Document:

THE SCHEDULE
                   THE VARIABLE SEPARATE ACCOUNTS
|-----------------------------------------------------------------------|
|-----------------------------------------------------------------------|
| Annuitant                   Owner                                     |
| MARK HARMON                 MARK HARMON                               |
|-----------------------------------------------------------------------|
|                                                                       |
| Initial Premium             Annuity Option        Annuity             |
|                                                   Commencement Date   |
|                                                                       |
| $120,000.00                 LIFE 10 YEAR          AUGUST 1, 2049      |
|                             CERTAIN                                   |
|-----------------------------------------------------------------------|
| Separate Account(s)                               Contract Number     |
| SEPARATE ACCOUNT B                                I000001-FP (Q)      |
|-----------------------------------------------------------------------|

DIVISIONS INVESTING IN SHARES OF A MUTUAL FUND

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

      SERIES                             SERIES
      ------                             ------
      Equity Income                      Real Estate
      Fully Managed                      Hard Assets
      Value Equity                       Limited Maturity Bond
      Small Cap                          Liquid Asset
      Capital Appreciation               Strategic Equity
      Rising Dividends                   Managed Global
      Mid-Cap Growth                     Research
      Total Return                       Growth
      Capital Growth                     Global Fixed Income
      Emerging Markets                   Developing World

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

                   PORTFOLIO
                   ---------
                   High Yield Bond
                   StocksPlus Growth and Income

The Divisions below invests in shares of the mutual fund portfolio
(the "Portfolio") designated.  Each portfolio is a part of The Galaxy
VIP fund, managed by Fleet Investment Advisors, Inc.

                   PORTFOLIO
                   ---------
                   Equity
                   Small Company Growth
                   Asset Allocation
                   Growth & Income
                   High Quality Bond

GA-IA-1037-02/97             3BFIRST GOLDEN AMERICAN
LIFE INSURANCE COMPANY
OF NEW YORK                                  SECTION 72 RIDER
A stock company
------------------------------------------------------------------------------

REQUIRED DISTRIBUTION OF PROCEEDS ON DEATH OF OWNER

  This Rider is required to qualify the Contract to which it is
  attached as an annuity contract under Section 72 of the Internal
  Revenue Code of 1986, as amended (the "Code").  Where the terms
  of this Rider are in conflict with the terms of the Contract, the
  Rider will control.  First Golden American Life Insurance Company
  of New York, "First Golden American", reserves the right to amend
  or administer the Contract and Rider as necessary to comply with
  applicable tax requirements.  This Rider and the Contract should
  be construed so that they comply with applicable tax
  requirements.

DEATH OF OWNER ON OR AFTER ANNUITY COMMENCEMENT DATE

  IF ANY OWNER DIES ON OR AFTER the Annuity Commencement Date but
  prior to the time the entire interest in the Contract has been
  distributed, the remaining portion will be distributed at least
  as rapidly as under the method of distribution being used as of
  the date of the Owner's or Annuitant's death.

DEATH OF OWNER PRIOR TO ANNUITY COMMENCEMENT DATE

       IF ANY OWNER DIES PRIOR TO the Annuity Commencement Date,
  the entire interest in the Contract will be distributed within
  five years of the Owner's death.
       However, this distribution requirement will be considered
  satisfied as to any portion of the Owner's interest in the
  Contract which is payable to or for the benefit of a Designated
  Beneficiary and which will be distributed over the life of such
  Designated Beneficiary or over a period not extending beyond the
  life expectancy of that Designated Beneficiary, provided such
  distributions begin within one year of the Owner's death.  If the
  Designated Beneficiary is the surviving spouse of the decedent,
  the Contract may be continued in the name of the spouse as Owner
  and these distribution rules are applied by treating the spouse
  as the Owner.  However, on the death of the surviving spouse,
  this provision regarding spouses may not be used again.
       If any Owner is not an individual, the death or change
  (where permitted) of the Annuitant will be treated as the death
  of an Owner.
       The Designated Beneficiary is the person entitled to
  ownership rights under the Contract.  Thus, where no death
  benefit has become payable, the Designated Beneficiary, for the
  purposes of applying this Rider, will be the Owner(s).  Where a
  death benefit has become payable, the Designated Beneficiary, for
  the purposes of applying this Rider, is the person(s) entitled to
  the death benefit, generally the Beneficiary or surviving Owners,
  as appropriate.  Upon the death of any Owner, the Designated
  Beneficiary will become the Owner or, if an individual, will
  become the Annuitant.
                         *         *         *
  An Owner may notify First Golden American as to the manner of
  payment under this Rider.  If such Owner has not so notified
  First Golden American prior to his or her death, the Designated
  Beneficiary under the Contract may so notify First Golden
  American.

          FIRST GOLDEN AMERICAN LIFE INSURANCE COMPANY OF NEW YORK

       President                         Secretary

FG-IA-1000-12/95RELIASTAR LIFE INSURANCE COMPANY OF NEW YORK
------------------------------------------------------------------------------
                                     Variable Products Customer Service Center
                                                           1475 Dunwoody Drive
                                                       West Chester, PA  19380

                           CHANGE OF NAME ENDORSEMENT

The Contract/Certificate to which this endorsement is attached is amended as
follows:

         The corporate name of the insurer providing coverage under the
         Contract/Certificate has been changed to RELIASTAR LIFE INSURANCE
         COMPANY OF NEW YORK.

         Wherever the name First Golden American Life Insurance Company of New
         York appears, it is changed to be RELIASTAR LIFE INSURANCE COMPANY OF
         NEW YORK.

         The Home Office address of ReliaStar Life Insurance Company of
         New York is: 1000 Woodbury Rd., Woodbury, NY 11797.

In all other respects, the Contract/Certificate is unchanged.

                             /S/ Paula Cludray-Engelke

                             Secretary

FG-RA-1097RELIASTAR LIFE                                            DEFERRED COMBINATION
INSURANCE COMPANY                                         VARIABLE AND FIXED
OF NEW YORK                                               ANNUITY CERTIFICATE

A stock company
--------------------------------------------------------------------------------

--------------------------------------------------------------------------------
  Contractholder                              Group Contract Number
  FIRST GOLDEN INVESTORS TRUST                FG000012-0E
 -------------------------------------------------------------------------------
  Annuitant                Owner
  JOHN DOE                 JOHN SMITH
                           JANE SMITH
--------------------------------------------------------------------------------
  Initial Premium          Annuity Option              Annuity Commencement Date
  $10,000.00               LIFE 10 YEAR CERTAIN        OCTOBER 18, 2013
--------------------------------------------------------------------------------
  Separate Account(s)                                  Contract Number
  SEPARATE ACCOUNT NY-B AND THE FIXED ACCOUNT          C000001-FP (Q)
--------------------------------------------------------------------------------
         In this Certificate you or your refers to the Owner shown above. We,
our or us refers to ReliaStar Life Insurance Company of New York. Our home
office is at 1000 Woodbury Rd., Woodbury, NY 11797. You may allocate this
Certificate's Accumulation Value among the Separate Account Divisions and the
Fixed Account as shown in the Schedule.

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

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

          RIGHT TO EXAMINE THIS CERTIFICATE: You may return this Certificate to
us or the agent through whom you purchased it within 10 days after you
receive it. Upon receipt we will promptly refund the greater of: 1) the
premium paid, or 2) the Accumulation Value plus any charges we have
deducted as of the effective date of cancellation.

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

Signed for ReliaStar Life Insurance Company of New York on the group Contract
Issue Date.

                                         Secretary  /S/ Paula Cludray-Engelke

                                         President  /S/ Chris Schreier

Variable Products Customer Service Center
1475 Dunwoody Drive
West Chester, PA 19380

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

DEFERRED COMBINATION VARIABLE AND FIXED ANNUITY CERTIFICATE - NO DIVIDENDS

Variable Cash Surrender Values while the Owner is living and prior to the
Annuity Commencement Date. Death benefit subject to guaranteed minimum.
Additional Premium Payment Option. Partial Withdrawal Option. Non-participating.
Investment results reflected in values.

FG-CA-1000-08/97

<PAGE>

<TABLE>
<CAPTION>
                                TABLE OF CONTENTS
--------------------------------------------------------------------------------
<S>                                                 <C>              <C>                                               <C>
THE SCHEDULE.....................................   3                YOUR CERTIFICATE BENEFITS .....................   12

     Premium Payment and Investment Information                            Cash Value Benefit
     The Variable Separate Accounts                                        Partial Withdrawal Option
     Certificate Facts                                                     Proceeds Payable to the Beneficiary
     Charges
     Income Plan Factors                                             DEATH BENEFIT PROCEEDS.........................   13

INTRODUCTION TO THIS CERTIFICATE.................   4                      Proceeds Payable to the Beneficiary

     The Certificate                                                 CHOOSING AN INCOME PLAN........................   14
     The Owner
     The Annuitant                                                         Annuity Benefits
     The Beneficiary                                                       Annuity Commencement Date Selection
     Change of Owner or Beneficiary                                        Frequency Selection
                                                                           The Income Plan
PREMIUM PAYMENTS AND ALLOCATION CHANGES..........   6                      The Annuity Options
                                                                           Payments When Named Person Dies
     Initial Premium Payment
     Additional Premium Payment Option                               OTHER IMPORTANT INFORMATION....................   16
     Your Right to Change Allocation of
        Accumulation Value                                                 Sending Notice to Us
     What Happens if a Division is Not Available                           Reports to Owner
                                                                           Assignment - Using this Certificate as
HOW WE MEASURE THE CONTRACT'S                                                Collateral Security
     ACCUMULATION VALUE..........................   7                      Changing the Group Contract
                                                                           Contract Changes - Applicable Tax Law
                    THE VARIABLE SEPARATE ACCOUNTS                         Misstatement of Age or Sex
                           VALUATION PERIOD                                Non-Participating
                          ACCUMULATION VALUE                               Payments We may Defer
     Accumulation Value in each Division and Fixed                         Authority to Make Agreements
        Allocation                                                         Required Note on Our Computations
     Fixed Account
     Measurement of Investment Experience
     Charges Deducted from Accumulation Value on
        each Contract Processing Date

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

     THE SCHEDULE

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

FG-CA-1000-08/97                       2

</TABLE>
<PAGE>

                                  THE SCHEDULE
                       PAYMENT AND INVESTMENT INFORMATION
--------------------------------------------------------------------------------

--------------------------------------------------------------------------------
  Contractholder                              Group Contract Number
  FIRST GOLDEN INVESTORS TRUST                FG000012-0E
 -------------------------------------------------------------------------------
  Annuitant                Owner
  JOHN DOE                 JOHN SMITH
                           JANE SMITH
--------------------------------------------------------------------------------
  Annuitant's Issue Age    Annuitant's Sex          Certificateowner's Issue Age
  76                       MALE                     76
--------------------------------------------------------------------------------
  Initial Premium          Annuity Option           Annuity Commencement Date
  $10,000.00               LIFE 10 YEAR CERTAIN     OCTOBER 18, 2013
--------------------------------------------------------------------------------
  Certificate Date         Certificate Issue Date   Certificate Number
  FEBRUARY 18, 2001        AUGUST 15, 2001          C000001-FP (Q)
--------------------------------------------------------------------------------
  Separate Account(s)
  SEPARATE ACCOUNT NY-B AND THE FIXED ACCOUNT
--------------------------------------------------------------------------------

PREMIUM PAYMENT AND INVESTMENT INFORMATION

Initial premium payment received:                    $10,000.00

Your initial Accumulation Value has been invested as follows:

                                      Percentage of
            Divisions               Accumulation Value

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

FG-CA-1000-08/97 Q DB3                 3A1

<PAGE>

                                  THE SCHEDULE
                       PAYMENT AND INVESTMENT INFORMATION
--------------------------------------------------------------------------------

--------------------------------------------------------------------------------
  Contractholder                              Group Contract Number
  FIRST GOLDEN INVESTORS TRUST                FG000012-0E
 -------------------------------------------------------------------------------
  Annuitant                Owner
  JOHN DOE                 JOHN SMITH
                           JANE SMITH
--------------------------------------------------------------------------------
  Annuitant's Issue Age    Annuitant's Sex          Certificateowner's Issue Age
  76                       MALE                     76
--------------------------------------------------------------------------------
  Initial Premium          Annuity Option           Annuity Commencement Date
  $10,000.00               LIFE 10 YEAR CERTAIN     OCTOBER 18, 2013
--------------------------------------------------------------------------------
  Certificate Date         Certificate Issue Date   Certificate Number
  FEBRUARY 18, 2001        AUGUST 15, 2001          C000001-FP (Q)
--------------------------------------------------------------------------------
  Separate Account(s)
  SEPARATE ACCOUNT NY-B AND THE FIXED ACCOUNT
--------------------------------------------------------------------------------

PREMIUM PAYMENT AND INVESTMENT INFORMATION

Additional Premium Payment Information

In no event may you contribute to your IRA for the taxable year in which you
attain age 70 1/2 and thereafter except for rollover contributions. The minimum
additional payment which may be made is $250.00.

ACCUMULATION VALUE ALLOCATION RULES

The maximum number of Divisions in which you may be invested at any one time is
sixteen. You are currently allowed unlimited allocation changes per Contract
Year without charge. We reserve the right to impose a charge as shown in the
Charges section of the Schedule for any allocation change in excess of twelve
per Certificate Year. We also reserve the right to limit, upon notice, the
maximum number of allocation changes you may make within a Certificate Year.

FG-CA-1000-08/97 Q DB3                 3A1 (CONT'D)

<PAGE>

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

 -------------------------------------------------------------------------------
  Annuitant                Owner
  JOHN DOE                 JOHN SMITH
                           JANE SMITH
--------------------------------------------------------------------------------
  Initial Premium          Annuity Option           Annuity Commencement Date
  $10,000.00               LIFE 10 YEAR CERTAIN     OCTOBER 18, 2013
--------------------------------------------------------------------------------
  Separate Account(s)                               Certificate Number
  SEPARATE ACCOUNT NY-B AND THE FIXED ACCOUNT       C000001-FP (Q)
--------------------------------------------------------------------------------

  Separate Account NY-B (the "Account") is a unit investment trust Separate
  Account, organized in and governed by the laws of the State of New York, our
  state of domicile. The Account is divided into Divisions.

  Each Division listed below invests in shares of the mutual fund portfolio (the
  "Series") designated. Each portfolio is a part of the GCG Trust.

<TABLE>
SERIES                     SERIES                 SERIES                   SERIES
------                     ------                 ------                   ------
<S>                        <C>                    <C>                      <C>
All Cap                    Small Cap              Hard Assets              Liquid Asset
Investors                  Mid-Cap Growth         Limited Maturity Bond    Strategic Equity
Equity Income              Capital Growth         Capital Appreciation     Managed Global
Fully Managed              Large Cap Value        Rising Dividends         Research
Value Equity               Real Estate            Total Return             Growth
Asset Allocation Growth    Special Situations     Core Bond                Developing World
Diversified Mid-Cap        Internet Tollkeeper                             Growth and Income
</TABLE>

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

                         PORTFOLIO
                         ---------
                         Pilgrim Worldwide Growth

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

                         PORTFOLIO
                         ---------
                         Prudential Jennison
                         SP Jennison International Growth

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

                         PORTFOLIO
                         ---------
                         PIMCO High Yield Bond
                         PIMCO StocksPLUS Growth & Income

NOTE: PLEASE REFER TO THE PROSPECTUS FOR THE CONTRACT AND THE TRUSTS FOR MORE
      DETAILS

FG-CA-1000-08/97                       3B

<PAGE>

                       THIS PAGE INTENTIONALLY LEFT BLANK
                       ----------------------------------

FG-CA-1000-08/97

<PAGE>

                                  THE SCHEDULE
                   THE VARIABLE SEPARATE ACCOUNTS (CONTINUED)
--------------------------------------------------------------------------------

 -------------------------------------------------------------------------------
  Annuitant                Owner
  JOHN DOE                 JOHN SMITH
                           JANE SMITH
--------------------------------------------------------------------------------
  Initial Premium          Annuity Option           Annuity Commencement Date
  $10,000.00               LIFE 10 YEAR CERTAIN     OCTOBER 18, 2013
--------------------------------------------------------------------------------
  Separate Account(s)                               Certificate Number
  SEPARATE ACCOUNT NY-B AND THE FIXED ACCOUNT       C000001-FP (Q)
--------------------------------------------------------------------------------

DIVISIONS INVESTING IN SHARES OF A MUTUAL FUND (CONTINUED)
    The division listed below invests in shares of the mutual fund portfolios
    (the "Portfolios") designated. The portfolios are a part of the Pilgrim
    Variable Products Trust managed by ING Pilgrim Investments LLC.

                         PORTFOLIO
                         ---------
                         Pilgrim VP Growth Opportunities
                         Pilgrim VP MagnaCap
                         Pilgrim VP Small Cap Opportunities

    The Division listed below invests in shares of the mutual fund portfolios
    (the "Portfolios") designated. The portfolios are a part of the ProFunds
    managed by ProFund Advisors LLC.

                         PORTFOLIO
                         ---------
                         ProFund VP Bull
                         ProFund VP Europe 30
                         ProFund VP Small-Cap

  Each Division listed below invests in shares of the mutual fund portfolio (the
  "Portfolio") designated. Each portfolio is a part of the Galaxy VIP Funds.

                         PORTFOLIO
                         ---------
                         Asset Allocation
                         Equity
                         Growth & Income
                         High Quality Bond
                         Small Company Growth

NOTE: PLEASE REFER TO THE PROSPECTUS FOR THE CONTRACT AND THE TRUSTS FOR MORE
      DETAILS

FG-CA-1000-08/97                       3B (CONT'D)

<PAGE>

                                  THE SCHEDULE

                                CERTIFICATE FACTS
--------------------------------------------------------------------------------

 -------------------------------------------------------------------------------
  Annuitant                Owner
  JOHN DOE                 JOHN SMITH
                           JANE SMITH
--------------------------------------------------------------------------------
  Initial Premium          Annuity Option           Annuity Commencement Date
  $10,000.00               LIFE 10 YEAR CERTAIN     OCTOBER 18, 2013
--------------------------------------------------------------------------------
  Separate Account(s)                               Certificate Number
  SEPARATE ACCOUNT NY-B AND THE FIXED ACCOUNT       C000001-FP (Q)
--------------------------------------------------------------------------------

CONTRACT FACTS

Contract Processing Date

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

Specially Designated Division

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

PARTIAL WITHDRAWALS

The maximum amount that can be withdrawn in a Certificate Year without being
considered an Excess Partial Withdrawal is 15% of the Accumulation Value as of
the date of the withdrawal. We will collect a Surrender Charge for Excess
Partial Withdrawals and a charge for any unrecovered premium taxes. In no event
may a Partial Withdrawal be greater than 90% of the Cash Surrender Value.

Conventional Partial Withdrawals

     Minimum Withdrawal Amount:        $1,000

Any Conventional Partial Withdrawal from a Fixed Allocation is subject to a
Market Value Adjustment unless taken from a Fixed Allocation within thirty days
prior to the Maturity Date of such Fixed Allocation.

Systematic Partial Withdrawals

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

     Minimum Withdrawal Amount:        $100.00

     Maximum Withdrawal Amount:

         Separate Account Divisions:   1.25% monthly or 3.75% quarterly of
                                       Accumulation Value.

         Fixed Allocations:            Interest earned on a Fixed Allocation
                                       in prior month (for monthly withdrawals)
                                       or prior quarter (for quarterly
                                       withdrawals).

A Systematic Partial Withdrawal from a Fixed Allocation is not subject to Market
Value Adjustments.

IRA Partial Withdrawals for Qualified Certificates Only

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

FG-CA-1000-08/97 Q DB3                 3C1

<PAGE>

                                  The Schedule
                          CERTIFICATE FACTS (continued)
--------------------------------------------------------------------------------

 -------------------------------------------------------------------------------
  Annuitant                Owner
  JOHN DOE                 JOHN SMITH
                           JANE SMITH
--------------------------------------------------------------------------------
  Initial Premium          Annuity Option           Annuity Commencement Date
  $10,000.00               LIFE 10 YEAR CERTAIN     OCTOBER 18, 2013
--------------------------------------------------------------------------------
  Separate Account(s)                               Certificate Number
  SEPARATE ACCOUNT NY-B AND THE FIXED ACCOUNT       C000001-FP (Q)
--------------------------------------------------------------------------------

Death Benefit

The Death Benefit is the greater of (i) the Cash Surrender Value, (ii) the
Accumulation Value, and (iii) the sum of premiums paid, less any Partial
Withdrawals.

Guaranteed Death Benefit

On the Contract Date, the Guaranteed Death Benefit is the Initial Premium. On
subsequent Valuation Dates, the Guaranteed Death Benefit is calculated as
follows:

Standard:
---------
     (1)  Start with the Guaranteed Death Benefit from the prior Valuation Date;
     (2)  Add any additional premiums paid during the current Valuation Period
          to (1);
     (3)  Subtract any Partial Withdrawal made during the current Valuation
          Period from (2).

Change of Owner

When the ownership changes, the new Owner's age at the time of the change will
be used as the basis for the death benefit. The new Owner's death will determine
when a death benefit is payable.

The Guaranteed Death Benefit Option after the change of Contractowner will
remain the same as before the change.

FG-CA-1000-08/97 Q DB3                 3C2
<PAGE>

                                  The Schedule
                          CERTIFICATE FACTS (continued)
--------------------------------------------------------------------------------

 -------------------------------------------------------------------------------
  Annuitant                Owner
  THOMAS J. DOE            JOHN Q. PUBLIC
--------------------------------------------------------------------------------
  Initial Premium          Annuity Option           Annuity Commencement Date
  $10,000.00               LIFE 10 YEAR CERTAIN     JANUARY 1, 2053
--------------------------------------------------------------------------------
  Separate Account(s)                               Certificate Number
  SEPARATE ACCOUNT NY-B AND THE FIXED ACCOUNT       123456
--------------------------------------------------------------------------------

CHOOSING AN INCOME PLAN

Required Date of Annuity Commencement

Distributions from a Certificate funding a qualified plan must commence no later
than April 1st of the calendar year following the calendar year in which the
Owner attains age 70 1/2.

The Annuity Commencement Date is required to be the same date as the Certificate
Processing Date in the month following the Annuitant's 90th birthday. If, on the
Annuity Commencement Date, a Surrender Charge remains, your elected Annuity
Option must include a period certain of at least five years duration. In
applying the Accumulation Value, we may first collect any Premiums Taxes due us.

Minimum Annuity Income Payment

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

FIXED ACCOUNT

Minimum Fixed Allocation

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

Guaranteed Minimum Interest Rate - 3%.

Guarantee Periods

We currently offer Guarantee Periods of 1,3,5,7 and 10 year.

We reserve the right to offer Guarantee Periods of durations other than those
available on the Certificate Date.

Index Rate

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

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

FG-CA-1000-08/97 Q DB3                 3C3

<PAGE>

                                  The Schedule
                                     CHARGES
--------------------------------------------------------------------------------

 -------------------------------------------------------------------------------
  Annuitant                Owner
  JOHN DOE                 JOHN SMITH
                           JANE SMITH
--------------------------------------------------------------------------------
  Initial Premium          Annuity Option           Annuity Commencement Date
  $10,000.00               LIFE 10 YEAR CERTAIN     OCTOBER 18, 2013
--------------------------------------------------------------------------------
  Separate Account(s)                               Certificate Number
  SEPARATE ACCOUNT NY-B AND THE FIXED ACCOUNT       C000001-FP (Q)
--------------------------------------------------------------------------------

Charge Deduction Division

All charges against the Accumulation Value in this Certificate will be deducted
from the Liquid Asset Division.

Deductions from Premiums - None

Deductions from Accumulation Value

Administrative Charge - We charge $30 to cover a portion of our ongoing
---------------------
administrative expenses for each Certificate Processing Period. The charge is
incurred at the beginning of the Certificate Processing Period and deducted on
the Certificate Processing Date at the end of the period. At the time of
deduction, this charge will be waived if: (1) The Accumulation Value is at least
$100,000; or (2) The sum of premiums paid to date is at least $100,000

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

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

          Complete Years Elapsed                     Surrender
          Since Premium Payment                       Charges
          ----------------------                      -------
                     0                                  7%
                     1                                  7%
                     2                                  6%
                     3                                  5%
                     4                                  4%
                     5                                  3%
                     6                                  1%
                    7+                                  0%

For the purpose of calculating the Surrender Charge for an Excess Partial
Withdrawal; a) we treat premiums as being withdrawn on a first-in, first-out
basis; and b) amounts withdrawn which are not considered an Excess Partial
Withdrawal are not considered a withdrawal of any premium payments.

FG-CA-1000-08/97 Q DB3                 3D1

<PAGE>

                                  The Schedule
                                     CHARGES
--------------------------------------------------------------------------------

 -------------------------------------------------------------------------------
  Annuitant                Owner
  THOMAS J. DOE            JOHN Q. PUBLIC
--------------------------------------------------------------------------------
  Initial Premium          Annuity Option           Annuity Commencement Date
  $10,000.00               LIFE 10 YEAR CERTAIN     JANUARY 1, 2053
--------------------------------------------------------------------------------
  Separate Account(s)                               Certificate Number
  SEPARATE ACCOUNT NY-B AND THE FIXED ACCOUNT       123456
--------------------------------------------------------------------------------

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

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

Deductions from the Divisions

Mortality and Expense Risk Charge - We deduct 0.003446% of the assets in the
---------------------------------
Separate Account Division on a daily basis (equivalent to an annual rate of
1.25%) for mortality and expense risks. This charge is not deducted from the
Fixed Account values.

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

FG-CA-1000-08/97 Q DB3                 3D2

<PAGE>

                                  THE SCHEDULE
                         INCOME PLAN FACTORS (continued)
--------------------------------------------------------------------------------

 -------------------------------------------------------------------------------
  Annuitant                Owner
  JOHN DOE                 JOHN SMITH
                           JANE SMITH
--------------------------------------------------------------------------------
  Initial Premium          Annuity Option           Annuity Commencement Date
  $10,000.00               LIFE 10 YEAR CERTAIN     OCTOBER 18, 2013
--------------------------------------------------------------------------------
  Separate Account(s)                               Certificate Number
  SEPARATE ACCOUNT NY-B AND THE FIXED ACCOUNT       C000001-FP (Q)
--------------------------------------------------------------------------------

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

                       TABLE FOR INCOME FOR A FIXED PERIOD

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

                                  11          $8.88          21         $5.33
        2        $42.96           12           8.26          22          5.16
        3         29.06           13           7.73          23          5.00
        4         22.12           14           7.28          24          4.85
        5         17.95           15           6.89          25          4.72
        6         15.18           16           6.54          26          4.60
        7         13.20           17           6.24          27          4.49
        8         11.71           18           5.98          28          4.38
        9         10.56           19           5.74          29          4.28
       10          9.64           20           5.53          30          4.19

                            TABLE FOR INCOME FOR LIFE

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

         50            $4.53/4.19          $4.38/4.13           $4.40/4.12
         55             4.93/4.52           4.68/4.40            4.74/4.42
         60             5.45/4.96           4.99/4.72            5.16/4.79
         65             6.11/5.52           5.30/5.07            5.75/5.29
         70             6.91/6.26           5.54/5.40            6.52/5.97
         75             7.79/7.18           5.68/5.62            7.33/6.74
         80             8.61/8.18           5.75/5.73            8.61/7.90
     85 & Over          9.24/9.01           5.77/5.76           10.43/9.50

FG-CA-1000-08/97 Q DB3                 3E

<PAGE>

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

THE CERTIFICATE

You supply us with necessary information and the Initial Premium Payment
required to put this Certificate in effect. In return, we provide benefits as
stated in the group contract and described in this Certificate.

THE OWNER

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

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

THE ANNUITANT

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

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

THE BENEFICIARY

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

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

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

FG-CA-1000-08/97                       4

<PAGE>

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

CHANGE OF OWNER OR BENEFICIARY

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

FG-CA-1000-08/97                       5

<PAGE>

                     PREMIUM PAYMENTS AND ALLOCATION CHARGES
--------------------------------------------------------------------------------

INITIAL PREMIUM PAYMENT

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

ADDITIONAL PREMIUM PAYMENT OPTION

You may make additional premium payments at any time before the Annuity
Commencement Date. Satisfactory notice to us must be given for additional
premium payments. Restrictions on additional premium payments, such as the
Attained Age of the Annuitant or Owner and the timing and amount of each
payment, are shown in the Schedule. We reserve the right to defer acceptance of
or to return any additional premium payments.

As of the date we receive and accept your additional premium payment:

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

                  (2) The increase in the Accumulation Value will be allocated
                      among the Divisions and the Fixed Allocations in
                      accordance with your instructions. If you do not provide
                      such instructions, allocation will be among the Divisions
                      in proportion to the amount of Accumulation Value in each
                      Division as of the date we receive and accept your
                      additional premium payment. Allocations to the Fixed
                      Account will be made only upon specific request.

Where to Make Payments

Remit the premium payments to our Variable Products Customer Service Center. On
request we will give you a receipt signed by one of our officers.

YOUR RIGHT TO CHANGE ALLOCATION OF ACCUMULATION VALUE

The Accumulation Value may be reallocated among the Divisions and the Fixed
Allocations prior to the Annuity Commencement Date. The number of free
allocation changes each Contract Year that we will allow is shown in the
Schedule. To make an allocation change, you must provide us with satisfactory
notice at our Variable Products Customer Service Center. The change will take
effect when we receive the notice. Restrictions for reallocation into and out of
the Divisions are shown in the Schedule. An allocation from the Fixed Allocation
may be subject to a Market Value Adjustment. See Market Value Adjustment.

WHAT HAPPENS IF A DIVISION IS NOT AVAILABLE

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

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

FG-CA-1000-08/97                       6

<PAGE>

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

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

THE VARIABLE SEPARATE ACCOUNTS

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

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

We may offer certain non-registered Series or Variable Separate Accounts. Any
such Series or Variable Separate Account is shown in the Schedule.

Divisions of the Variable Separate Account

A Unit Investment Trust Variable Separate Account includes Divisions, each
investing in a designated investment portfolio. The Divisions and the investment
portfolios in which they invest, if applicable, are specified in the Schedule.
Some of the portfolios designated may be managed by a separate investment
adviser. Such adviser may be registered under the Investment Advisers Act of
1940.

Changes Within the Separate Accounts

We may, from time to time, make additional Separate Account Divisions available
to you. These Divisions will invest in investment portfolios we find suitable
for the group contract. We also have the right to eliminate Divisions from a
Separate Account, to combine two or more Divisions or to substitute a new
portfolio for the portfolio in which a Division invests. A substitution may
become necessary if, in our judgment, a portfolio or Division no longer suits
the purposes of the group contract. This may happen due to a change in laws or
regulations, or a change in a portfolio's investment objectives or restrictions,
or because the portfolio or Division is no longer available for investment, or
for some other reason. We will get prior approval from the insurance department
of our state of domicile before making such a substitution. This approval
process is on file with the insurance department of the jurisdiction in which
this Certificate is delivered. We will also get any required approval from the
SEC and any other required approvals before making such a substitution.

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

When permitted by law, we reserve the right to:

     (1)  Deregister a Separate Account under the Investment Company Act of
          1940;

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

     (3)  Restrict or eliminate any voting rights of Owners, or other persons
          who have voting rights as to a Separate Account; and,

     (4)  Combine a Separate Account with other Separate Accounts.

FG-CA-1000-08/97                       7

<PAGE>

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

VALUATION PERIOD

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

ACCUMULATION VALUE

The Accumulation Value of this Certificate is equal to the sum of the amounts
that you have in each Division and the Fixed Allocations. You select how your
Accumulation Value is allocated. The maximum number of Divisions and Fixed
Allocations to which you may allocate Accumulation Value at any one time is
shown in the Schedule.

ACCUMULATION VALUE IN EACH DIVISION AND FIXED ALLOCATION

On the Certificate Date

On the Contract Date, the Accumulation Value is allocated to each Division and
the Fixed Allocations as shown in the Schedule.

On each Valuation Date

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

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

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

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

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

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

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

                    (7)  We subtract from (6) the amounts allocated to that
                         Division or Fixed Allocation for: (a) any charges due
                         for the Optional Benefit Riders as shown in the
                         Schedule; (b) any Certificate charges as shown in the
                         Schedule;.

All amounts in (7) are allocated to each Division or Fixed Allocation as
explained in Charges Deducted from Accumulation Value.

FIXED ACCOUNT

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

Guarantee Periods

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

FG-CA-1000-08/97                       8

<PAGE>

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

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

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

Market Value Adjustments

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

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

                          (    1  +  I      )   N/365
                          (-----------------)           - 1
                          (1  +  J  +  .0025)

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

Market Value Adjustments will be applied as follows:

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

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

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

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

FG-CA-1000-08/97                        9

<PAGE>

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

MEASUREMENT OF INVESTMENT EXPERIENCE

Index of Investment Experience

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

How We Determine the Experience Factor

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

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

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

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

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

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

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

Net Rate of Return for a Separate Account Division

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

Interest Credited to a Fixed Allocation

A Fixed Allocation will be credited with the Guaranteed Interest Rate for the
Guarantee Period in effect on the date the premium or reallocation is applied.
Once applied, such rate will be guaranteed until that Fixed Allocation's
Maturity Date. Interest will be credited daily at a rate to yield the declared
annual Guaranteed Interest Rate. We periodically declare Guaranteed Interest
Rates for then-available Guarantee Periods. No Guaranteed Interest Rate will be
less than the Minimum Guaranteed Interest Rate shown in the Schedule.

CHARGES DEDUCTED FROM ACCUMULATION VALUE ON EACH CERTIFICATE PROCESSING DATE

All charges and fees are shown in the Schedule.

Charge Deduction Division Option

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

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

     (2)  If these charges exceed the Accumulation Value in the Divisions, any
          excess over such value will be deducted from the Fixed Account.

Any charges deducted from the Fixed Account will be taken from Fixed Allocations
starting with the Guarantee Period nearest its Maturity Date until such charges
have been paid.

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

FG-CA-1000-08/97                       10

<PAGE>

                            YOUR CERTIFICATE BENEFITS
--------------------------------------------------------------------------------

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

CASH VALUE BENEFIT

Cash Surrender Value

The Cash Surrender Value before the Annuity Commencement Date, is determined as
follows:

     (1)  We take the Certificate's Accumulation Value;

     (2)  We adjust for any applicable Market Value Adjustment;

     (3)  We deduct any Surrender Charge;

     (4)  We deduct any charges shown in the Schedule that have been incurred
          but not yet deducted, including:

          (a)  any quarterly administrative fee to be deducted on the next
               Certificate Processing Date;

          (b)  the pro rata part of any charges for Optional Benefit Riders; and

          (c)  any applicable premium or similar tax.

Cancelling to Receive the Cash Surrender Value

At any time before the Annuity Commencement Date, you may surrender this
Certificate to us. To do this, you must return this Certificate with a signed
request for cancellation to our Variable Products Customer Service Center.

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

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

PARTIAL WITHDRAWAL OPTION

After the first Certificate Anniversary, you may make a Partial Withdrawal once
in each Certificate Year without incurring a Partial Withdrawal Charge. Any
additional Partial Withdrawals in a Certificate Year are subject to a Partial
Withdrawal Charge. The minimum amount that may be withdrawn is shown in the
Schedule. The maximum amount that may be withdrawn is shown in the Schedule. Any
withdrawal you make will not be treated as premium only for the purposes of
calculating the Surrender Charge. To take a Partial Withdrawal, you must provide
us with satisfactory notice at our Variable Products Customer Service Center.

FG-CA-1000-08/97                       11

<PAGE>

                             DEATH BENEFIT PROCEEDS
--------------------------------------------------------------------------------

PROCEEDS PAYABLE TO THE BENEFICIARY

Prior to the Annuity Commencement Date

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

How to Claim Payments to Beneficiary

We must receive proof of the Owner's (or annuitant's) death before we will make
any payments to the beneficiary. We will calculate the death benefit as of the
date we receive due proof of death. The beneficiary should contact our Variable
Products Customer Service Center for instructions.

Guaranteed Death Benefit

On the Certificate Date the Guaranteed Death Benefit is equal to the premium
paid. On subsequent Valuation Dates, the Guaranteed Death Benefit is calculated
as shown in the Schedule. A Change of Owner will affect the Guaranteed Death
Benefit, as shown in the Schedule.

FG-CA-1000-08/97                       12

<PAGE>

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

ANNUITY BENEFITS

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

ANNUITY COMMENCEMENT DATE SELECTION

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

FREQUENCY SELECTION

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

THE INCOME PLAN

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

Our approval is needed for any option where:

          (1)  The person named to receive payment is other than the Owner or
               Beneficiary; or

          (2)  The person named is not a natural person, such as a corporation;
               or

          (3)  Any income payment would be less than the minimum annuity income
               payment shown in the Schedule.

THE ANNUITY OPTIONS

There are four Options to choose from.  They are:

Option 1.  Income for a Fixed Period

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

Option 2.  Income for Life

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

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

FG-CA-1000-08/97                       13

<PAGE>

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

Option 3.  Joint Life Income

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

Option 4.  Annuity Plan

An amount can be used to buy any single premium annuity we offer for the
Option's effective date.

The current annuity payment rates available when the value of the Certificate is
applied to an income plan will be no less than single premium immediate annuity
rates of the same rating class we then offer.

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

PAYMENT WHEN NAMED PERSON DIES

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

          (1)  For Option 1 or for any remaining guaranteed payments in Option
               2, payments will be continued.

          (2)  For Option 3, no amounts are payable after both named persons
               have died.

          (3)  For Option 4, the annuity agreement will state the amount due, if
               any.

FG-CA-1000-08/97                       14

<PAGE>

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

ENTIRE CONTRACT

The group contract, including any attached Rider, Endorsement, amendment and the
application of the contractholder, constitute the entire contract between the
contractholder and us. All statements made by the contractholder, any Owner or
any annuitant will be deemed representations and not warranties. No such
statement will be used in any contest unless it is contained in the application
signed by the contractholder or in a written instrument signed by the Owner, a
copy of which has been furnished to the Owner, the beneficiary or to the
contractholder.

SENDING NOTICE TO US

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

REPORTS TO OWNER

We will send you a report, at least once in each Certificate quarter, within 31
days of each calendar quarter showing the Accumulation Value, the Cash Surrender
Value and the Death Benefit of your Certificate as of the end of the Certificate
Processing Period. The report will also show the allocation of the Accumulation
Value as of such date and the amounts deducted from or added to the Accumulation
Value since the last report. The report will also include any other information
that may be currently required by the insurance supervisory official of the
jurisdiction in which this Certificate is delivered.

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

ASSIGNMENT - USING THIS CERTIFICATE AS COLLATERAL SECURITY

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

CHANGING THE GROUP CONTRACT

This group contract or any additional Benefit Riders may be changed to another
Annuity Plan according to our rules at the time of the change.

CONTRACT CHANGES - APPLICABLE TAX LAW

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

MISSTATEMENT OF AGE OR SEX

If an age or sex has been misstated, the amounts payable or benefits provided by
this Certificate shall be those that the premium payment made would have bought
at the correct age or sex.

NON-PARTICIPATING

This Certificate does not participate in the divisible surplus of ReliaStar Life
Insurance Company of New York.

FG-CA-1000-08/97                       15

<PAGE>

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

PAYMENTS WE MAY DEFER

     We may not be able to determine the value of the assets of the Divisions
     because:

          (1)  The NYSE is closed for trading;

          (2)  The SEC determines that a state of emergency exists; or

          (3)  An order or pronouncement of the SEC permits a delay for the
               protection of Certificate Owners.

          (4)  The check used to pay the premium has not cleared through the
               banking system. This may take up to 15 days.

     During such times, as to amounts allocated to the Divisions, we may delay;

          (1)  Determination and payment of the Cash Surrender Value;

          (2)  Determination and payment of any death benefit if death occurs
               before the Annuity Commencement Date;

          (3)  Allocation changes of the Accumulation Value; or,

          (4)  Application of the Accumulation Value under an income plan.

We reserve the right to delay payment of amounts allocated to the Fixed Account
for up to six months.

AUTHORITY TO MAKE AGREEMENTS

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

          (1)  Change any of this Certificate's terms;

          (2)  Extend the time for premium payments; or

          (3)  Make any agreement binding on us.

REQUIRED NOTE ON OUR COMPUTATIONS

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

FG-CA-1000-08/97                       16

<PAGE>

DEFERRED COMBINATION VARIABLE AND FIXED ANNUITY CERTIFICATE - NO DIVIDENDS
--------------------------------------------------------------------------------

     Variable Cash Surrender Values while the Owner is living and prior to the
     Annuity Commencement Date. Death benefit subject to guaranteed minimum.
     Additional premium payment option. Partial Withdrawal option.
     Non-participating. Investment results reflected in values.

FG--CA-1000-08/97

<PAGE>

                                  THE SCHEDULE
                       PAYMENT AND INVESTMENT INFORMATION
--------------------------------------------------------------------------------

--------------------------------------------------------------------------------
  Contractholder                              Group Contract Number
  FIRST GOLDEN INVESTORS TRUST                FG000012-0E
 -------------------------------------------------------------------------------
  Annuitant                Owner
  JOHN DOE                 JOHN SMITH
                           JANE SMITH
--------------------------------------------------------------------------------
  Annuitant's Issue Age    Annuitant's Sex          Certificateowner's Issue Age
  76                       MALE                     76
--------------------------------------------------------------------------------
  Initial Premium          Annuity Option           Annuity Commencement Date
  $10,000.00               LIFE 10 YEAR CERTAIN     OCTOBER 18, 2013
--------------------------------------------------------------------------------
  Certificate Date         Certificate Issue Date   Certificate Number
  FEBRUARY 18, 2001        AUGUST 15, 2001          C000001-FP (Q)
--------------------------------------------------------------------------------
  Separate Account(s)
  SEPARATE ACCOUNT NY-B AND THE FIXED ACCOUNT
--------------------------------------------------------------------------------

PREMIUM PAYMENT AND INVESTMENT INFORMATION

Initial premium payment received:                    $10,000.00

Your initial Accumulation Value has been invested as follows:

                                                   Percentage of
                   Divisions                    Accumulation Value
         -----------------------------    ------------------------------
                     Total                             100%
                     =====                             ====

FG-CA-1000-08/97 NQ DB3                3A1

<PAGE>

                                  THE SCHEDULE
                       PAYMENT AND INVESTMENT INFORMATION
--------------------------------------------------------------------------------

--------------------------------------------------------------------------------
  Contractholder                              Group Contract Number
  FIRST GOLDEN INVESTORS TRUST                FG000012-0E
 -------------------------------------------------------------------------------
  Annuitant                Owner
  JOHN DOE                 JOHN SMITH
                           JANE SMITH
--------------------------------------------------------------------------------
  Annuitant's Issue Age    Annuitant's Sex          Certificateowner's Issue Age
  76                       MALE                     76
--------------------------------------------------------------------------------
  Initial Premium          Annuity Option           Annuity Commencement Date
  $10,000.00               LIFE 10 YEAR CERTAIN     OCTOBER 18, 2013
--------------------------------------------------------------------------------
  Certificate Date         Certificate Issue Date   Certificate Number
  FEBRUARY 18, 2001        AUGUST 15, 2001          C000001-FP (Q)
--------------------------------------------------------------------------------
  Separate Account(s)
  SEPARATE ACCOUNT NY-B AND THE FIXED ACCOUNT
--------------------------------------------------------------------------------

PREMIUM PAYMENT AND INVESTMENT INFORMATION

Additional Premium Payment Information

We will accept additional premium payments until either the Annuitant or the
Owner reaches the Attained Age of 85. The minimum additional payment which may
be made is $500.00

ACCUMULATION VALUE ALLOCATION RULES

The maximum number of Divisions in which you may be invested at any one time is
sixteen. You are currently allowed unlimited allocation changes per Contract
Year without charge. We reserve the right to impose a charge as shown in the
Charges section of the Schedule for any allocation change in excess of twelve
per Certificate Year. We also reserve the right to limit, upon notice, the
maximum number of allocation changes you may make within a Certificate Year.

FG-CA-1000-08/97 NQ DB3             3A1 (CONT'D)

<PAGE>

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

 -------------------------------------------------------------------------------
  Annuitant                Owner
  JOHN DOE                 JOHN SMITH
                           JANE SMITH
--------------------------------------------------------------------------------
  Initial Premium          Annuity Option           Annuity Commencement Date
  $10,000.00               LIFE 10 YEAR CERTAIN     OCTOBER 18, 2013
--------------------------------------------------------------------------------
  Separate Account(s)                               Certificate Number
  SEPARATE ACCOUNT NY-B AND THE FIXED ACCOUNT       C000001-FP
--------------------------------------------------------------------------------

DIVISIONS INVESTING IN SHARES OF A MUTUAL FUND

  Separate Account NY-B (the "Account") is a unit investment trust Separate
  Account, organized in and governed by the laws of the State of New York, our
  state of domicile. The Account is divided into Divisions.

  Each Division listed below invests in shares of the mutual fund portfolio (the
  "Series") designated. Each portfolio is a part of the GCG Trust.

<TABLE>
SERIES                     SERIES                 SERIES                   SERIES
------                     ------                 ------                   ------
<S>                        <C>                    <C>                      <C>
All Cap                    Small Cap              Hard Assets              Liquid Asset
Investors                  Mid-Cap Growth         Limited Maturity Bond    Strategic Equity
Equity Income              Capital Growth         Capital Appreciation     Managed Global
Fully Managed              Large Cap Value        Rising Dividends         Research
Value Equity               Real Estate            Total Return             Growth
Asset Allocation Growth    Special Situations     Core Bond                Developing World
Diversified Mid-Cap        Internet Tollkeeper                             Growth and Income
</TABLE>

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

                         PORTFOLIO
                         ---------
                         Pilgrim Worldwide Growth

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

                         PORTFOLIO
                         ---------
                         Prudential Jennison
                         SP Jennison International Growth

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

                         PORTFOLIO
                         ---------
                         PIMCO High Yield Bond
                         PIMCO StocksPLUS Growth & Income

NOTE: PLEASE REFER TO THE PROSPECTUS FOR THE CONTRACT AND THE TRUSTS FOR MORE
      DETAILS

FG-CA-1000-08/97                       3B

<PAGE>

                       THIS PAGE INTENTIONALLY LEFT BLANK
                       ----------------------------------

FG-CA-1000-08/97

<PAGE>

                                  THE SCHEDULE
                   THE VARIABLE SEPARATE ACCOUNTS (CONTINUED)
--------------------------------------------------------------------------------

 -------------------------------------------------------------------------------
  Annuitant                Owner
  JOHN DOE                 JOHN SMITH
                           JANE SMITH
--------------------------------------------------------------------------------
  Initial Premium          Annuity Option           Annuity Commencement Date
  $10,000.00               LIFE 10 YEAR CERTAIN     OCTOBER 18, 2013
--------------------------------------------------------------------------------
  Separate Account(s)                               Certificate Number
  SEPARATE ACCOUNT NY-B AND THE FIXED ACCOUNT       C000001-FP
--------------------------------------------------------------------------------

DIVISIONS INVESTING IN SHARES OF A MUTUAL FUND (CONTINUED)
    The division listed below invests in shares of the mutual fund portfolios
    (the "Portfolios") designated. The portfolios are a part of the Pilgrim
    Variable Products Trust managed by ING Pilgrim Investments LLC.

                         PORTFOLIO
                         ---------
                         Pilgrim VP Growth Opportunities
                         Pilgrim VP MagnaCap
                         Pilgrim VP Small Cap Opportunities

    The Division listed below invests in shares of the mutual fund portfolios
    (the "Portfolios") designated. The portfolios are a part of the ProFunds
    managed by ProFund Advisors LLC.

                         PORTFOLIO
                         ---------
                         ProFund VP Bull
                         ProFund VP Europe 30
                         ProFund VP Small-Cap

  Each Division listed below invests in shares of the mutual fund portfolio (the
  "Portfolio") designated. Each portfolio is a part of the Galaxy VIP Funds.

                         PORTFOLIO
                         ---------
                         Asset Allocation
                         Equity
                         Growth & Income
                         High Quality Bond
                         Small Company Growth

NOTE: PLEASE REFER TO THE PROSPECTUS FOR THE CONTRACT AND THE TRUSTS FOR MORE
      DETAILS

FG-CA-1000-08/97                   3B (CONT'D)

<PAGE>

                                  THE SCHEDULE
                                CERTIFICATE FACTS
--------------------------------------------------------------------------------

 -------------------------------------------------------------------------------
  Annuitant                Owner
  JOHN DOE                 JOHN SMITH
                           JANE SMITH
--------------------------------------------------------------------------------
  Initial Premium          Annuity Option           Annuity Commencement Date
  $10,000.00               LIFE 10 YEAR CERTAIN     OCTOBER 18, 2013
--------------------------------------------------------------------------------
  Separate Account(s)                               Certificate Number
  SEPARATE ACCOUNT NY-B AND THE FIXED ACCOUNT       C000001-FP
--------------------------------------------------------------------------------

CONTRACT FACTS

Contract Processing Date

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

Specially Designated Division

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

PARTIAL WITHDRAWALS

The maximum amount that can be withdrawn in a Certificate Year without being
considered an Excess Partial Withdrawal is 15% of the Accumulation Value as of
the date of the withdrawal. We will collect a Surrender Charge for Excess
Partial Withdrawals and a charge for any unrecovered premium taxes. In no event
may a Partial Withdrawal be greater than 90% of the Cash Surrender Value.

Conventional Partial Withdrawals

     Minimum Withdrawal Amount:        $1,000

Any Conventional Partial Withdrawal from a Fixed Allocation is subject to a
Market Value Adjustment unless taken from a Fixed Allocation within thirty days
prior to the Maturity Date of such Fixed Allocation.

Systematic Partial Withdrawals

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

     Minimum Withdrawal Amount:        $100.00

     Maximum Withdrawal Amount:

        Separate Account Divisions:    1.25% monthly or 3.75% quarterly of
                                       Accumulation Value.

        Fixed Allocations:             Interest earned on a Fixed Allocation
                                       in prior month (for monthly withdrawals)
                                       or prior quarter (for quarterly
                                       withdrawals).

A Systematic Partial Withdrawal from a Fixed Allocation is not subject to Market
Value Adjustments.

FG-CA-1000-08/97 NQ DB3                3C1

<PAGE>

                                  The Schedule
                          CERTIFICATE FACTS (continued)
--------------------------------------------------------------------------------

 -------------------------------------------------------------------------------
  Annuitant                Owner
  JOHN DOE                 JOHN SMITH
                           JANE SMITH
--------------------------------------------------------------------------------
  Initial Premium          Annuity Option           Annuity Commencement Date
  $10,000.00               LIFE 10 YEAR CERTAIN     OCTOBER 18, 2013
--------------------------------------------------------------------------------
  Separate Account(s)                               Certificate Number
  SEPARATE ACCOUNT NY-B AND THE FIXED ACCOUNT       C000001-FP
--------------------------------------------------------------------------------

Death Benefit

The Death Benefit is the greater of (i) the Cash Surrender Value, (ii) the
Accumulation Value, and (iii) the sum of premiums paid, less any Partial
Withdrawals.

Guaranteed Death Benefit

On the Contract Date, the Guaranteed Death Benefit is the Initial Premium. On
subsequent Valuation Dates, the Guaranteed Death Benefit is calculated as
follows:

Standard:
---------
     (4)  Start with the Guaranteed Death Benefit from the prior Valuation Date;
     (5)  Add any additional premiums paid during the current Valuation Period
          to (1);
     (6)  Subtract any Partial Withdrawal made during the current Valuation
          Period from (2).

Change of Owner

When the ownership changes, the new Owner's age at the time of the change will
be used as the basis for the death benefit. The new Owner's death will determine
when a death benefit is payable.

The Guaranteed Death Benefit Option after the change of Contractowner will
remain the same as before the change.

FG-CA-1000-08/97 NQ DB3                3C2

<PAGE>

                                  The Schedule
                          CERTIFICATE FACTS (continued)
--------------------------------------------------------------------------------

 -------------------------------------------------------------------------------
  Annuitant                Owner
  THOMAS J. DOE            JOHN Q. PUBLIC
--------------------------------------------------------------------------------
  Initial Premium          Annuity Option           Annuity Commencement Date
  $10,000.00               LIFE 10 YEAR CERTAIN     JANUARY 1, 2053
--------------------------------------------------------------------------------
  Separate Account(s)                               Certificate Number
  SEPARATE ACCOUNT NY-B AND THE FIXED ACCOUNT       123456
--------------------------------------------------------------------------------

CHOOSING AN INCOME PLAN

Required Date of Annuity Commencement

Distributions from a Certificate funding a qualified plan must commence no later
than April 1st of the calendar year following the calendar year in which the
Owner attains age 70 1/2.

The Annuity Commencement Date is required to be the same date as the Certificate
Processing Date in the month following the Annuitant's 90th birthday. If, on the
Annuity Commencement Date, a Surrender Charge remains, your elected Annuity
Option must include a period certain of at least five years duration. In
applying the Accumulation Value, we may first collect any Premiums Taxes due us.

Minimum Annuity Income Payment

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

FIXED ACCOUNT

Minimum Fixed Allocation

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

Guaranteed Minimum Interest Rate - 3%.

Guarantee Periods

We currently offer Guarantee Periods of 1,3,5,7 and 10 year.

We reserve the right to offer Guarantee Periods of durations other than those
available on the Certificate Date.

Index Rate

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

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

FG-CA-1000-08/97 NQ DB3                3C3

<PAGE>

                                  The Schedule
                                     CHARGES
--------------------------------------------------------------------------------

 -------------------------------------------------------------------------------
  Annuitant                Owner
  JOHN DOE                 JOHN SMITH
                           JANE SMITH
--------------------------------------------------------------------------------
  Initial Premium          Annuity Option           Annuity Commencement Date
  $10,000.00               LIFE 10 YEAR CERTAIN     OCTOBER 18, 2013
--------------------------------------------------------------------------------
  Separate Account(s)                               Certificate Number
  SEPARATE ACCOUNT NY-B AND THE FIXED ACCOUNT       C000001-FP
--------------------------------------------------------------------------------

Charge Deduction Division

All charges against the Accumulation Value in this Certificate will be deducted
from the Liquid Asset Division.

Deductions from Premiums - None

Deductions from Accumulation Value

Administrative Charge - We charge $30 to cover a portion of our ongoing
---------------------
administrative expenses for each Certificate Processing Period. The charge is
incurred at the beginning of the Certificate Processing Period and deducted on
the Certificate Processing Date at the end of the period. At the time of
deduction, this charge will be waived if: (3) The Accumulation Value is at least
$100,000; or (4) The sum of premiums paid to date is at least $100,000

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

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

          Complete Years Elapsed                     Surrender
          Since Premium Payment                       Charges
          ----------------------                      -------
                     0                                  7%
                     1                                  7%
                     2                                  6%
                     3                                  5%
                     4                                  4%
                     5                                  3%
                     6                                  1%
                    7+                                  0%

For the purpose of calculating the Surrender Charge for an Excess Partial
Withdrawal; a) we treat premiums as being withdrawn on a first-in, first-out
basis; and b) amounts withdrawn which are not considered an Excess Partial
Withdrawal are not considered a withdrawal of any premium payments.

FG-CA-1000-08/97 NQ DB3                3D1

<PAGE>

                                  The Schedule
                                     CHARGES
--------------------------------------------------------------------------------

--------------------------------------------------------------------------------
  Annuitant                Owner
  THOMAS J. DOE            JOHN Q. PUBLIC
--------------------------------------------------------------------------------
  Initial Premium          Annuity Option           Annuity Commencement Date
  $10,000.00               LIFE 10 YEAR CERTAIN     JANUARY 1, 2053
--------------------------------------------------------------------------------
  Separate Account(s)                               Certificate Number
  SEPARATE ACCOUNT NY-B AND THE FIXED ACCOUNT       123456
--------------------------------------------------------------------------------

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

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

Deductions from the Divisions

Mortality and Expense Risk Charge - We deduct 0.003446% of the assets in the
---------------------------------
Separate Account Division on a daily basis (equivalent to an annual rate of
1.25%) for mortality and expense risks. This charge is not deducted from the
Fixed Account values.

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

FG-CA-1000-08/97 NQ DB3                3D2

<PAGE>

                                  THE SCHEDULE
                         INCOME PLAN FACTORS (continued)
--------------------------------------------------------------------------------

--------------------------------------------------------------------------------
  Annuitant                Owner
  JOHN DOE                 JOHN SMITH
                           JANE SMITH
--------------------------------------------------------------------------------
  Initial Premium          Annuity Option           Annuity Commencement Date
  $10,000.00               LIFE 10 YEAR CERTAIN     OCTOBER 18, 2013
--------------------------------------------------------------------------------
  Separate Account(s)                               Certificate Number
  SEPARATE ACCOUNT NY-B AND THE FIXED ACCOUNT       C000001-FP
--------------------------------------------------------------------------------

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

                       TABLE FOR INCOME FOR A FIXED PERIOD

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

                                   11          $8.88          21         $5.33
        2         $42.96           12           8.26          22          5.16
        3          29.06           13           7.73          23          5.00
        4          22.12           14           7.28          24          4.85
        5          17.95           15           6.89          25          4.72
        6          15.18           16           6.54          26          4.60
        7          13.20           17           6.24          27          4.49
        8          11.71           18           5.98          28          4.38
        9          10.56           19           5.74          29          4.28
       10           9.64           20           5.53          30          4.19

                            TABLE FOR INCOME FOR LIFE

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

       50             $4.53/4.19           $4.38/4.13           $4.40/4.12
       55              4.93/4.52            4.68/4.40            4.74/4.42
       60              5.45/4.96            4.99/4.72            5.16/4.79
       65              6.11/5.52            5.30/5.07            5.75/5.29
       70              6.91/6.26            5.54/5.40            6.52/5.97
       75              7.79/7.18            5.68/5.62            7.33/6.74
       80              8.61/8.18            5.75/5.73            8.61/7.90
   85 & Over           9.24/9.01            5.77/5.76           10.43/9.50

FG-CA-1000-08/97 NQ DB3                3E

<PAGE>

                                  THE SCHEDULE
                       PAYMENT AND INVESTMENT INFORMATION
--------------------------------------------------------------------------------

--------------------------------------------------------------------------------
  Contractholder                              Group Contract Number
  FIRST GOLDEN INVESTORS TRUST                FG000012-0E
 -------------------------------------------------------------------------------
  Annuitant                Owner
  JOHN DOE                 JOHN SMITH
                           JANE SMITH
--------------------------------------------------------------------------------
  Annuitant's Issue Age    Annuitant's Sex          Certificateowner's Issue Age
  76                       MALE                     76
--------------------------------------------------------------------------------
  Initial Premium          Annuity Option           Annuity Commencement Date
  $10,000.00               LIFE 10 YEAR CERTAIN     OCTOBER 18, 2013
--------------------------------------------------------------------------------
  Certificate Date         Certificate Issue Date   Certificate Number
  FEBRUARY 18, 2001        AUGUST 15, 2001          C000001-FP (Q)
--------------------------------------------------------------------------------
  Separate Account(s)
  SEPARATE ACCOUNT NY-B AND THE FIXED ACCOUNT
--------------------------------------------------------------------------------

PREMIUM PAYMENT AND INVESTMENT INFORMATION

Initial premium payment received:            $10,000.00

Your initial Accumulation Value has been invested as follows:

                                                      Percentage of
              Divisions                             Accumulation Value
    -----------------------------             ------------------------------
                Total                                      100%
                =====                                      ====

FG-CA-1000-08/97 Q DB2                 3A1

<PAGE>

                                  THE SCHEDULE
                       PAYMENT AND INVESTMENT INFORMATION
--------------------------------------------------------------------------------

--------------------------------------------------------------------------------
  Contractholder                              Group Contract Number
  FIRST GOLDEN INVESTORS TRUST                FG000012-0E
 -------------------------------------------------------------------------------
  Annuitant                Owner
  JOHN DOE                 JOHN SMITH
                           JANE SMITH
--------------------------------------------------------------------------------
  Annuitant's Issue Age    Annuitant's Sex          Certificateowner's Issue Age
  76                       MALE                     76
--------------------------------------------------------------------------------
  Initial Premium          Annuity Option           Annuity Commencement Date
  $10,000.00               LIFE 10 YEAR CERTAIN     OCTOBER 18, 2013
--------------------------------------------------------------------------------
  Certificate Date         Certificate Issue Date   Certificate Number
  FEBRUARY 18, 2001        AUGUST 15, 2001          C000001-FP (Q)
--------------------------------------------------------------------------------
  Separate Account(s)
  SEPARATE ACCOUNT NY-B AND THE FIXED ACCOUNT
--------------------------------------------------------------------------------

PREMIUM PAYMENT AND INVESTMENT INFORMATION

Additional Premium Payment Information

In no event may you contribute to your IRA for the taxable year in which you
attain age 70 1/2 and thereafter except for rollover contributions. The minimum
additional payment which may be made is $250.00.

ACCUMULATION VALUE ALLOCATION RULES

The maximum number of Divisions in which you may be invested at any one time is
sixteen. You are currently allowed unlimited allocation changes per Contract
Year without charge. We reserve the right to impose a charge as shown in the
Charges section of the Schedule for any allocation change in excess of twelve
per Certificate Year. We also reserve the right to limit, upon notice, the
maximum number of allocation changes you may make within a Certificate Year.

FG-CA-1000-08/97 Q DB2             3A1 (CONT'D)

<PAGE>

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

 -------------------------------------------------------------------------------
  Annuitant                Owner
  JOHN DOE                 JOHN SMITH
                           JANE SMITH
--------------------------------------------------------------------------------
  Initial Premium          Annuity Option           Annuity Commencement Date
  $10,000.00               LIFE 10 YEAR CERTAIN     OCTOBER 18, 2013
--------------------------------------------------------------------------------
  Separate Account(s)                               Certificate Number
  SEPARATE ACCOUNT NY-B AND THE FIXED ACCOUNT       C000001-FP
--------------------------------------------------------------------------------

DIVISIONS INVESTING IN SHARES OF A MUTUAL FUND

  Separate Account NY-B (the "Account") is a unit investment trust Separate
  Account, organized in and governed by the laws of the State of New York, our
  state of domicile. The Account is divided into Divisions.

  Each Division listed below invests in shares of the mutual fund portfolio (the
  "Series") designated. Each portfolio is a part of the GCG Trust.

<TABLE>
SERIES                     SERIES                 SERIES                  SERIES
------                     ------                 ------                  ------
<S>                        <C>                    <C>                     <C>
All Cap                    Small Cap              Hard Assets             Liquid Asset
Investors                  Mid-Cap Growth         Limited Maturity Bond   Strategic Equity
Equity Income              Capital Growth         Capital Appreciation    Managed Global
Fully Managed              Large Cap Value        Rising Dividends        Research
Value Equity               Real Estate            Total Return            Growth
Asset Allocation Growth    Special Situations     Core Bond               Developing World
Diversified Mid-Cap        Internet Tollkeeper                            Growth and Income
</TABLE>

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

                         PORTFOLIO
                         ---------
                         Pilgrim Worldwide Growth

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

                         PORTFOLIO
                         ---------
                         Prudential Jennison
                         SP Jennison International Growth

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

                         PORTFOLIO
                         ---------
                         PIMCO High Yield Bond
                         PIMCO StocksPLUS Growth & Income

     NOTE: PLEASE REFER TO THE PROSPECTUS FOR THE CONTRACT AND THE TRUSTS FOR
           MORE DETAILS

FG-CA-1000-08/97                       3B

<PAGE>

                       THIS PAGE INTENTIONALLY LEFT BLANK
                       ----------------------------------

FG-CA-1000-08/97

<PAGE>

                                  THE SCHEDULE
                   THE VARIABLE SEPARATE ACCOUNTS (CONTINUED)
--------------------------------------------------------------------------------

--------------------------------------------------------------------------------
  Annuitant                Owner
  JOHN DOE                 JOHN SMITH
                           JANE SMITH
--------------------------------------------------------------------------------
  Initial Premium          Annuity Option           Annuity Commencement Date
  $10,000.00               LIFE 10 YEAR CERTAIN     OCTOBER 18, 2013
--------------------------------------------------------------------------------
  Separate Account(s)                               Certificate Number
  SEPARATE ACCOUNT NY-B AND THE FIXED ACCOUNT       C000001-FP
--------------------------------------------------------------------------------

DIVISIONS INVESTING IN SHARES OF A MUTUAL FUND (CONTINUED)
    The division listed below invests in shares of the mutual fund portfolios
    (the "Portfolios") designated. The portfolios are a part of the Pilgrim
    Variable Products Trust managed by ING Pilgrim Investments LLC.

                         PORTFOLIO
                         ---------
                         Pilgrim VP Growth Opportunities
                         Pilgrim VP MagnaCap
                         Pilgrim VP Small Cap Opportunities

    The Division listed below invests in shares of the mutual fund portfolios
    (the "Portfolios") designated. The portfolios are a part of the ProFunds
    managed by ProFund Advisors LLC.

                         PORTFOLIO
                         ---------
                         ProFund VP Bull
                         ProFund VP Europe 30
                         ProFund VP Small-Cap

  Each Division listed below invests in shares of the mutual fund portfolio (the
  "Portfolio") designated. Each portfolio is a part of the Galaxy VIP Funds.

                         PORTFOLIO
                         ---------
                         Asset Allocation
                         Equity
                         Growth & Income
                         High Quality Bond
                         Small Company Growth

     NOTE: PLEASE REFER TO THE PROSPECTUS FOR THE CONTRACT AND THE TRUSTS FOR
           MORE DETAILS

FG-CA-1000-08/97                   3B (CONT'D)

<PAGE>

                                  THE SCHEDULE
                                CERTIFICATE FACTS
--------------------------------------------------------------------------------

--------------------------------------------------------------------------------
  Annuitant                Owner
  JOHN DOE                 JOHN SMITH
                           JANE SMITH
--------------------------------------------------------------------------------
  Initial Premium          Annuity Option           Annuity Commencement Date
  $10,000.00               LIFE 10 YEAR CERTAIN     OCTOBER 18, 2013
--------------------------------------------------------------------------------
  Separate Account(s)                               Certificate Number
  SEPARATE ACCOUNT NY-B AND THE FIXED ACCOUNT       C000001-FP
--------------------------------------------------------------------------------

CONTRACT FACTS

Contract Processing Date

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

Specially Designated Division

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

PARTIAL WITHDRAWALS

The maximum amount that can be withdrawn in a Certificate Year without being
considered an Excess Partial Withdrawal is 15% of the Accumulation Value as of
the date of the withdrawal. We will collect a Surrender Charge for Excess
Partial Withdrawals and a charge for any unrecovered premium taxes. In no event
may a Partial Withdrawal be greater than 90% of the Cash Surrender Value.

Conventional Partial Withdrawals

     Minimum Withdrawal Amount:       $1,000

Any Conventional Partial Withdrawal from a Fixed Allocation is subject to a
Market Value Adjustment unless taken from a Fixed Allocation within thirty days
prior to the Maturity Date of such Fixed Allocation.

Systematic Partial Withdrawals

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

     Minimum Withdrawal Amount:       $100.00

     Maximum Withdrawal Amount:

        Separate Account Divisions:   1.25% monthly or 3.75% quarterly of
                                      Accumulation Value.

        Fixed Allocations:            Interest earned on a Fixed Allocation in
                                      prior month (for monthly withdrawals) or
                                      prior quarter (for quarterly
                                      withdrawals).

A Systematic Partial Withdrawal from a Fixed Allocation is not subject to Market
Value Adjustments.

IRA Partial Withdrawals for Qualified Certificates Only

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

FG-CA-1000-08/97 Q DB2                 3C1

<PAGE>

                                  The Schedule
                          CERTIFICATE FACTS (continued)
--------------------------------------------------------------------------------

--------------------------------------------------------------------------------
  Annuitant                Owner
  JOHN DOE                 JOHN SMITH
                           JANE SMITH
--------------------------------------------------------------------------------
  Initial Premium          Annuity Option           Annuity Commencement Date
  $10,000.00               LIFE 10 YEAR CERTAIN     OCTOBER 18, 2013
--------------------------------------------------------------------------------
  Separate Account(s)                               Certificate Number
  SEPARATE ACCOUNT NY-B AND THE FIXED ACCOUNT       C000001-FP
--------------------------------------------------------------------------------

Death Benefit

The Death Benefit is the greatest of (i) the Accumulation Value, (ii) the
Guaranteed Death Benefit, (iii) the Cash Surrender Value, and (iv) the sum of
premiums paid, less any partial withdrawals.

Guaranteed Death Benefit

On the Contract Date, the Guaranteed Death Benefit is the Initial Premium. On
subsequent Valuation Dates, the Guaranteed Death Benefit is calculated as
follows:

Annual Ratchet:
---------------
     (1)  Start with the Guaranteed Death Benefit from the prior Valuation Date;

     (2)  Add to (1) any additional premium paid since the prior Valuation Date
          and subtract from (1) any Partial Withdrawals taken since the prior
          Valuation Date;

     (3)  On a Valuation Date which occurs through the Contract Year in which
          the Owner's Attained Age is 80 and which is also a Contract
          Anniversary, if the Owner is alive (the Annuitant if the Owner is not
          an individual), we set the Guaranteed Death Benefit equal to the
          greater of (2) or the Accumulation Value as of such date. On all other
          Valuation Dates, the Guaranteed Death Benefit is equal to (2).

Change of Owner

When the ownership changes, the new Owner's age at the time of the change will
be used as the basis for the death benefit. The new Owner's death will determine
when a death benefit is payable.

If the new Contractowner's age is less than or equal to 79, the Guaranteed Death
Benefit Option in effect prior to the change of Contractowner will remain in
effect. If the new Contractowner's age is greater than 79, the Guaranteed Death
Benefit will be zero and the Death Benefit shall be the greatest of Cash
Surrender Value, the Accumulation Value, and the sum of premiums paid, less any
Partial Withdrawals.

FG-CA-1000-08/97 Q DB2                 3C2

<PAGE>

                                  The Schedule
                          CERTIFICATE FACTS (continued)
--------------------------------------------------------------------------------

--------------------------------------------------------------------------------
  Annuitant                Owner
  THOMAS J. DOE            JOHN Q. PUBLIC
--------------------------------------------------------------------------------
  Initial Premium          Annuity Option           Annuity Commencement Date
  $10,000.00               LIFE 10 YEAR CERTAIN     JANUARY 1, 2053
--------------------------------------------------------------------------------
  Separate Account(s)                               Certificate Number
  SEPARATE ACCOUNT NY-B AND THE FIXED ACCOUNT       123456
--------------------------------------------------------------------------------

CHOOSING AN INCOME PLAN

Required Date of Annuity Commencement

Distributions from a Certificate funding a qualified plan must commence no later
than April 1st of the calendar year following the calendar year in which the
Owner attains age 70 1/2.

The Annuity Commencement Date is required to be the same date as the Certificate
Processing Date in the month following the Annuitant's 90th birthday. If, on the
Annuity Commencement Date, a Surrender Charge remains, your elected Annuity
Option must include a period certain of at least five years duration. In
applying the Accumulation Value, we may first collect any Premiums Taxes due us.

Minimum Annuity Income Payment

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

FIXED ACCOUNT

Minimum Fixed Allocation

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

Guaranteed Minimum Interest Rate - 3%.

Guarantee Periods

We currently offer Guarantee Periods of 1,3,5,7 and 10 year.

We reserve the right to offer Guarantee Periods of durations other than those
available on the Certificate Date.

Index Rate

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

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

FG-CA-1000-08/97 Q DB2                 3C3

<PAGE>

                                  The Schedule
                                     CHARGES
--------------------------------------------------------------------------------

--------------------------------------------------------------------------------
  Annuitant                Owner
  JOHN DOE                 JOHN SMITH
                           JANE SMITH
--------------------------------------------------------------------------------
  Initial Premium          Annuity Option           Annuity Commencement Date
  $10,000.00               LIFE 10 YEAR CERTAIN     OCTOBER 18, 2013
--------------------------------------------------------------------------------
  Separate Account(s)                               Certificate Number
  SEPARATE ACCOUNT NY-B AND THE FIXED ACCOUNT       C000001-FP (Q)
--------------------------------------------------------------------------------

Charge Deduction Division

All charges against the Accumulation Value in this Certificate will be deducted
from the Liquid Asset Division.

Deductions from Premiums - None

Deductions from Accumulation Value

Administrative Charge - We charge $30 to cover a portion of our ongoing
---------------------
administrative expenses for each Certificate Processing Period. The charge is
incurred at the beginning of the Certificate Processing Period and deducted on
the Certificate Processing Date at the end of the period. At the time of
deduction, this charge will be waived if: (5) The Accumulation Value is at least
$100,000; or (6) The sum of premiums paid to date is at least $100,000

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

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

          Complete Years Elapsed                     Surrender
          Since Premium Payment                       Charges
          ----------------------                      -------
                     0                                  7%
                     1                                  7%
                     2                                  6%
                     3                                  5%
                     4                                  4%
                     5                                  3%
                     6                                  1%
                    7+                                  0%

For the purpose of calculating the Surrender Charge for an Excess Partial
Withdrawal; a) we treat premiums as being withdrawn on a first-in, first-out
basis; and b) amounts withdrawn which are not considered an Excess Partial
Withdrawal are not considered a withdrawal of any premium payments.

FG-CA-1000-08/97 Q DB2                 3D1

<PAGE>

                                  The Schedule
                                     CHARGES
--------------------------------------------------------------------------------

--------------------------------------------------------------------------------
  Annuitant                Owner
  THOMAS J. DOE            JOHN Q. PUBLIC
--------------------------------------------------------------------------------
  Initial Premium          Annuity Option           Annuity Commencement Date
  $10,000.00               LIFE 10 YEAR CERTAIN     JANUARY 1, 2053
--------------------------------------------------------------------------------
  Separate Account(s)                               Certificate Number
  SEPARATE ACCOUNT NY-B AND THE FIXED ACCOUNT       123456
--------------------------------------------------------------------------------

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

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

Deductions from the Divisions

Mortality and Expense Risk Charge - We deduct 0.003446% of the assets in the
---------------------------------
Separate Account Division on a daily basis (equivalent to an annual rate of
1.25%) for mortality and expense risks. This charge is not deducted from the
Fixed Account values.

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

FG-CA-1000-08/97 Q DB2                 3D2

<PAGE>

                                  THE SCHEDULE
--------------------------------------------------------------------------------

--------------------------------------------------------------------------------
  Annuitant                Owner
  JOHN DOE                 JOHN SMITH
                           JANE SMITH
--------------------------------------------------------------------------------
  Initial Premium          Annuity Option           Annuity Commencement Date
  $10,000.00               LIFE 10 YEAR CERTAIN     OCTOBER 18, 2013
--------------------------------------------------------------------------------
  Separate Account(s)                               Certificate Number
  SEPARATE ACCOUNT NY-B AND THE FIXED ACCOUNT       C000001-FP (Q)
--------------------------------------------------------------------------------

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

                       TABLE FOR INCOME FOR A FIXED PERIOD

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

                                  11          $8.88           21         $5.33
        2         $42.96          12           8.26           22          5.16
        3          29.06          13           7.73           23          5.00
        4          22.12          14           7.28           24          4.85
        5          17.95          15           6.89           25          4.72
        6          15.18          16           6.54           26          4.60
        7          13.20          17           6.24           27          4.49
        8          11.71          18           5.98           28          4.38
        9          10.56          19           5.74           29          4.28
       10           9.64          20           5.53           30          4.19

                            TABLE FOR INCOME FOR LIFE

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

        50              $4.53/4.19           $4.38/4.13          $4.40/4.12
        55               4.93/4.52            4.68/4.40           4.74/4.42
        60               5.45/4.96            4.99/4.72           5.16/4.79
        65               6.11/5.52            5.30/5.07           5.75/5.29
        70               6.91/6.26            5.54/5.40           6.52/5.97
        75               7.79/7.18            5.68/5.62           7.33/6.74
        80               8.61/8.18            5.75/5.73           8.61/7.90
    85 & Over            9.24/9.01            5.77/5.76          10.43/9.50

FG-CA-1000-08/97 Q DB2                 3E

<PAGE>

                                  THE SCHEDULE
                       PAYMENT AND INVESTMENT INFORMATION
--------------------------------------------------------------------------------

--------------------------------------------------------------------------------
  Contractholder                              Group Contract Number
  FIRST GOLDEN INVESTORS TRUST                FG000012-0E
 -------------------------------------------------------------------------------
  Annuitant                Owner
  JOHN DOE                 JOHN SMITH
                           JANE SMITH
--------------------------------------------------------------------------------
  Annuitant's Issue Age    Annuitant's Sex          Certificateowner's Issue Age
  76                       MALE                     76
--------------------------------------------------------------------------------
  Initial Premium          Annuity Option           Annuity Commencement Date
  $10,000.00               LIFE 10 YEAR CERTAIN     OCTOBER 18, 2013
--------------------------------------------------------------------------------
  Certificate Date         Certificate Issue Date   Certificate Number
  FEBRUARY 18, 2001        AUGUST 15, 2001          C000001-FP (Q)
--------------------------------------------------------------------------------
  Separate Account(s)
  SEPARATE ACCOUNT NY-B AND THE FIXED ACCOUNT
--------------------------------------------------------------------------------

PREMIUM PAYMENT AND INVESTMENT INFORMATION

Initial premium payment received:     $10,000.00

Your initial Accumulation Value has been invested as follows:

                                                    Percentage of
                Divisions                         Accumulation Value
      -----------------------------         ------------------------------
                  Total                                  100%
                  =====                                  ====

FG-CA-1000-08/97 NQ DB2                3A1

<PAGE>

                                  THE SCHEDULE
                       PAYMENT AND INVESTMENT INFORMATION
--------------------------------------------------------------------------------

--------------------------------------------------------------------------------
  Contractholder                              Group Contract Number
  FIRST GOLDEN INVESTORS TRUST                FG000012-0E
 -------------------------------------------------------------------------------
  Annuitant                Owner
  JOHN DOE                 JOHN SMITH
                           JANE SMITH
--------------------------------------------------------------------------------
  Annuitant's Issue Age    Annuitant's Sex          Certificateowner's Issue Age
  76                       MALE                     76
--------------------------------------------------------------------------------
  Initial Premium          Annuity Option           Annuity Commencement Date
  $10,000.00               LIFE 10 YEAR CERTAIN     OCTOBER 18, 2013
--------------------------------------------------------------------------------
  Certificate Date         Certificate Issue Date   Certificate Number
  FEBRUARY 18, 2001        AUGUST 15, 2001          C000001-FP (Q)
--------------------------------------------------------------------------------
  Separate Account(s)
  SEPARATE ACCOUNT NY-B AND THE FIXED ACCOUNT
--------------------------------------------------------------------------------

PREMIUM PAYMENT AND INVESTMENT INFORMATION

Additional Premium Payment Information

We will accept additional premium payments until either the Annuitant or the
Owner reaches the Attained Age of 85. The minimum additional payment which may
be made is $500.00

ACCUMULATION VALUE ALLOCATION RULES

The maximum number of Divisions in which you may be invested at any one time is
sixteen. You are currently allowed unlimited allocation changes per Contract
Year without charge. We reserve the right to impose a charge as shown in the
Charges section of the Schedule for any allocation change in excess of twelve
per Certificate Year. We also reserve the right to limit, upon notice, the
maximum number of allocation changes you may make within a Certificate Year.

FG-CA-1000-08/97 NQ DB2             3A1 (CONT'D)

<PAGE>

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

--------------------------------------------------------------------------------
  Annuitant                Owner
  JOHN DOE                 JOHN SMITH
                           JANE SMITH
--------------------------------------------------------------------------------
  Initial Premium          Annuity Option           Annuity Commencement Date
  $10,000.00               LIFE 10 YEAR CERTAIN     OCTOBER 18, 2013
--------------------------------------------------------------------------------
  Separate Account(s)                               Certificate Number
  SEPARATE ACCOUNT NY-B AND THE FIXED ACCOUNT       C000001-FP
--------------------------------------------------------------------------------

  Separate Account NY-B (the "Account") is a unit investment trust Separate
  Account, organized in and governed by the laws of the State of New York, our
  state of domicile. The Account is divided into Divisions.

  Each Division listed below invests in shares of the mutual fund portfolio (the
  "Series") designated. Each portfolio is a part of the GCG Trust.

<TABLE>
SERIES                      SERIES                 SERIES                  SERIES
------                      ------                 ------                  ------
<S>                         <C>                    <C>                     <C>
All Cap                     Small Cap              Hard Assets             Liquid Asset
Investors                   Mid-Cap Growth         Limited Maturity Bond   Strategic Equity
Equity Income               Capital Growth         Capital Appreciation    Managed Global
Fully Managed               Large Cap Value        Rising Dividends        Research
Value Equity                Real Estate            Total Return            Growth
Asset Allocation Growth     Special Situations     Core Bond               Developing World
Diversified Mid-Cap         Internet Tollkeeper                            Growth and Income
</TABLE>

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

                         PORTFOLIO
                         ---------
                         Pilgrim Worldwide Growth

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

                         PORTFOLIO
                         ---------
                         Prudential Jennison
                         SP Jennison International Growth

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

                         PORTFOLIO
                         ---------
                         PIMCO High Yield Bond
                         PIMCO StocksPLUS Growth & Income

NOTE: PLEASE REFER TO THE PROSPECTUS FOR THE CONTRACT AND THE TRUSTS FOR MORE
      DETAILS

FG-CA-1000-08/97                       3B

<PAGE>

                       THIS PAGE INTENTIONALLY LEFT BLANK
                       ----------------------------------

FG-CA-1000-08/97

<PAGE>

                                  THE SCHEDULE
                   THE VARIABLE SEPARATE ACCOUNTS (CONTINUED)
--------------------------------------------------------------------------------

--------------------------------------------------------------------------------
  Annuitant                Owner
  JOHN DOE                 JOHN SMITH
                           JANE SMITH
--------------------------------------------------------------------------------
  Initial Premium          Annuity Option           Annuity Commencement Date
  $10,000.00               LIFE 10 YEAR CERTAIN     OCTOBER 18, 2013
--------------------------------------------------------------------------------
  Separate Account(s)                               Certificate Number
  SEPARATE ACCOUNT NY-B AND THE FIXED ACCOUNT       C000001-FP
--------------------------------------------------------------------------------

DIVISIONS INVESTING IN SHARES OF A MUTUAL FUND (CONTINUED)
    The division listed below invests in shares of the mutual fund portfolios
    (the "Portfolios") designated. The portfolios are a part of the Pilgrim
    Variable Products Trust managed by ING Pilgrim Investments LLC.

                         PORTFOLIO
                         ---------
                         Pilgrim VP Growth Opportunities
                         Pilgrim VP MagnaCap
                         Pilgrim VP Small Cap Opportunities

    The Division listed below invests in shares of the mutual fund portfolios
    (the "Portfolios") designated. The portfolios are a part of the ProFunds
    managed by ProFund Advisors LLC.

                         PORTFOLIO
                         ---------
                         ProFund VP Bull
                         ProFund VP Europe 30
                         ProFund VP Small-Cap

  Each Division listed below invests in shares of the mutual fund portfolio (the
  "Portfolio") designated. Each portfolio is a part of the Galaxy VIP Funds.

                         PORTFOLIO
                         ---------
                         Asset Allocation
                         Equity
                         Growth & Income
                         High Quality Bond
                         Small Company Growth

NOTE: PLEASE REFER TO THE PROSPECTUS FOR THE CONTRACT AND THE TRUSTS FOR MORE
      DETAILS

FG-CA-1000-08/97                   3B (CONT'D)

<PAGE>

                                  THE SCHEDULE
                                CERTIFICATE FACTS
--------------------------------------------------------------------------------

--------------------------------------------------------------------------------
  Annuitant                Owner
  JOHN DOE                 JOHN SMITH
                           JANE SMITH
--------------------------------------------------------------------------------
  Initial Premium          Annuity Option           Annuity Commencement Date
  $10,000.00               LIFE 10 YEAR CERTAIN     OCTOBER 18, 2013
--------------------------------------------------------------------------------
  Separate Account(s)                               Certificate Number
  SEPARATE ACCOUNT NY-B AND THE FIXED ACCOUNT       C000001-FP
--------------------------------------------------------------------------------

CONTRACT FACTS

Contract Processing Date

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

Specially Designated Division

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

PARTIAL WITHDRAWALS

The maximum amount that can be withdrawn in a Certificate Year without being
considered an Excess Partial Withdrawal is 15% of the Accumulation Value as of
the date of the withdrawal. We will collect a Surrender Charge for Excess
Partial Withdrawals and a charge for any unrecovered premium taxes. In no event
may a Partial Withdrawal be greater than 90% of the Cash Surrender Value.

Conventional Partial Withdrawals

     Minimum Withdrawal Amount:      $1,000

Any Conventional Partial Withdrawal from a Fixed Allocation is subject to a
Market Value Adjustment unless taken from a Fixed Allocation within thirty days
prior to the Maturity Date of such Fixed Allocation.

Systematic Partial Withdrawals

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

     Minimum Withdrawal Amount:      $100.00

     Maximum Withdrawal Amount:

        Separate Account Divisions:  1.25% monthly or 3.75% quarterly of
                                     Accumulation Value.

        Fixed Allocations:           Interest earned on a Fixed Allocation in
                                     prior month (for monthly withdrawals) or
                                     prior quarter (for quarterly
                                     withdrawals).

A Systematic Partial Withdrawal from a Fixed Allocation is not subject to Market
Value Adjustments.

FG-CA-1000-08/97 NQ DB2                3C1

<PAGE>

                                  The Schedule
                          CERTIFICATE FACTS (continued)
--------------------------------------------------------------------------------

--------------------------------------------------------------------------------
  Annuitant                Owner
  JOHN DOE                 JOHN SMITH
                           JANE SMITH
--------------------------------------------------------------------------------
  Initial Premium          Annuity Option           Annuity Commencement Date
  $10,000.00               LIFE 10 YEAR CERTAIN     OCTOBER 18, 2013
--------------------------------------------------------------------------------
  Separate Account(s)                               Certificate Number
  SEPARATE ACCOUNT NY-B AND THE FIXED ACCOUNT       C000001-FP
--------------------------------------------------------------------------------

Death Benefit

The Death Benefit is the greatest of (i) the Accumulation Value, (ii) the
Guaranteed Death Benefit, (iii) the Cash Surrender Value, and (iv) the sum of
premiums paid, less any partial withdrawals.

Guaranteed Death Benefit

On the Contract Date, the Guaranteed Death Benefit is the Initial Premium. On
subsequent Valuation Dates, the Guaranteed Death Benefit is calculated as
follows:

Annual Ratchet:
---------------
     (4)  Start with the Guaranteed Death Benefit from the prior Valuation Date;
     (5)  Add to (1) any additional premium paid since the prior Valuation Date
          and subtract from (1) any Partial Withdrawals taken since the prior
          Valuation Date;
     (6)  On a Valuation Date which occurs through the Contract Year in which
          the Owner's Attained Age is 80 and which is also a Contract
          Anniversary, if the Owner is alive (the Annuitant if the Owner is not
          an individual), we set the Guaranteed Death Benefit equal to the
          greater of (2) or the Accumulation Value as of such date. On all other
          Valuation Dates, the Guaranteed Death Benefit is equal to (2).

Change of Owner

When the ownership changes, the new Owner's age at the time of the change will
be used as the basis for the death benefit. The new Owner's death will determine
when a death benefit is payable.

If the new Contractowner's age is less than or equal to 79, the Guaranteed Death
Benefit Option in effect prior to the change of Contractowner will remain in
effect. If the new Contractowner's age is greater than 79, the Guaranteed Death
Benefit will be zero and the Death Benefit shall be the greatest of Cash
Surrender Value, the Accumulation Value, and the sum of premiums paid, less any
Partial Withdrawals.

FG-CA-1000-08/97 NQ DB2                3C2

<PAGE>

                                  The Schedule
                          CERTIFICATE FACTS (continued)
--------------------------------------------------------------------------------

--------------------------------------------------------------------------------
  Annuitant                Owner
  THOMAS J. DOE            JOHN Q. PUBLIC
--------------------------------------------------------------------------------
  Initial Premium          Annuity Option           Annuity Commencement Date
  $10,000.00               LIFE 10 YEAR CERTAIN     JANUARY 1, 2053
--------------------------------------------------------------------------------
  Separate Account(s)                               Certificate Number
  SEPARATE ACCOUNT NY-B AND THE FIXED ACCOUNT       123456
--------------------------------------------------------------------------------

CHOOSING AN INCOME PLAN

Required Date of Annuity Commencement

Distributions from a Certificate funding a qualified plan must commence no later
than April 1st of the calendar year following the calendar year in which the
Owner attains age 70 1/2.

The Annuity Commencement Date is required to be the same date as the Certificate
Processing Date in the month following the Annuitant's 90th birthday. If, on the
Annuity Commencement Date, a Surrender Charge remains, your elected Annuity
Option must include a period certain of at least five years duration. In
applying the Accumulation Value, we may first collect any Premiums Taxes due us.

Minimum Annuity Income Payment

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

FIXED ACCOUNT

Minimum Fixed Allocation

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

Guaranteed Minimum Interest Rate - 3%.

Guarantee Periods

We currently offer Guarantee Periods of 1,3,5,7 and 10 year.

We reserve the right to offer Guarantee Periods of durations other than those
available on the Certificate Date.

Index Rate

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

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

FG-CA-1000-08/97 NQ DB2                3C3

<PAGE>

                                  The Schedule
                                     CHARGES
--------------------------------------------------------------------------------

--------------------------------------------------------------------------------
  Annuitant                Owner
  JOHN DOE                 JOHN SMITH
                           JANE SMITH
--------------------------------------------------------------------------------
  Initial Premium          Annuity Option           Annuity Commencement Date
  $10,000.00               LIFE 10 YEAR CERTAIN     OCTOBER 18, 2013
--------------------------------------------------------------------------------
  Separate Account(s)                               Certificate Number
  SEPARATE ACCOUNT NY-B AND THE FIXED ACCOUNT       C000001-FP
--------------------------------------------------------------------------------

Charge Deduction Division

All charges against the Accumulation Value in this Certificate will be deducted
from the Liquid Asset Division.

Deductions from Premiums - None

Deductions from Accumulation Value

Administrative Charge - We charge $30 to cover a portion of our ongoing
---------------------
administrative expenses for each Certificate Processing Period. The charge is
incurred at the beginning of the Certificate Processing Period and deducted on
the Certificate Processing Date at the end of the period. At the time of
deduction, this charge will be waived if: (7) The Accumulation Value is at least
$100,000; or (8) The sum of premiums paid to date is at least $100,000

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

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

          Complete Years Elapsed                     Surrender
          Since Premium Payment                       Charges
          ----------------------                      -------
                     0                                  7%
                     1                                  7%
                     2                                  6%
                     3                                  5%
                     4                                  4%
                     5                                  3%
                     6                                  1%
                    7+                                  0%

For the purpose of calculating the Surrender Charge for an Excess Partial
Withdrawal; a) we treat premiums as being withdrawn on a first-in, first-out
basis; and b) amounts withdrawn which are not considered an Excess Partial
Withdrawal are not considered a withdrawal of any premium payments.

FG-CA-1000-08/97 NQ DB2                3D1

<PAGE>

                                  The Schedule
                                     CHARGES
--------------------------------------------------------------------------------

--------------------------------------------------------------------------------
  Annuitant                Owner
  THOMAS J. DOE            JOHN Q. PUBLIC
--------------------------------------------------------------------------------
  Initial Premium          Annuity Option           Annuity Commencement Date
  $10,000.00               LIFE 10 YEAR CERTAIN     JANUARY 1, 2053
--------------------------------------------------------------------------------
  Separate Account(s)                               Certificate Number
  SEPARATE ACCOUNT NY-B AND THE FIXED ACCOUNT       123456
--------------------------------------------------------------------------------

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

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

Deductions from the Divisions

Mortality and Expense Risk Charge - We deduct 0.003446% of the assets in the
---------------------------------
Separate Account Division on a daily basis (equivalent to an annual rate of
1.25%) for mortality and expense risks. This charge is not deducted from the
Fixed Account values.

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

FG-CA-1000-08/97 NQ DB2                3D2

<PAGE>

                                  THE SCHEDULE
                         INCOME PLAN FACTORS (continued)
--------------------------------------------------------------------------------

--------------------------------------------------------------------------------
  Annuitant                Owner
  JOHN DOE                 JOHN SMITH
                           JANE SMITH
--------------------------------------------------------------------------------
  Initial Premium          Annuity Option           Annuity Commencement Date
  $10,000.00               LIFE 10 YEAR CERTAIN     OCTOBER 18, 2013
--------------------------------------------------------------------------------
  Separate Account(s)                               Certificate Number
  SEPARATE ACCOUNT NY-B AND THE FIXED ACCOUNT       C000001-FP
--------------------------------------------------------------------------------

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

                       TABLE FOR INCOME FOR A FIXED PERIOD

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

                                  11         $8.88           21        $5.33
        2        $42.96           12          8.26           22         5.16
        3         29.06           13          7.73           23         5.00
        4         22.12           14          7.28           24         4.85
        5         17.95           15          6.89           25         4.72
        6         15.18           16          6.54           26         4.60
        7         13.20           17          6.24           27         4.49
        8         11.71           18          5.98           28         4.38
        9         10.56           19          5.74           29         4.28
       10          9.64           20          5.53           30         4.19

                            TABLE FOR INCOME FOR LIFE

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

       50            $4.53/4.19         $4.38/4.13           $4.40/4.12
       55             4.93/4.52          4.68/4.40            4.74/4.42
       60             5.45/4.96          4.99/4.72            5.16/4.79
       65             6.11/5.52          5.30/5.07            5.75/5.29
       70             6.91/6.26          5.54/5.40            6.52/5.97
       75             7.79/7.18          5.68/5.62            7.33/6.74
       80             8.61/8.18          5.75/5.73            8.61/7.90
   85 & Over          9.24/9.01          5.77/5.76           10.43/9.50

FG-CA-1000-08/97 NQ DB2                3E

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