Document:

EX-(4).(a)

Table of Contents

 The United States Life Insurance Company in the City of New York 

A STOCK COMPANY       NEW YORK, NEW YORK 

 
 

 
 THE UNITED STATES LIFE INSURANCE COMPANY IN THE CITY OF NEW YORK (“We”, “Us”, the
“Company”, or “US Life”) agrees to provide benefits to the Owner in accordance with the provisions set forth in this Contract and in consideration of the Application and Purchase Payments We receive. 

The value of amounts allocated to the Separate Account during the accumulation and annuity periods is not guaranteed, and will increase or
decrease in value based upon the investment experience of the Variable Portfolios You choose. 
 The Separate Account Charge is
charged against the assets of the Separate Account. This charge includes fees for mortality and expense risk and the distribution expense. On an annualized basis the charge equals [0.50%]

.. These charges are assessed, on a simple interest basis, as a percentage of the average daily ending value of the assets attributable to the Accumulation Units of the Variable Portfolios to which your Contract Value is
allocated. The daily charge is 1/365th of the annualized charge. Thus, the smallest annual effective rate of the investment return that would have to be earned on assets of the Separate Account so
that the dollar amount of variable annuity payments will not decrease is [4.02%]

, compounded daily. The Contract’s assumed rate of return is based on compound interest. 
 The
Fixed Account Options, Dollar Cost Averaging (DCA) Fixed Account Option(s) or one or more fixed account Guarantee Periods may not be available on the Contract Date. Please check with Your registered representative for availability of these options
as well as the Contract Data Page, which lists available options. 
 Purchase Payments are subject to the limitations defined in this Contract.

 This Contract may include one or more endorsement(s) or rider(s) as part of the Entire Contract containing definitions and
additional terms affecting how this Contract may work. You should carefully read the Entire Contract. 
 RIGHT TO EXAMINE – If,
within 10 days of receipt of this Contract (60 days if the Contract replaced any other life insurance or annuity contract(s)) You are not satisfied with it, You may return this Contract to Our Annuity Service Center or to the agent through whom the
Contract was purchased. The Company will refund the Purchase Payment, including any fees or other charges, or the Contract Value, whichever is greater, computed as of the business day during which we receive the Contract. Upon such refund, the
Contract shall be void. 
 For Individual Retirement Annuities, or if a refund of the Purchase Payment(s) is required, We reserve the
right to allocate Your Purchase Payment(s) to [a money market or similar portfolio]

 until the end of the Right To Examine period. 
 With 30 days advance notice, we may cease offering Fixed
Account Guarantee Period Options and/or Dollar Cost Averaging Fixed Account Options if market conditions are such that we are not able to credit the Minimum Guarantee Rate shown on the Contract Data Page. 

Signed at the Home Office on the Contract Date. 
  

 

  

					
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 TABLE OF CONTENTS 

 

					
	 Contract Data Page
	  	 	Page 3	  
		
	 Definitions
	  	 	Page 4	  
		
	 Purchase Payment Provisions
	  	 	Page 7	  
		
	 Accumulation Provisions
	  	 	Page 8	  
		
	 Charges and Deductions
	  	 	Page 9	  
		
	 Transfer Provisions
	  	 	Page 10	  
		
	Withdrawal Provisions	  	 	Page 11	  
		
	Death Benefit Provisions	  	 	Page 11	  
		
	Annuity Provisions	  	 	Page 13	  
		
	General Provisions	  	 	Page 14	  
		
	Annuity Income Payment Options	  	 	Page 18	  

  

					
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 CONTRACT DATA PAGE 

Contract Number: [P9999999999]

                 Contract Date: [May 2, 2011]

 
 Owner: [JOHN DOE]

     Date of Birth: [March 1, 1976]

 Age at Issue: [35]

 
 

 [Owner: [JANE DOE]

        Date of Birth: [June 10, 1976]

   Age at Issue: [34]

] 
 Annuitant: [JOHN DOE]

         Date of Birth: [March 1, 1976]

 Age at Issue: [35]

 
 

 [Annuitant: [JANE DOE]        Date of Birth: [June 10, 1976]

  Age at Issue: [34]

] 
 Beneficiary: [As named by You]

 
 Initial Purchase Payment: [$25,000.00]

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

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

 
 Minimum Subsequent Purchase Payment: [$500]

 
 Purchase Payments are subject to the limitations defined in this Contract. 

Fixed Account Options – Minimum Guarantee Rate: [1.0%]

 
 With 30 days advance notice, we may cease offering the Fixed Account Options, Fixed Account Guarantee Period
Options and/or Dollar Cost Averaging Fixed Account Options if market conditions are such that we are not able to credit the Minimum Guarantee Rate Shown on this page. 

Fixed Account Options: [1 Year Fixed, 6 Month DCA Fixed, 1 Year DCA Fixed]

 
 Minimum Partial Withdrawal Amount: [$1,000]

 
 Minimum Systematic Withdrawal Amount: [$100]

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

 
 Minimum Transfer Amount: [$100]

 
 Separate Account Charge [(including guaranteed death benefit risk charge of [0.10%])]: [0.50%

 
 Annual Contract Maintenance Fee: [$0]

 
 Transfer Fee: [$25]

 
 Earliest Annuity Date After the Contract Date: 13 Months 

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

 
 Separate Account: [FS VARIABLE SEPARATE ACCOUNT]

 
 Optional Elections:
                                    Optional Election Details:

 (Maximum Anniversary Value
                                 See Attached Endorsement USLE-8023)(12/15)

 

  

					
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 DEFINITIONS 

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

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

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

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

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

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

The Annuity Service Center is the address shown on Page 1 of this Contract where all Purchase Payments and requests regarding this Contract are
to be sent. 
 ANNUITY UNIT 
 An Annuity
Unit is a unit of measure determined on or after the Annuity Date and is used to compute Annuity Income Payments from the Variable Portfolio(s) if Variable Annuitization is selected. 

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

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

  

					
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 CONTINUATION DATE 

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

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

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

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

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

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

 FIXED ACCOUNT OPTION(S) 
 The Fixed
Account Option(s) are investment options, if available under this Contract, that become part of the Company’s general asset account and are credited with a fixed rate of interest declared by the Company. The general asset account contains all
the assets of the Company except for the Separate Account and other segregated asset accounts. The amount You have in any Fixed Account Option at a given time is a result of Purchase Payment(s) You have allocated to it or any part of Your Contract
Value You have transferred to it. 
 GUARANTEE PERIOD 

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

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

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

  

					
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 LATEST ANNUITY DATE 

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

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

PAYEE 
 The person receiving Annuity Income Payments under
this Contract. 
 PURCHASE PAYMENTS 

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

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

The Separate Account is a segregated asset account named on the Contract Data Page. The Separate Account consists of Variable Portfolios, each
investing in shares of the Underlying Fund(s). The assets of the Separate Account are not commingled with the general assets and liabilities of the Company. Income, gains and losses, whether or not realized, from assets allocated to the Separate
Accounts shall be credited to or charged against the applicable Separate Account without regard to other income, gains, or losses of the Company. We will maintain Separate Account assets with a value at least equal to the amounts accumulated in
accordance with the applicable agreements with respect to this Separate Account, and also the reserves for variable annuities in the course of payment. The portion of the assets of the Separate Account not exceeding the reserves and other contract
liabilities shall not be chargeable with liabilities arising out of any other business of Ours. The value of amounts allocated to the Variable Portfolios of the Separate Account is not guaranteed. 

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

SUBSEQUENT PURCHASE PAYMENTS 
 Subsequent Purchase
Payments are Purchase Payments made after the initial Purchase Payment. 
 UNDERLYING FUND 

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

  

					
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 VARIABLE PORTFOLIO 

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

WE, OUR, US, THE COMPANY 
 We, Our, Us, The Company refers
to The United States Life Insurance Company in the City of New York. 
 WITHDRAWAL(S) 

Withdrawals are any amount(s) withdrawn by the Owner from the Contract Value. 

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

YOU, YOUR 
 You, Your refers to the Owner. 

PURCHASE PAYMENT PROVISIONS 

PURCHASE PAYMENTS 
 Purchase Payments are
flexible. This means that, subject to Company disclosed restrictions, You may change the amounts, frequency and/or timing of Purchase Payments. Purchase Payments can be made at any time after the Contract Date, but must be received at Our Annuity
Service Center before the Purchase Payment Age Limit, as shown on the Contract Data Page. With instructions from You, Purchase Payments will be allocated to the Variable Portfolio(s) and/or Fixed Account Option(s), if available. We reserve the
right, upon advance notice to You, to: 1) limit the maximum amount of Purchase Payments; and 2) discontinue acceptance of any subsequent Purchase Payment(s) received on or after the first Contract Anniversary, if an optional guaranteed living
benefit is elected. We will apply these limitations in a uniform and non-discriminatory manner. 
 DOLLAR COST AVERAGING (DCA) FIXED ACCOUNT OPTION(S)

 Any portion of a Purchase Payment allocated to the DCA Fixed Account Option(s), if available, must be transferred to the Variable
Portfolio(s) within the specified DCA Fixed Account Option period. Upon termination of the DCA program, any amounts remaining in the DCA Fixed Account Option(s) will be transferred to the DCA target allocation(s) for the program being terminated. We
reserve the right to impose a maximum contribution level on Purchase Payments allocated to a DCA Fixed Account Option(s) and/or change the terms and conditions of the DCA program at any time. We reserve the right to cease offering DCA Fixed Account
Option(s). Upon annuitization, any amounts remaining in the DCA Fixed Account Option(s) will be applied to a Fixed Annuitization. The unit values credited and applied to Your Contract are determined on each date of transfer. The minimum contribution
amount that may be allocated to the DCA Fixed Account Option(s) is $600 for the 6 month DCA and $1,200 for the 1 year DCA. 
 CHANGES TO VARIABLE
PORTFOLIO OFFERINGS 

  

					
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 If the shares of an Underlying Fund should no longer be available for investment by the Separate
Account, then We may substitute shares of another Underlying Fund, for shares already purchased, or to be purchased in the future. At any given time, some Variable Portfolios may not be available for receipt of Purchase Payment(s) or transfer(s).
Substitutions may be necessary and will be carried out in accordance with any applicable state and/or federal laws or regulations. 
 MINIMUM CONTRACT
VALUE 
 If Your Contract Value falls below the Minimum Amount Remaining After Any Partial Withdrawal, as shown on the Contract Data
Page, as a result of taking partial Withdrawals, subject to applicable state and federal laws, rules and regulations, We may treat Your partial Withdrawal request as a request for a total Withdrawal and terminate Your Contract. 

ACCUMULATION PROVISIONS 

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

The Separate Account Accumulation Value under the Contract is the sum of the Accumulation Unit Values held in the Variable Portfolios for You.
The Company does not hold itself out to be a trustee of the Separate Account. 
 NUMBER OF ACCUMULATION UNITS 

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

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

The Accumulation Unit Value for that Variable Portfolio for the Business Day in which the Purchase Payment or transfer amount
is allocated to the Variable Portfolio. 
 The number of Accumulation Units will be reduced for Withdrawals, Annuitizations, amounts
transferred out of a Variable Portfolio, the Contract Maintenance Fee, if applicable, and applicable charges for any elected features as set forth in endorsements or riders to this Contract. Any reduction to the Contract Value will be made as of the
Business Day in which We receive all requirements In Writing for the transaction, as appropriate. 
 ACCUMULATION UNIT VALUE (AUV) 

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

  

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

  

	 	(a)	 is the Variable Portfolio’s income and capital gains and losses (whether realized or unrealized) on the
current Business Day; 

  

	 	(b)	 is the value of the Variable Portfolio for the immediately preceding Business Day; and 

 

	 	(c)	 is the daily Separate Account charge. 

 

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

 

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

 

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

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

FIXED ACCOUNT GUARANTEE PERIOD OPTIONS AND INTEREST CREDITING 

The portion of Your Contract Value within the Fixed Account Option(s), if any, is credited with interest at rates guaranteed by Us for the
Guarantee Period (s) selected. Interest is credited on a daily basis at the then applicable effective interest rate for the applicable Guarantee Period. You may select from one or more Guarantee Periods which We may offer at any particular
time. We reserve the right at any time to add or discontinue Guarantee Periods. A Written notification will be provided to the Owner at least 30 days prior to the discontinuation of a Guarantee Period. If You have allocated any part of Your initial
Purchase Payment to a Guarantee Period, the percentage allocated, as well as the duration of the Guarantee Period, is shown on the Application or administrative election form as completed by You. 

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

We will deduct the following charges from the Contract: 

  

					
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 CONTRACT MAINTENANCE FEE 

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

 
 SEPARATE ACCOUNT CHARGE 

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

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

TRANSFER PROVISIONS 

Subject to applicable restrictions, You may transfer all or part of Your Contract Value amongst the Variable Portfolios and/or available Fixed
Account Option(s) (unless otherwise noted). The minimum amount that can be transferred is subject to the Minimum Transfer Amount, as shown on the Contract Data page. The amount that can remain in a Variable Portfolio and/or available Fixed Account
Option is subject to Company limits. We reserve the right to restrict Your transfer privileges. 
 Due to the risks that frequent transfers
impose upon Owners and other investors in Variable Portfolio(s) and/or Underlying Funds, We or the manager of an Underlying Fund may limit transfer and impose other requirements to minimize these risks, including but not limited to, requiring a
minimum amount that can be transferred, and an amount that can remain in a Variable Portfolio and/or available Fixed Account Option after a transfer. 

TRANSFERS BEFORE THE ANNUITY DATE 
 Before
the Annuity Date, transfers are subject to certain restrictions as indicated above and on the Contract Data Page. You may transfer all or a portion of Your Contract Value from one Variable Portfolio to another Variable Portfolio(s) or any available
Fixed Account Option(s) other than the DCA Fixed Account Option(s). You may also transfer all or a portion of Your Contract Value from any available Fixed Account Option(s) to the Variable Portfolio(s) and/or any available Fixed Account Option(s)
other than the DCA Fixed Account Option(s) of the Contract. A transfer to a Variable Portfolio will result in the redemption of Accumulation Units in a Variable Portfolio and the purchase of Accumulation Units in the other Variable Portfolio.
Transfers will be effective at the end of the Business Day on which We receive Your completed Written transfer request. 
 Unless You
instruct Us to make a transfer, Your allocation to any available Fixed Account Option(s) and Variable Portfolio(s) will remain unchanged, subject to the terms of the Contract. We reserve the right to terminate Your ability to transfer to any
discontinued Fixed Account Option(s) and/or Variable Portfolio(s). A Written notification will be provided to You at Your last known address prior to any such termination of Your ability to transfer. 

  

					
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 TRANSFERS AFTER THE ANNUITY DATE 

On and after the Annuity Date, transfers into and out of any available Fixed Account Option(s) are not allowed. You may transfer all or a
portion of Your Annuity Units from one Variable Portfolio to another Variable Portfolio(s). A transfer will result in the redemption of Annuity Units in a Variable Portfolio and the purchase of Annuity Units in the other Variable Portfolio.
Transfers will be effective on the last Business Day of the month on which We receive Your Written request for the transfer. 
 
WITHDRAWAL PROVISIONS 
 On or before the Annuity Date and while You are living, You may withdraw all (“total Withdrawal”)
or part of Your Contract Value under this Contract by informing Us In Writing. The Minimum Partial Withdrawal Amount is shown on the Contract Data Page. 

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

SYSTEMATIC WITHDRAWAL PROGRAM 
 Prior to
the Annuity Date, You may elect to participate in a Systematic Withdrawal Program by informing Us at Our Annuity Service Center. The Systematic Withdrawal Program allows You to make automatic Withdrawals from Your Contract monthly, quarterly,
semiannually or annually. The Minimum Systematic Withdrawal Amount is shown on the Contract Data Page. You may terminate Your participation in the Systematic Withdrawal Program at any time by sending Us a Written request. 

DEATH BENEFIT PROVISIONS 

Notwithstanding any provision of this Contract to the contrary, all payments of benefits under this Contract will be made in a manner that
satisfies the requirements of IRC Section 72(s), as amended from time to time. If the Contract is owned by a trust or other non-natural person, We will treat the death of any Annuitant as the death of the “Primary Annuitant” and as
the death of any Owner. 
 DUE PROOF OF DEATH 
 Due
Proof of Death means any Written proof, which may include but is not limited to: 
 1.  a certified
copy of a death certificate; or 
 2.  a certified copy of a decree of a court of competent
jurisdiction as to the finding of death; or 
 3.  a Written statement by a medical doctor who
attended the deceased Owner at the time of death. 
 DEATH OF OWNER BEFORE THE ANNUITY DATE 

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

  

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

  

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

 

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

  

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

The entire interest in the Contract will be distributed within the five year period specified under applicable laws and regulations,
commencing with the date of death of the Owner unless option 2 or 3 was selected under DEATH OF OWNER BEFORE THE ANNUITY DATE. 
 Upon the
Continuing Spouse’s death, the entire interest of the Contract must be distributed immediately under option 1, 2 or 4 as provided under DEATH OF OWNER BEFORE THE ANNUITY DATE. 

AMOUNT OF DEATH BENEFIT 
 The amount of
the Death Benefit is the Contract Value on the Business Day during which We receive all Required Documentation. 
 SPOUSAL BENEFICIARY CONTINUATION

 If the Spousal Beneficiary continues the Contract on the Continuation Date (“Continuing Spouse”), the amount continued is
the Death Benefit, which is the Contract Value on the Business Day during which We receive all Required Documentation. 
 DEATH OF OWNER OR ANNUITANT ON
OR AFTER THE ANNUITY DATE 
 If any Owner or Annuitant dies on or after the Annuity Date and before the entire interest in the Contract
has been distributed, We will continue to make payments of any remaining portion of the Annuity Income Payment(s) to the Beneficiary under the existing Annuity Income Payments, if a specified term was elected, upon Our receipt of all Required
Documentation. For further information pertaining to death of the Annuitant, see ANNUITY INCOME PAYMENT OPTIONS. 
 BENEFICIARY 

The Beneficiary is selected by the Owner. While the Owner is living and before the Annuity Date, the Owner may change the Beneficiary by
Written Notice. A change in Beneficiary will take effect on the date We receive the Written Notice. If two or more persons are named as Beneficiaries under the Contract, those surviving the Owner will share equally unless otherwise specified by the
Owner and each must elect to receive their respective portions of the Death Benefit according to the options listed under DEATH OF 

  

					
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OWNER BEFORE THE ANNUITY DATE. Joint Owners, if applicable, shall be each other’s primary Beneficiary. Joint Annuitants, if any, when the Owner is a non-natural person, shall be each
other’s primary Beneficiary. Any other Beneficiary designation will be treated as a contingent Beneficiary. 
 If the Annuitant
survives the Owner, and there are no surviving Beneficiaries, the Annuitant will be deemed the Beneficiary. Joint Annuitants, if any, when the Owner is a trust or other non-natural person, shall be each other’s primary Beneficiary. Any other
Beneficiary designation will be treated as a contingent Beneficiary. 
 If the Owner is also the Annuitant and there are no surviving
Beneficiaries, upon Our receipt of all Required Documentation, We will pay the Death Benefit to the estate of the Owner in accordance with option 1, under DEATH OF OWNER BEFORE THE ANNUITY DATE. 

ANNUITY PROVISIONS 

ANNUITY DATE 
 You may specify an Annuity
Date. You may change the Annuity Date at any time, at least seven days prior to the Annuity Date, by Written Notice. The Annuity Date must always be the first day of the calendar month. The Earliest Annuity Date After the Contract Date is shown on
the Contract Date Page. The Annuity Date must not be beyond the Latest Annuity Date shown on the Contract Data Page. If no Annuity Date is specified by You, the Annuity Date will be the Latest Annuity Date. 

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

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

The amount of the Owner’s initial monthly payment will be at least equal to the monthly payment produced by the application of an amount
equal to the Contract Value of this Contract to purchase any single consideration immediate annuity contract offered by the Company at the same time to the same class of annuitants. 

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

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

  

					
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 AMOUNT OF VARIABLE ANNUITY INCOME PAYMENTS 

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

  

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

  

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

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

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

  

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

  

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

 

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

  

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

  

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

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

  

					
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 ENTIRE CONTRACT 

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

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

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

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

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

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

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

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

 

	(a)	 the NYSE is closed (other than customary weekend and holiday closings); 

	(b)	 trading on the NYSE is restricted; 

	(c)	 an emergency exists such that it is not reasonably practical to dispose of securities in the Variable
Portfolios or to determine the value of its assets; 

	(d)	 the United States Securities and Exchange Commission, by order, so permits for the protection of Owners; or

  

					
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	(e)	 We are on notice that this Contract is the subject of a court proceeding, an arbitration, a regulatory matter
or other legal action. 

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

The provisions of this Contract will be interpreted by the laws of the State of New York, the state in which this Contract is delivered. Any
provision which, on the Contract Date, is in conflict with the law of such state is amended to conform to the minimum requirements of such law. The paid-up annuity benefits, cash surrender benefits, and death benefits provided under this Contract
are not less than those required by the state where the contract was issued. 
 CHANGES IN LAW 

If the laws governing this Contract or the taxation of benefits under the Contract change, We will amend this Contract, subject to New York
State Department of Financial Services approval, to comply with any changes. 
 ASSIGNMENT / CHANGE OF OWNER 

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

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

 CLAIMS OF CREDITORS 
 To the extent
permitted by law, no right or proceeds payable under this Contract will be subject to claims of creditors or legal process. 
 PREMIUM TAXES OR OTHER
TAXES 
 We may deduct from Your Contract Value any premium tax or other taxes payable to a state or other government entity, if
applicable. Should We advance any amount so due, We are not waiving any right to collect such amount at a later date. We will deduct any withholding taxes required by applicable law. 

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

  

					
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 PERIODIC REPORTS 

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

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

This Contract does not share in Our surplus. 
 WAIVER 

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

  

					
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 ANNUITY INCOME PAYMENT OPTIONS 

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

  
 

 
 The annuity rates pertaining to the Actuarial Basis of Computation will be furnished upon Your request. 

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

Payments payable to a Payee during the lifetime of the Annuitant. No further annuity income payments are payable after the death of the
Annuitant. 
 OPTIONS 2 & 2v - JOINT AND SURVIVOR LIFE ANNUITY 

Payments payable to the Payee during the lifetime of the Annuitant and during the lifetime of a designated second person. No further Annuity
Income Payments are payable after the deaths of both the Annuitant and the designated second person. 
 OPTIONS 3 & 3v - JOINT AND SURVIVOR LIFE
ANNUITY - WITH 120 OR 240 MONTHLY PAYMENTS GUARANTEED 
 Payments payable to the Payee during the lifetime of the Annuitant and during
the lifetime of a designated second person. If, at the death of the survivor, Annuity Income Payments have been made for less than 120 or 240 monthly periods, the remaining guaranteed Annuity Income Payments will be continued to the Beneficiary. If,
at the death of the survivor, Annuity Income Payments have been made for at least 120 or 240 monthly periods, as selected at the time of annuitization, no further annuity income payments will be made. 

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

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

  

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

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

  

					
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 The United States Life Insurance Company in the City of New York 

A STOCK COMPANY        NEW YORK, NEW YORK 

 
  

FLEXIBLE PAYMENT FIXED AND VARIABLE DEFERRED ANNUITY CONTRACT 

Nonparticipating 
 Copyright ©
2016 American International Group, Inc. All rights reserved. 

  

					
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	  	20EX-(4).(b)

 THE UNITED STATES LIFE INSURANCE COMPANY IN THE CITY OF NEW YORK 

[OPTIONAL]

 GUARANTEED LIVING BENEFIT ENDORSEMENT 
 Notwithstanding any provision in the Contract to the contrary,
this Endorsement becomes a part of the Contract to which it is attached. Should any provision in this Endorsement conflict with the Contract, the provisions of this Endorsement will prevail. 

Subject to the terms and conditions set forth herein this [optional]

 Guaranteed Living Benefit Endorsement provides for guaranteed income over the lifetime of the Covered Person(s). You may take Withdrawals under the Guaranteed Living Benefit as prescribed by this Endorsement while
this Endorsement is in effect. 
 ENDORSEMENT DATA PAGE 
  

			
	 COVERED PERSON(S):
	  	 [John Doe

Jane Doe]

		
	 ENDORSEMENT EFFECTIVE DATE:
	  	 [March 1, 2016]

		
	 PURCHASE PAYMENT DOLLAR LIMIT:
	  	 The sum of all Purchase Payments cannot exceed [$1,000,000]

 without prior Company approval

		
	 PURCHASE PAYMENT RESTRICTION:
	  	 [Purchase Payments received on or after the [first]

 [Contract Anniversary]

 will not be accepted into the Contract.]

		
	 [INVESTMENT REQUIREMENTS:
	  	 Every Purchase Payment and Spousal Beneficiary Continuation contribution, if any, must be allocated by You in accordance
with the investment options approved by Us, which includes a mandatory allocation of every Purchase Payment and Spousal Beneficiary Continuation contribution, if any, to the Secure Value Account, as shown below. We will notify You of any change to
the permitted investment options.]

		
	 SECURE VALUE ACCOUNT ALLOCATION:
	  	 [20%]

 of Purchase Payment(s) and Spousal Beneficiary Continuation contribution, if applicable

 ENDORSEMENT FEE: 

The Endorsement Fee is assessed against the Income Base and deducted from the portion of the Contract Value allocated to the Variable
Portfolio(s) or Subaccount(s) at the end of each Benefit [Quarter]

.. The Initial Annual Fee Rate is guaranteed not to change for the first Benefit [Year]

. After the [first]

 Benefit [Year]

, on each Benefit [Quarter]

 Anniversary, we will (1) deduct the fee in effect for the previous Benefit [Quarter]

; and (2) determine the fee rate applicable to the next Benefit [Quarter]

.. The fee rate can increase or decrease each Benefit [Quarter]

, subject to the minimums and maximums in the table below:

 
  

									
	 	 	 	 	 
	
Number of Covered    

Persons on

Endorsement
 Effective
Date
	  	 Initial Annual

Fee Rate
	  	 Minimum Annual

Fee Rate
	  	 Maximum Annual

Fee Rate
	  	
Maximum Annualized

Fee Rate Increase or

Decrease Each Benefit

[Quarter]*

	One Covered Person	  	[1.10%]	  	[0.60%]	  	[2.20%]	  	+/- [0.25%]
	Two Covered Persons	  	[1.35%]	  	[0.60%]	  	[2.70%]	  	+/- [0.25%]

   *The fee rate can increase or decrease no more than [0.0625% each [quarter]

 (0.25%/4)]

.. 
  

			
	 [GROSS]

 INCOME CREDIT PERCENTAGE:
	  	 [6%]

		
	 INCOME CREDIT PERIOD:
	  	 Beginning on the Endorsement Effective Date and ending [12 years later]

  

					
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 MAXIMUM ANNUAL WITHDRAWAL AND PROTECTED INCOME PAYMENT PERCENTAGES: 11 Covered Person(s) Age at First Withdrawal
Maximum Annual Withdrawal   Percentage Protected Income Payment Percentage One Covered   Person Two Covered   Persons One [or Two
    Covered Person(s)]       If the Income Base is increased to   the Highest Anniversary Value on or after Age [65]
(One or Two Covered Person(s)) [Less than Age 65 [5.50%] 10 [5.0%] 10 [3.0%] 10 [4.0%] 10 Age 65 and older] 10 [5.50%] 10 [5.0%] 10 [4.0%] 10 [4.0%] 10 MINIMUM INCOME BASE: [200%] 12 of Purchase Payments
received in the [1st] 6 Benefit [Year] 6 effective on the [12th] 6 Benefit [Year] 6 Anniversary provided no Withdrawals are taken before the [12th] 6 Benefit [Year] 6 Anniversary. EARLIEST CANCELLATION DATE OF THE GUARANTEED LIVING BENEFIT: The
[10th] Benefit Year Anniversary following the Endorsement Effective Date BENEFIT WITHDRAWAL CHARGE: You may incur a Benefit Withdrawal Charge if You take a partial Withdrawal that exceeds the Maximum Annual Withdrawal Amount or a total Withdrawal of
all Your Contract Value before the end of the [10th] Benefit Year Anniversary following the Endorsement Effective Date. The Benefit Withdrawal Charge is assessed against the [amount in excess of the Maximum Annual Withdrawal Amount] and deducted
from:     1. The partial Withdrawal amount on the date a Withdrawal in excess of the Maximum Annual Withdrawal Amount is taken; and     2. The [Contract Value] upon a total Withdrawal of all Your Contract
Value. The Benefit Withdrawal Charge is shown below. NUMBER OF FULL BENEFIT YEARS ELAPSED SINCE ENDORSEMENT EFFECTIVE DATE BENEFIT WITHDRAWAL CHARGE* 0 9.00% 1 8.50% 2 7.50% 3 6.50% 4 5.50% 5 4.50% 6
3.50% 7 2.50% 8 1.50% 9 0.50% 10+ 0% *Assessed as a percentage of the Withdrawal amount in excess of Maximum Annual Withdrawal Amount upon a partial Withdrawal or the Contract Value in excess of Maximum Annual Withdrawal Amount, upon a total
Withdrawal of all Your Contract Value. [PAYMENTS IN CONNECTION WITH DISTRIBUTION OF THE CONTRACT This provision applies only to the Contract to which this Endorsement is attached. If Withdrawal(s) taken to cover payments to the Agent in connection
with advisory or investment management services (Advisory Fee) are greater than the Maximum Annual Withdrawal Amount in any given Benefit Year, no portion of Advisory Fee payments [up to [1.0%] of the Contract Value associated with the Contract in
which this Endorsement is attached to] will be treated as an Excess Withdrawal provided You enroll in the Systematic Withdrawal Program for Advisory Fees. However, any portion of a Withdrawal in a Benefit Year that is greater than the Maximum Annual
Withdrawal Amount (or Required Minimum Distribution as described below in this Endorsement) and greater than the Advisory Fee will be considered an Excess Withdrawal for the purpose of the recalculation of the Income Base, Maximum Annual Withdrawal
Amount [and Protected Income Payment]. ] 

  

					
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 DEFINITIONS 

For purposes of this Endorsement, the following definitions apply. Terms not defined in this Endorsement shall have the same meaning as
defined in the Contract. 
 AGE 
 The
attained age as of the Covered Person’s last birthday. If there are two Covered Persons on the Endorsement Data Page, the Age of the younger Covered Person or in the event of the death of one Covered Person, the surviving Covered Person as of
their last birthday. 
 BENEFIT ANNIVERSARY VALUE 

The Contract Value including any applicable Spousal Beneficiary Continuation contribution, as measured on each Benefit [Year]

 Anniversary. 
 BENEFIT [QUARTER]

 
 Each consecutive [3 month]

 period starting on the Endorsement Effective Date. 
 BENEFIT [QUARTER]

 ANNIVERSARY 
 The date following each consecutive [3 month]

 period starting on the Endorsement Effective Date. If the next Benefit [Quarter]

 Anniversary has no corresponding date the Benefit [Quarter]

 Anniversary will be deemed to be the following day. 
 BENEFIT YEAR 

Each consecutive one year period starting on the Endorsement Effective Date. 

BENEFIT YEAR ANNIVERSARY 
 The date on
which each Benefit Year begins. 
 COVERED PERSON(S) 

The person(s) named on the Endorsement Data Page whose lives are used to determine the amount and duration of Withdrawals. The Covered
Person(s) cannot be changed. 
 EARLIEST CANCELLATION DATE OF THE GUARANTEED LIVING BENEFIT 

The earliest Benefit Year Anniversary is as shown on the Endorsement Data Page. This is the earliest date You may cancel this Endorsement. 

ENDORSEMENT EFFECTIVE DATE 
 The date when
this Endorsement becomes effective as shown on the Endorsement Data Page. 
 EXCESS WITHDRAWAL 

Any Withdrawal in a Benefit [Year]

 taken after the Maximum Annual Withdrawal Amount has been withdrawn, and/or any portion of a Withdrawal that causes the total Withdrawals in a Benefit [Year]

 to exceed the Maximum Annual Withdrawal Amount. 
 HIGHEST ANNIVERSARY VALUE 

The Benefit Anniversary Value that is the greater of (1) all Benefit Anniversary Values; and (2) Purchase Payments, subject to the
Purchase Payment Restriction shown on the Endorsement Data Page while this Endorsement is effective and the Contract Value is greater than zero. 

INCOME BASE 
 The Income Base is used to
determine the Endorsement Fee, the Maximum Annual Withdrawal Amount and the Protected Income Payment. 
 INCOME CREDIT 

An amount that may be added to the Income Base during the Income Credit Period that is equal to the Net Income Credit Percentage multiplied by
the Income Credit Base. 
 INCOME CREDIT BASE 

A factor which is used to determine the amount of any Income Credit during the Income Credit Period. 

  

					
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 INCOME CREDIT PERIOD 

The period of time over which We calculate an Income Credit that may be added to the Income Base. 

MAXIMUM ANNUAL WITHDRAWAL AMOUNT 
 The
maximum amount that may be withdrawn each Benefit [Year]

 while the Contract Value is greater than zero and the Covered Person(s) is living without reducing the Income Base and the Income Credit Base, if applicable and also without reducing any Income Credit to zero. 

MAXIMUM ANNUAL WITHDRAWAL PERCENTAGE 
 The
percentage, as referenced on the Endorsement Data Page used to determine the Maximum Annual Withdrawal Amount available for Withdrawal each Benefit [Year]

 while the Contract Value is greater than zero and the Covered Person(s) is living. 
 MINIMUM INCOME BASE 

The guaranteed minimum amount to which the Income Base and the Income Credit Base, if applicable, could be increased on a specified Benefit
[Year]

 Anniversary provided no Withdrawals are taken before the [12th ]

 Benefit [Year]

 Anniversary. 
 NET INCOME CREDIT PERCENTAGE 

A percentage calculated as the difference between the [Gross]

 Income Credit Percentage as shown on the Endorsement Data Page, and the percentage calculated as the sum of all Withdrawals taken during the preceding Benefit [Year]

 divided by the Income Base before determining the Income Base for the next Benefit [Year]

.. 
 PROTECTED INCOME PAYMENT 

The amount to be paid each [year]

 over the remaining lifetime of the Covered Person(s) after the Contract Value is reduced to zero but the Income Base is still greater than zero. 

PROTECTED INCOME PAYMENT PERCENTAGE 
 The
percentage, as referenced on the Endorsement Data Page, used to determine the Protected Income Payment. 
 YOU, YOUR 

The Covered Person(s) under this Endorsement. 

GUARANTEED LIVING BENEFIT PROVISIONS 

The Guaranteed Living Benefit described in this Endorsement provides for guaranteed Withdrawals over the lifetime of the Covered Person(s),
subject to the following provisions: 
 Calculation of the Factors of the Guaranteed Living Benefit 

To determine the Guaranteed Living Benefit, We use the following factors: Income Base, Income Credit Base, Income Credit, Net Income Credit
Percentage, Income Credit Period, Minimum Income Base, Maximum Annual Withdrawal Amount, Maximum Annual Withdrawal Percentage, Protected Income Payment, and Protected Income Payment Percentage. These factors are not used in the calculation of the
Contract Value or any other benefits under the Contract. 
 Withdrawals taken under this Living Benefit are treated like any other
Withdrawal under the Contract for purposes of calculating Contract Value, including any fees and charges applicable to any other benefits under the Contract. In any Benefit [Year]

, Withdrawals up to Maximum Annual Withdrawal Amount are not subject to the Benefit Withdrawal Charge shown on the Endorsement Data Page. 

Calculation of the Income Base 

Calculation of the Income Base if the Endorsement is Elected on the Contract Date 

If this Living Benefit is elected on the Contract Date, the initial Income Base is equal to the initial Purchase Payment. 

Calculation of the Income Base if the Endorsement is Elected After the Contract Date 

If this Living Benefit is elected after the Contract Date, the initial Income Base is the Contract Value on the Endorsement
Effective Date, which is considered the initial Purchase Payment and is subject to the Purchase Payment Restriction shown on the Endorsement Data Page. 

  

					
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 Thereafter, on each Benefit [Year]

 Anniversary, the Income Base is automatically increased to the greater of (a), or (b) where: 
  

	 	(a)	 is the Highest Anniversary Value; and 

	 	(b)	 is the current Income Base, plus the Income Credit, if any. 

The Income Base will continue to be calculated on each Benefit [Year]

 Anniversary while this Endorsement is in effect and both the Contract Value and Income Base are greater than zero. 

Calculation of the Income Credit Base 

Calculation of the Income Credit Base if the Endorsement is Elected on the Contract Date 

The Income Credit Base is used to calculate the amount of the Income Credit during the Income Credit Period. If this Living
Benefit is elected on the Contract Date, the initial Income Credit Base is equal to the initial Purchase Payment. 

Calculation of the Income Credit Base if the Endorsement is Elected After the Contract Date 

If this Living Benefit is elected after the Contract Date, the initial Income Credit Base is the Contract Value on the
Endorsement Effective Date, which is considered the initial Purchase Payment and is subject to the Purchase Payment Restriction shown on the Endorsement Data Page. 

Thereafter, the Income Credit Base is increased and decreased as follows: 

Increases in the Income Credit Base 

The Income Credit Base increases each time Purchase Payments are made, subject to the Purchase Payment Restriction shown on the
Endorsement Data Page. The Income Credit Base also increases to the Highest Anniversary Value when the Income Base is increased to the Highest Anniversary Value. 

Decreases in the Income Credit Base 

The Income Credit Base decreases each time an Excess Withdrawal is taken, in the same proportion by which the Contract Value is
reduced by the amount in excess of the Maximum Annual Withdrawal Amount. 
 Calculation of the Income Credit 

On each Benefit [Year]

 Anniversary during the Income Credit Period, if Excess Withdrawals were not taken during the previous Benefit [Year]

, the Income Credit is determined by multiplying the Net Income Credit Percentage by the Income Credit Base. If any Excess Withdrawals were taken in the previous Benefit [Year]

, then the Income Credit is reduced to zero for that Benefit [Year]

.. The [Gross]

 Income Credit Percentage is shown on the Endorsement Data Page. 
 Calculation of the Minimum Income Base 

Calculation of the Minimum Income Base if the Endorsement is Elected on the Contract Date 

If this Living Benefit is elected on the Contract Date, the Minimum Income Base is as shown on the Endorsement Data Page. 

Calculation of the Minimum Income Base if the Endorsement is Elected After the Contract Date 

If this Living Benefit is elected after the Contract Date, the Minimum Income Base is [200%]

 of the Contract Value on the Endorsement Effective Date, which is considered the initial Purchase Payment and is subject to the Purchase Payment Restriction shown on the Endorsement Data Page. 

The Income Base and Income Credit Base, if applicable, will be increased to at least the Minimum Income Base on the [12th ]

 Benefit [Year]

 Anniversary, provided no Withdrawals are taken prior to that anniversary. If You are eligible for the Minimum Income Base, the Income Base on the [12th ]

 Benefit [Year]

 Anniversary is the greater of (a) or (b), where: 
  

	 	(a)	 is the current Income Base; and 

 

	 	(b)	 is the Minimum Income Base. 

  

					
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 Calculation of the Maximum Annual Withdrawal Amount 

The Maximum Annual Withdrawal Amount is calculated by multiplying the Income Base by the Maximum Annual Withdrawal Percentage as shown on the
Endorsement Data Page, which is determined by Your Age at the time You first take a Withdrawal from Your Contract and the number of Covered Person(s) shown on the Endorsement Data Page. 

Withdrawals during a Benefit [Year]

 that in total are less than or equal to the Maximum Annual Withdrawal Amount will not reduce the Maximum Annual Withdrawal Amount and the Income Base, and the Income Credit Base if applicable. If you take an Excess
Withdrawal in a Benefit [Year]

, the Income Credit is reduced to zero for that Benefit [Year]

.. If You choose to take less than the Maximum Annual Withdrawal Amount in any Benefit [Year], You may not carry over the unused amount for withdrawal in subsequent Benefit [Years]

.. Your Maximum Annual Withdrawal Amount in any year will not be recalculated solely as a result of taking less than the entire Maximum Annual Withdrawal Amount in the prior year. 

Calculation of the Protected Income Payment 

If the Contract Value is reduced to zero due to unfavorable investment performance, Withdrawal up to the Maximum Annual Withdrawal Amount, or
any combination of these factors, but the Income Base is still greater than zero, You may be eligible to receive the Protected Income Payment. The Protected Income Payment is calculated by multiplying the Income Base by the applicable Protected
Income Payment Percentage, which is determined by Your Age at the time You first take a Withdrawal from Your Contract, as shown on the Endorsement Data Page. You will receive the Protected Income Payment each year for the remaining lifetime of the
Covered Person(s). 
 Increases and Decreases in the Income Base and the Impact to Your Maximum Annual Withdrawal Amount 

Increases in the Income Base 
 The Income
Base is increased anytime a Purchase Payment is allocated to Your Contract, subject to the Purchase Payment Restriction shown on the Endorsement Data Page. The Income Base is also increased by any available Income Credit on any Benefit [Year]

 Anniversary during the Income Credit Period if You have taken no Excess Withdrawals, or as a result of a Highest Anniversary Value being achieved resulting in the Income Base being stepped up on a Benefit [Year]

 Anniversary. In addition, the Income Base can also be increased to the Minimum Income Base on the [12th ]

 Benefit [Year]

 Anniversary, provided no Withdrawals are taken before the [12th ]

 Benefit [Year]

 Anniversary. In the Benefit [Year(s)]

 during which Purchase Payments are allocated to Your Contract, any remaining Withdrawals of the Maximum Annual Withdrawal Amount will be based on the increased Maximum Annual Withdrawal Amount reduced by Withdrawals
previously taken in that Benefit [Year]

.. If the Income Base is increased on a Benefit [Year]

 Anniversary, the Maximum Annual Withdrawal Amount will be recalculated on that Benefit [Year]

 Anniversary, applicable to the coming Benefit [Year]

, by multiplying the increased Income Base by the applicable Maximum Annual Withdrawal Percentage. The Endorsement Fee will be assessed on the increased Income Base. 

Decreases in the Income Base 
 Excess
Withdrawals reduce Your Income Base on the date the Excess Withdrawal occurs. Any Excess Withdrawal in a Benefit [Year]

 reduces the Income Base in the same proportion by which the Contract Value is reduced by the Excess Withdrawal. As a result of a reduction of the Income Base, the Maximum Annual Withdrawal Amount will also be
reduced. The new Maximum Annual Withdrawal Amount will be equal to the reduced Income Base multiplied by the applicable Maximum Annual Withdrawal Percentage. The last recalculated Maximum Annual Withdrawal Amount in a given Benefit [Year]

 is available for Withdrawal at the beginning of the next Benefit [Year]

 and may be lower than the previous Benefit [Year’s]

 Maximum Annual Withdrawal Amount. When the Contract Value is less than the Income Base, Excess Withdrawals will reduce the Income Base by an amount which is greater than the amount of the Excess Withdrawal. In addition,
no Income Credit will be added to the Income Base in that Benefit [Year]

.. 
 The Income Base is a factor used to determine the Maximum Annual Withdrawal Amount and Protected Income
Payment as well as the Endorsement Fee. The Income Base is not an amount that You can withdraw. Excess Withdrawals may reduce future benefits by more than the dollar amount of the Withdrawal. Excess Withdrawals will incur a Charge for Partial/Full
Termination if they occur during the applicable period indicated on the Endorsement Data Page. If You have any questions regarding whether a potential Withdrawal would be an Excess Withdrawal, please call Our Annuity Service Center. 

Required Minimum Distributions (RMD) 

This provision applies only to the Contract to which this Endorsement is attached. If you are taking RMD and the RMD amount, based only
on this Contract, is greater than the Maximum Annual Withdrawal Amount in any given Benefit [Year]

, no portion of the RMD will be treated as an Excess Withdrawal provided you enroll in the Company’s systematic withdrawal program for RMD. However, any portion of a Withdrawal in a Benefit [Year]

 that is more than the greater of 

  

					
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	  	6	  	

 
both the Maximum Annual Withdrawal Amount and the RMD amount will be considered an Excess Withdrawal for the purpose of the recalculation of the Income Credit Base, Income Base and Maximum Annual
Withdrawal Amount. Furthermore, the Income Credit will be reduced to zero if total Excess Withdrawals taken in any Benefit [Year]

, including RMD withdrawals, are in excess of the Maximum Annual Withdrawal Amount. 
 If Your Contract Value Is Reduced to
Zero 
 If Your Contract Value is reduced to zero because of an Excess Withdrawal, no further benefits will be payable under this
Endorsement or the Contract, and Your Contract along with the Endorsement will terminate. However, if Your Contract Value is reduced to zero due to unfavorable investment performance and/or fees, Withdrawal(s) up to the Maximum Annual Withdrawal
Amount (or if applicable, the RMD amount as described above) or any combination of these factors, and the Income Base is greater than zero, We will pay the remaining Maximum Annual Withdrawal Amount for that Benefit [Year]

 in the same frequency withdrawals had been taken, i.e. monthly or quarterly. Thereafter, we will pay the Protected Income Payment over the remaining lifetime of the Covered Person(s) which will be calculated by
multiplying the Income Base by the Protected Income Payment Percentage, as shown on the Endorsement Data Page. 
 Because the Contract Value
has been reduced to zero, the Income Base will no longer be increased to the Highest Anniversary Value, no Endorsement fee will be deducted, and if applicable Income Credits will not be applied. In addition, all other benefits under the Contract
with the exception of payment of the Protected Income Payment, will be terminated and You may no longer make subsequent Purchase Payments or transfers, and no Death Benefit is payable. 

When the Contract Value equals zero and the Income Base is greater than zero, to receive any remaining Living Benefit, you must select one of
the following payment options: 
  

	 	1.	 The Protected Income Payment, divided equally and paid on a monthly, quarterly, semi-annual or annual
frequency as selected by You until the date of Your death(s); or 

  

	 	2.	 Any payment option mutually agreeable between You and Us. 

Once You select a payment option, it cannot be changed. If You do not select a payment option above, the remaining benefit will be paid as an
amount based on the Protected Income Payment Percentage. This amount will be divided equally and paid on a [quarterly]

 basis until the date of death of the Covered Person(s). 
 Latest Annuity Date 

If the Contract Value and the Income Base are greater than zero on the Latest Annuity Date, You must select one of the following options: 

 

	 	1.	 Annuitize the Contract Value under the Annuity Provisions of the Contract; or 

 

	 	2.	 Annuitize the Contract and elect to receive the current Maximum Annual Withdrawal Amount as of the Latest
Annuity Date for a fixed period while You are alive. The fixed period is determined by dividing the contract value on the Latest Annuity Date by the Maximum Annual Withdrawal Amount. Any applicable premium taxes will be deducted from the Contract
Value prior to determining the fixed period. After that fixed period ends, you will receive the Protected Income Payment, as of the Latest Annuity Date, divided equally and paid on a monthly, quarterly, semi-annual or annual frequency as selected by
You until the date of death of the Covered Person(s); or 

  

	 	3.	 Any payment option mutually agreeable between You and Us. 

If You do not select an option listed above, on the Latest Annuity Date, We may annuitize the Contract Value in accordance with Option 2
above, divided equally and paid on a [quarterly]

 frequency until the date of death of the Covered Person(s). Endorsement Fees are no longer deducted upon annuitization on the Latest Annuity Date. 

Secure Value Account Allocation(s) 
 If
applicable, Secure Value Account Allocation(s) is/are required only while the Endorsement is effective. Amounts allocated to the Secure Value Account(s) are not subject to the Separate Account Charge. Amounts allocated to the Secure Value Account(s)
may not be transferred to any other investment option as long as the Endorsement is effective and We will not rebalance amounts allocated to the Secure Value Account(s) in accordance with the automatic asset rebalancing program. You may not transfer
into or out of the Secure Value Account(s). You may not request the entire amount of any Withdrawal to be deducted solely from the Secure Value Account(s). Rather, any Withdrawal reduces the amount invested in the Secure Value Account(s) in the same
proportion that the Withdrawal reduces the Contract Value. 

  

					
	 USLE-8042 (4/16)
	  	7	  	

 [Investment Requirements 

If applicable, in addition to the Secure Value Account Allocation while the Endorsement is effective, We require that you allocate your
Purchase Payment(s), and Spousal Beneficiary Continuation contribution, if applicable, and Contract Value in accordance with established requirements stated in the Prospectus. We require enrollment in a quarterly automatic asset rebalancing program
that complies with the investment requirements. In addition to quarterly asset rebalancing, We will initiate rebalancing in accordance with your most current and compliant automatic asset rebalancing instructions on file after any Withdrawal or
transfer You initiate.]

 
 Misstatement of Age or Sex 

The Misstatement of Age or Sex provision included in Your Contract shall apply to the Covered Person(s) under this Endorsement and may impact
the Maximum Annual Withdrawal Amount. 
 Termination of Withdrawals Over Two Lives 

If there are two Covered Persons on the Endorsement Effective Date, Withdrawals guaranteed for the life of one of the Covered Persons will
terminate if: 
  

	 	1.	 One of the two Covered Persons is removed from the Endorsement due to any reason other than death; or

  

	 	2.	 The Covered Persons are no longer married at the time of death of the first Covered Person.

 Termination of Withdrawals guaranteed for the life of one Covered Person does not impact any other terms and conditions
of this Endorsement, including the applicable Endorsement Fee, which is based on the number of Covered Persons on this Endorsement Effective Date. 

Cancellation of the Guaranteed Living Benefit 

You may cancel this Endorsement as detailed below on or after the Earliest Cancellation Date of the Guaranteed Living Benefit as shown on the
Endorsement Data Page. You may cancel this Endorsement by means of a Written request as detailed below. The Guaranteed Living Benefit may not be re-elected or reinstated after a cancellation. 

Cancellation Effective Date 
 If Your cancellation request
is received: 
  

	 	1.	 On or before the Earliest Cancellation Date of the Guaranteed Living Benefit, the cancellation is effective on
the Earliest Cancellation Date of the Guaranteed Living Benefit date as shown on the Endorsement Data Page; 

  

	 	2.	 In any Benefit [Year]

 after the Earliest Cancellation Date of the Guaranteed Living Benefit date, the cancellation is effective on the Benefit [Quarter]

 Anniversary following Our receipt of the cancellation request. 

 Termination of the Guaranteed Living
Benefit 
 This Endorsement and the Endorsement Fee will terminate automatically upon the occurrence of one of the following: 

 

	 	1.	 Death of the Covered Person, or if there were two Covered Persons, upon the death of the surviving Covered
Person; or 

	 	2.	 A Death Benefit is paid resulting in the Contract being terminated; or 

	 	3.	 The Contract is annuitized; or 

	 	4.	 An Excess Withdrawal that reduces the Contract Value and Income Base to zero; or 

	 	5.	 Any change occurs that removes one or all Covered Persons from the Contract except as noted above under
“Termination of Withdrawals Over Two Lives”; or 

	 	6.	 The Contract is cancelled or surrendered for any reason; or 

	 	7.	 Assignment of any Contract Owner rights under this Endorsement to a third party; or 

	 	8.	 You elect to cancel this Endorsement. 

On the termination effective date, amounts allocated to the Secure Value Account will be automatically transferred to a 1-Year Fixed Account
option, if available, or a money market or similar portfolio. Purchase Payments may no longer be allocated to the Secure Value Account after termination. From the day following the automated transfer, you may transfer this amount to another
available investment option under the Contract for a period of [90 days]

 during which the transfer will not count against the annual number of free transfers or incur a transfer fee. 

If You surrender Your Contract while Your Contract Value is greater than zero, We will assess a pro-rata charge for the Endorsement Fee
applicable to the Benefit [Quarter]

 in which the surrender occurs if the Contract was surrendered before the end of a Benefit [Quarter]

.. The pro-rated charge is calculated by multiplying the fee by the number of days between the date when the prior fee was last assessed and the date of surrender, divided by the number of days between the prior and

  

					
	 USLE-8042 (4/16)
	  	8	  	

 
the next Benefit [Quarter]

 Aniversaries. Thereafter, You will no longer be charged an Endorsement Fee. If You surrender Your Contract, You will also incur a Benefit Withdrawal Charge if You take a total Withdrawal of all Your Contract Value
during the applicable period indicated on the Endorsement Data Page 
 Death of Covered Person(s) 

If there is one Covered Person and that person dies, this Endorsement and the Endorsement Fee will be terminated. 

If there are two Covered Persons, upon the first death, if the surviving Covered Person is eligible and elects to continue the Contract, this
Endorsement is also continued. Upon the election of continuation, the Endorsement Effective Date, the applicable Endorsement Fee, and the Maximum Annual Withdrawal and Protected Income Payment Percentages based on two Covered Persons will not
change. 
 Signed for the Company to be effective on the Endorsement Effective Date. 

THE UNITED STATES LIFE INSURANCE COMPANY IN THE CITY OF NEW YORK 

                    

 
  
 

 

  

					
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	  	9

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