  	3.46	  	3.24
	 70
	  	3.99	  	3.72
	 75
	  	4.66	  	4.34
	 80
	  	5.50	  	5.16
	 85
	  	6.45	  	6.16

 
 

  
 Option 3: Joint and Last Survivor Life Annuity
 
  

											
	 	  	 	  	 	  	 Age of Female Annuitant

						
	 Attained age

of Male Annuitant
	  	10 Years
Younger	  	5 Years Younger	  	 Same

Age
	  	 5 Years

Older
	  	 10 Years            

Older

	 55
	  	2.09	  	2.21	  	2.34	  	2.45	  	2.54
	 60
	  	2.26	  	2.42	  	2.57	  	2.71	  	2.82
	 65
	  	2.48	  	2.67	  	2.86	  	3.04	  	3.19
	 70
	  	2.75	  	3.00	  	3.25	  	3.49	  	3.69
	 75
	  	3.10	  	3.42	  	3.77	  	4.09	  	4.37
	 80
	  	3.55	  	4.00	  	4.48	  	4.95	  	5.33
	 85
	  	4.18	  	4.82	  	5.51	  	6.17	  	6.69

 Option 4: Joint and Last Survivor Annuity with 10 Years of Income Payments Guaranteed 

 

											
	 	  	 	  	 	  	 Age of Female Annuitant

						
	 Attained age

of Male Annuitant
	  	10 Years
Younger	  	5 Years Younger	  	 Same

Age
	  	 5 Years

Older
	  	 10 Years            

Older

	 55
	  	2.09	  	2.21	  	2.34	  	2.45	  	2.54
	 60
	  	2.26	  	2.42	  	2.57	  	2.71	  	2.82
	 65
	  	2.48	  	2.67	  	2.86	  	3.04	  	3.19
	 70
	  	2.75	  	2.99	  	3.25	  	3.48	  	3.68
	 75
	  	3.09	  	3.42	  	3.76	  	4.08	  	4.34
	 80
	  	3.55	  	3.99	  	4.45	  	4.88	  	5.19
	 85
	  	4.15	  	4.76	  	5.38	  	5.89	  	6.22

 Monthly installments for ages not shown will be furnished on request] 

  

					
	L-22494 (09/12)	 	14	 	

  
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BLANK 

  

					
	L-22494 (09/12)	 		 	

 SINGLE PREMIUM DEFERRED ANNUITY CONTRACT 

NONPARTICIPATING 
 NO DIVIDENDS 

BRIGHTHOUSE LIFE INSURANCE COMPANY 
 (A Stock
Company) 
 1209 Orange Street 
 Wilmington, DE 19801

  

					
	L-22494 (09/12)	 		 	

 CONTRACT SCHEDULE 
  

							
	 OWNER: John Doe
	  	 SEX: M
	    	 AGE AT ISSUE:   35
	  	
	 JOINT OWNER: Jane Doe
	  	 SEX: F
	    	 AGE AT ISSUE:   35
	  	
	 ANNUITANT: John Doe
	  	 SEX: M
	    	 AGE AT ISSUE:   35
	  	
	 CONTRACT NUMBER: 12345678
	  	 ISSUE DATE: February 15, 2013
	  	
	 PLAN TYPE: Non-Qualified
	  	 ANNUITY DATE: February 15, 2068
	  	

 SINGLE PURCHASE PAYMENT:  $25,000.00 

SHIELD OPTIONS 
 SEPARATE ACCOUNT:
          Brighthouse Separate Account SA 
 Shield Options and Indices by Term Available at Issue: 

Each Shield Option will have an associated Cap Rate or a Step Rate.  
  

					
	Shield Options
	Term	  	Index	  	  Minimum Guaranteed Cap/Step Rate  
	Shield 15
	 	  	S&P 500® Index	  	8.00%
	6 Year Term	  	Russell 2000® Index	  	8.00%
	 	  	MSCI EAFE Index	  	8.00%
	Shield 10
	 	  	S&P 500® Index1 	  	2.00%
	 	  	S&P 500® Index Step Rate	  	1.50%
	1 Year Term	  	Russell 2000® Index2 	  	2.00%
	 	  	Russell 2000® Index Step Rate	  	1.50%
	 	  	MSCI EAFE Index3 	  	2.00%
	 	  	MSCI EAFE Index Step Rate	  	1.50%
	 	  	S&P 500® Index	  	8.00%
	6 Year Term	  	Russell 2000® Index	  	8.00%
	 	  	MSCI EAFE Index	  	8.00%

 Index-linked returns do not include the portion of returns generated by dividends; and the elements used in determining
the credited rate from the index are not guaranteed and can be changed by the Company, subject to any contract guarantees, and any such changes can affect the return. 

FIXED ACCOUNT 
 Minimum Guaranteed Interest Rate:
                1.00% annually  
 Interest Rate Term:
                                         
   1 year 
 Minimum Allocation:
                            $500  

TRANSFER REQUIREMENTS: 
 TRANSFER PERIOD: 

The 5 Calendar Days following the Contract Anniversary coinciding with the end of the Term for each applicable Shield Option and/or the end of the
Interest Rate Term for the Fixed Account. 
 TRANSFERS: 

  

					
	L-22495 (09/12)	 	17	 	

 During the Accumulation Period you may only make a transfer to the Fixed Account and to a new Shield
Option(s) during the Transfer Period, subject to availability. The effective date of such transfer is the first day of the Fixed Account Interest Rate Term and/or Shield Option(s) to which the transfer is made. 

At the end of the Term, the Investment Amount will automatically be renewed into the same Shield Option unless you elect to transfer into a different
Shield Option or the Fixed Account Option at that time. If the Shield Option is no longer available at the end of the existing Term, these amounts will automatically transfer into the Fixed Account at the end of the Term unless otherwise directed by
You. If the Fixed Account is not available, these amounts will automatically transfer into the Shield Option with, in order of priority, the shortest Term, the highest Shield Rate, and the lowest Cap Rate from the Shield Options available at the end
of the Term unless otherwise directed by You. 
 At the end of the Interest Rate Term, the Fixed Account Value will automatically be renewed into the
Fixed Account unless you elect to transfer into a Shield Option at that time. If the Fixed Account is no longer available at the end of the existing Fixed Account Term, these amounts will automatically transfer into the Shield Option with, in order
of priority, the shortest Term, the highest Shield Rate, and the lowest Cap Rate from the Shield Options available at the end of the Interest Rate Term unless otherwise directed by You. 

BENEFICIARY: As designated by you as of the Issue Date unless changed in accordance with the Contract provisions. 

WITHDRAWALS: 
 Free Withdrawal Amount:
Each Contract Year after the first Contract Year, you may withdraw a portion of your Account Value free from any Withdrawal Charge. The Free Withdrawal Amount each Contract Year is equal to 10% of the Account Value as of the prior Contract
Anniversary less the total amount withdrawn, as described in the Withdrawal Provisions, from the Account Value in the current Contract Year. The Free Withdrawal Amount is non-cumulative and is not carried over
to other Contract Years.  
 Withdrawal Charge: The Withdrawal Charge is a percentage of the amount withdrawn from the Account Value in a Contract Year
in excess of the Free Withdrawal Amount. The Withdrawal Charge is calculated at the time of each withdrawal using the appropriate withdrawal charge percentage from the following schedule: 

WITHDRAWAL CHARGE PERCENTAGES 
  

					
	Number of Complete	  		 	
	 Contract Years Since Issue	  	% Charge	 	
	Date	  	 	 	 
	                0	  	7%	 
	                1	  	7%	 
	                2	  	6%	 
	                3	  	5%	 
	                4	  	4%	 
	                5	  	3%	 
	                6 or more	  	0%	 

 In addition to any waiver of Withdrawal Charges set forth in the Contract or Rider(s), no Withdrawal Charge will be deducted from
the Account Value in the event of: 
  

	1.	Maturity of the Contract; or 

	2.	Payment of the Death Benefit; or 

	3.	Application of your Account Value to an Annuity Option; or 

	4.	If the withdrawal is required for you to avoid Federal Income Tax penalties or to satisfy Federal Income Tax rules concerning minimum distribution requirements that apply to this annuity (except for RMDs on a decedent
Roth IRA.) For purposes of this exception, we assume that this annuity is the only contract or funding vehicle from which distributions are required to be taken, and we will ignore all other Account Values; or 

	5.	If you properly “re-characterize” as permitted under Federal Tax Law your traditional IRA deferred annuity or Roth IRA deferred annuity issued by us; or 

	6.	If we agree in writing that none will apply. For example, we may waive the Withdrawal Charge if you directly transfer the amount withdrawn to a funding vehicle pre-approved by
us.  

 Minimum Partial Withdrawal:
                $500.00 
 Minimum Account Value which must remain in
the Contract after a Partial Withdrawal: $2,000.00 

  

					
	L-22495 (09/12)	 	18	 	

 ANNUITY OPTION INFORMATION: 

	1.	 The Annuity Date must be the first day of a calendar month. Unless otherwise directed by you, the Annuity Date is the
first day of the calendar month following the Annuitant’s 90th birthday or 10 years from the Issue Date, whichever is later, or a later
date if we agree. 

	2.	 The Annuity Date must not be less than 13 months from the Issue Date. 

	3.	 For Income Payments, the Fixed Annuity Tables are based on the Annuity 2000 Mortality Table with 15 years of mortality
improvement based upon projection Scale AA, a 7 year age setback and interest at 1.00%. 

 ANNUITY SERVICE OFFICE: 

Brighthouse Life Insurance Company 
 P.O. Box 10366 

Des Moines, IA  50306-0366 
 (800)
777-5897 

  

					
	L-22495 (09/12)	 	19	 	

 ENDORSEMENTS AND RIDERS ATTACHED TO THIS CONTRACT: 

Fixed Account Rider 
 Death Benefit Rider – Return of Premium  

Waiver of Withdrawal Charge for Nursing Home Confinement Rider 
 Waiver of Withdrawal
Charge for Terminal Illness Rider  
 Individual Retirement Annuity Qualification Rider  

Roth Individual Retirement Annuity (“Roth IRA”) Endorsement  

Individual Non-Qualified Annuity Endorsement 

  

					
	L-22495 (09/12)	 	20	 	

 1The S&P 500 Index is a product of S&P
Dow Jones Indices LLC (“SPDJI”), and has been licensed for use by affiliates of Brighthouse Financial, Inc. including Brighthouse Services, LLC and Brighthouse Life Insurance Company (collectively, “Brighthouse Financial”).
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 Brighthouse Financial. This annuity product is not sponsored, endorsed, sold or promoted by SPDJI, Dow Jones, S&P, any of their respective
affiliates (collectively, “S&P Dow Jones Indices”). S&P Dow Jones Indices makes no representation or warranty, express or implied, to the owners of this annuity product any member of the public regarding the advisability of
investing in securities generally or in this annuity product particularly or the ability of the S&P 500 Index to track general market performance. S&P Dow Jones Indices’ only relationship to Brighthouse Financial with respect to the
S&P 500 Index is the licensing of the Index and certain trademarks, service marks and/or trade names of S&P Dow Jones Indices or its licensors. The S&P 500 Index is determined, composed and calculated by S&P Dow Jones Indices without
regard to Brighthouse Financial or this annuity product. S&P Dow Jones Indices have no obligation to take the needs of Brighthouse Financial or the owners of this annuity product into consideration in determining, composing or calculating the
S&P 500 Index. S&P Dow Jones Indices is not responsible for and has not participated in the determination of the prices, and amount of this annuity product or the timing of the issuance or sale of this annuity product or in the determination
or calculation of the equation by which this annuity product is to be converted into cash, surrendered or redeemed, as the case may be. S&P Dow Jones Indices has no obligation or liability in connection with the administration, marketing or
trading of this annuity product. There is no assurance that investment products based on the S&P 500 Index will accurately track index performance or provide positive investment returns. S&P Dow Jones Indices LLC is not an investment
advisor. Inclusion of a security within an index is not a recommendation by S&P Dow Jones Indices to buy, sell, or hold such security, nor is it considered to be investment advice. Notwithstanding the foregoing, CME Group Inc. and its affiliates
may independently issue and/or sponsor financial products unrelated to this annuity product currently being issued by Brighthouse Financial, but which may be similar to and competitive with this annuity product. In addition, CME Group Inc. and its
affiliates may trade financial products which are linked to the performance of the S&P 500 Index. 
 S&P DOW JONES INDICES DOES NOT GUARANTEE
THE ADEQUACY, ACCURACY, TIMELINESS AND/OR THE COMPLETENESS OF THE S&P 500 INDEX OR ANY DATA RELATED THERETO OR ANY COMMUNICATION, INCLUDING BUT NOT LIMITED TO, ORAL OR WRITTEN COMMUNICATION (INCLUDING ELECTRONIC COMMUNICATIONS) WITH RESPECT
THERETO. S&P DOW JONES INDICES SHALL NOT BE SUBJECT TO ANY DAMAGES OR LIABILITY FOR ANY ERRORS, OMISSIONS, OR DELAYS THEREIN. S&P DOW JONES INDICES MAKES NO EXPRESS OR IMPLIED WARRANTIES, AND EXPRESSLY DISCLAIMS ALL WARRANTIES, OF
MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE OR USE OR AS TO RESULTS TO BE OBTAINED BY BRIGHTHOUSE FINANCIAL, OWNERS OF THIS ANNUITY PRODUCT, OR ANY OTHER PERSON OR ENTITY FROM THE USE OF THE S&P 500 INDEX OR WITH RESPECT TO ANY DATA
RELATED THERETO. WITHOUT LIMITING ANY OF THE FOREGOING, IN NO EVENT WHATSOEVER SHALL S&P DOW JONES INDICES BE LIABLE FOR ANY INDIRECT, SPECIAL, INCIDENTAL, PUNITIVE, OR CONSEQUENTIAL DAMAGES INCLUDING BUT NOT LIMITED TO, LOSS OF PROFITS, TRADING
LOSSES, LOST TIME OR GOODWILL, EVEN IF THEY HAVE BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES, WHETHER IN CONTRACT, TORT, STRICT LIABILITY, OR OTHERWISE. THERE ARE NO THIRD PARTY BENEFICIARIES OF ANY AGREEMENTS OR ARRANGEMENTS BETWEEN S&P DOW
JONES INDICES AND BRIGHTHOUSE FINANCIAL OTHER THAN THE LICENSORS OF S&P DOW JONES INDICES. 

2This annuity product is not sponsored, endorsed, sold or promoted by Frank Russell Company
(“Russell”). Russell makes no representation or warranty, express or implied, to the owners of this annuity product or any member of the public regarding the advisability of investing in securities generally or in this annuity product
particularly or the ability of the Russell 2000® Index to track general stock market performance or a segment of the same. Russell’s publication of the Russell 2000® Index in no way suggests or implies an opinion by Russell as to the advisability of investment in any or all of the securities upon which the Russell 2000® Index is based. Russell’s only relationship to affiliates of Brighthouse Financial, Inc. including Brighthouse Services, LLC and Brighthouse Life Insurance Company (collectively,
“Brighthouse Financial”) is the licensing of certain trademarks and trade names of Russell and of the Russell 2000® Index which is determined, composed and calculated by Russell
without regard to Brighthouse Financial or this annuity product. Russell is not responsible for and has not reviewed this annuity product nor any associated literature or publications and Russell makes no representation or warranty express or
implied as to their accuracy or completeness, or otherwise. Russell reserves the right, at any time and without notice, to alter, amend, terminate or in any way change the Russell 2000® Index.
Russell has no obligation or liability in connection with the administration, marketing or trading of this annuity product. 
 RUSSELL DOES NOT
GUARANTEE THE ACCURACY AND/OR THE COMPLETENESS OF THE RUSSELL 2000® INDEX OR ANY DATA INCLUDED THEREIN AND RUSSELL SHALL HAVE NO LIABILITY FOR ANY ERRORS, OMISSIONS, OR INTERRUPTIONS THEREIN.
RUSSELL MAKES NO WARRANTY, EXPRESS OR IMPLIED, AS TO 

  

					
	L-22495 (09/12)	 	21	 	

 RESULTS TO BE OBTAINED BY BRIGHTHOUSE FINANCIAL, INVESTORS, OWNERS OF THIS ANNUITY PRODUCT OR ANY
OTHER PERSON OR ENTITY FROM THE USE OF THE RUSSELL 2000® INDEX OR ANY DATA INCLUDED THEREIN. RUSSELL MAKES NO EXPRESS OR IMPLIED WARRANTIES, AND EXPRESSLY DISCLAIMS ALL WARRANTIES OF
MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE OR USE WITH RESPECT TO THE RUSSELL 2000® INDEX OR ANY DATA INCLUDED THEREIN. WITHOUT LIMITING ANY OF THE FOREGOING, IN NO EVENT SHALL
RUSSELL HAVE ANY LIABILITY FOR ANY SPECIAL, PUNITIVE, INDIRECT, OR CONSEQUENTIAL DAMAGES (INCLUDING LOST PROFITS), EVEN IF NOTIFIED OF THE POSSIBILITY OF SUCH DAMAGES. 

3THIS ANNUITY PRODUCT IS NOT SPONSORED, ENDORSED, SOLD OR PROMOTED BY MSCI INC.
(“MSCI”), ANY OF ITS AFFILIATES, ANY OF ITS INFORMATION PROVIDERS OR ANY OTHER THIRD PARTY INVOLVED IN, OR RELATED TO, COMPILING, COMPUTING OR CREATING ANY MSCI INDEX (COLLECTIVELY, THE “MSCI PARTIES”). THE MSCI
INDEXES ARE THE EXCLUSIVE PROPERTY OF MSCI. MSCI AND THE MSCI INDEX NAMES ARE SERVICE MARK(S) OF MSCI OR ITS AFFILIATES AND HAVE BEEN LICENSED FOR USE FOR CERTAIN PURPOSES BY AFFILIATES OF BRIGHTHOUSE FINANCIAL, INC. INCLUDING BRIGHTHOUSE SERVICES,
LLC AND BRIGHTHOUSE LIFE INSURANCE COMPANY (COLLECTIVELY, “BRIGHTHOUSE FINANCIAL”). NONE OF THE MSCI PARTIES MAKES ANY REPRESENTATION OR WARRANTY, EXPRESS OR IMPLIED, TO THE ISSUER OR OWNERS OF THIS ANNUITY PRODUCT OR ANY OTHER PERSON OR
ENTITY REGARDING THE ADVISABILITY OF INVESTING IN PRODUCTS GENERALLY OR IN THIS ANNUITY PRODUCT PARTICULARLY OR THE ABILITY OF ANY MSCI INDEX TO TRACK CORRESPONDING STOCK MARKET PERFORMANCE. MSCI OR ITS AFFILIATES ARE THE LICENSORS OF CERTAIN
TRADEMARKS, SERVICE MARKS AND TRADE NAMES AND OF THE MSCI INDEXES WHICH ARE DETERMINED, COMPOSED AND CALCULATED BY MSCI WITHOUT REGARD TO THIS ANNUITY PRODUCT OR THE ISSUER OR OWNERS OF THIS ANNUITY PRODUCT OR ANY OTHER PERSON OR ENTITY. NONE OF THE
MSCI PARTIES HAS ANY OBLIGATION TO TAKE THE NEEDS OF THE ISSUER OR OWNERS OF THIS ANNUITY PRODUCT OR ANY OTHER PERSON OR ENTITY INTO CONSIDERATION IN DETERMINING, COMPOSING OR CALCULATING THE MSCI INDEXES. NONE OF THE MSCI PARTIES IS RESPONSIBLE FOR
OR HAS PARTICIPATED IN THE DETERMINATION OF THE TIMING OF, PRICES AT, OR QUANTITIES OF THIS ANNUITY PRODUCT TO BE ISSUED OR IN THE DETERMINATION OR CALCULATION OF THE EQUATION BY OR THE CONSIDERATION INTO WHICH THIS ANNUITY PRODUCT IS REDEEMABLE.
FURTHER, NONE OF THE MSCI PARTIES HAS ANY OBLIGATION OR LIABILITY TO THE ISSUER OR OWNERS OF THIS ANNUITY PRODUCT OR ANY OTHER PERSON OR ENTITY IN CONNECTION WITH THE ADMINISTRATION, MARKETING OR OFFERING OF THIS ANNUITY PRODUCT. 

ALTHOUGH MSCI SHALL OBTAIN INFORMATION FOR INCLUSION IN OR FOR USE IN THE CALCULATION OF THE MSCI INDEXES FROM SOURCES THAT MSCI CONSIDERS RELIABLE,
NONE OF THE MSCI PARTIES WARRANTS OR GUARANTEES THE ORIGINALITY, ACCURACY AND/OR THE COMPLETENESS OF ANY MSCI INDEX OR ANY DATA INCLUDED THEREIN. NONE OF THE MSCI PARTIES MAKES ANY WARRANTY, EXPRESS OR IMPLIED, AS TO RESULTS TO BE OBTAINED BY THE
ISSUER OF THIS ANNUITY PRODUCT, OWNERS OF THIS ANNUITY PRODUCT, OR ANY OTHER PERSON OR ENTITY, FROM THE USE OF ANY MSCI INDEX OR ANY DATA INCLUDED THEREIN. NONE OF THE MSCI PARTIES SHALL HAVE ANY LIABILITY FOR ANY ERRORS, OMISSIONS OR INTERRUPTIONS
OF OR IN CONNECTION WITH ANY MSCI INDEX OR ANY DATA INCLUDED THEREIN. FURTHER, NONE OF THE MSCI PARTIES MAKES ANY EXPRESS OR IMPLIED WARRANTIES OF ANY KIND, AND THE MSCI PARTIES HEREBY EXPRESSLY DISCLAIM ALL WARRANTIES OF MERCHANTABILITY AND FITNESS
FOR A PARTICULAR PURPOSE, WITH RESPECT TO EACH MSCI INDEX AND ANY DATA INCLUDED THEREIN. WITHOUT LIMITING ANY OF THE FOREGOING, IN NO EVENT SHALL ANY OF THE MSCI PARTIES HAVE ANY LIABILITY FOR ANY DIRECT, INDIRECT, SPECIAL, PUNITIVE, CONSEQUENTIAL
OR ANY OTHER DAMAGES (INCLUDING LOST PROFITS) EVEN IF NOTIFIED OF THE POSSIBILITY OF SUCH DAMAGES. 
 No purchaser, seller or holder of this annuity
product, or any other person or entity, should use or refer to any MSCI trade name, trademark or service mark to sponsor, endorse, market or promote this security without first contacting MSCI to determine whether MSCI’s permission is required.
Under no circumstances may any person or entity claim any affiliation with MSCI without the prior written permission of MSCI. 

  

					
	L-22495 (09/12)	 	22EX-10.12

 Exhibit 10.12 

FORM OF DIRECTOR AND OFFICER INDEMNIFICATION AGREEMENT 

This Director and Officer Indemnification Agreement, dated as of
                            , 2018 (this “Agreement”), is made by and between
Veoneer, Inc., a Delaware corporation (the “Company”), and
                                         
       (“Indemnitee”). 
 RECITALS: 

A. Section 141 of the Delaware General Corporation Law provides that the business and affairs of a corporation shall be managed by or
under the direction of its board of directors. Section 142 of the Delaware General Corporation Law authorizes the appointment of persons to serve as officers of a corporation. 

B. By virtue of the managerial prerogatives vested in the directors and officers of a Delaware corporation, directors and officers act as
fiduciaries of the corporation and its stockholders. 
 C. Thus, it is critically important to the Company and its stockholders that the
Company be able to attract and retain the most capable persons reasonably available to serve as directors and officers of the Company. 
 D.
In recognition of the need for corporations to be able to induce capable and responsible persons to accept positions in corporate management, Delaware law authorizes (and in some instances requires) corporations to indemnify their directors and
officers, and further authorizes corporations to purchase and maintain insurance for the benefit of their directors and officers. 
 E. The
Delaware courts have recognized that indemnification by a corporation serves the dual policies of (1) allowing corporate officials to resist unjustified lawsuits, secure in the knowledge that, if vindicated, the corporation will bear the
expense of litigation, and (2) encouraging capable individuals to serve as corporate directors and officers, secure in the knowledge that the corporation will absorb the costs of defending their honesty and integrity. 

F. The number of lawsuits challenging the judgment and actions of directors and officers of Delaware corporations, the costs of defending those
lawsuits and the threat to directors’ personal assets have all materially increased over the past several years, chilling the willingness of capable individuals to undertake the responsibilities imposed on corporate directors and officers. 

G. Recent federal legislation and rules adopted by the Securities and Exchange Commission and the national securities exchanges have exposed
such directors and officers to new and substantially broadened civil liabilities. 
 H. Under Delaware law, a director’s or
officer’s right to be reimbursed for the costs of defense of criminal actions, whether such claims are asserted under state or federal law, does not depend upon the merits of the claims asserted against the director or officer and is separate
and distinct from any right to indemnification the director or officer may be able to establish. 

 I. Indemnitee is, or will be, a director and/or officer of the Company and his willingness to
serve in such capacity is predicated, in substantial part, upon the Company’s willingness to indemnify him in accordance with the principles reflected above, to the fullest extent permitted by the laws of the State of Delaware, and upon the
other undertakings set forth in this Agreement. 
 J. Therefore, in recognition of the need to provide Indemnitee with substantial protection
against personal liability, in order to procure Indemnitee’s continued service as a director of the Company and to enhance Indemnitee’s ability to serve the Company in an effective manner, and in order to provide such protection pursuant
to express contract rights (intended to be enforceable irrespective of, among other things, any amendment to the Company’s certificate of incorporation or bylaws (collectively, the “Constituent Documents”), any change in
the composition of the Company’s Board of Directors (the “Board”) or any change-in-control or business combination transaction relating to
the Company), the Company wishes to provide in this Agreement for the indemnification of and the advancement of Expenses to Indemnitee as set forth in this Agreement and for the continued coverage of Indemnitee under the Company’s
directors’ and officers’ liability insurance policies. 
 K. In light of the considerations referred to in the preceding recitals,
it is the Company’s intention and desire that the provisions of this Agreement be construed liberally, subject to their express terms, to maximize the protections to be provided to Indemnitee hereunder. 

AGREEMENT: 
 NOW,
THEREFORE, the parties hereby agree as follows: 
 1. Certain Definitions. In addition to terms defined elsewhere herein, the
following terms have the following meanings when used in this Agreement with initial capital letters: 
 (a) “Change in
Control” shall have occurred at such time, if any, Incumbent Directors cease for any reason to constitute a majority of Directors. For purpose of this Section 1(a), “Incumbent Directors” means the
individuals who, as of the date hereof, are Directors of the Company and any individual becoming a Director subsequent to the date hereof whose election, nomination for election by the Company’s stockholders, or appointment, was approved by a
vote of at least two-thirds of the then Incumbent Directors (either by a specific vote or by approval of the proxy statement of the Company in which such person is named as a nominee for director, without
objection to such nomination); provided, that an individual shall not be an Incumbent Director if such individual’s election or appointment to the Board occurs as a result of an actual or threatened election contest (as described in Rule
14a-12(c) of the Securities Exchange Act of 1934, as amended) with respect to the election or removal of Directors or other actual or threatened solicitation of proxies or consents by or on behalf of a Person
other than the Board. 
 (b) “Claim” means (i) any threatened, asserted, pending or completed claim, demand,
action, suit, arbitration, alternate dispute resolution mechanism, administrative hearing or any other proceeding, whether civil, criminal, administrative or investigative (including on appeal), and whether made pursuant to federal, state or other
law; or (ii) any inquiry or investigation, whether made, instituted or conducted, by or in the right of the Company or any 

  
 2 

 
other Person, including any federal, state or other governmental entity, that Indemnitee determines might lead to the institution of any such claim, demand, action, suit, arbitration, alternate
dispute resolution mechanism, administrative hearing or any other proceeding. For the avoidance of doubt, the Company intends indemnity to be provided hereunder in respect of acts or failure to act prior to, on or after the date hereof. 

(c) “Controlled Affiliate” means any corporation, limited liability company, partnership, joint venture, trust or other
entity or enterprise, whether or not for profit, that is directly or indirectly controlled by the Company. For purposes of this definition, “control” means the possession, directly or indirectly, of the power to direct or cause the
direction of the management or policies of an entity or enterprise, whether through the ownership of voting securities, through other voting rights, by contract or otherwise; provided, that direct or indirect Beneficial Ownership of capital
stock or other interests in an entity or enterprise entitling the holder to cast 15% or more of the total number of votes generally entitled to be cast in the election of directors (or persons performing comparable functions) of such entity or
enterprise shall be deemed to constitute control for purposes of this definition. 
 (d) “Disinterested Director”
means a director of the Company who is not and was not a party to the Claim in respect of which indemnification is sought by Indemnitee. 

(e) “Expenses” means attorneys’ and experts’ fees and expenses and all other costs and expenses paid or
payable in connection with investigating, defending, being a witness in or participating in (including on appeal), or preparing to investigate, defend, be a witness in or participate in (including on appeal), any Claim. Expenses shall include
expenses incurred in connection with any appeal resulting from any Claim, including, without limitation, the premium, security for and other costs relating to any cost bond, supersedeas bond or other appeal bond or its equivalent. 

(f) “Indemnifiable Claim” means any Claim based upon, arising out of or resulting from (i) any actual, alleged or
suspected act or failure to act by Indemnitee related to the fact that Indemnitee is or was a director, officer, employee or agent of the Company or is or was a director, officer, employee, member, manager, trustee or agent of any other corporation,
limited liability company, partnership, joint venture, trust or other entity or enterprise, whether or not for profit, as to which Indemnitee is or was serving at the request of the Company, (ii) any actual, alleged or suspected act or failure
to act by Indemnitee in respect of any business, transaction, communication, filing, disclosure or other activity of the Company or any other entity or enterprise referred to in clause (i) of this sentence, or (iii) Indemnitee’s
status as a current or former director, officer, employee or agent of the Company or as a current or former director, officer, employee, member, manager, trustee or agent of the Company or any other entity or enterprise referred to in
clause (i) of this sentence or any actual, alleged or suspected act or failure to act by Indemnitee in connection with any obligation or restriction imposed upon Indemnitee by reason of such status. In addition to any service at the actual
request of the Company, for purposes of this Agreement, Indemnitee shall be deemed to be serving or to have served at the request of the Company as a director, officer, employee, member, manager, agent, trustee or other fiduciary of another entity
or enterprise if Indemnitee is or was serving as a director, officer, employee, member, manager, agent, trustee or other fiduciary of such entity or enterprise and (A) such entity or enterprise is or at the time of such service was a Controlled
Affiliate, (B) such entity or enterprise is or at the time of such service was an employee benefit 

  
 3 

 
plan (or related trust) sponsored or maintained by the Company or a Controlled Affiliate, or (C) the Company or a Controlled Affiliate (by action of the Board, any committee thereof or the
Company’s Chief Executive Officer (“CEO”) (other than as the CEO him or herself)) caused or authorized Indemnitee to be nominated, elected, appointed, designated, employed, engaged or selected to serve in such capacity.

 (g) “Indemnifiable Losses” means any and all Losses relating to, arising out of or resulting from any
Indemnifiable Claim; provided, that Indemnifiable Losses shall not include Losses incurred by Indemnitee in respect of any Indemnifiable Claim (or any matter or issue therein) as to which Indemnitee shall have been adjudged liable to the
Company in a final non-appealable adjudication by a court of competent jurisdiction, unless and only to the extent that the Delaware Court of Chancery or the court in which such Indemnifiable Claim was brought
shall determine upon application that, despite the adjudication of liability but in view of all the circumstances of the case, Indemnitee is fairly and reasonably entitled to indemnification for such Expenses as the Delaware Court of Chancery or
such other court shall deem proper. 
 (h) “Independent Counsel” means a law firm, or a member of a law firm, that is
experienced in matters of corporation law and neither presently is, nor in the past five years has been, retained to represent: (i) the Company (or any Subsidiary) or Indemnitee in any matter material to either such party (other than with
respect to matters concerning the Indemnitee under this Agreement, or of other indemnitees under similar indemnification agreements) or (ii) any other named (or, as to a threatened matter, reasonably likely to be named) party to the
Indemnifiable Claim giving rise to a claim for indemnification hereunder. Notwithstanding the foregoing, the term “Independent Counsel” shall not include any person who, under the applicable standards of professional conduct then
prevailing, would have a conflict of interest in representing either the Company or Indemnitee in an action to determine Indemnitee’s rights under this Agreement. 

(i) “Losses” means any and all Expenses, damages, losses, liabilities, judgments, fines, penalties (whether civil,
criminal or other) and amounts paid or payable in settlement, including all interest, assessments any federal, state, local or foreign taxes imposed as a result of the actual or deemed receipt of any payments under this Agreement and other charges
paid or payable in connection with or in respect of investigating, defending, being a witness in or participating in (including on appeal), or preparing to defend, be a witness or participate in, any Claim. 

(j) “Person” means any individual, entity, or group, within the meaning of Section 13(d)(3) or 14(d)(2) of the
Securities Exchange Act of 1934, as amended. 
 (k) “Standard of Conduct” means the standard for conduct by
Indemnitee that is a condition precedent to indemnification of Indemnitee hereunder against Indemnifiable Losses relating to, arising out of or resulting from an Indemnifiable Claim. The Standard of Conduct is (i) good faith and reasonable
belief by Indemnitee that his action was in or not opposed to the best interests of the Company and, with respect to any criminal action or proceeding, that Indemnitee had no reasonable cause to believe that his conduct was unlawful, or
(ii) any other applicable standard of conduct that may hereafter be substituted under Section 145(a) or (b) of the Delaware General Corporation Law or any successor to such provision(s). 

  
 4 

 2. Services to the Company. Indemnitee agrees to serve or continue to serve as a
director or officer of the Company for so long as Indemnitee is duly elected or appointed or until Indemnitee tenders his or her resignation or is no longer serving in such capacity. This Agreement shall not be deemed an employment agreement between
the Company and Indemnitee. 
 3. Indemnification Obligation. Subject only to Section 8, the exclusions set forth in
Section 13 and to the proviso in this Section, the Company shall indemnify, defend and hold harmless Indemnitee, to the fullest extent permitted by the laws of the State of Delaware in effect on the date hereof or as such laws may from time to
time hereafter be amended to increase the scope of such permitted indemnification, against any and all Indemnifiable Claims and Indemnifiable Losses; provided, that, except as provided in Sections 5 and 22, Indemnitee shall not be
entitled to indemnification pursuant to this Agreement in connection with any Claim initiated by Indemnitee against the Company or any director or officer of the Company unless the Company has joined in or consented to the initiation of such Claim.
The Company acknowledges that the foregoing obligation is substantially broader than that now provided by applicable law and the Company’s Constituent Documents and intends that it be interpreted consistently with this Section and the recitals
to this Agreement. 
 4. Advancement of Expenses. Indemnitee shall have the right to advancement by the Company prior to
the final disposition of any Indemnifiable Claim of any and all Expenses relating to, arising out of or resulting from any Indemnifiable Claim paid or incurred by Indemnitee or which Indemnitee determines in good faith are reasonably likely to be
paid or incurred by Indemnitee and as to which Indemnitee’s counsel provides supporting documentation. Without limiting the generality or effect of any other provision hereof, Indemnitee’s right to such advancement is not subject to the
satisfaction of any Standard of Conduct. Without limiting the generality or effect of the foregoing, within ten business days after any request by Indemnitee that is accompanied by supporting documentation for specific Expenses to be reimbursed or
advanced, the Company shall, in accordance with such request (but without duplication), (a) pay such Expenses on behalf of Indemnitee, (b) advance to Indemnitee funds in an amount sufficient to pay such Expenses, or (c) reimburse
Indemnitee for such Expenses; provided, that Indemnitee shall repay, without interest any amounts actually advanced to Indemnitee that, at the final disposition of the Indemnifiable Claim to which the advance related, were in excess of
amounts paid or payable by Indemnitee in respect of Expenses relating to, arising out of or resulting from such Indemnifiable Claim. In connection with any such payment, advancement or reimbursement, at the request of the Company, Indemnitee shall
execute and deliver to the Company an undertaking, which need not be secured and shall be accepted without reference to Indemnitee’s ability to repay the Expenses, by or on behalf of the Indemnitee, to repay any amounts paid, advanced or
reimbursed by the Company in respect of Expenses relating to, arising out of or resulting from any Indemnifiable Claim in respect of which it shall have been determined, following the final disposition of such Indemnifiable Claim and in accordance
with Section 8, that Indemnitee is not entitled to indemnification hereunder. Indemnification for Additional Expenses. Without limiting the generality or effect of the foregoing, the Company shall indemnify, defend and hold harmless
Indemnitee against and, if requested by Indemnitee, shall reimburse Indemnitee for, or advance to Indemnitee, within ten business days of such request accompanied by supporting documentation for specific Expenses to be reimbursed or advanced, any
and all Expenses paid or incurred by Indemnitee or which Indemnitee determines in good faith are reasonably likely to be paid or incurred by Indemnitee in connection with any Claim 

  
 5 

 
made, instituted or conducted by Indemnitee for (a) indemnification or reimbursement or advance payment of Expenses by the Company under any provision of this Agreement, or under any other
agreement or provision of the Constituent Documents now or hereafter in effect relating to Indemnifiable Claims, and/or (b) recovery under any directors’ and officers’ liability insurance policies maintained by the Company, regardless
in each case of whether Indemnitee ultimately is determined to be entitled to such indemnification, reimbursement, advance or insurance recovery, as the case may be; provided, that Indemnitee shall return, without interest, any such advance
of Expenses (or portion thereof) which remains unspent at the final disposition of the Claim to which the advance related. 
 5.
Partial Indemnity. If Indemnitee is entitled under any provision of this Agreement to indemnification by the Company for some or a portion of any Indemnifiable Loss but not for all of the total amount thereof, the Company shall nevertheless
indemnify Indemnitee for the portion thereof to which Indemnitee is entitled. 
 6. Procedure for Notification. To obtain
indemnification under this Agreement in respect of an Indemnifiable Claim or Indemnifiable Loss, Indemnitee shall submit to the Company a written request therefor, including a brief description (based upon information then available to Indemnitee)
of such Indemnifiable Claim or Indemnifiable Loss. If, at the time of the receipt of such request, the Company has directors’ and officers’ liability insurance in effect under which coverage for such Indemnifiable Claim or Indemnifiable
Loss is potentially available, the Company shall give prompt written notice of such Indemnifiable Claim or Indemnifiable Loss to the applicable insurers in accordance with the procedures set forth in the applicable policies. The Company shall
provide to Indemnitee a copy of such notice delivered to the applicable insurers and, upon Indemnitee’s request, copies of all subsequent correspondence between the Company and such insurers regarding the Indemnifiable Claim or Indemnifiable
Loss, in each case substantially concurrently with the delivery thereof by the Company. The failure by Indemnitee to timely notify the Company of any Indemnifiable Claim or Indemnifiable Loss shall not relieve the Company from any liability
hereunder unless, and only to the extent that, the Company did not otherwise learn of such Indemnifiable Claim or Indemnifiable Loss and such failure results in forfeiture by the Company of substantial defenses, rights or insurance coverage. 

7. Determination of Right to Indemnification. 

(a) To the extent that Indemnitee shall have been successful on the merits or otherwise in defense of any Indemnifiable Claim or any portion
thereof or in defense of any issue or matter therein, including dismissal without prejudice, Indemnitee shall be indemnified against all Indemnifiable Losses relating to, arising out of or resulting from such Indemnifiable Claim in accordance with
Section 3 and no Standard of Conduct Determination (as defined in Section 8(b)) shall be required. To the extent that Indemnitee’s involvement in a Claim relating to an Indemnifiable Event is to prepare to serve and/or serve as a
witness, and not as a party, the Indemnitee shall be indemnified against all Losses incurred in connection therewith to the fullest extent allowable by law and no Standard of Conduct Determination shall be required. 

  
 6 

 (b) To the extent that the provisions of Section 8(a) are inapplicable to an Indemnifiable
Claim that shall have been finally disposed of, any determination of whether Indemnitee has satisfied the applicable Standard of Conduct (a “Standard of Conduct Determination”) shall be made as follows:
(i) if a Change in Control shall not have occurred, or if a Change in Control shall have occurred but Indemnitee shall have requested that the Standard of Conduct Determination be made pursuant to this clause (i), (A) by a majority vote of
the Disinterested Directors, even if less than a quorum of the Board, (B) if such Disinterested Directors so direct, by a majority vote of a committee of Disinterested Directors designated by a majority vote of all Disinterested Directors, or
(C) if there are no such Disinterested Directors, or if a majority of the Disinterested Directors so direct, by Independent Counsel in a written opinion addressed to the Board, a copy of which shall be delivered to Indemnitee; and (ii) if
a Change in Control shall have occurred and Indemnitee shall not have requested that the Standard of Conduct Determination be made pursuant to clause (i), by Independent Counsel in a written opinion addressed to the Board, a copy of which shall
be delivered to Indemnitee. Indemnitee shall cooperate with reasonable requests of the individual or firm making such Standard of Conduct Determination, including providing to such Person documentation or information which is not privileged or
otherwise protected from disclosure and which is reasonably available to Indemnitee and reasonably necessary to such determination without incurring any unreimbursed cost in connection therewith. The Company shall indemnify and hold harmless
Indemnitee against and, if requested by Indemnitee, shall reimburse Indemnitee for, or advance to Indemnitee, within ten business days of such request accompanied by supporting documentation for specific costs and expenses to be reimbursed or
advanced, any and all costs and expenses (including attorneys’ and experts’ fees and expenses) incurred by Indemnitee in so cooperating with the Person making such Standard of Conduct Determination. 

(c) The Company shall use its reasonable efforts to cause any Standard of Conduct Determination required under Section 8(b) to be made as
promptly as practicable. If (i) the Person empowered or selected under Section 8 to make the Standard of Conduct Determination shall not have made a determination within 30 calendar days after the later of (A) receipt by the
Company of written notice from Indemnitee advising the Company of the final disposition of the applicable Indemnifiable Claim (the date of such receipt being the “Notification Date”) and (B) the selection of an
Independent Counsel, if such determination is to be made by Independent Counsel, that is permitted under the provisions of Section 8(e) to make such determination, and (ii) Indemnitee shall have fulfilled his/her obligations set forth in
the second sentence of Section 8(b), then Indemnitee shall be deemed to have satisfied the applicable Standard of Conduct; provided, that such 30-day period may be extended for a reasonable time,
not to exceed an additional 30 calendar days, if the Person making such determination in good faith requires such additional time for the obtaining or evaluation or documentation and/or information relating thereto. 

(d) If (i) Indemnitee shall be entitled to indemnification hereunder against any Indemnifiable Losses pursuant to Section 8(a),
(ii) no determination of whether Indemnitee has satisfied any applicable standard of conduct under Delaware law is a legally required condition precedent to indemnification of Indemnitee hereunder against any Indemnifiable Losses, or
(iii) Indemnitee has been determined or deemed pursuant to Section 8(b) or (c) to have satisfied the applicable Standard of Conduct, then the Company shall pay to Indemnitee, within ten business days after the later of (x) the
Notification Date in respect of the Indemnifiable Claim or portion thereof to which such Indemnifiable Losses are related, out of which such Indemnifiable Losses arose or from which such Indemnifiable Losses resulted and (y) the earliest date
on which the applicable criterion specified in clause (i), (ii) or (iii) above shall have been satisfied, an amount equal to the amount of such Indemnifiable Losses. Nothing herein is intended to mean or imply that the Company is intending to
use Section 145(f) of the Delaware General Corporation Law to dispense with a requirement that Indemnitee meet the applicable Standard of Conduct where it is otherwise required by such statute. 

  
 7 

 (e) If a Standard of Conduct Determination is required to be, but has not been, made by
Independent Counsel pursuant to Section 8(b)(i), the Independent Counsel shall be selected by the Board or a Board Committee, and the Company shall give written notice to Indemnitee advising him or her of the identity of the Independent Counsel
so selected. If a Standard of Conduct Determination is required to be, or to have been, made by Independent Counsel pursuant to Section 8(b)(ii), the Independent Counsel shall be selected by Indemnitee, and Indemnitee shall give written notice
to the Company advising it of the identity of the Independent Counsel so selected. In either case, Indemnitee or the Company, as applicable, may, within five business days after receiving written notice of selection from the other, deliver to the
other a written objection to such selection; provided, that such objection may be asserted only on the ground that the Independent Counsel so selected does not satisfy the criteria set forth in the definition of “Independent
Counsel” in Section 1(h), and the objection shall set forth with particularity the factual basis of such assertion. Absent a proper and timely objection, the Person so selected shall act as Independent Counsel. If such written objection is
properly and timely made and substantiated, (i) the Independent Counsel so selected may not serve as Independent Counsel unless and until such objection is withdrawn or a court has determined that such objection is without merit and
(ii) the non-objecting party may, at its option, select an alternative Independent Counsel and give written notice to the other party advising such other party of the identity of the alternative
Independent Counsel so selected, in which case the provisions of the two immediately preceding sentences and clause (i) of this sentence shall apply to such subsequent selection and notice. If applicable, the provisions of clause (ii) of
the immediately preceding sentence shall apply to successive alternative selections. If no Independent Counsel that is permitted under the foregoing provisions of this Section 8(e) to make the Standard of Conduct Determination shall have been
selected within 30 calendar days after the Company gives its initial notice pursuant to the first sentence of this Section 8(e) or Indemnitee gives its initial notice pursuant to the second sentence of this Section 8(e), as the case
may be, either the Company or Indemnitee may petition the Court of Chancery of the State of Delaware for resolution of any objection which shall have been made by the Company or Indemnitee to the other’s selection of Independent Counsel and/or
for the appointment as Independent Counsel of a person or firm selected by the Court or by such other person as the Court shall designate, and the person or firm with respect to whom all objections are so resolved or the person or firm so appointed
will act as Independent Counsel. In all events, the Company shall pay all of the actual and reasonable fees and expenses of the Independent Counsel incurred in connection with the Independent Counsel’s determination pursuant to
Section 8(b). 
 8. Presumption of Entitlement. 

(a) In making a determination of whether Indemnitee has been successful on the merits or otherwise in defense of any Indemnifiable Claim or any
portion thereof or in defense of any issue or matter therein, the Company acknowledges that a resolution, disposition or outcome short of dismissal or final judgment, including outcomes that permit Indemnitee to avoid expense, delay, embarrassment,
injury to reputation, distraction, disruption or uncertainty, may constitute such success. In the event that any Indemnifiable Claim or any portion thereof or issue or matter therein is resolved or disposed of in any manner other than by adverse
judgment 

  
 8 

 
against Indemnitee (including any resolution or disposition thereof by means of settlement with or without payment of money or other consideration), it shall be presumed that Indemnitee has been
successful on the merits or otherwise in defense of such Indemnifiable Claim or portion thereof or issue or matter therein. The Company may overcome such presumption only by its adducing clear and convincing evidence to the contrary. 

(b) Notwithstanding any other provision hereof, in making any Standard of Conduct Determination, the Person making such determination shall
presume that Indemnitee has satisfied the applicable Standard of Conduct, and the Company may overcome such presumption only by its adducing clear and convincing evidence to the contrary. Any Standard of Conduct Determination that Indemnitee has
satisfied the applicable standard of conduct shall be final and binding in all respects, including with respect to any litigation or other action or proceeding initiated by Indemnitee to enforce his or her rights hereunder. Any Standard of Conduct
Determination that is adverse to Indemnitee may be challenged by the Indemnitee in the Court of Chancery of the State of Delaware. No determination by the Company (including by its directors or any Independent Counsel) that Indemnitee has not
satisfied any applicable standard of conduct shall be a defense to any Claim by Indemnitee for indemnification or reimbursement or advance payment of Expenses by the Company hereunder or create a presumption that Indemnitee has not met any
applicable standard of conduct. 
 (c) Without limiting the generality or effect of Section 9(b), (i) to the extent that any
Indemnifiable Claim relates to any entity or enterprise (other than the Company) referred to in clause (i) of the first sentence of the definition of “Indemnifiable Claim,” Indemnitee shall be deemed to have satisfied the applicable
standard of conduct if Indemnitee acted in good faith and in a manner Indemnitee reasonably believed to be in or not opposed to the interests of such entity or enterprise (or the owners or beneficiaries thereof, including in the case of any employee
benefit plan the participants and beneficiaries thereof) and, with respect to any criminal action or proceeding, had no reasonable cause to believe that his or her conduct was unlawful, and (ii) in all cases, any belief of Indemnitee that is
based on the records or books of account of the Company, including financial statements, or on information supplied to Indemnitee by the directors or officers of the Company in the course of their duties, or on the advice of legal counsel for the
Company, the Board, any committee of the Board or any director, or on information or records given or reports made to the Company, the Board, any committee of the Board or any director by an independent certified public accountant or by an appraiser
or other expert selected by or on behalf of the Company, the Board, any committee of the Board or any director shall be deemed to be reasonable. 

9. No Other Presumption. For purposes of this Agreement, the termination of any Claim by judgment, order, settlement (whether
with or without court approval) or conviction, or upon a plea of nolo contendere or its equivalent, will not create a presumption that Indemnitee did not meet any applicable Standard of Conduct or that indemnification hereunder is otherwise
not permitted. 
 10. Non-Exclusivity. The rights of Indemnitee hereunder will
be in addition to any other rights Indemnitee may have under the Constituent Documents, or the substantive laws of the Company’s jurisdiction of incorporation, any other contract or otherwise (collectively, “Other Indemnity
Provisions”); provided, that (a) to the extent that Indemnitee otherwise would have any greater right to indemnification under any Other Indemnity Provision, Indemnitee will 

  
 9 

 
without further action be deemed to have such greater right hereunder, and (b) to the extent that any change is made to any Other Indemnity Provision which permits any greater right to
indemnification than that provided under this Agreement as of the date hereof, Indemnitee will be deemed to have such greater right hereunder. The Company may not, without the consent of Indemnitee, adopt any amendment to any of the Constituent
Documents the effect of which would be to deny, diminish or encumber Indemnitee’s right to indemnification under this Agreement. 

11. Liability Insurance and Funding. For the duration of Indemnitee’s service as a director and/or officer of the Company
and for so long as Indemnitee shall be subject to any pending Claim relating to an Indemnifiable Claim thereafter, the Company shall use commercially reasonable efforts (taking into account the scope and amount of coverage available relative to the
cost thereof) to cause to be maintained in effect policies of directors’ and officers’ liability insurance providing coverage for Indemnitee that is at least as favorable in scope and amount to that provided by the Company’s current
policies of directors’ and officers’ liability insurance. Upon request, the Company shall provide Indemnitee or his or her counsel with a copy of all directors’ and officers’ liability insurance applications, binders, policies,
declarations, endorsements and other related materials. In all policies of directors’ and officers’ liability insurance obtained by the Company, Indemnitee shall be named as an insured in such a manner as to provide Indemnitee the same
rights and benefits, subject to the same limitations, as are accorded to the Company’s directors and officers most favorably insured by such policy. Notwithstanding the foregoing, (i) the Company may, but shall not be required to, create a
trust fund, grant a security interest or use other means, including a letter of credit, to ensure the payment of such amounts as may be necessary to satisfy its obligations to indemnify and advance expenses pursuant to this Agreement and
(ii) in renewing or seeking to renew any insurance hereunder, the Company will not be required to expend more than 3.0 times the premium amount of the immediately preceding policy period (equitably adjusted if necessary to reflect differences
in policy periods). 
 12. Exclusions from Indemnification. Notwithstanding anything in this Agreement to the contrary, the
Company shall not be obligated to: 
 (a) indemnify Indemnitee if a final non-appealable adjudication
by a court of competent jurisdiction determines that such indemnification is prohibited by applicable law; 
 (b) indemnify Indemnitee for
the disgorgement of profits arising from the purchase or sale by Indemnitee of securities of the Company in violation of Section 16(b) of the Exchange Act, or any similar successor statute; or 

(c) indemnify or advance funds to Indemnitee for Indemnitee’s reimbursement to the Company of any bonus or other incentive-based or
equity-based compensation previously received by Indemnitee or payment of any profits realized by Indemnitee from the sale of securities of the Company, as required in each case under the Exchange Act (including any such reimbursements under
Section 304 of the Sarbanes-Oxley Act of 2002 in connection with an accounting restatement of the Company or the payment to the Company of profits arising from the purchase or sale by Indemnitee of securities in violation of Section 306 of
the Sarbanes-Oxley Act). 

  
 10 

 13. Subrogation. In the event of payment under this Agreement, the Company shall be
subrogated to the extent of such payment to all of the related rights of recovery of Indemnitee against other Persons (other than Indemnitee’s successors), including any entity or enterprise referred to in clause (i) of the definition of
“Indemnifiable Claim” in Section 1(f). Indemnitee shall execute all papers reasonably required to evidence such rights (all of Indemnitee’s reasonable Expenses, including attorneys’ fees and charges, related thereto to be
reimbursed by or, at the option of Indemnitee, advanced by the Company). 
 14. No Duplication of Payments. The Company shall
not be liable under this Agreement to make any payment to Indemnitee in respect of any Indemnifiable Losses to the extent Indemnitee has otherwise already actually received payment (net of Expenses incurred in connection therewith) under any
insurance policy, the Constituent Documents and Other Indemnity Provisions or otherwise (including from any entity or enterprise referred to in clause (i) of the definition of “Indemnifiable Claim” in Section 1(f)) in respect of
such Indemnifiable Losses otherwise indemnifiable hereunder. 
 15. Defense of Claims. Subject to the provisions of applicable
policies of directors’ and officers’ liability insurance, the Company shall be entitled to participate in the defense of any Indemnifiable Claim or to assume or lead the defense thereof with counsel reasonably satisfactory to the
Indemnitee; provided, that if Indemnitee determines, after consultation with counsel selected by Indemnitee, that (a) the use of counsel chosen by the Company to represent Indemnitee would present such counsel with an actual or potential
conflict, (b) the named parties in any such Indemnifiable Claim (including any impleaded parties) include both the Company and Indemnitee and Indemnitee shall conclude that there may be one or more legal defenses available to him or her that
are different from or in addition to those available to the Company, (c) any such representation by such counsel would be precluded under the applicable standards of professional conduct then prevailing, or (d) Indemnitee has interests in
the claim or underlying subject matter that are different from or in addition to those of other Persons against whom the Claim has been made or might reasonably be expected to be made, then Indemnitee shall be entitled to retain separate counsel
(but not more than one law firm plus, if applicable, local counsel in respect of any particular Indemnifiable Claim for all indemnitees in Indemnitee’s circumstances) at the Company’s expense. The Company shall not be liable to Indemnitee
under this Agreement for any amounts paid in settlement of any threatened or pending Indemnifiable Claim effected without the Company’s prior written consent. The Company shall not, without the prior written consent of the Indemnitee, effect
any settlement of any threatened or pending Indemnifiable Claim which the Indemnitee is or could have been a party unless such settlement solely involves the payment of money and includes a complete and unconditional release of the Indemnitee from
all liability on any claims that are the subject matter of such Indemnifiable Claim. Neither the Company nor Indemnitee shall unreasonably withhold its consent to any proposed settlement; provided, that Indemnitee may withhold consent to any
settlement that does not provide a complete and unconditional release of Indemnitee. 
 16. Successors and Binding Agreement. 

(a) The Company shall require any successor (whether direct or indirect, by purchase, merger, consolidation, reorganization or otherwise) to
all or substantially all of the business or assets of the Company expressly to assume and agree to perform this Agreement in the same manner and to the same extent the Company would be required to perform if no such

  
 11 

 
succession had taken place. This Agreement shall be binding upon and inure to the benefit of the Company and any successor to the Company, including any Person acquiring directly or indirectly
all or substantially all of the business or assets of the Company whether by purchase, merger, consolidation, reorganization or otherwise (and such successor will thereafter be deemed the “Company” for purposes of this
Agreement), but shall not otherwise be assignable or delegable by the Company. 
 (b) This Agreement shall inure to the benefit of and be
enforceable by the Indemnitee’s personal or legal representatives, executors, administrators, heirs, distributees, legatees and other successors. 

(c) This Agreement is personal in nature and neither of the parties hereto shall, without the consent of the other, assign or delegate this
Agreement or any rights or obligations hereunder except as expressly provided in Sections 17(a) and 17(b). Without limiting the generality or effect of the foregoing, Indemnitee’s right to receive payments hereunder shall not be
assignable, whether by pledge, creation of a security interest or otherwise, other than by a transfer by the Indemnitee’s will or by the laws of descent and distribution, and, in the event of any attempted assignment or transfer contrary to
this Section 17(c), the Company shall have no liability to pay any amount so attempted to be assigned or transferred. 
 17.
Notices. For all purposes of this Agreement, all communications, including notices, consents, requests or approvals, required or permitted to be given hereunder must be in writing and shall be deemed to have been duly given when hand
delivered or dispatched by electronic facsimile transmission (with receipt thereof orally confirmed), or one business day after having been sent for next-day delivery by a nationally recognized overnight
courier service, addressed to the Company (to the attention of the Secretary of the Company) and to Indemnitee at the applicable address shown on the signature page hereto, or to such other address as any party may have furnished to the other in
writing and in accordance herewith, except that notices of changes of address will be effective only upon receipt 
 18. Governing
Law. The validity, interpretation, construction and performance of this Agreement shall be governed by and construed in accordance with the substantive laws of the State of Delaware, without giving effect to the principles of conflict of laws of
such State. The Company and Indemnitee each hereby irrevocably consent to the jurisdiction of the Chancery Court of the State of Delaware for all purposes in connection with any action or proceeding which arises out of or relates to this Agreement,
waive all procedural objections to suit in that jurisdiction, including objections as to venue or inconvenience, agree that service in any such action may be made by notice given in accordance with Section 18 and also agree that any action
instituted under this Agreement shall be brought only in the Chancery Court of the State of Delaware. 
 19. Validity. If any
provision of this Agreement or the application of any provision hereof to any Person or circumstance is held invalid, unenforceable or otherwise illegal, the remainder of this Agreement and the application of such provision to any other Person or
circumstance shall not be affected, and the provision so held to be invalid, unenforceable or otherwise illegal shall be reformed to the extent, and only to the extent, necessary to make it enforceable, valid or legal. In the event that any court or
other adjudicative body shall decline to reform any provision of this Agreement held to be invalid, unenforceable or otherwise illegal as 

  
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contemplated by the immediately preceding sentence, the parties thereto shall take all such action as may be necessary or appropriate to replace the provision so held to be invalid, unenforceable
or otherwise illegal with one or more alternative provisions that effectuate the purpose and intent of the original provisions of this Agreement as fully as possible without being invalid, unenforceable or otherwise illegal. 

20. Miscellaneous. No provision of this Agreement may be waived, modified or discharged unless such waiver, modification or
discharge is agreed to in writing signed by Indemnitee and the Company. No waiver by either party hereto at any time of any breach by the other party hereto or compliance with any condition or provision of this Agreement to be performed by such
other party shall be deemed a waiver of similar or dissimilar provisions or conditions at the same or at any prior or subsequent time. No agreements or representations, oral or otherwise, expressed or implied with respect to the subject matter
hereof have been made by either party that are not set forth expressly in this Agreement. This Agreement shall not impose any obligation on Indemnitee or the Company to continue Indemnitee’s service to the Company beyond any period otherwise
required by law or by other agreements or commitments of the parties, if any. 
 21. Legal Fees and Expenses. It is the intent
of the Company that Indemnitee not be required to incur legal fees and or other Expenses associated with the interpretation, enforcement or defense of Indemnitee’s rights under this Agreement by litigation or otherwise because the cost and
expense thereof would substantially detract from the benefits intended to be extended to Indemnitee hereunder. Accordingly, without limiting the generality or effect of any other provision hereof, if it should reasonably appear to Indemnitee that
the Company has failed to comply with any of its obligations under this Agreement or in the event that the Company or any other Person takes or threatens to take any action to declare this Agreement void or unenforceable, or institutes any
litigation or other action or proceeding designed to improperly deny, or to improperly recover from, Indemnitee the benefits provided or intended to be provided to Indemnitee hereunder, the Company irrevocably authorizes the Indemnitee from time to
time to retain counsel of Indemnitee’s choice, at the expense of the Company as hereafter provided, to advise and represent Indemnitee in connection with any such interpretation, enforcement or defense, including the initiation or defense of
any litigation or other legal action, whether by or against the Company or any director, officer, stockholder or other Person affiliated with the Company, in any jurisdiction. Without limiting the generality or effect of any other provision hereof
or respect to whether Indemnitee prevails, in whole or in part, in connection with any of the foregoing, the Company will pay and be solely financially responsible for any and all attorneys’ and related fees and expenses actually and reasonably
incurred by Indemnitee in connection with any of the foregoing. 
 22. Certain Interpretive Matters. Unless the context of this
Agreement otherwise requires, (a) ”it” or “its” or words of any gender include each other gender, (b) words using the singular or plural number also include the plural or singular number, respectively, (c) the
terms “hereof,” “herein,” “hereby” and derivative or similar words refer to this entire Agreement, (d) the terms “Article,” “Section,” “Annex” or “Exhibit” refer to the
specified Article, Section, Annex or Exhibit of or to this Agreement, (e) the terms “include,” “includes” and “including” will be deemed to be followed by the words “without limitation” (whether or not so
expressed), and (f) the word “or” is disjunctive but not exclusive. Whenever this Agreement refers to a number of days, such number will refer to calendar days unless business days are specified and

  
 13 

 
whenever action must be taken (including the giving of notice or the delivery of documents) under this Agreement during a certain period of time or by a particular date that ends or occurs on a non-business day, then such period or date will be extended until the immediately following business day. As used herein, “business day” means any day other than Saturday, Sunday or a United States federal
holiday. 
 23. Entire Agreement. This Agreement and the Constituent Documents constitute the entire agreement, and supersede
all prior agreements and understandings, both written and oral, between the parties hereto with respect to the subject matter of this Agreement. Any prior agreements or understandings between the parties hereto with respect to indemnification are
hereby terminated and of no further force or effect. 
 24. Counterparts. This Agreement may be executed in one or more
counterparts, each of which will be deemed to be an original but all of which together shall constitute one and the same agreement. 

[signature page follows] 

  
 14 

 IN WITNESS WHEREOF, Indemnitee has executed and the Company has caused its duly authorized
representative to execute this Agreement as of the date first above written. 
  

			
	VEONEER, INC.
		
	By:	 	                                      
                                         
 
	Name:                                   
                                         

	Title:                                   
                                         
  
	
	[INDEMNITEE]
	
	  

	Name:                                   
                                         

	
	Address:
	  

	  

	  

  
 15

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