Document:

rila287contract

     [Home Office:               [Service Center:   1  Corporate Way            P.O. Box 24068   Lansing,  Michigan 48951    Lansing, MI 48909-4068      1-800-644-4565] www.jackson.com]                               Jackson National Life Insurance Company®      Thank you for choosing Jackson National Life Insurance Company, also referred to as "the   Company" or "Jackson®."                              READ YOUR CONTRACT CAREFULLY.      This annuity contract is issued by the Company and is a legal agreement between the Owner   ("You") and Jackson.      PLEASE NOTE THAT THIS CONTRACT HAS REFERENCES TO AND UTILIZATION OF   EXTERNAL INDEXES. WHILE THE CONTRACT VALUES MAY BE AFFECTED BY THE   EXTERNAL INDEXES, THE CONTRACT DOES NOT DIRECTLY PARTICIPATE IN ANY   STOCK OR EQUITY INVESTMENTS. AN INDEX ADJUSTMENT TO THE INDEX ACCOUNT   IS NOT GUARANTEED AND MAY VARY BASED UPON THE PERFORMANCE OF THE   INDEXES.      WHEN ALL OR ANY PORTION OF THE INDEX ACCOUNT VALUE IS WITHDRAWN,   ANNUITIZED, OR TRANSFERRED TO THE FIXED ACCOUNT, IT MAY BE SUBJECT TO A   MARKET VALUE ADJUSTMENT (MVA) AS SET FORTH IN THE CONTRACT DATA PAGES.   THE WITHDRAWAL VALUE AVAILABLE UNDER THIS CONTRACT IS EQUAL TO THE   CONTRACT VALUE ADJUSTED FOR ANY APPLICABLE MVA.      NOTICE OF RIGHT TO EXAMINE CONTRACT   YOU MAY RETURN THIS CONTRACT TO THE FINANCIAL PROFESSIONAL WHO SOLD   YOU THE CONTRACT OR THE COMPANY WITHIN [10] DAYS AFTER YOU RECEIVE IT   ([30] DAYS AFTER YOU RECEIVE IT IF IT WAS PURCHASED AS A REPLACEMENT   CONTRACT). THE COMPANY WILL REFUND THE PREMIUM PAID TO THE FIXED   ACCOUNT, LESS THE AMOUNT OF ANY PARTIAL WITHDRAWALS FROM THE FIXED   ACCOUNT, PLUS THE INDEX ACCOUNT VALUE WITHOUT DEDUCTION FOR ANY FEES   AND CHARGES. RETURNED CONTRACTS ARE VOID.      The Telephone Number for the [Issue State] Department of Insurance is [Insurance Department   telephone number].   INDIVIDUAL SINGLE PREMIUM DEFERRED              This Contract is signed by the Company REGISTERED INDEX-LINKED ANNUITY.  DEATH BENEFIT AVAILABLE.  INCOME OPTION AVAILABLE.  NON-PARTICIPATING.                                                                                 President                                                                                  Secretary   RILA287 

 

                                TABLE OF CONTENTS                       Provision Page Number                Contract Data Pages                                          [3a                Definitions                                                    4                General Provisions                                             8                Contract Option Provisions                                    12                Withdrawal Provisions                                         14                Death Benefit Provisions                                      16                Income Provisions                                             19                Termination Provisions                                       22]          If You have questions about this Contract or require information about coverage or complaint  resolutions, You may contact the Company's Service Center identified on the Contract's cover  page.            RILA287 2 

 

                              CONTRACT DATA PAGES     Contract Number:                   [1234567890]       Owner: [John Doe]       Owner Issue Age:                   [80]       Joint Owner:                       [No Joint Owner]       Joint Owner Issue Age:             [N/A]       Annuitant: [John Doe]       Annuitant Issue Age:               [80]       Joint Annuitant:                   [No Joint Annuitant]       Joint Annuitant Issue Age:         [N/A]       Issue Date:                        [January 15, 2021]       Issue State:                       [MI]       Premium Amount:                    [$25,000]       Income Date:                       [January 15, 2036]       Primary Beneficiary(ies):          [Brian Doe]       Contingent Beneficiary(ies):       [Jane Doe]                                              RILA287-CB1 3a 

 

                        CONTRACT DATA PAGES (CONT'D)    FIXED ACCOUNT INFORMATION:    Fixed Account Minimum Interest Rate (FAMIR): [1.00%]    Fixed Account Minimum Value Percentage: [87.50%]    Fixed Account Minimum Value Annual Expense Allowance: [$50]    INTEREST RATE FOR ADJUSTMENTS DUE TO MISSTATEMENT OF AGE OR SEX: [1.00%]    WITHDRAWALS:    Minimum partial withdrawal amount unless as a scheduled part of an automatic  withdrawal program: [$500]    Minimum partial withdrawal amount as a scheduled part of an automatic withdrawal  program: [$50]    Minimum Contract Value remaining after a partial withdrawal: [$2,000]    MVA Free Withdrawal Percentage: [10%]     PREMIUM:    Premium is money paid into this Contract for allocation into a Contract Option. This is a single  Premium Contract. The Company may waive minimum and maximum Premium at any time, on  a nondiscriminatory basis.     Minimum Premium:           [$25,000]    Maximum Premium:           [$1,000,000]    SEPARATE ACCOUNT:    [RILA Separate Account]    RILA287-CB1 3b 

 

                        CONTRACT DATA PAGES (CONT'D)    MARKET VALUE ADJUSTMENT (MVA):    An MVA is a positive or negative adjustment the Company applies to amounts You remove from  an Index Account Option due to withdrawals, annuitizations or transfers to the Fixed Account  during the MVA Period. In the event of a total withdrawal, any applicable MVA is applied to the  Index Account value, less any MVA Free Withdrawal amount available at the time of the total  withdrawal.     MVA Period: First [six (6)] Contract Years.    The MVA reflects the movement in the MVA Reference Rate since the Issue Date.    The MVA may:  1.  reduce the value of the amount paid, annuitized or transferred if the MVA Reference Rate     on the date You remove Index Account value from an Index Account Option is greater than     the MVA Reference Rate on the Issue Date of Your Contract; or  2.  increase the value of the amount paid, annuitized or transferred if the MVA Reference Rate     on the date You remove Index Account value from an Index Account Option is less than the     MVA Reference Rate on the Issue Date of Your Contract.    The Company applies the same MVA formula regardless of whether the formula results in an  increase or decrease to amounts You remove from an Index Account Option.    MVA formula. The Company calculates the MVA by multiplying the amount You withdraw less  any applicable charges by the result of the formula below:                                         (m/12)                                                [1+ I ]                                             -1                                                    (m/12)                                  [1+J  ]                       where:    I  is  the MVA Reference Rate on the Issue Date  J  is  the MVA Reference Rate on the date of withdrawal  m  is  the number of complete months remaining from the date of the removal to the end of the         MVA Period.    The Company will not apply an MVA to:  1.  death benefit proceeds;  2.  payment of charges or fees;   3.  amounts You allocate to an Income Option that is life contingent or results in payments     spread over at least five (5) years;  4.  transfers within the Index Account;  5.  exercise of Your Notice of Right to Examine Contract Provision;  6.  withdrawals taken under the MVA Free Withdrawal provision;  7.  withdrawals taken to satisfy the Required Minimum Distribution (RMD);  8.  amounts You remove on the Latest Income Date;  9.  amounts You remove from Your Contract after the end of MVA Period; or  10. withdrawals or transfers from the Fixed Account.    RILA287-CB1 3c 

 

                        CONTRACT DATA PAGES (CONT'D)    MARKET VALUE ADJUSTMENT (MVA) (continued):    MVA Reference Rate: [Bloomberg Barclays U.S. Intermediate Corporate Bond Index Yield to  Maturity]    The MVA Reference Rate applied on any day will be the MVA Reference Rate published on the  prior Business Day.    If the MVA Reference Rate is not published on the Business Day before the MVA is calculated,  the Company will use the MVA Reference Rate for the most recent Business Day it was  published.    Discontinuation of or Substantial Change to the MVA Reference Rate. In the event that the  MVA Reference Rate is no longer published, is discontinued, or if the calculation is substantially  changed on the date You remove Contract Value from Your Contract then the Company may  substitute a comparable method for determining the MVA Reference Rate. The Company will  obtain approval from Your state insurance department and will notify You and any assignee  before using a substitute method to calculate the MVA.    RILA287-CB1 3d 

 

                                                    CONTRACT DATA PAGES (CONT'D)                                                                                                                                  TABLE OF INCOME OPTIONS                      The following table shows income values for each $1,000 of net proceeds applied to the Income           Option.                        UNDER OPTION 4                                             MONTHLY INSTALLMENTS UNDER OPTIONS 1 OR 3                                                                                                                                                                                                                                                                                         No. of   Monthly   Age of        No. of Mos.      Age of        No. of Mos.        Age of         No. of Mos.       Age of         No. of Mos.  Monthly    Install- Annui-         Certain         Annui-          Certain          Annui-          Certain          Annui-          Certain   Install-  ments     tant                           tant                              tant                            tant   ments                       Male Life 120 240 Male                  Life    120 240 Female Life 120 240 Female                         Life    120 240    60       17.09      40     2.33 2.32 2.31          68      4.72    4.57 4.02        40      2.22 2.22 2.21           68      4.36    4.26 3.86    72       14.31      41     2.37 2.36 2.35          69      4.90    4.72 4.09        41      2.26 2.26 2.25           69      4.52    4.40 3.94    84       12.33      42     2.41 2.41 2.39          70      5.09    4.89 4.16        42      2.30 2.30 2.29           70      4.69    4.55 4.02    96       10.84      43     2.45 2.45 2.43          71      5.31    5.06 4.23        43      2.34 2.34 2.32           71      4.87    4.70 4.09    108       9.68      44     2.50 2.50 2.47          72      5.54    5.24 4.29        44      2.38 2.38 2.36           72      5.06    4.87 4.16    120       8.76      45     2.55 2.54 2.52          73      5.79    5.43 4.34        45      2.42 2.42 2.40           73      5.28    5.04 4.22    132       8.00      46     2.60 2.59 2.56          74      6.06    5.63 4.39        46      2.47 2.47 2.45           74      5.51    5.23 4.28    144       7.37      47     2.65 2.64 2.61          75      6.35    5.83 4.43        47      2.52 2.51 2.49           75      5.76    5.42 4.34    156       6.84      48     2.71 2.70 2.66          76      6.67    6.04 4.47        48      2.57 2.56 2.54           76      6.03    5.62 4.38    168       6.38      49     2.77 2.76 2.71          77      7.02    6.26 4.50        49      2.62 2.61 2.59           77      6.33    5.83 4.43    180       5.98      50     2.83 2.82 2.76          78      7.40    6.48 4.52        50      2.67 2.67 2.64           78      6.65    6.04 4.46    192       5.64      51     2.89 2.88 2.82          79      7.81    6.70 4.54        51      2.73 2.72 2.69           79      7.01    6.26 4.49    204       5.33      52     2.96 2.94 2.88          80      8.27    6.92 4.56        52      2.79 2.78 2.74           80      7.40    6.48 4.52    216       5.06      53     3.03 3.01 2.94          81      8.76    7.13 4.57        53      2.85 2.84 2.80           81      7.83    6.70 4.54    228       4.82      54     3.10 3.08 3.00          82      9.30    7.34 4.58        54      2.92 2.91 2.85           82      8.29    6.92 4.56    240       4.60      55     3.18 3.16 3.06          83      9.89    7.53 4.58        55      2.99 2.98 2.91           83      8.80    7.13 4.57    252       4.40      56     3.26 3.23 3.13          84     10.54 7.72 4.59           56      3.07 3.05 2.98           84      9.35    7.33 4.58    264       4.22      57     3.35 3.32 3.19          85     11.26 7.88 4.59           57      3.14 3.12 3.04           85      9.95    7.52 4.58    276       4.06      58     3.44 3.40 3.26          86     12.05 8.03 4.59           58      3.23 3.20 3.11           86      10.59 7.70 4.59    288       3.90      59     3.54 3.49 3.34          87     12.91 8.17 4.59           59      3.31 3.29 3.18           87      11.28 7.87 4.59    300       3.77      60     3.64 3.59 3.41          88     13.86 8.28 4.60           60      3.40 3.37 3.25           88      12.03 8.02 4.59    312       3.64      61     3.74 3.69 3.48          89     14.88 8.38 4.60           61      3.50 3.46 3.32           89      12.84 8.15 4.59    324       3.52      62     3.86 3.79 3.56          90     15.99 8.46 4.60           62      3.60 3.56 3.40           90      13.71 8.27 4.60    336       3.41      63     3.98 3.91 3.64          91     17.17 8.53 4.60           63      3.71 3.66 3.47           91      14.66 8.37 4.60    348       3.31      64     4.11 4.02 3.71          92     18.43 8.58 4.60           64      3.82 3.77 3.55           92      15.70 8.45 4.60    360       3.21      65     4.24 4.15 3.79          93     19.78 8.63 4.60           65      3.95 3.88 3.63           93      16.86 8.53 4.60                        66     4.39 4.28 3.87          94     21.20 8.66 4.60           66      4.07 4.00 3.71           94      18.13 8.58 4.60                        67     4.55 4.42 3.95          95     22.67 8.68 4.60           67      4.21 4.12 3.79           95      19.53 8.63 4.60                                 Note: Due to the volume of relevant information, the Table does not provide income values for           Option 2 described in the Income Provisions. Those values are available from the Company's           Service Center upon request. You may contact the Company's Service Center as shown on the           cover page of the Contract.                      BASIS OF COMPUTATION. The [2012 Individual Annuity Mortality Period Table, with an           interest rate of 1.00% and a 0% expense load], provides the actuarial basis for the Table of           Income Options. The Table of Income Options does not include any applicable tax.             RILA287-CB1 3e 

 

                                      DEFINITIONS    ANNUITANT. The natural person(s) so designated on the Contract Data Pages, or by  subsequent designation, on whose life the Company determines the amount of Income  Payments provided by the Contract. References to the Annuitant include all Joint Annuitants, if  applicable.    BENEFICIARY(IES). The natural person(s) or legal entity(ies) You designate as Primary or  Contingent Beneficiary(ies) to receive any death benefit provided by the Contract. The initial  Beneficiary(ies) are shown on the Contract Data Pages.    BUSINESS DAY. Any day that the Company and the New York Stock Exchange (NYSE) are  open for business. The Business Day ends when the NYSE closes for the day.    CONTRACT. The Individual Single Premium Deferred Registered Index-Linked Annuity  described herein.    CONTRACT ANNIVERSARY. Each one-year anniversary of the Issue Date.    CONTRACT OPTION(S). The Contract Options for this Contract are the Fixed Account and the  Index Account.     CONTRACT VALUE. The Contract Value is equal to the sum of the Fixed Account value and  the Index Account value. See the Contract Option Provisions for details of how the Fixed  Account value and Index Account value are determined.     CONTRACT YEAR. The twelve-month period beginning on the Issue Date and on any Contract  Anniversary thereafter while the Contract remains in force.    CREDITING METHOD. A method of calculating the Index Adjustment. See the Supplemental  Contract Data Pages and Crediting Method Endorsements for details.     DUE PROOF. Evidence of death, including but not limited to a certified death certificate issued  by the governmental authority for the location of the death, or other lawful evidence the  Company requires.    FIXED ACCOUNT. A Contract Option in which amounts earn a declared rate of interest for a  certain period.    FIXED ACCOUNT MINIMUM INTEREST RATE (FAMIR). The Fixed Account Minimum Interest  Rate is the minimum annual percentage at which Your money allocated to the Fixed Account  will grow. The Company uses this rate to determine the Fixed Account Minimum Value (FAMV).  The FAMIR is shown on the Contract Data Pages and is guaranteed for the life of the Contract.    RILA287 4 

 

                                DEFINITIONS (CONT'D)    FIXED ACCOUNT MINIMUM VALUE (FAMV). The FAMV is equal to all amounts allocated to  the Fixed Account, net of applicable taxes, multiplied by the Fixed Account Minimum Value  Percentage, and;  1.  reduced by partial withdrawals and transfers from the Fixed Account, and the Fixed      Account Minimum Value Annual Expense Allowance; then  2.  accumulated at the FAMIR.    FIXED ACCOUNT MINIMUM VALUE ANNUAL EXPENSE ALLOWANCE. An annual  deduction from the FAMV. On each Contract Anniversary, the Company will deduct the Fixed  Account Minimum Value Annual Expense Allowance from the FAMV. The Fixed Account  Minimum Value Annual Expense Allowance is shown on the Contract Data Pages.    FIXED ACCOUNT MINIMUM VALUE PERCENTAGE. The Fixed Account Minimum Value  Percentage is multiplied by Premiums and transfers allocated to the Fixed Account in the  determination of the FAMV. The Fixed Account Minimum Value Percentage is shown on the  Contract Data Pages.    GOOD ORDER. The Company's receipt of all Premium, information, documentation, and/or  instructions the Company requires before it will issue the Contract, credit any interest, or  execute any transaction.     INCOME DATE. The date on which Income Payments are scheduled to begin as described in  the Income Provisions. The Income Date is shown on the Contract Data Pages.    INCOME OPTION. Payment options as provided under the Income Provisions.     INDEX(ES). A benchmark used to determine the Index Adjustment, if any, for a particular Index  Account Option. See the Supplemental Contract Data Pages for the available Indexes as of the  Issue Date.     INDEX ACCOUNT. A Contract Option in which amounts are subject to an Index Adjustment for  a specified period of time. See the Supplemental Contract Data Pages and Crediting Method  Endorsements for detailed descriptions of the Index Account Options within the Index Account.  Index Account Option availability is subject to change at the discretion of the Company on a  non-discriminatory basis.    INDEX ACCOUNT OPTION. An option within the Index Account for allocation of Contract  Value. Each Index Account Option is defined by its term, Index and Crediting Method.    INDEX ACCOUNT OPTION ANNIVERSARY. The Business Day concurrent with or immediately  following each anniversary of the Issue Date.      RILA287 5 

 

                                DEFINITIONS (CONT'D)    INDEX ACCOUNT OPTION TERM ANNIVERSARY. The Business Day concurrent with or  immediately following the end of an Index Account Option term.    INDEX ADJUSTMENT (IA). The adjustment amount to an Index Account Option on the Index  Account Option Term Anniversary. This adjustment can be positive or negative, depending on  Index performance and Crediting Method.    INDEX ADJUSTMENT FACTOR(S). Parameters used to determine the Index Adjustment.  These parameters are specific to the applicable Crediting Method(s). See the Supplemental  Contract Data Pages and Crediting Method endorsements for additional details.    INTERIM VALUE. The quantity used to adjust the Index Account Option value for withdrawals  prior to the end of the Index Account Option term. The Interim Value uses prorated Index  Adjustment Factors based on the elapsed portion of the Index Account Option term and the  Interim Value Proration Factor (IVPF). For detailed information on the Interim Value, see the  Crediting Method endorsements and the Supplemental Contract Data Pages.    ISSUE DATE. The date the Company issued the Contract. The Issue Date is shown on the  Contract Data Pages.    JOINT ANNUITANT. Each of multiple Annuitants.    JOINT OWNER. Each of multiple Owners.    LATEST INCOME DATE (LID). The Contract Anniversary on which You will be 95 years old, or  such earlier date required by a Qualified Plan, law or regulation.    MARKET VALUE ADJUSTMENT (MVA). A positive or negative adjustment to amounts You  remove from an Index Account Option due to withdrawals, annuitizations or transfers to the  Fixed Account during the MVA Period. The MVA formula and the MVA Period are shown on the  Contract Data Pages.    NON-QUALIFIED PLAN. A retirement plan which does not qualify for favorable tax treatment  under Sections 401, 403, 408, or 408A of the Internal Revenue Code, as amended.    OWNER ("YOU," "YOUR"). The natural person(s) or legal entity(ies) that has all rights under  the Contract, and is shown on the Contract Data Pages, or by subsequent designation. In this  Contract, "You" and "Your" also mean the Owner. References to the Owner include all Joint  Owners, if applicable.    PREMIUM. Money paid into this Contract for allocation into the Contract Options.    QUALIFIED PLAN. A retirement plan which qualifies for favorable tax treatment under Sections  401, 403, 408, or 408A of the Internal Revenue Code, as amended.      RILA287 6 

 

                                DEFINITIONS (CONT'D)    REQUIRED MINIMUM DISTRIBUTION (RMD). For certain Qualified Plan contracts, the RMD is  the amount defined by the Internal Revenue Code and the implementing regulations as the  minimum distribution requirement that applies to this Contract only.    SERVICE CENTER. The Company's administrative address and telephone number as identified  on the Contract's cover page or as the Company may designate from time to time.    WITHDRAWAL VALUE. The amount available upon a total withdrawal. The Withdrawal Value is  equal to the Contract Value, adjusted for any applicable MVA.      RILA287 7 

 

                               GENERAL PROVISIONS    ANNUITANT. You may change the Annuitant at any time before the Income Date, unless the  Contract is owned by a legal entity. If the Contract is owned by a legal entity, the Company will  use the oldest Annuitant's age for all Contract purposes unless otherwise specified in the  Contract. Unless You specify otherwise, a change of Annuitant will take effect on the date the  request is signed by You, subject to any payments the Company has made or other actions the  Company has taken before the Company receives and records Your request. The Company  reserves the right to limit the number of Joint Annuitants to two (2). When the Owner is a legal  entity, the Annuitant may not be changed.    ASSIGNMENT. To the extent allowed by state law, the Company may refuse consent to any  assignment at any time, on a nondiscriminatory basis, if the assignment or ownership change  would result in noncompliance with any applicable state or federal regulation. Unless restricted  by endorsement, You may assign ownership of this Contract subject to the interests of  assignees and irrevocable Beneficiaries. The Company will only be bound by an assignment if a  request is submitted in a form acceptable to the Company, received in Good Order at the  Company's Service Center, recorded and acknowledged by the Company. Unless You specify  otherwise, an assignment will take effect on the date the request is signed by You, subject to  any payments the Company has made or other actions the Company has taken before the  Company receives and records Your request.     The Company assumes no responsibility for the validity or tax consequences of any  assignment. If You make an assignment, You may have to pay taxes. The Company  encourages You to seek legal and/or tax advice.    BENEFICIARY. You may change the Beneficiaries, subject to the interest of assignees and  irrevocable Beneficiaries. The Company will only be bound by a change in Beneficiary if a  request is submitted in a form acceptable to the Company, received in Good Order at the  Company's Service Center and recorded. Any previously designated irrevocable Beneficiary  must consent in writing to any change in Beneficiary. Unless You specify otherwise, a change of  Beneficiary will take effect on the date the request is signed by You, subject to any payments  the Company has made or other actions the Company has taken before the Company receives  and records Your request, and while You are alive.    CONFORMITY WITH LAWS. This Contract will be interpreted under the law of the state in  which it is issued and any applicable federal laws. Any provision that is in conflict with the laws  of the state in which the Contract is issued, or any federal law is amended to conform to the  minimum requirements of such law.    DEFERRAL OF PAYMENTS. If approved in writing by the chief insurance regulator of the  Company's state of domicile, the Company may defer payment of Your request for a partial  and/or total withdrawal from the Contract for a period not exceeding six (6) months. The  Company will credit interest on deferred amounts as required by law. The Company will not  defer payment of death benefits.      RILA287 8  

 

                         GENERAL PROVISIONS (CONT'D)    ENTIRE CONTRACT. The Contract, application, if any, and any attached endorsements and  amendments together make up the entire Contract between You and the Company. All  statements made by the applicant to procure the Contract will, in the absence of fraud, be  deemed representations and not warranties.    INCONTESTABILITY. The Company may only contest this Contract when an applicant has  procured the Contract by fraud, and only if permitted by law in the state in which the Company  delivered the Contract or issued the Contract for delivery.    MINIMUM VALUES. Any Withdrawal Values and death benefits that may be available under  this Contract are not less than the minimum benefits required by any statute of the state in  which the Contract is delivered.    MISSTATEMENT OF AGE AND/OR SEX. If Your or the Annuitant's age and/or sex is misstated  at the time the Contract's Income Payments become payable, the Company will adjust the  payments to reflect income consistent with the correct age and/or sex. Immediately upon  discovery, the Company will adjust the next payment due as a credit or charge, as appropriate,  for any underpayments or overpayments using the Interest Rate for Adjustments Due to  Misstatement of Age or Sex shown on the Contract Data Pages.    MODIFICATION OF CONTRACT. No financial professional has authority to change or waive  any of this Contract's provisions. No change to or waiver of this Contract's terms is valid unless  in writing and signed by the Company's President, Vice President, Secretary or Assistant  Secretary; provided, however, that the Company may amend any Contract term, and administer  the Contract, to conform to the Internal Revenue Code.    NONPARTICIPATING. This Contract is nonparticipating and does not share in the Company's  surplus or earnings.    OWNER. To the extent allowed by state law, the Company may refuse consent to an ownership  change at any time, on a nondiscriminatory basis, if the ownership change would result in  noncompliance with any applicable state or federal regulation. Unless restricted by  endorsement, You may change the Owner or any Joint Owner. The Company will use the oldest  Owner's age for all Contract purposes unless otherwise specified in the Contract. The Company  will only be bound by a change of ownership if submitted in a form acceptable to the Company,  received in Good Order at the Company's Service Center, recorded and acknowledged by the  Company. No person whose age exceeds the maximum issue age in effect for this Contract as  of the Issue Date may become a new Owner. Unless You specify otherwise, a change of  ownership will take effect on the date the request is signed by You, subject to any payments the  Company has made or other actions the Company has taken before the Company receives and  records Your request. Joint Owners have equal ownership rights; therefore, each Owner must  authorize any exercise of Contract rights unless the Joint Owners instruct the Company in  writing to act upon authorization of an individual Joint Owner. The Company reserves the right  to limit the number of Joint Owners to two (2).    The Company assumes no responsibility for the validity or tax consequences of any  ownership change. If You make an ownership change, You may have to pay taxes. The  Company encourages You to seek legal and/or tax advice.    RILA287 9 

 

                         GENERAL PROVISIONS (CONT'D)    PROOF OF AGE, SEX AND/OR SURVIVAL. The Company may require proof of age and/or  sex, satisfactory to the Company at any time. If any payment required by this Contract depends  on a living Annuitant, Owner, or Beneficiary, the Company may require proof of that person's  survival satisfactory to the Company.    PROTECTION OF PROCEEDS. A Beneficiary may not assign Contract proceeds before the  proceeds are payable. Contract proceeds are not subject to the claims of creditors or to legal  process unless required by applicable law.    REPORTS. The Company will send a report to Your last address in the Company's records at  least annually before the Income Date. In the case of Joint Owners, the Company will send  reports only to the primary Owner's address. If You have elected electronic delivery, a report  may be provided in the form of an email to Your last email address in the Company's records, or  a notice to You of a document's availability on the Company's website. Each report will provide  at least the following information:  1.  the dates that begin and end the reporting period;   2.  the Contract Value at the beginning and at the end of the current reporting period prior to the     application of any MVA;  3.  the Withdrawal Value at the end of the reporting period;   4.  the MVA amount the Company used to determine the Withdrawal Value;   5.  the amounts the Company has credited to and deducted from the Contract Value during the     reporting period;  6.  the death benefit at the end of the reporting period; and  7.  any other information state and federal law require.     You may receive copies of reports the Company provides upon request at no additional charge.    You will receive a confirmation statement for certain transactions at the time they occur.    SEPARATE ACCOUNT. The Company holds certain investments supporting the assets  allocated to the Index Account in a non-insulated, non-unitized Separate Account. The Separate  Account is established pursuant to the laws of the Company's domiciliary state solely for the  purpose of supporting obligations under the Contract. You do not directly participate in the  performance of assets held in the Separate Account; and do not have any direct claim on them.  Assets of the Separate Account are chargeable with the claims of any of the Company's  contract owners as well as the Company's creditors and are subject to the liabilities arising out  of any other business the Company conducts. The Separate Account is not registered under the  Investment Company Act of 1940. The name of the Separate Account is shown on the Contract  Data Pages.    TAXES. This Contract is intended to be treated as an annuity contract for federal income tax  purposes. Accordingly, for all Non-Qualified Contracts all provisions of this Contract shall be  interpreted and administered in accordance with the requirements of Section 72(s) of the  Internal Revenue Code. The Company will deduct any taxes attributed to the Contract and  payable to a government entity from the Contract Value. The Company reserves the right to  deduct any amounts the Company might advance to pay taxes from the Contract Value. The  Company will withhold taxes required by law from any amounts payable from this Contract.   RILA287 10 

 

                         GENERAL PROVISIONS (CONT'D)    WRITTEN NOTICE. Written information or instructions You intend to give the Company must be  in Good Order and delivered to the Company's Service Center, unless the Company advises  You otherwise. Instructions included in the Written Notice will take effect on the date the  Company receives the notice in Good Order at the Company's Service Center, unless otherwise  provided in the notice or in this Contract, or unless the Company advises You otherwise.    The Company will deliver any notice or communication to Your last address in the Company's  records unless You request otherwise in writing. If You have elected electronic delivery,  communication may be provided in the form of an email to Your last email address in the  Company's records, or a notice to You of a document's availability on the Company's website.  You are responsible for notifying the Company of any address change, email address change,  or any error in a Company notice sent to You. In the case of Joint Owners, the Company will  send notices and other communications to the primary Owner's address.      RILA287 11 

 

                          CONTRACT OPTION PROVISIONS    The Contract contains two (2) types of Contract Options: Fixed Account and Index Account.    Upon Good Order, all Premium will be allocated to the Contract Options as elected on the  application. The Company reserves the right to restrict or prohibit allocation of Premium to the  Fixed Account at its discretion, on a non-discriminatory basis, at any time. No Premium will be  accepted after the Issue Date.    TRANSFERS.    Transfers may only occur on the Contract Anniversary, when transferring out of the Fixed  Account, and on the Index Account Option Term Anniversary when transferring out of an Index  Account Option. When the Contract Anniversary or Index Account Option Term Anniversary  occurs on a non-Business Day, the transfer will be effective on the following Business Day using  the following Business Day's values. You will receive notice thirty (30) days prior to the Index  Account Option Term Anniversary. The notice will include information on the Contract Options  available to You. You may request a transfer to or from the Fixed Account and to or from the  Index Account Options. You may also request transfers among the available Index Account  Options within the Index Account. Transfers from an Index Account Option to the Fixed Account  may incur an MVA. A request for a transfer must be received in Good Order prior to the Index  Account Option Term Anniversary. If no transfer request is received on or prior to the Index  Account Option Term Anniversary, the Fixed Account value will remain in the Fixed Account and  the Index Account Option value(s) will be reallocated to the same Index Account Option(s) for the  same term, Crediting Method and Index, if available.     If the Crediting Method, or Index is no longer available as of the Index Account Option Term  Anniversary, the Index Account Option value(s) will be reallocated to the Fixed Account, without  being subject to an MVA, until further instruction is received.     If You do not select an Index Account Option term within thirty (30) days prior to the end of the  expired Index Account Option term:  1.  if the same Index Account Option term is available at the time and does not extend beyond     the Income Date, the Company will renew the Index Account Option into the same Index     Account Option term.  2.  if the same Index Account Option term is available at the time but extends beyond the Income     Date, the Company will select the available Index Account Option term that ends closest to     but before the Income Date.  3.  if the same Index Account Option term is not available at the time but would not extend     beyond the Income Date were it available, the Company will select the available Index     Account Option term with the period closest to but less than the Index Account Option term     that just ended.    Unless specified otherwise, transfers will be taken from the Index Account Options and the Fixed  Account in proportion to their current value. The Company reserves the right, to restrict or prohibit  transfers from the Index Account Option to the Fixed Account, at its discretion, on a  nondiscriminatory basis, at any time.    RILA287 12 

 

                   CONTRACT OPTION PROVISIONS (CONT'D)    Transfers from a Fixed Account will reduce the Fixed Account value by the transfer amount  requested. Transfers into a Fixed Account will increase the Fixed Account value by the transfer  amount requested. Transfers from an Index Account Option will reduce the Index Account  Option value by the transfer amount requested. Transfers into an Index Account Option will  increase the Index Account Option value by the transfer amount requested.    Fixed Account. The Fixed Account is an annually renewable fixed account. The Company will  credit interest to amounts allocated to the Fixed Account. Such interest will be credited at such  rate(s) as the Company prospectively declares on a periodic basis, at the sole discretion of the  Company. On each Contract Anniversary the interest rate for the Fixed Account is subject to  change. In no event will the interest rate credited by the Company to the Fixed Account be less  than the FAMIR, as shown on the Contract Data Pages, per annum.    Index Account Option. An option within the Index Account for allocation of Contract Value,  defined by term, Index, and Crediting Method. The terms, Indexes, and Crediting Methods  available as of the Issue Date are shown on the Supplemental Contract Data Pages. Availability  of terms, Indexes, and Crediting Methods are subject to change at the sole discretion of the  Company on a non-discriminatory basis.    Fixed Account Value. The Fixed Account value is equal to (1) the value of Premium and any  amounts transferred from the Index Account into the Fixed Account, adjusted for any applicable  MVA; (2) plus interest credited daily at a rate not less than the FAMIR, as shown on the  Contract Data Pages, per annum; (3) less any gross partial withdrawals; (4) less any amounts  transferred out of the Fixed Account. The Fixed Account Value will never be less than the  FAMV.    Index Account Value. The Index Account value is equal to the sum of the Index Account  Option values.    The Index Account Option value at the beginning of the Index Account Option term is equal to  the amount allocated or transferred to the Index Account Option less the amount transferred out  of the Index Account Option. Transfers out of the Index Account Option to the Fixed Account will  be adjusted for any applicable MVA.    During the Index Account Option term, the Index Account Option value is equal to the Interim  Value, which is the greater of the Index Account Option value at the beginning of the term  reduced for any partial withdrawals from the Index Account Option during the Index Account  Option term, including any MVA, in the same proportion as the Interim Value was reduced on  the date of the withdrawal, plus the prorated Index Adjustment subject to prorated Index  Adjustment Factors and the IVPF, or zero. Additional detail on Index Adjustment Factors can be  found in the Crediting Method endorsements and Supplemental Contract Data Pages.    On the Index Account Option Term Anniversary, the Index Account Option value is equal to the  greater of the Index Account Option value at the beginning of the Index Account Option term,  reduced for any partial withdrawals from the Index Account Option during the Index Account  Option term, including any MVA, in the same proportion as the Interim Value was reduced on  the date of the withdrawal, plus the Index Adjustment subject to Index Adjustment Factors, or  zero. Additional detail on Index Adjustment Factors can be found in the Crediting Method  endorsements and Supplemental Contract Data Pages.   RILA287 13 

 

                             WITHDRAWAL PROVISIONS    On or before the Income Date, You may request a total or partial withdrawal of the Contract  Value by submitting a request to the Company's Service Center in a form acceptable to the  Company.    The withdrawal will be processed after a withdrawal request is received at the Service Center in  Good Order. If a total withdrawal is requested, You must submit the Contract to the Service  Center with the withdrawal request.    TOTAL WITHDRAWAL. During the MVA Period, the Withdrawal Value for a total withdrawal  from the Contract is equal to the Contract Value adjusted for any applicable MVA. After the  expiration of the MVA Period, the Withdrawal Value for a total withdrawal from the Contract is  equal to Contract Value. A total withdrawal terminates Your Contract.    In no event will a total withdrawal from the Fixed Account be less than the FAMV.    No withdrawal may exceed the Withdrawal Value.    PARTIAL WITHDRAWAL. Any partial withdrawal from an Index Account Option may be subject  to an MVA. At least the Minimum Contract Value remaining after a partial withdrawal, as shown  on the Contract Data Pages, must remain after any partial withdrawal. With the exception of an  MVA Free Withdrawal, unless You request otherwise, a gross partial withdrawal will be  deducted from the Fixed Account and the Index Account Option(s) in proportion to their current  values. The gross partial withdrawal deducted from the Index Account Option(s) will then be  adjusted for any applicable MVA.    If the gross amount of the partial withdrawal would reduce the Contract Value below the  Minimum Contract Value remaining after a partial withdrawal, as shown on the Contract Data  Pages, the Company will treat the withdrawal request as a total withdrawal and the Withdrawal  Value will be paid.    The amount payable as a result of the partial withdrawal will be determined at the end of the  Business Day on which the Company receives Your request for withdrawal in Good Order at the  Company's Service Center.     Partial Withdrawals will reduce each Index Account Option's value at the beginning of the term  in the same proportion that its Interim Value was reduced on the date of the withdrawal.    QUALIFIED PLAN CONTRACT REQUIRED MINIMUM DISTRIBUTIONS. Qualified Plan  Contract RMDs are based upon Your Contract Value, and applicable federal tax law  requirements. You may request a withdrawal for an RMD by submitting a written request to the  Service Center on a Company provided form.    RILA287 14 

 

                       WITHDRAWAL PROVISIONS (CONT'D)    The Company will waive any MVA if the gross amount withdrawn does not exceed the  Contract's RMD amount. However, if a gross withdrawal amount is greater than the Contract's  RMD amount, the excess amount of the gross partial withdrawal is subject to an MVA in the  same proportion as the gross withdrawal amount is deducted from the Index Account Option(s).    AUTOMATIC WITHDRAWAL. You may elect to take an automatic withdrawal by withdrawing a  specific sum or a certain percentage of the Contract Value on a monthly, quarterly, semiannual  or annual basis, subject to the Minimum Partial Withdrawal amount made as a scheduled part of  an automatic withdrawal program, as shown on the Contract Data Pages. Automatic  withdrawals are treated as partial withdrawals and will be counted in determining the amount  taken as an MVA Free Withdrawal in any Contract Year. Automatic withdrawals in excess of the  MVA Free Withdrawal amount may be subject to an MVA. If an automatic withdrawal causes the  Withdrawal Value to fall to zero, future automatic withdrawals will terminate. If the automatic  withdrawal would reduce the Contract Value below the Minimum Contract Value remaining after  a partial withdrawal, as shown on the Contract Data Pages, the Company will treat the  automatic withdrawal as a total withdrawal and the Withdrawal Value will be paid.    MVA FREE WITHDRAWAL. During each Contract Year, certain partial withdrawals from the  Index Account will not incur an MVA. The amount of MVA Free Withdrawal available in any  Contract Year is equal to the greater of:  1.  the MVA Free Withdrawal Percentage, as shown on the Contract Data Pages, multiplied by     the Index Account value at the beginning of the Contract Year; or   2. zero    The MVA Free Withdrawal can be taken as a single withdrawal or multiple withdrawals  throughout the Contract Year. The amount of Your MVA Free Withdrawal available will vary  throughout the Contract Year depending on previous withdrawals of Your MVA Free Withdrawal  amount. The amount of Your MVA Free Withdrawal available will reduce due to withdrawals  from the Index Account during the Contract Year.    MVA Free Withdrawals will be deducted from the Index Account Options in proportion to their  current values within the Index Account.     Any amount withdrawn to satisfy an RMD may reduce the amount of Your MVA Free  Withdrawal available.    No MVA Free Withdrawal may exceed the Withdrawal Value.    Withdrawals during the Contract Year in excess of the MVA Free Withdrawal may be subject to  any applicable MVA.    RILA287 15 

 

                           DEATH BENEFIT PROVISIONS    NATURAL OWNER'S DEATH BEFORE THE INCOME DATE. Upon Your death or the death of  any Joint Owner, before the Income Date, the Company will pay the death benefit to the  Beneficiary(ies) designated by You.     Upon the death of the first Joint Owner, the surviving Joint Owner will become the Primary  Beneficiary and will receive the death benefit payable. Any other Beneficiary designation on  record at the Company's Service Center at the time of the first Joint Owner's death will be  treated as a Contingent Beneficiary.    ANNUITANT'S DEATH BEFORE THE INCOME DATE. Upon the death of an Annuitant who is  not an Owner before the Income Date, the Contract remains in force and the Owner becomes  the Annuitant. The Owner may designate a new Annuitant, subject to the Company's  administrative rules then in effect. No death benefit is payable on the death of an Annuitant who  is not also an Owner.     If the Contract is owned by a legal entity, upon the death of the Annuitant, (in the case of Joint  Annuitants, upon the death of the first Annuitant) the Company will pay the death benefit to the  Beneficiary(ies) designated by the Owner, or, if no Beneficiary(ies) survive the applicable death,  to the Owner.     DEATH BENEFIT AMOUNT BEFORE THE INCOME DATE. The death benefit amount before  the Income Date is equal to the current Contract Value.    DEATH BENEFIT PAYMENT OPTIONS BEFORE THE INCOME DATE. Unless You  designated a Pre-selected Death Benefit Option, a Beneficiary entitled to the death benefit  before the Income Date must request that the Company pay the death benefit according to one  of the death benefit options below:    Option 1 - single lump-sum payment;  Option 2 - payment of the entire death benefit distributed within five (5) years of the date of the            relevant death; or  Option 3 - Income Payments of the death benefit with distributions beginning within one (1) year           of the date of the relevant death:           (i) over the lifetime of the Beneficiary; or           (ii) over a period not extending beyond the life expectancy of the Beneficiary.     The Company may make available other death benefit payment options.    A Beneficiary that wishes to elect payment under Option 3 must do so no later than sixty (60)  days from the date the Company receives Due Proof of death in Good Order at the Company's  Service Center.    RILA287 16 

 

                     DEATH BENEFIT PROVISIONS (CONT'D)    Any portion of the death benefit not applied under Option 3 must be paid within five (5) years  from Your death. The death benefit will remain invested in accordance with the allocation  selected by You until a payout option is selected or the Beneficiary specifies otherwise.    DEATH BENEFIT PAYMENT OPTIONS FOR QUALIFIED PLANS. For Qualified Plans, the  death benefit payment options may be limited under the terms of the plan endorsement in order  to qualify under the Internal Revenue Code.     BENEFICIARY'S ENTITLEMENT TO DEATH BENEFIT BEFORE THE INCOME DATE. The  Company will pay the death benefit to Primary Beneficiaries or, if none exist, to Contingent  Beneficiaries, in equal shares (the "default allocation") unless You have designated otherwise  (the "designated allocation"). A Beneficiary that dies before or within ten (10) days (or different  period as prescribed by applicable law) of Your death is not entitled to any death benefit. In that  circumstance, the Company will pay the deceased Beneficiary's share of the death benefit to  surviving Beneficiaries in the same proportion as the designated allocation or, if applicable, the  default allocation. If no Beneficiary survives You, the Company will pay the death benefit to Your  estate.    PAYMENT OF DEATH BENEFIT. The Company will pay the death benefit to the Beneficiary  upon receipt of a request for payment with Due Proof of the relevant death in Good Order at the  Company's Service Center. If the Company has received Due Proof of death, the Company will  calculate the share of the death benefit due to a Beneficiary using Contract values established  at the end of the Business Day on the date the Company receives a claim form with a payment  option elected from that Beneficiary. If the Company has not received Due Proof of death or any  other required documentation, the Company will calculate the share of the death benefit due to  a Beneficiary using Contract values established at the end of the Business Day on the date the  Company receives any remaining required documentation. The Index Adjustments may cause  the calculation of a Beneficiary's death benefit share to differ from the calculation of another  Beneficiary's death benefit share. The Company will pay interest on a Beneficiary's death  benefit share as required by law.     Each Beneficiary entitled to the death benefit bears the investment risk associated with amounts  allocated to any Index Account Option until the Company calculates their share of the death  benefit.    If any death benefit is due to an Owner's estate, the Company will pay the benefit in a single  lump-sum payment.     If a single lump-sum payment is elected, the Contract will remain in force and will accrue  interest, at current rate(s) based on the Contract's current Crediting Method/Index combinations,  until the Company first receives Due Proof of death in Good Order. After that time, the rate of  interest will equal the rate of interest applicable to death benefit left on deposit with the  Company on the date of Your death.    The Company will pay the death benefit in accordance with applicable laws and regulations  governing death benefit payments and in accordance with the Company's administrative  procedures.    RILA287 17  

 

                     DEATH BENEFIT PROVISIONS (CONT'D)    Spousal Continuation Option Instead of Death Benefit. Unless the Contract is subject to a  Pre-selected Death Benefit Option, a spouse who is a Joint Owner or Beneficiary of the  deceased Owner may elect to continue the Contract in his or her own name as described below  and exercise the Owner's rights under the Contract instead of taking the standard death benefit.    For purposes of the Spousal Continuation Option, the "continuation date" is the date on which  the Company receives the spouse's written request to elect the Spousal Continuation Option  and Due Proof of the relevant death in Good Order at the Company's Service Center.    The Spousal Continuation Option is void in the event the original Contract Owner is no longer  the Contract Owner or in the event the Contract has been assigned. The Spousal Continuation  Option may be exercised only once and may not be available if You designated a Pre-selected  Death Benefit Option.    Pre-selected Death Benefit Option. Before the Income Date, You may designate the option  according to which the Company will pay the death benefit from the death benefit payment  options described in the Contract, or other death benefit options made available by the  Company. You may do so by submitting a designation in a form acceptable to the Company in  Good Order to the Company's Service Center. Pre-selected Death Benefit Options are effective  only after being recorded by the Company. The Company will pay the death benefit consistent  with Your Pre-selected Death Benefit Option unless the Internal Revenue Code requires  otherwise, or Your election requires payment over a period that exceeds the Beneficiary's life  expectancy as determined by the Company.    Only You may revoke or change a Pre-selected Death Benefit Option. To do so, You must  submit a request in a form acceptable to the Company to the Company's Service Center.  Revocations of and changes to a Pre-selected Death Benefit Option are effective only after  being recorded by the Company.    RILA287 18  

 

                                 INCOME PROVISIONS    INCOME DATE. Income Payments begin on the Income Date. If You do not select an Income  Date, the Income Date is the LID. You may change the Income Date to any date that is not later  than the LID by submitting Written Notice in Good Order to the Company's Service Center at  least seven (7) days before the Income Date.    INCOME PAYMENT. On or before the Income Date, You may elect payment in a single lump- sum. A single lump-sum payment is considered a total withdrawal and terminates the Contract.  The Company will make payment to You or another payee You specify. Alternatively, You may  elect an Income Option to begin on the Income Date. The Company will apply the Contract  Value, less applicable taxes, adjusted for any applicable MVA, to provide You income according  to Your selected Income Option.    INCOME OPTIONS. You may elect payment as provided in Options 1, 2, 3, or 4 below. You  may elect an Income Option up to thirty (30) days before the Income Date by submitting Written  Notice in Good Order to the Company's Service Center. The Company will make payment to  You or another payee You specify.    If You do not select an Income Option the Company will make payments as provided in Option 3  below, with 120 months certain. The Company will make payments monthly, quarterly,  semiannually or annually as You elect. However, if the Contract Value on the Income Date is  less than $2,000, the Company may pay out the Contract Value in one (1) lump-sum payment  instead of providing Income Payments according to the Income Option You elect. If the first  monthly payment provided would be less than $20, the Company may make payments  quarterly, semiannually or annually to achieve an initial payment of at least $20, or the  Company may pay out the Contract Value in one (1) single lump-sum payment.    At the time of their commencement, Income Payments will not be less than those that would be  provided by the application of an equivalent amount to purchase a single premium immediate  annuity contract from the Company at purchase rates the Company offered on the Income Date  to annuitants in the same class as the Annuitant.    YOU MAY NOT TAKE WITHDRAWALS DURING ANY PERIOD THE COMPANY IS MAKING  PAYMENTS FOR AN ANNUITANT'S LIFETIME.    OPTION 1 - LIFE INCOME. A monthly payment for the Annuitant's lifetime. All payments end  upon the Annuitant's death. However, in the event of the Annuitant's death before the first  monthly payment, the Company will pay the amount allocated to this Income Option to You or, if  You are deceased, to Your Beneficiary. No MVA applies to Contract Value applied to Option 1.    OPTION 2 - JOINT AND SURVIVOR INCOME. A monthly payment for the longer of the  Annuitant's lifetime or that of a second person You designate. Upon the occasion of the first  person to die, monthly payments continue during the survivor's lifetime at either the full amount  previously payable or as a percentage (either one-half or two-thirds) of the full amount, as You  select at the time You elect the Income Option.    All payments end upon the death of the last surviving Annuitant. However, in the event of the  deaths of the Annuitant and the designated second person before the first monthly payment, the  Company will pay the amount allocated to this Income Option to You or, if You are deceased,  Your Beneficiary. No MVA applies to Contract Value applied to Option 2.   RILA287 19 

 

                          INCOME PROVISIONS (CONT'D)    OPTION 3 - LIFE INCOME WITH 120 OR 240 MONTHLY PAYMENTS GUARANTEED. A  monthly payment for the Annuitant's lifetime with the guarantee that the Company will make no  fewer than 120 or 240 monthly payments to You. If the Owner is an entity, at the Annuitant's  death, if fewer than the guaranteed number of payments have been made, the remaining  guaranteed payments will be made to the Owner as previously scheduled. If the Owner is the  Annuitant, in the event You die before the Company makes the specified number of guaranteed  payments, Your Beneficiary may elect to continue to receive the Income Payments according to  the terms of this Contract, or alternatively may elect to receive the present value of any  remaining guaranteed payments in a single lump-sum payment. The present value of any  remaining guaranteed payments will be based on the total Income Payments as of the date of  the calculation. The Company will determine the interest rate used in this present value  calculation, but in no instance will it be greater than (one) 1 percentage point higher than the  rate used to calculate the initial Income Payment. No MVA applies to Contract Value applied to  Option 3.    OPTION 4 - INCOME FOR A SPECIFIED PERIOD. A monthly payment for any whole number  of years ranging from 5 to 30. In the event You die before the Company makes the specified  number of payments, Your Beneficiary may elect to continue to receive the Income Payments  according to the terms of this Contract, or alternatively may elect to receive the present value of  any remaining guaranteed payments in a single lump-sum payment. The present value of any  remaining guaranteed payments will be based on the total Income Payments as of the date of  the calculation. The Company will determine the interest rate used in this present value  calculation, but in no instance will it be greater than (one) 1 percentage point higher than the  rate used to calculate the initial Income Payment. No MVA applies to Contract Value applied to  payments spread over five (5) years or more under Option 4.    ADDITIONAL INCOME OPTIONS. The Company may make available other Income Options.    DEATH BENEFIT AMOUNT AFTER THE INCOME DATE. On or after the Income Date, upon  any Owner's death, any remaining Income Payments will be paid in accordance with the Income  Options of this Contract and will be paid at least as rapidly as the payment method in effect as  of the Owner's death.     OWNER'S DEATH AFTER THE INCOME DATE. Upon the death of any Owner who is not also  an Annuitant after the Income Date, any remaining Income Payments due will continue at least  as rapidly as the payment method in effect as of the date of the Owner's death. Upon the death  of the last surviving Joint Owner after the Income Date, any remaining Income Payments will be  paid to the Beneficiary.    ANNUITANT'S DEATH AFTER THE INCOME DATE. Upon the death of the Annuitant after the  Income Date, the death benefit, if any, will be as specified in the Income Option elected. Any  life-contingent Income Payments cease on the death of the Annuitant.    RILA287 20 

 

                          INCOME PROVISIONS (CONT'D)    BENEFICIARY'S ENTITLEMENT TO INCOME PAYMENTS AFTER THE INCOME DATE.  Upon the death of any Owner, the Company will pay any remaining Income Payments due to  Primary Beneficiaries or, if none exist, to the Contingent Beneficiaries, in equal shares (the  "default allocation") unless You have designated otherwise (the "designated allocation"). A  Beneficiary that dies before or within ten (10) days (or different period as prescribed by  applicable law) of Your death is not entitled to remaining Income Payments due; in that  circumstance, the Company will pay any remaining Income Payments due the deceased  Beneficiary to surviving Beneficiaries in the same proportion as the designated allocation or, if  applicable, the default allocation. If no Beneficiary survives You, the Company will pay  remaining Income Payments to Your estate.   RILA287 21 

 

                             TERMINATION PROVISIONS    This Contract terminates and all Contract benefits, will end on the earlier of:  1.  the date You take a total withdrawal;  2.  the date the Contract Value is reduced to zero for any reason, or;  3.  the date upon which the Company receives Due Proof of Your (or any Joint Owner's) death     and all Beneficiaries' election of a death benefit payment option in Good Order at the     Company's Service Center, unless the Contract is continued by the spouse under the     Spousal Continuation Option.    RILA287 22rila285application

JACKSON MARKET LINK PRO ADVISORY SM   (01/21)  APPLICATION FOR AN INDIVIDUAL SINGLE PREMIUM DEFERRED REGISTERED INDEX-LINKED ANNUITY (RILA285/RILA287)                                                                                                   Home Office:  Lansing, Michigan                                                                                                                 www.jackson.com  First Class Mail: P.O. Box 30314                  Lansing, MI 48909-7814                                                               Customer Care: 800-873-5654                                                                                                                  Fax: 800-943-6761 Overnight Mail:  1 Corporate Way                                                                   Email: customercare@jackson.com                  Lansing, MI 48951                    Linking/BIN/Brokerage Acct. Number   (if applicable)          Jackson   pre-assigned Contract Number  (if applicable)                    Primary Owner   PLEASE PRINT    CLEARLY        Type of Ownership:                       Individual/Joint       Custodian         Trust          Corporation/Pension Plan         Government Entity    Please see the Social Security Number              or Tax ID Number                         Phone Number    (include area code)   Good Order    Checklist for    additional    requirements.                                      Country of Residence                   U.S. Citizen     Yes        No                                                       Sex       Male       Female                   Date of Birth (mm/dd/yyyy)          Email Address  (print clearly)   If U.S.   citizenship is   not selected,   and a Social   First Name                   Middle Name                  Last Name   Security   Number with a   U.S. address is                  Non-Natural Owner/Entity Name    (if applicable)   listed, along   with the   absence of any   other foreign  Physical Address Line 1 (No P.O. Boxes)                             Physical Address Line 2   indicator,   Jackson   National Life   Insurance      Physical Address City                                               State    ZIP   Company   (Jackson) will   assume an   active U.S.    Mailing Address Line 1                                              Mailing Address Line 2   citizenship   status.                  Mailing Address City                                                State    ZIP                    ICC20 R280 11/20                                  Page 1 of 11                                    R285 01/21

 

               Joint Owner                 Social Security Number            Date of Birth (mm/dd/yyyy)        Email Address  (print clearly)                                                   Country of Residence                 U.S. Citizen      Yes       No                                                       Sex       Male        Female  In the case of First Name                   Middle Name                  Last Name Joint Owners,  all  correspondence Relationship to Owner                                               Phone Number   (include area code) and required  documentation  will be sent to  the address of Physical Address Line 1 (No P.O. Boxes)                             Physical Address Line 2 the Primary  Owner.                Physical Address City                                               State    ZIP                  Primary Annuitant  Complete this  Social Security Number            Date of Birth (mm/dd/yyyy)        Phone Number   (include area code) section if  different than  Primary Owner.  If Primary                                       Country of Residence Annuitant  section is left U.S. Citizen     Yes       No                                                       Sex        Male       Female blank, the  Annuitant will First Name                    Middle Name                 Last Name default to the  Primary Owner.                Physical Address Line 1 (No P.O. Boxes)                             Physical Address Line 2                 Physical Address City                                               State    ZIP                  Joint Annuitant Complete this  section if     Social Security Number                                                    Date of Birth (mm/dd/yyyy) different than  Joint Owner. If                                          Joint Annuitant Not Applicable Joint Annuitant  section is left                                  Country of Residence blank, the Joint  Annuitant will U.S. Citizen      Yes       No                                                       Sex        Male       Female default to the  Joint Owner.   First Name                   Middle Name                  Last Name                  Relationship to Primary Annuitant                                   Phone Number   (include area code)                 Physical Address Line 1 (No P.O. Boxes)                             Physical Address Line 2                 Physical Address City                                               State    ZIP                  ICC20 R280 11/20                                  Page 2 of 11                                    R285 01/21

 

               Beneficiary(ies) It is required for                                                                                                     Percentage of Good Order          Primary                           Sex      Male       Female                                             % that the Death                                                                                     Death Benefit Benefit                 Social Security/Tax ID Number     Date of Birth (mm/dd/yyyy)        Relationship to Owner Percentage be  whole  numbers and  must total     First Name                   Middle Name                 Last Name 100% for each  beneficiary  type.                 Non-Natural Owner/Entity Name   (if applicable)                     Phone Number  (include area code) If Percentage of  Death Benefit is  left blank, all  beneficiaries  Physical Address Line 1 (No P.O. Boxes)                             Physical Address Line 2 will receive  equal shares.                Physical Address City                                               State    ZIP Please use the  Beneficiary  Designation  Supplement  form X3041 for                                                                                     Percentage of additional          Primary      Contingent           Sex      Male       Female                                             % beneficiaries.                                                                                     Death Benefit                Social Security/Tax ID Number     Date of Birth (mm/dd/yyyy)        Relationship to Owner                 First Name                   Middle Name                 Last Name                  Non-Natural Owner/Entity Name   (if applicable)                     Phone Number  (include area code)                 Physical Address Line 1 (No P.O. Boxes)                             Physical Address Line 2                 Physical Address City                                               State    ZIP                                                                                                      Percentage of                     Primary      Contingent           Sex      Male       Female                                             %                                                                                                    Death Benefit                Social Security/Tax ID Number     Date of Birth (mm/dd/yyyy)        Relationship to Owner                 First Name                   Middle Name                 Last Name                  Non-Natural Owner/Entity Name   (if applicable)                     Phone Number  (include area code)                 Physical Address Line 1 (No P.O. Boxes)                             Physical Address Line 2                 Physical Address City                                               State    ZIP                  ICC20 R280 11/20                                  Page 3 of 11                                    R285 01/21

 

               Annuity Type  The Registered     Non-Tax Qualified           IRA - Traditional*        Roth IRA*           SEP           403(b) TSA  Index-Linked  Annuity  Automatic          Stretch IRA        Non-Qualified Stretch       Roth Conversion    Other: Withdrawal     *Tax Contribution Year(s) and Amounts: Request form  (R4370) will be Year:                      $                      Year:                      $ required if a  Stretch Annuity  Type is elected. Premium Payment External  Transfers: The Select method of payment and note approximate amount: Request for  Transfer or    Check Attached  $                         Check In Transit $                       Wire  $ Exchange of  Assets form  (X3783) must  be submitted if Anticipated total amount from internal transfer(s) $ Jackson is to  request the  release of     Anticipated total amount from external transfer(s) to be requested by Jackson $ funds.                 Anticipated total amount from external transfer(s) to be requested by For more than  Financial Professional or Owner (Jackson will NOT request funds)       $ two account  transfers,  please provide  account        If Jackson is NOT requesting funds, please provide the following information: information on                                                                              Transfer     Anticipated the Letter of  Company releasing funds         Account number           Maturity date       type         transfer amount Instruction form  (X4250) and                                                                                     Full                                                                                                        $ submit with                                                                                     Partial application.                                                                                                  Full                                                                                                        $                                                                                                 Partial                 We reserve the right to refuse a Premium payment that is comprised of multiple payments over a period of                 time. If we permit you to make multiple payments as part of your Premium payment, the Contract will not                 be issued until all such payments are received. We reserve the right to hold such multiple payments in a                 non-interest bearing account until the Issue Date.   It is required for  Good Order     Statement Regarding Existing Policies or Annuity Contracts that this entire  section be     I (We) certify that with regard to Jackson or any other company:   completed.     (Please select one) COMPLETE  X0512                             I (We) do not have existing life                    I (We) do have existing life insurance  "REPLACEMENT  OF LIFE                    insurance policies or annuity contracts.            policies or annuity contracts. INSURANCE OR  ANNUITIES"     Notice to Financial Professional: If the Applicant does have existing life insurance policies or annuity  WHERE          contracts you must present and read to the Applicant the Replacement of Life Insurance or Annuities form  REQUIRED       (X0512 - state variations apply) and return the notice, signed by both the Financial Professional and  (must be dated                 Applicant, with the Application. on or before  the Application  Sign Date to be            Are you replacing or changing an existing life in Good Order).                            insurance policy or annuity contract?                       Yes         No                  ICC20 R280 11/20                                  Page 4 of 11                                    R285 01/21

 

                 Contract Options        PLEASE NOTE: Contract Options are subject to availability.  Tell us how  you want                                                        S&P 500   Index your annuity  premium                             Index Account Options                    1-Year    %      3-Year    %     6-Year    % invested.  Whole                                         Cap percentages only. TOTAL                         10%       Performance Trigger ALLOCATION MUST EQUAL             BUFFER                 Performance Trigger Plus 100%.                                     20%       Cap                                      30%       Cap  Certain                                       Cap broker-dealers                      10% may limit the           FLOOR                 Performance Trigger Index Account  Options and/or                      20%       Cap Fixed Account  under the  Contract. Please                                             Russell 2000   Index see Client  Acknowledg-                        Index Account Options                     1-Year    %     3-Year    %      6-Year    % ments on pages  9 and 10.                                               Cap                                      10%       Performance Trigger                         BUFFER                 Performance Trigger Plus                                      20%       Cap                                      30%       Cap                                                Cap                                     10%                         FLOOR                 Performance Trigger                                      20%       Cap                                                                 MSCI EAFE Index                                      Index Account Options                    1-Year    %      3-Year    %     6-Year    %                                                Cap                                      10%       Performance Trigger                         BUFFER                 Performance Trigger Plus                                      20%       Cap                                      30%       Cap                                                Cap                                     10%                         FLOOR                 Performance Trigger                                      20%       Cap                                                    CONTRACT OPTIONS CONTINUED ON PAGE 6.                  ICC20 R280 11/20                                  Page 5 of 11                                    R285 01/21

 

                Contract Options        PLEASE NOTE: Contract Options are subject to availability. (continued from page 5)  Tell us how  you want                                               MSCI Emerging Markets Index your annuity  premium                            Index Account Options                    1-Year    %      3-Year    %     6-Year    % invested.  Whole                                         Cap percentages only. TOTAL                         10%       Performance Trigger ALLOCATION MUST EQUAL            BUFFER                  Performance Trigger Plus 100%.                                     20%       Cap                                      30%       Cap  Certain                                       Cap broker-dealers                      10% may limit the          FLOOR                  Performance Trigger Index Account  Options and/or                      20%       Cap Fixed Account  under the  Contract. Please                                          MSCI KLD 400 Social Index see Client  Acknowledg-                        Index Account Options                    1-Year    %      3-Year    %      6-Year    % ments on pages  9 and 10.                                     Cap                                      10%       Performance Trigger                        BUFFER                  Performance Trigger Plus                                      20%       Cap                                      30%       Cap                                                Cap                                     10%                        FLOOR                  Performance Trigger                                      20%       Cap                          Fixed Account          1-Year    %                          Fixed Account                   ICC20 R280 11/20                                  Page 6 of 11                                    R285 01/21

 

                Annuitization/Income Date                  Specify Income Date   (mm/dd/yyyy)           If an Annuitization/Income Date is not specified, the                                                               Company will default to the Latest Income Date as shown                                                               in the Contract.                   Telephone/Electronic Information Authorization This  authorization   If you want to authorize an individual other than your Financial Professional to receive Contract information via  is not extended telephone and/or in writing, please provide that individual's information here. Select one option. to Telephone/ Electronic  Transaction         Telephone communication             Written communication           Telephone and written communication Authorization.                  First Name                       Middle Name                        Last Name If no election is  made, Jackson  will default to  " Telephone     Social Security Number                                    Date of Birth (mm/dd/yyyy) and written  communication."                   Telephone/Electronic Transaction Authorization If no election  is made,        By checking "Yes," I (we) authorize Jackson to accept Contract Option changes via telephone, internet, or other  Jackson will    electronic medium from me (us) and my (our) Financial Professional, subject to Jackson's administrative procedures.  default to  " No."          Do you consent to Telephone/Electronic Transfer Authorization?          Yes           No                        This            Jackson has administrative procedures that are designed to provide reasonable assurances that telephone/electronic authorization   authorizations are genuine. If Jackson fails to employ such procedures, it may be held liable for losses resulting is not extended from a failure to use such procedures. I (We) release Jackson, its affiliates, subsidiaries, and agents from all  to the          damages related in any way to its acting upon any unauthorized telephone/electronic instruction. I (We)  Telephone/      understand and agree that Jackson reserves the right to terminate or modify these telephone/electronic privileges  Electronic      at any time, without cause and without notice to me (us). Information  Authorization.                   ICC20 R280 11/20                                  Page 7 of 11                                    R285 01/21

 

                 Electronic Delivery Authorization If no election is                   Do you consent to Electronic made, Jackson                                       Yes        No will default to  Delivery of documents? " No."                  Check the box(es) next to the types of documents you wish to receive electronically. If Electronic Delivery is  Selection of     authorized, but no document type is selected, the selection will default to "All Documents." "ALL  DOCUMENTS"           ALL DOCUMENTS               Prospectuses and prospectus supplements              Annual reports currently  excludes tax            Annual statements               Transaction confirmations          Other Contract-related correspondence documents.  Authorizing   Electronic  Delivery of      My email address is: annual  statements will  automatically    If you consent, Jackson will transmit documents related to your policy/contract by electronic means, to the extent  enroll you to    that electronic transmission is consistent with applicable state and federal law. Any document that we send by  receive          electronic means, which complies with applicable law, will have the same force and effect as if that document was  quarterly        sent in paper format. summaries.  Quarterly                   Jackson will only transmit documents to you electronically if you consent. Your consent is voluntary and will continue  summaries are  only available   until revoked. For Jointly owned contracts, all Joint Owners are consenting to the electronic delivery and use of the  via Electronic   single email address above.  Delivery.                  You may request paper copies, whether or not you consent or revoke your consent for electronic delivery, at any time  Please provide   for no charge. Certain types of correspondence may continue to be delivered by the United States Postal Service for  one email        compliance reasons. Even if you have given us consent, we are not required to make electronic delivery and we have  address and      the right to deliver any documents or communication in paper form. Registration on Jackson's website  print clearly.   (www.jackson.com) is required for electronic delivery of Contract-related correspondence.  If you authorize You can change your mind and revoke your consent to electronic delivery at any time and have Jackson transmit  Electronic       documents via paper mail by notifying Jackson. To revoke your consent to electronic delivery, update your email  Delivery but do  address, or request paper copies, please contact the appropriate Jackson Service Center or go to www.jackson.com. not provide an   email address    There is no charge for electronic delivery of electronic communications, although you may incur the costs of internet  or the address                   access and of such computer and related hardware and software as may be necessary for you to receive, process and  is illegible,  Electronic       retain electronic documents and communications from Jackson. The computer hardware and software requirements  Delivery  will   that are necessary to receive, process and retain electronic communications that are subject to this consent are as  not be initiated. follows: To view and download material electronically, you must have a computer with internet access, an active                   email account and Adobe Acrobat Reader. If you don't already have Adobe Acrobat Reader, you can download it free                   from www.adobe.com.                    ICC20 R280 11/20                                  Page 8 of 11                                    R285 01/21

 

Notice to Applicant  Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal  offense and subject to penalties under state law.  Client Acknowledgments  1.    I (We) hereby represent to the best of my (our) knowledge and belief that each of the statements and        answers contained in this application are true, complete and correctly recorded. 2.    I (We) certify that the Social Security or Taxpayer Identification number(s) shown above is (are) correct. 3.    I (We) certify that the date of birth of the Owner and any Joint Owner, primary spousal Beneficiary, Annuitant        or Joint Annuitant, if applicable, stated in this application is (are) true and correctly recorded. 4.    I (We) hereby represent to the best of my (our) knowledge and belief that I have made an informed decision        to purchase this product and, if applicable, have reviewed the differences between this product and my        original product. The product fits  my investment needs and objectives, liquidity needs, time horizon, risk        tolerance and my (our) general financial situation.  5.    I understand the restrictions imposed by 403(b)(11) of the Internal Revenue Code. I understand the        investment alternatives available under my employer's 403(b) plan, to which I may elect to transfer my        contract value. 6.    I (We) understand that while the values of the Contract may be affected by an external Index, the Contract        does not participate in any stock or equity investment. 7.    I (We) understand that the capping component in this Contract may limit the Index Adjustment credited to        the Index Account Option Value on each Index Account Option Term Anniversary, regardless of the        performance of the Indices. 8.    I (We) have received the applicable current Buffers/Floors, Caps/Rates and any other Index Adjustment Factors        associated with this Contract. 9.    I (We) understand that to the extent I (we) have been permitted to make a Premium payment comprised of        multiple payments over a period of time, my (our) Contract will not be issued until all such payments are        received, and all Premium payments will be held in a non-interest bearing account until the date my (our)        Contract is issued.  10.   I (We) have been given a current prospectus for this registered index-linked annuity product.                                                                   CLIENT ACKNOWLEDGMENTS                                                                 CONTINUED ON PAGE 10.   ICC20 R280 11/20                                  Page 9 of 11                                    R285 01/21

 

                 Client Acknowledgments           (continued from page 9)                   11.   I (We) understand that Jackson issues other annuities with similar features, limitations, minimum Caps/Rates                         and charges. I (We) have discussed the alternatives with my (our) Financial Professional, including that similar                         products with higher or lower Caps/Rates may be available through other broker-dealers.                  12.   I (We) understand that allocations to the Index Account Options, with certain exceptions, are subject to                         a Market Value Adjustment if withdrawn, annuitized, or transferred to the Fixed Account which may                        reduce amounts paid, annuitized, or transferred. (Only applicable to Contracts with a Market Value                        Adjustment.)                  13.   I (We) understand that the product being applied for is a registered index-linked annuity product.                  14.   I acknowledge and represent that I have executed this application, and that my signature below (including                         my electronic signature) is my true and valid signature. I further authorize Jackson to accept any electronic                         signature that I may make to this application.                  15.   I (We) understand that certain broker-dealers may limit the Contract Options available under the Contract. I                         (We) have discussed these limitations with my (our) financial professional and have been provided with a list                         of Contract Options currently available for election through my (our) broker-dealer.  I (We) understand that                         any application including an election of a Contract Option not available through my (our) broker-dealer will                         not be accepted. I (We) understand that the Contract Options not available through my (our) broker-dealer                         may be available through other broker-dealers.                    Client Signatures It is required for                   Owner's Signature                                           Date Signed (mm/dd/yyyy)  State where signed Good Order  that all  applicable  parties to the                   Owner's Title (required if owned by an Entity) Contract sign  here.                   Joint Owner's Signature                                                               Date Signed  (mm/dd/yyyy)  Required  replacement  forms must be    Annuitant's Signature (if other than Owner)                 Date Signed (mm/dd/yyyy)  State where signed signed on or  before the  application  signature        Joint Annuitant's Signature (if other than Joint Owner)                               Date Signed  (mm/dd/yyyy) date.                                     Not FDIC/NCUA Insured          Not Bank/CU guaranteed         May lose value                                             Not a deposit       Not insured by any federal agency                    ICC20 R280 11/20                                  Page 10 of 11                                   R285 01/21

 

               Financial Professional Acknowledgments Complete this  certification  I certify that: regarding sales  material section   I did not use sales material(s) during the presentation of this Jackson product to the applicant. only if:                     I used only Jackson-approved sales material(s) during the presentation of this Jackson product to the applicant.   Your client  has other          In addition, copies of all approved sales material(s) used during the presentation were left with the applicant. existing policies  or annuity     By signing this form, I certify that: contracts AND            1. I am authorized and qualified to discuss the Contract herein applied for.   Will be either 2. I have reviewed all of the client's information, and I believe that my recommendation to purchase this annuity is  terminating any   in line with the client's financial situation and investment needs, and meets the appropriate standard of care (i.e.  of those                    suitability or best interest) based on the facts disclosed to said client. I also attest that I have provided the client  existing policies  or using the      with all pertinent information about the product, including disclosure of risks involved, allowing the client to  funds from        make an educated and informed decision about this purchase. Based on my completion of the required general  existing policies annuity and/or Jackson product training, I believe this transaction is suitable and in the best interest of the client  to fund this      given the client's financial situation and needs. new Contract.                 3. The applicable current Buffers/Floors, Caps/Rates and any other Index Adjustment Factors associated with this                    Contract have been presented and explained to the Owner(s).                 4. I have not made statements that differ from this material nor have I made any promises about the expected  All Financial                    future Index Account Option values of this Contract. Professional  certifications, 5. I have read Jackson's Position With Respect to the Acceptability of Replacements (XADV5790) and ensure that  licenses and      this replacement (if applicable) is consistent with that position. trainings must  be completed   6. The applicant's Statement Regarding Existing Policies or Annuity Contracts has been answered correctly to the  prior to          best of my knowledge and belief. application  execution.     7. The applicant's statement as to whether or not an existing life insurance policy or annuity contract is being                    replaced is true and accurate to the best of my knowledge and belief.                8. I have discussed all applicable limitations to Contract Options availability with the applicant and have provided                    the applicant with a list of Contract Options currently available for election.                   Financial Professional #1 Signature                        Date Signed(mm/dd/yyyy)    Jackson Assigned ID                  First Name                          Middle Name                       Last Name                 Email Address   (print clearly)                            Business Phone Number  (include area code) Extension                  If more than one Financial Professional is participating on this case, please provide the additional Financial                 Professional names and Jackson Assigned IDs for each.                 Financial Professional Name #2                             Jackson Assigned ID                 Financial Professional Name #3                             Jackson Assigned ID                 Financial Professional Name #4                             Jackson Assigned ID                  ICC20 R280 11/20                                  Page 11 of 11                                   R285 01/21

Source: [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00316-of-00352.parquet"}, [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00316-of-00352.parquet"}]]