Document:

EX-10.1

 

Exhibit 10.1

MetLife
®

Metropolitan
Life Insurance Company
200 Park Avenue, New York, New York 10166

Metropolitan Life Insurance Company (“MetLife”), a stock company, will pay the benefits
specified in the Exhibits of this policy subject to the terms and provisions of this policy. The
Schedule of Exhibits lists each Exhibit to this policy, to whom it applies and its effective
date.

	 	 	 
	Policyholder:

	 	Goldman, Sachs & Co.
	 
	 	 
	Group Policy No.:

	 	34834-1-G

EFFECTIVE DATE

This policy will take effect on January 1, 2006. This policy is a rewrite of Group Policy Number
34834-G which was issued by MetLife and took effect on November 1, 1992.

POLICY ANNIVERSARIES

Policy anniversaries will be January 1, 2006 and each subsequent January 1.

PREMIUM PAYMENTS

This policy is issued in return for the payment by the Policyholder of required Premiums.
Premiums are payable at the home office of MetLife or to its authorized agent. The first
Premium is due on and must be paid by this policy’s effective date. Any later Premiums are due
monthly in advance on the first day of each Policy Month. These dates are the Premium Due
Dates.

POLICY SITUS

This policy is issued for delivery in and governed by the laws of New York.

Signed as of this policy’s effective date at MetLife’s home office in New York, New York.

	 	 	 
	

	 	
	Gwenn L. Carr

	 	C. Robert Henrikson
	Senior Vice President and Secretary

	 	President and Chief Operating Officer

	 	 	 	 	 	 	 	 	 
	Signed by

	 	 	 	 
	 	Date	 	 
	 

	 	 
	 	 	 	 	 	 
	 

	 	(A MetLife licensed agent or resident agent as required by law.)	 	 	 	 	 	 

			
	 	 	 
	GROUP TERM LIFE INSURANCE POLICY
	 	NON-DIVIDEND PAYING

					
	 	 	 	 	 
	GPNP99
	 	34834-1-G
	 	Page 1

 

 

TABLE OF CONTENTS

	 	 	 	 	 
	Section	 	Page
	 
	 	 	 	 
	POLICY FACE PAGE
	 	 	 	 
	Effective Date
	 	 	1	 
	Policy Anniversaries
	 	 	1	 
	Premium Payments
	 	 	1	 
	Policy Situs
	 	 	1	 
	 
	 	 	 	 
	DEFINITIONS
	 	 	3	 
	 
	 	 	 	 
	SCHEDULE OF INSURANCE
	 	 	4	 
	 
	 	 	 	 
	ELIGIBILITY AND EFFECTIVE DATES OF INSURANCE
	 	 	4	 
	 
	 	 	 	 
	CONTRIBUTIONS
	 	 	4	 
	 
	 	 	 	 
	PREMIUM RATE(S)
	 	 	 	 
	Initial Rate(s)
	 	 	4	 
	Frequency of Premium Payment
	 	 	4	 
	Computation of Premium
	 	 	4	 
	Premiums for Changes in Insurance
	 	 	4	 
	Right to Change Premium Rates
	 	 	5	 
	 
	 	 	 	 
	GRACE PERIOD
	 	 	6	 
	 
	 	 	 	 
	END OF INSURANCE PROVIDED BY THIS POLICY
	 	 	6	 
	 
	 	 	 	 
	REINSTATEMENT
	 	 	7	 
	 
	 	 	 	 
	GENERAL PROVISIONS
	 	 	 	 
	Entire Contract
	 	 	7	 
	Policy Changes or Waivers
	 	 	7	 
	Incontestability: Statements Made by the Policyholder
	 	 	7	 
	Incontestability: Statements Made by Covered Persons
	 	 	7	 
	Certificates
	 	 	8	 
	Data Needed
	 	 	8	 
	Misstatement of Age
	 	 	8	 
	Non-Dividend Paying
	 	 	8	 
	Conformity with Law
	 	 	8	 
	 
	 	 	 	 
	SCHEDULE OF EXHIBITS
	 	SCH/EXHIBITS
	EXHIBIT 1: Schedule of Premium Rates
	 	EXHIBIT1 
	EXHIBIT 2: Certificate Forms
	 	EXHIBIT2 

					
	 	 	 	 	 
	GPNP99
	 	34834-1-G
	 	Page 2

 

 

DEFINITIONS

As used in this policy, the terms listed below will have the meanings defined below. When
defined terms are used in this policy, they will appear with initial capitalization. The
plural use of a term defined in the singular will share the same meaning.

Contribution means the amount the Policyholder may require the Employee to pay towards the
total Premium that MetLife charges for the insurance provided by this policy.

Contributory Insurance means insurance for which the Policyholder may require the Employee to
pay at least part of the Premium.

Covered Person means an Employee and/or a Dependent as set forth in the Exhibit which applies
to the Employee.

Dependent is defined in the Exhibit which applies to the Employee.

Employee is described in the Exhibit which applies to
the Employee.

Employer means the Policyholder shown on page 1.

Noncontributory Insurance means insurance for which the Policyholder may not require the Employee
to pay any part of the Premium.

Policy Anniversary is defined on page 1.

Policy
Month. The first Policy Month will begin on the effective date shown on page 1. Subsequent
Policy Months will begin on the same day of each subsequent calendar month.

Premium
means the amount the Policyholder must pay to MetLife for all the insurance provided
under this policy.

Premium Due Date is defined on page 1.

Signed means any symbol or method executed or adopted by a person with the present intention
to authenticate a record, and which is on or transmitted by paper or electronic media, and
which is consistent with applicable law.

Written or Writing means a record which is on or transmitted by paper or electronic media,
and which is consistent with applicable law.

					
	 	 	 	 	 
	GPNP99
	 	34834-1-G
	 	Page 3

 

 

SCHEDULE OF INSURANCE

The Schedules of Insurance which apply under this policy are set forth in the Exhibits.

ELIGIBILITY AND EFFECTIVE DATES OF INSURANCE

The Eligibility and Effective Dates of Insurance provisions that apply under this policy are
set forth in the Exhibits.

CONTRIBUTIONS

The Policyholder will not require an Employee to contribute to the cost of Noncontributory
Insurance.

The maximum amount that an Employee may be required to contribute to the cost of Contributory
Insurance will not exceed the Premium charged for the amounts of such insurance.

PREMIUM RATE(S)

Initial Rate(s)

The initial Premium rate(s) are shown in Exhibit 1.

Frequency of Premium Payment

Premiums for this policy will be paid as shown on page 1. MetLife and the Policyholder may
agree that payment be made in advance every 3, 6 or 12 months.

Computation of Premium

The Premium due on any Premium Due Date is determined by the total amount of insurance
provided by this policy on such Premium Due Date, multiplied by the appropriate Premium
rate(s) which are then in effect subject to any Premium adjustments, if applicable.

MetLife may use any reasonable method to compute Premiums due under this policy.

Premiums for Changes in Insurance

For insurance that takes effect after the first day of a Policy Month, Premium will be
charged from the first day of the next Policy Month. However, if a policy amendment or
evidence of good health is required for such insurance, Premium will be charged as of the
date such insurance takes effect.

If this policy ends, or if insurance ends for a class of persons, Premium will be charged to
the date insurance ends. If insurance ends for other reasons, Premium
will be charged to the end of
the Policy Month in which insurance ends.

					
	 	 	 	 	 
	GPNP99
	 	34834-1-G
	 	Page 4

 

 

PREMIUM RATES (Continued)

Right to Change Premium Rates

MetLife may change Premium rates for changes which materially affect the risk assumed for
the insurance provided by this policy, as follows:

	1.	 	when this policy is amended or endorsed;
	 
	2.	 	when a class of eligible persons is added to or deleted from this policy for any reason
including corporate restructuring, acquisition, spin-off or similar situations;
	 
	3.	 	when a Policyholder’s subsidiary, affiliate, division, branch or other similar entity is added to
or deleted from this policy for any reason including corporate restructuring, acquisition,
spin-off or similar situations;
	 
	4.	 	when there is a significant change in the geographic distribution of insured Employees;
	 
	5.	 	when applicable law requires a change in:

	 	a.	 	the insurance provided by this policy; and/or
	 
	 	b.	 	the class of persons eligible for insurance under this policy; or

	6.	 	when a Premium Due Date coincides with or next follows:

	 	a.	 	a change greater than 10% in the number of Covered Persons since the later of the
policy Effective Date and the last date Premium rates were changed; or
	 
	 	b.	 	a change greater than 10% in the amount of insurance provided by this policy since the
later of the policy Effective Date and the last date Premium rates were changed.

In
addition, MetLife may change Premium rates:

	1.	 	except as may be stated in Exhibit 1, on any date on or after the first Policy Anniversary;
this will be done no more frequently than every 12 months and
only if MetLife notifies the
Policyholder, in Writing, at least 31 days before such change; and
	 
	2.	 	on any other date agreed to by MetLife and the Policyholder.

The new Premium rates will apply only to Premiums due on or after the date the rate change
takes effect.

					
	 	 	 	 	 
	GPNP99
	 	34834-1-G
	 	Page 5

 

 

GRACE PERIOD

Each Premium due after the effective date of this policy may be paid up to 31 days after
its Premium Due Date. This period is the grace period. The insurance provided by this policy
will stay in effect during this period. MetLife will notify the Policyholder in Writing that, if
the Premium is not paid by the end of the grace period, this policy
will end at the end of the last
day of the grace period. If MetLife fails to give Written notice to the Policyholder, this
policy will continue in effect until the date such notice is given.

Policyholder’s intent to end this policy during the grace period. The Policyholder may notify
MetLife in Writing prior to the end of the grace period of its intent to end this policy before the end
of the grace period. In this case, this policy will end on the later of:

	1.	 	the date stated in the notice; or
	 
	2.	 	the date MetLife receives the notice.

If the Policyholder replaces this policy with another group insurance policy but does
not give MetLife notice of intent to end this policy, the grace
period provisions will apply.

Grace period extensions. MetLife may extend the grace period by giving Written notice to the
Policyholder. Such notice will state the date this policy will end if the Premium remains
unpaid.

Premiums must be paid for a grace period, any extension of such period and any period
insurance under this policy was in effect for which Premium was not paid.

END OF INSURANCE PROVIDED BY THIS POLICY

The Policyholder can end this policy by giving 60 days advance Written notice to MetLife. The policy
will end on the later of:

	1.	 	the date stated in the notice; or
	 
	2.	 	the date MetLife receives the notice.

MetLife can end this policy as follows:

	1.	 	on the date Premium is not paid when due, subject to the Grace Period provisions; or
	 
	2.	 	on any Premium Due Date, by giving the Policyholder 31 days advance Written notice, if less
than:

	 	a.	 	for Contributory Insurance other than Optional Life Insurance
and Dependent Life Insurance,
75% of persons eligible under this policy are insured for such Contributory Insurance; or
	 
	 	 	 	for Optional Life Insurance and Dependent Life Insurance 25% of persons eligible under this
policy are insured for such Contributory Insurance; or
	 
	 	b.	 	100% of persons eligible under this policy are insured for Noncontributory Insurance; or
	 
	 	c.	 	50 Employees are insured by this Policy;

	3.	 	on any Premium Due Date, by giving the Policyholder 60 days advance Written notice, if
the Policyholder fails to provide information on a timely basis or perform any obligations
required by this policy or any applicable law; or

					
	 	 	 	 	 
	GPNP99
	 	34834-1-G
	 	Page 6

 

 

END OF INSURANCE PROVIDED BY THIS POLICY (Continued)

	4.	 	on any Policy Anniversary, except during a Rate Guarantee Period as may be provided in Exhibit
1, by giving the Policyholder 31 days advance Written notice.

This policy will end on the date on which the last certificate in effect under this policy ends.

If this policy ends, all Premiums due must be paid. If MetLife accepts Premium after the
date this policy ends, such acceptance will not act to reinstate the
policy. MetLife will refund
any unearned Premium.

REINSTATEMENT

The Policyholder may request to reinstate this policy within one year from the date it ended. The
request must be in Writing and it must provide MetLife with information that MetLife requires
to consider such request. If MetLife approves the request, the policy
will be reinstated on the date
stated in Writing by MetLife.

GENERAL PROVISIONS

Entire Contract. The entire contract is made up of the following:

	1.	 	this policy, including its Exhibits which include the certificate(s);
	 
	2.	 	the Policyholder’s application; and
	 
	3.	 	the amendments and endorsements to this policy, if any.

Policy Changes or Waivers. The terms and provisions of this policy may be changed, at any
time, without the consent of the Covered Persons or anyone else with a beneficial interest
in it. MetLife will issue amendments or endorsements to effect such
changes. MetLife will only
make changes that are consistent with applicable law. An amendment or
endorsement will not affect
the insurance provided under certificates issued before the effective date of the change, unless
retroactivity is consistent with applicable law.

An officer of MetLife must approve in Writing any change or waiver of the terms and provisions of
this policy. A sales representative, or other MetLife employee, who
is not an officer of MetLife
does not have MetLife’s authority to approve such changes or waivers. A change or waiver will
be evidenced by an amendment Signed by
an officer of MetLife and the Policyholder or an endorsement Signed by an
officer of MetLife. A copy of the amendment or endorsement will be provided to the Policyholder for
attachment to this policy and the amendment or endorsement will become a part of this policy.

Incontestability: Statements Made by the Policyholder. Any statement made by the
Policyholder will be considered a representation and not a warranty. MetLife will not use such
statement to contest insurance, reduce benefits or defend a claim unless it is contained in a
Written application, Signed by the Policyholder. MetLife will not use such statement to contest
life insurance after it has been in force for 2 years from its effective date, or date of
last reinstatement.

Incontestability: Statements Made by Covered Persons. Any statement made by a Covered Person
will be considered a representation and not a warranty. MetLife will not use such statement to
contest insurance, reduce benefits or defend a claim unless the following requirements are met:

	1.	 	the statement is in a Written application or enrollment form;
	 
	2.	 	the Covered Person has Signed the application or enrollment form; and
	 
	3.	 	a copy of the application or enrollment form has been given to the Covered Person or his
beneficiary.

MetLife will not use a Covered Person’s statements which relate to insurability to contest life
insurance after it has been in force for 2 years during his life. In addition, MetLife will not use
such statements to contest an increase or benefit addition to such insurance after the increase
or benefit has been in force for 2 years during his life.

					
	 	 	 	 	 
	GPNP99
	 	34834-1-G
	 	Page 7

 

 

GENERAL PROVISIONS (Continued)

Certificates. MetLife will issue certificates to the Policyholder for delivery to each
Covered Person, as appropriate. Such certificate will describe the
Covered Person’s benefits and
rights under this policy. “Certificate” includes any of
MetLife’s insurance riders, notices or
other attachments to the certificate.

Data
Needed. The Policyholder will provide MetLife with all the data needed to compute
Premiums and carry out the terms of this policy. MetLife may examine such data at any
reasonable time. If MetLife or the Policyholder make a clerical error
in keeping the data, the Premium and/or benefits will
be adjusted according to the correct data. An error will not end insurance validly in effect,
nor will it continue insurance validly ended.

Misstatement of Age. If a Covered Person’s age is misstated, the correct age will be used to
determine if insurance is in effect and, as appropriate, adjust the
Premium and/or benefits.

Non-Dividend Paying. This policy does not pay dividends.

Conformity with Law. If the terms and provisions of this policy do not conform to any applicable
law, this policy shall be interpreted to so conform.

					
	 	 	 	 	 
	GPNP99
	 	34834-1-G
	 	Page 8

 

 

SCHEDULE OF EXHIBITS

	 	 	 	 	 	 	 
	Exhibit	 	 	 	 	 	Effective
	Number	 	Exhibit Type	 	Applies To	 	Date
	 
	 	 	 	 	 	 
	1

	 	Schedule of Premium Rates
	 	All Covered

Persons
	 	January 1, 2006
	 
	 	 	 	 	 	 
	2

	 	Certificate Forms
	 	All Covered

Persons
	 	January 1, 2006

	 	 	 
	GPNP99

	 	34834-1-G
	SCH/EXHIBITS

	 	DATE: January 1, 2006

 

 

EXHIBIT 1

SCHEDULE OF PREMIUM RATES

The initial monthly Premium rates in effect January 1, 2006, for the insurance provided by
this policy are as follows:

Rate Guarantee Period

Subject to the Right to Change Premium Rates provision on page 5, the Executive
Life, Basic Life, Optional Life and Dependent Life Premium rates will be in effect for the
period which begins on January 1, 2006 and ends on December 31, 2007.

Executive
Life Benefits for Employees:

	 	 	 	 	 
	 	 	Amount Per $1,000 of
	 	 	Executive Life Benefits
	Aqe of Employee	 	in force hereunder
	Less than 25
	 	$	0.053	 
	25 but less than 29
	 	$	0.063	 
	30 but less than 35
	 	$	0.084	 
	35 but less than 40
	 	$	0.097	 
	40 but less than 45
	 	$	0.112	 
	45 but less than 50
	 	$	0.163	 
	50 but less than 55
	 	$	0.264	 
	55 but less than 60
	 	$	0.457	 
	60 but less than 65
	 	$	0.771	 
	65 but less than 70
	 	$	1.455	 
	70 and older
	 	$	2.358	 

Basic Life Benefis for Employees: — $0.090 per $1,000 of Basic Life Benefits in force
hereunder.

Optional Life Benefits for Employees:

	 	 	 	 	 
	 	 	Amount Per $1,000 of
	 	 	Optional Life Benefits
	Aqe of Employee	 	in force hereunder
	Less than 25
	 	$	0.05	 
	25 but less than 30
	 	$	0.06	 
	30 but less than 35
	 	$	0.08	 
	35 but less than 40
	 	$	0.09	 
	40 but less than 45
	 	$	0.10	 
	45 but less than 50
	 	$	0.15	 
	50 but less than 55
	 	$	0.23	 
	55 but less than 60
	 	$	0.43	 
	60 but less than 65
	 	$	0.66	 
	65 but less than 70
	 	$	0.678	 
	70 but less than 75
	 	$	1.27	 
	75 but less than 80
	 	$	1.27	 
	80 but less than 85
	 	$	1.353	 
	85 but less than 90
	 	$	1.563	 
	90 and older
	 	$	1.709	 

	 	 	 
	GPNP99

	 	34834-1-G
	EXHIBIT1

	 	DATE: January 1, 2006

 

 

Life
Benefits for Dependents:

	 	 	 	 	 
	 	 	Amount per Employee
	 	 	of Life Benefits
	 	 	for Dependents
	Aqe of Employee	 	in force hereunder
	Less than 25
	 	$	0.05	 
	25 but less than 30
	 	$	0.06	 
	30 but less than 35
	 	$	0.08	 
	35 but less than 40
	 	$	0.09	 
	40 but less than 45
	 	$	0.10	 
	45 but less than 50
	 	$	0.15	 
	50 but less than 55
	 	$	0.23	 
	55 but less than 60
	 	$	0.43	 
	60 but less than 65
	 	$	0.66	 
	65 but less than 70
	 	$	0.678	 
	70 but less than 75
	 	$	1.27	 
	75 but less than 80
	 	$	1.27	 
	80 but less than 85
	 	$	1.353	 
	85 but less than 90
	 	$	1.563	 
	90 and older
	 	$	1.709	 

	 	 	 
	GPNP99

	 	34834-1-G
	EXHIBIT1

	 	DATE: January 1, 2006

 

 

EXHIBIT 2

CERTIFICATE FORMS

	 	 	 	 	 	 	 
	Certificate	 	 	 	 	 	 
	Number	 	Certificate Form	 	Applies To	 	Effective Date
	 
	 	 	 	 	 	 
	1

	 	GCERT2000
	 	All Employees eligible for Basic

Life Insurance
	 	January 1, 2006
	 
	 	 	 	 	 	 
	2

	 	GCERT2000
	 	All Employees who Retired prior
to November 28, 1997 and are
eligible for Basic Life Insurance
	 	January 1, 2006
	 
	 	 	 	 	 	 
	3

	 	GCERT2000
	 	All Employees who Retired after
November 28, 1997 and are
eligible for Basic Life Insurance
	 	January 1, 2006
	 
	 	 	 	 	 	 
	4

	 	GCERT2000
	 	All Employees eligible for
Optional Life Insurance
	 	January 1, 2006
	 
	 	 	 	 	 	 
	5

	 	GCERT2000
	 	All Employees, except CCI,
eligible for Dependent Life
Insurance
	 	January 1, 2006
	 
	 	 	 	 	 	 
	6

	 	GCERT2000
	 	Employees of CCI eligible for
Dependent Life Insurance
	 	January 1, 2006
	 
	 	 	 	 	 	 
	7

	 	GCERT2000
	 	Executive Life
	 	January 1, 2006

	 	 	 
	GPNP99

	 	34834-1-G
	EXHIBIT2

	 	DATE: January 1, 2006

 

 

YOUR BENEFIT PLAN

GOLDMAN, SACHS & CO.

Executive Life Insurance

 

 

GOLDMAN, SACHS & CO.

180 Maiden Lane, 24th Floor

New York, NY 10038

TO OUR EMPLOYEES:

All of us appreciate the protection and security insurance provides.

This certificate describes the benefits that are available to you. We urge you to read it
carefully.

GOLDMAN, SACHS & CO.

 

 

MetLife
®

Metropolitan
Life Insurance Company
200 Park Avenue, New York, New York 10166

CERTIFICATE OF INSURANCE

Metropolitan
Life Insurance Company (“MetLife”), a stock company, certifies that You are
insured for the benefits described in this certificate, subject to the provisions of this
certificate. This certificate is issued to You under the Group Policy and it includes the terms and
provisions of the Group Policy that describe Your insurance. PLEASE READ THIS CERTIFICATE
CAREFULLY.

This certificate is part of the Group Policy. The Group Policy is a contract between
MetLife and the Policyholder and may be changed or ended without Your consent or notice to
You.

	 	 	 
	Policyholder:

	 	GOLDMAN, SACHS & CO.
	 
	 	 
	Group Policy Number:

	 	34834-1-G
	 
	 	 
	Type of Insurance:

	 	Term Life Insurance
	 
	 	 
	MetLife Toll Free Number(s):
	 	 
	For Claim Information

	 	FOR LIFE CLAIMS: 1-800-638-6420

THIS CERTIFICATE ONLY DESCRIBES LIFE INSURANCE. THE INSURANCE DESCRIBED DOES NOT PROVIDE BENEFITS
FOR LOSS CAUSED BY SICKNESS.

THE BENEFITS OF THE POLICY PROVIDING YOU COVERAGE ARE GOVERNED PRIMARILY BY THE LAWS OF A STATE
OTHER THAN FLORIDA.

THE GROUP INSURANCE POLICY PROVIDING COVERAGE UNDER THIS CERTIFICATE WAS ISSUED
IN A JURISDICTION OTHER THAN MARYLAND AND MAY NOT PROVIDE ALL THE BENEFITS
REQUIRED BY MARYLAND LAW.

For Residents of North Dakota: If you are not satisfied with your Certificate, You may
return it to Us within 20 days after You receive it, unless a claim has previously been received by
Us under Your Certificate. We wil refund within 30 days of our receipt of the returned Certificate
any Premium that has been paid and the Certificate will then be considered to have never been
issued. You should be aware that, if you elect to return the Certificate for a refund of
premiums, losses which otherwise would have been covered under your Certificate will not be covered.

WE ARE REQUIRED BY STATE LAW TO INCLUDE THE NOTICE(S) WHICH APPEAR ON THIS PAGE AND IN THE
NOTICE(S) SECTION WHICH FOLLOWS THIS PAGE. PLEASE READ THE(SE) NOTICE(S) CAREFULLY.

	 	 	 
	GCERT2000
	 	 
	fp

	 	1 

 

 

	 	 	 
	For Texas Residents:

	 	Para Residentes de Texas:
	 
	 	 
	IMPORTANT NOTICE

	 	AVISO IMPORTANTE
	 
	 	 
	To obtain information or make a complaint:

	 	Para obtener informacion o para someter una queja:
	 
	 	 
	You may call MetLife’s toll free telephone number

	 	Usted puede lIamar al numero de telefono gratis de
	for information or to make a complaint at

	 	MetLife para informacion o para someter una queja al
	 
	 	 
	1-800-638-6420

	 	1-800-638-6420
	 
	 	 
	You may contact the Texas Department of

	 	Puede comunicarse con el Departamento de Seguros
	Insurance to obtain information on companies,

	 	de Texas para obtener informacion acerca de
	coverages, rights or complaints at

	 	companias, coberturas, derechos o quejas al
	 
	 	 
	1-800-252-3439

	 	1-800-252-3439
	 
	 	 
	You may write the Texas Department of Insurance

	 	Puede escribir al Departamento de Seguros de Texas
	 
	 	 
	P.O. Box 149104

	 	P.O. Box 149104
	Austin, TX 78714-9104

	 	Austin, TX 78714-9104
	Fax # (512) 475-1771

	 	Fax # (512) 475-1771
	 
	 	 
	PREMIUM OR CLAIM DISPUTES: Should You

	 	DISPUTAS SOBRE PRIMAS O RECLAMOS: Si
	have a dispute concerning Your premium or about

	 	tiene una disputa concerniente a su
prima o a un
	a claim, You should contact MetLife first. If the

	 	reclamo, debe comunicarse con MetLife primero. Si
	dispute is not resolved, You may contact the Texas

	 	no se resuelve la disputa, puede entonces
	Department of Insurance.

	 	comunicarse con el departamento (TDI).
	 
	 	 
	ATTACH THIS NOTICE TO YOUR CERTIFICATE:

	 	UNA ESTE AVISO A SU CERTIFICADO:
	This notice is for information only and does not

	 	Este aviso es solo para proposito de informacion y no
	become a part or condition of the attached

	 	se convierte en parte o condicion del documento
	document.

	 	adjunto.

	 	 	 
	GCERT2000
	 	 
	notice/tx

	 	2 

 

 

NOTICE FOR RESIDENTS OF ARKANSAS

If You have a question concerning Your coverage or a claim, first contact the
Policyholder or group account administrator. If, after doing so, You still have a concern,
You may call the toll free telephone number shown on the Certificate Face Page.

If You are
still concerned after contacting both the Policyholder and MetLife, You should feel
free to contact:

Arkansas Insurance Department

Consumer Services Division

1200 West Third

Little Rock, Arkansas 72204-1904

1-800-852-5494

	 	 	 
	GCERT2000
	 	 
	notice/ar

	 	3 

 

 

NOTICE FOR RESIDENTS OF CALIFORNIA

IMPORTANT NOTICE

TO OBTAIN ADDITIONAL INFORMATION, OR TO MAKE A COMPLAINT, CONTACT THE
POLICYHOLDER OR THE METLIFE CLAIM OFFICE SHOWN ON THE EXPLANATION OF BENEFITS YOU
RECEIVE AFTER FILING A CLAIM.

IF, AFTER CONTACTING THE POLICYHOLDER AND/OR METLlFE, YOU FEEL THAT A SATISFACTORY
SOLUTION HAS NOT BEEN REACHED, YOU MAY FILE A COMPLAINT WITH THE CALIFORNIA INSURANCE
DEPARTMENT AT:

DEPARTMENT OF INSURANCE

300 SOUTH SPRING STREET

LOS ANGELES, CA 90013

1 (800) 927-4357

	 	 	 
	GCERT2000

	 	4 
	notice/ca
	 	 

 

 

CIVIL UNION NOTICE FOR RESIDENTS OF CONNECTICUT

Connecticut law provides that the following definition applies to Your certificate:

‘Civil Union’ means a civil union established pursuant to Pub. Act No. 05-10
Connecticut Legislative Session, entitled ‘An Act Concerning Civil Unions’.

Connecticut law provides that:

	•	 	Terms that mean or refer to a marital relationship, or that may be construed to mean or
refer to a marital relationship, such as ‘marriage,’ ‘spouse,’ ‘dependent,’ ‘relative,’
‘beneficiary,’ ‘survivor,’ ‘immediate family’, include the relationship created by a Civil Union.
	 
	•	 	Terms that mean or refer to the inception or dissolution of a marriage, such as ‘divorce decree,’
include the inception or dissolution of a Civil Union.

	 	 	 
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NOTICE FOR RESIDENTS OF GEORGIA

IMPORTANT NOTICE

The laws of the state of Georgia prohibit insurers from unfairly discriminating against any
person based upon his or her status as a victim of family violence.

	 	 	 
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NOTICE FOR RESIDENTS OF ILLINOIS

IMPORTANT NOTICE

To make a complaint to MetLife, You may write to:

MetLife

200 Park Avenue

New York, New York 10166

The address of the Illinois Department of Insurance is:

Illinois Department of Insurance

Public Services Division

Springfield, Illinois 62767

	 	 	 
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NOTICE FOR RESIDENTS OF NORTH CAROLINA

Read your Certificate Carefully.

IMPORTANT CANCELLATION INFORMATION

Please Read The Provision Entitled

DATE YOUR INSURANCE ENDS

Found on Pages e/ee

					
	 	 	 	 	 
	 	 	 	 	 
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NOTICE FOR RESIDENTS OF NORTH CAROLINA

UNDER NORTH CAROLINA GENERAL STATUTE SECTION 58-50-40, NO PERSON, EMPLOYER,
PRINCIPAL, AGENT, TRUSTEE, OR THIRD PARTY ADMINISTRATOR, WHO IS RESPONSIBLE FOR THE PAYMENT OF
GROUP HEALTH OR LIFE INSURANCE OR GROUP HEALTH PLAN PREMIUMS, FOR WHICH PAYMENT WAGES OR OTHER
FUNDS ARE WITHHELD FROM THE PERSONS INSURED,
SHALL:

	1.	 	CAUSE THE CANCELLATION OR NONRENEWAL OF GROUP HEALTH OR LIFE INSURANCE, HOSPITAL,
MEDICAL, OR DENTAL SERVICE CORPORATION PLAN, MULTIPLE EMPLOYER
WELFARE ARRANGEMENT, OR GROUP HEALTH PLAN COVERAGES AND THE CONSEQUENTIAL LOSS OF THE COVERAGES
OF THE PERSONS INSURED, BY WILLFULLY FAILING TO PAY THOSE PREMIUMS IN ACCORDANCE WITH THE TERMS
OF THE INSURANCE OR PLAN CONTRACT, AND
	 
	2.	 	WILLFULLY FAIL TO DELIVER, AT LEAST 45 DAYS BEFORE THE TERMINATION OF THOSE
COVERAGES, TO EACH NAMED INSURED A WRITTEN NOTICE OF THE PERSON’S INTENTION TO STOP
PAYMENT OF PREMIUMS. THIS WRITTEN NOTICE MUST ALSO CONTAIN A NOTICE TO THE NAMED INSUREDS OF
THEIR RIGHTS TO PURCHASE INDIVIDUAL POLICIES UNDER THE FEDERAL HEALTH INSURANCE PORTABILITY AND
ACCOUNTABILITY ACT AND UNDER ARTICLE 68 OF CHAPTER 58 OF THE GENERAL STATUTES.

Violation of this law is a felony if the insurance is, in whole or in part, paid for out of
wages withheld or other funds collected from the persons insured. Any person violating this law is
also subject to a court order requiring the person to compensate persons insured for expenses or
losses incurred as a result of the termination of the insurance.

					
	 	 	 	 	 
	 	 	 	 	 
	GCERT2000

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NOTICE FOR RESIDENTS OF UTAH

NOTICE TO POLICYHOLDERS

     Insurance companies licensed to sell life insurance, health insurance, or annuities in the
State of Utah are required by law to be members of an organization called the Utah Life and
Health Insurance Guaranty Association (“ULHIGA”). If an insurance company that is licensed to sell insurance in Utah
becomes insolvent (bankrupt), and is unable to pay claims to its policyholders, the law requires ULHIGA to pay
some of the insurance company’s claims. The purpose of this notice is to briefly describe
some of the benefits and limitations provided to Utah insureds by ULHIGA.

PEOPLE ENTITLED TO COVERAGE

	 	•	 	You must be a Utah resident.
	 
	 	•	 	You must have insurance coverage under an individual or group policy.

POLICIES COVERED

	 	•	 	ULHIGA provides coverage for certain life, health and annuity insurance policies.

EXCLUSIONS AND LIMITATIONS

     Several kinds of insurance policies are specifically excluded from coverage. There are also a
number of limitations to coverage. The following are not covered by ULHIGA:

	 	•	 	Coverage through an HMO.
	 
	 	•	 	Coverage by insurance companies not licensed in Utah.
	 
	 	•	 	Self-funded and self-insured coverage provided by an employer that is only
administered by an insurance company.
	 
	 	•	 	Policies protected by another state’s Guaranty Association.
	 
	 	•	 	Policies where the insurance company does not guarantee the benefits.
	 
	 	•	 	Policies where the policyholder bears the risk under the policy.
	 
	 	•	 	Re-insurance contracts.
	 
	 	•	 	Annuity policies that are not issued to and owned by an individual, unless the
annuity policy is issued to a pension benefit plan that is covered.
	 
	 	•	 	Policies issued to pension benefit plans protected by the Federal Pension Benefit
Guaranty Corporation.
	 
	 	•	 	Policies issued to entities that are not members of the ULHIGA, including health
plans, fraternal benefit societies, state pooling plans and mutual assessment companies.

     LIMITS ON AMOUNT OF COVERAGE

     Caps are placed on the amount ULHIGA will pay. These caps apply even if you are insured by
more than one policy issued by the insolvent company. The maximum ULHIGA will pay is the amount of
your coverage or $500,000 — whichever is lower. Other caps also apply:

	 	•	 	$100,000 in net cash surrender values.

					
	 	 	 	 	 
	 	 	 	 	 
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	 	•	 	$500,000 in life insurance death benefits (including cash surrender values).
	 
	 	•	 	$500,000 in health insurance benefits.
	 
	 	•	 	$200,000 in annuity benefits — if the annuity is issued to and owned by an individual
or the annuity is issued to a pension plan covering government employees.
	 
	 	•	 	$5,000,000 in annuity benefits to the contract holder of annuities issued to pension
plans covered by the law. (Other limitations apply).
	 
	 	•	 	Interest rates on some policies may be adjusted downward.

DISCLAIMER

PLEASE READ CAREFULLY:

	 	 	      COVERAGE FROM ULHIGA MAY BE UNAVAILABLE UNDER THIS POLICY. OR, IF AVAILABLE, IT
MAY BE SUBJECT TO SUBSTANTIAL LIMITATIONS OR EXCLUSIONS. THE DESCRIPTION OF
COVERAGES CONTAINED IN THIS DOCUMENT IS AN OVERVIEW. IT IS NOT A COMPLETE
DESCRIPTION. YOU CANNOT RELY ON THIS DOCUMENT AS A DESCRIPTION OF COVERAGE. FOR A
COMPLETE DESCRIPTION OF COVERAGE, CONSULT THE UTAH CODE, TITLE 31A, CHAPTER 28.
	 
	 	 	      COVERAGE IS CONDITIONED ON CONTINUED RESIDENCY IN THE STATE OF UTAH.
	 
	 	 	      THE PROTECTION THAT MAY BE PROVIDED BY ULHIGA IS NOT A SUBSTITUTE FOR
CONSUMERS’ CARE IN SELECTING AN INSURANCE COMPANY THAT IS WELL-MANAGED AND
FINANCIALLY STABLE.
	 
	 	 	      INSURANCE COMPANIES AND INSURANCE AGENTS ARE REQUIRED BY LAW TO GIVE YOU
THIS NOTICE. THE LAW DOES, HOWEVER, PROHIBIT THEM FROM USING THE EXISTENCE OF
ULDIGA AS AN INDUCEMENT TO SELL YOU INSURANCE.

THE ADDRESS OF ULHIGA, AND THE INSURANCE DEPARTMENT ARE PROVIDED BELOW.

Utah Life and Health Insurance

Guaranty Association

955 E. Pioneer Rd.

Draper, Utah 84114

 

Utah Insurance Department

State Office Building, Room 3110

Salt Lake City, Utah 84114

					
	 	 	 	 	 
	 	 	 	 	 
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CIVIL UNION NOTICE FOR RESIDENTS OF VERMONT

Vermont law provides that the following definitions apply to Your certificate:

	•	 	Terms that mean or refer to a marital relationship, or that may be construed to mean or
refer to a marital relationship, such as “marriage,” “spouse,” “husband,” “wife,”
“dependent,” “next of kin,” “relative,”
“beneficiary,” “survivor,” “immediate family” and any other such terms include the
relationship created by a Civil Union established according to Vermont law.
	 
	•	 	Terms that mean or refer to the inception or dissolution of a marriage, such as “date of
marriage,” “divorce decree,” “termination of marriage” and any other such terms include the
inception or dissolution of a Civil Union established according to Vermont law.
	 
	•	 	Terms that mean or refer to family relationships arising from a marriage, such as “family,”
“immediate family,” “dependent,” “children,” “next of kin,” “relative,” “beneficiary,”
“survivor” and any other such terms include family relationships created by a Civil Union
established according to Vermont law.
	 
	•	 	“Dependent” includes a spouse, a party to a Civil Union established according to Vermont
law, and a child or children (natural, stepchild, legally adopted or a minor or disabled
child who is dependent on the insured for support and maintenance) who is born to or brought to a
marriage or to a Civil Union established according to Vermont law.
	 
	•	 	“Child” includes a child (natural, stepchild, legally adopted or a minor or disabled child
who is dependent on the insured for support and maintenance) who is born to or brought to a marriage or to a
Civil Union established according to Vermont law.
	 
	•	 	“Civil Union” means a civil union established pursuant to Act 91 of the 2000 Vermont
Legislative Session, entitled “Act Relating to Civil Unions”.

All references in this notice to Civil Unions are limited to Civil Unions in which the parties are
residents of Vermont.

If dependent insurance for a spouse and/or child is not provided under Your certificate,
such insurance is not added by virtue of this notice.

For purposes of dependent insurance, any person who meets the definition of “dependent” as set
forth in this notice is required to meet all other applicable requirements in order to qualify for
such insurance.

This notice does not limit any definitions or terms included in Your certificate. It broadens
definitions and terms only to the extent required by Vermont law.

DISCLOSURE:

Vermont law grants parties to a Civil Union the same benefits, protections and
responsibilities that flow from marriage under state law. However, some or all of the benefits,
protections and responsibilities related to life and
health insurance that are available to married persons under federal law may not be
available to parties to a Civil Union. For example, a federal law, the Employee Retirement Income Security Act of
1974 known as “ERISA”, controls the employer/employee relationship with regard to determining
eligibility for enrollment in private employer benefit plans. Because of ERISA, Act 91 does not
state requirements pertaining to a private employer’s enrollment of a party to a Civil Union in an ERISA employee
benefit plan. However, governmental employers (not federal government) are required to provide life
and health benefits to the dependents of a party to a Civil Union if
the public employer provides such benefits to dependents of married persons. Federal law
also controls group health insurance continuation rights under “COBRA” for employers with 20 or more employees as
well as the Internal Revenue Code treatment of insurance premiums. As a result, parties to a Civil
Union and their families may or may not have access to certain benefits under this notice and the
certificate to which it is attached that derive from federal law. You are advised to seek
expert advice to determine Your rights under this notice and the certificate to which it is
attached.

					
	 	 	 	 	 
	 	 	 	 	 
	GCERT2000

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FOR RESIDENTS OF VIRGINIA

IMPORTANT INFORMATION REGARDING YOUR INSURANCE

In the event You need to contact someone about this insurance for any reason please
contact Your agent. If no agent was involved in the sale of this insuranæ, or if You have
additional questions You may contact the insurance company issuing this insurance at the
following address and telephone number:

MetLife

200 Park Avenue

New York, New York 10166

Attn: Corporate Customer Relations Department

To phone in a claim related question, You may call Claims Customer Service at:

1-800-275-4638

If You have been unable to contact or obtain satisfaction from the company or the agent,
You may contact the Virginia State Corporation Commission’s Bureau of Insurance at:

The Office of the Managed Care Ombudsman

Bureau of Insurance

P.O. Box 1157

Richmond, VA 23209

1-800-552-7945 — In-state toll-free

1-804-371-9691 — Out-of-state

Or:

The Virginia Department of Health (The Center for Quality Health Care Services and Consumer Protection)

3600 West Broad St

Suite 216

Richmond, VA 23230

1-800-955-1819

Written correspondence is preferable so that a record of Your inquiry is maintained. When
contacting Your agent, company or the Bureau of Insurance, have Your policy number available.

					
	 	 	 	 	 
	 	 	 	 	 
	GCERT2000

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NOTICE FOR RESIDENTS OF WISCONSIN

KEEP THIS NOTICE WITH YOUR INSURANCE PAPERS

PROBLEMS WITH YOUR INSURANCE? - If You are having problems with Your insurance company
or agent, do not hesitate to contact the insurance company or agent to resolve Your problem.

MetLife

Attn: Corporate Consumer Relations Department

200 Park Avenue

New York, NY 10166-0188

1-800-638-5433

You can also contact the OFFICE OF THE COMMISSIONER OF INSURANCE, a state agency which
enforces Wisconsin’s insurance laws, and file a complaint. You can contact the OFFICE OF THE
COMMISSIONER OF INSURANCE by contacting:

Office of the Commissioner of Insurance

Complaints Department

P.O. Box 7873

Madison, WI 53707-7873

1-800-236-8517 outside of Madison or 266-0103 in Madison.

					
	 	 	 	 	 
	 	 	 	 	 
	GCERT2000

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NOTICE FOR RESIDENTS OF ALL STATES

FRAUD WARNING

If You have applied for insurance under a policy issued in one of the following states,
or if You reside in one of the following states, note the following applicable warning:

For Residents of New York — only applies to Accident and Health Insurance (AD&D/Disability/Dental)

Any person who knowingly and with intent to defraud any insurance company or other person
files an application for insurance or statement of claim containing any materially false
information, or conceals for the purpose of misleading, information concerning any fact material
thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil
penalty not to exceed five thousand dollars and the stated value of the claim for each such
violation.

For Residents of Florida

Any person who knowingly and with intent to injure, defraud or deceive any insurer files a
statement of claim or an application containing any false, incomplete or misleading information is
guilty of a felony of the third degree.

For Residents of Massachusetts

Any person who knowingly and with intent to defraud any insurance company or other person
files an application for insurance or a statement of claim containing any materially false
information or conceals, for the purpose of misleading, information concerning any fact material
thereto commits a fraudulent insurance act, and may subject such person to criminal and civil
penalties.

For Residents of New Jersey

Any person who includes any false or misleading information on an application for an
insurance policy or who knowingly files a statement of claim containing any false or misleading
information is subject to criminal and civil penalties.

For Residents of Oklahoma

Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes
any claim for the proceeds of an insurance policy containing any false, incomplete or misleading
information is guilty of a felony.

For Residents of Kansas, Oregon, Washington and Vermont

Any person who knowingly and with intent to defraud any insurance company or other person
files an application for insurance containing any materially false information or conceals, for the
purpose of misleading, information concerning any fact material thereto may be guilty of insurance
fraud, and may be subject to criminal and civil penalties.

For Residents of Puerto Rico

Any person who, knowingly and with the intent to defraud, presents false information in an
insurance request form, or who presents, helps or has presented, a fraudulent claim for the payment
of a loss or other benefit, or presents more than one claim for the same damage or loss, will incur
a felony, and upon conviction will be penalized for each violation with a fine no less than five
thousand (5,000) dollars nor more than ten thousand (10,000), or imprisonment for a fixed term of
three (3) years, or both penalties. If aggravated circumstances prevail, the fixed established
imprisonment may be increased to a maximum of five (5) years; if attenuating circumstances prevail,
it may be reduced to a minimum of two (2) years.

For Residents of Virginia

It is a crime to provide knowingly false, incomplete or misleading information to an
insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines
and denial of insurance benefits.

For Residents of All Other States

Any person who knowingly and with intent to defraud any insurance company or other person
files an application for insurance or a statement of claim containing any materially false
information or conceals, for the purpose of misleading, information concerning any fact material
thereto commits a fraudulent insurance act, which may be a crime and may subject such person to
criminal and civil penalties.

					
	 	 	 	 	 
	 	 	 	 	 
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TABLE OF CONTENTS

	 	 	 	 	 
	Section	 	Page	 
	 
	 	 	 	 
	CERTIFICATE FACE PAGE
	 	 	1	 
	 
	 	 	 	 
	NOTICES
	 	 	2	 
	 
	 	 	 	 
	SCHEDULE OF BENEFITS
	 	 	17	 
	 
	 	 	 	 
	DEFINITIONS
	 	 	18	 
	 
	 	 	 	 
	ELIGIBILITY PROVISIONS: INSURANCE FOR YOU
	 	 	20	 
	 
	 	 	 	 
	Eligible Classes
	 	 	20	 
	 
	 	 	 	 
	Date You Are Eligible for Insurance
	 	 	20	 
	 
	 	 	 	 
	Enrollment Process
	 	 	20	 
	 
	 	 	 	 
	Date Your Insurance Takes Effect
	 	 	20	 
	 
	 	 	 	 
	Date Your Insurance Ends
	 	 	20	 
	 
	 	 	 	 
	CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT
	 	 	22	 
	 
	 	 	 	 
	For Family And Medical Leave
	 	 	22	 
	 
	 	 	 	 
	At Your Option: Portability
	 	 	22	 
	 
	 	 	 	 
	At The Policyholder’s Option
	 	 	23	 
	 
	 	 	 	 
	EVIDENCE OF INSURABILITY
	 	 	24	 
	 
	 	 	 	 
	LIFE INSURANCE: FOR YOU
	 	 	25	 
	 
	 	 	 	 
	LIFE INSURANCE: CONVERSION OPTION FOR YOU
	 	 	26	 
	 
	 	 	 	 
	FILING A CLAIM
	 	 	28	 
	 
	 	 	 	 
	GENERAL PROVISIONS
	 	 	29	 
	 
	 	 	 	 
	Assignment
	 	 	29	 
	 
	 	 	 	 
	Beneficiary
	 	 	29	 
	 
	 	 	 	 
	Entire Contract
	 	 	29	 
	 
	 	 	 	 
	Incontestability: Statements Made by You
	 	 	30	 
	 
	 	 	 	 
	Misstatement of Age
	 	 	30	 
	 
	 	 	 	 
	Conformity with Law
	 	 	30	 
	 
	 	 	 	 
	Autopsy
	 	 	30	 
	 
	 	 	 	 
	Gender
	 	 	30	 

					
	 	 	 	 	 
	 	 	 	 	 
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SCHEDULE OF BENEFITS

This schedule shows the benefits that are available under the Group Policy. You will
only be insured for the benefits:

	•	 	for which You become and remain eligible;
	 
	•	 	which You elect, if subject to election; and
	 
	•	 	which are in effect.

	 	 	 	 	 
	BENEFIT	 	BENEFIT AMOUNTS AND HIGHLIGHTS
	 
	 	 	 	 
	Life Insurance For You
	 	 	 	 
	 
	 	 	 	 
	          For Active Employees
	 		$2,000,000	 
	 
	 	 	 	 
	          Maximum Life Benefit
	 		$2,000,000	 

					
	 	 	 	 	 
	 	 	 	 	 
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DEFINITIONS

As used in this certificate, the terms listed below will have the meanings set forth below.
When defined terms are used in this certificate, they will appear with initial capitalization. The
plural use of a term defined in the singular will share the same meaning.

Actively at Work or Active Work means that You are performing all of the usual and customary duties
of Your job on a Full-Time basis. This must be done at:

	•	 	the Policyholder’s place of business;
	 
	•	 	an alternate place approved by the Policyholder; or
	 
	•	 	a place to which the Policyholder’s business requires You to travel.

You will be deemed to be Actively at Work during weekends or Policyholder approved vacations,
holidays or business closures if You were Actively at Work on the last scheduled work day preceding
such time off.

Beneficiary means the person(s) to whom We will pay insurance as determined in accordance with the
GENERAL PROVISIONS section.

Full-Time means Active Work on the Policyholder’s regular work schedule for the
eligible class of employees to which You belong.

Noncontributory Insurance means insurance for which the Policyholder does not require You to pay
any part of the premium.

Physician means:

	•	 	a person licensed to practice medicine in the jurisdiction where such services are performed; or
	 
	•	 	any other person whose services, according to applicable law, must be treated as Physician’s
services for purposes of the Group Policy. Each such person must be licensed in the
jurisdiction where he performs the service and must act within the scope of that license. He must
also be certified and/or registered if required by such jurisdiction.

The term does not include:

	•	 	You;
	 
	•	 	Your Spouse; or
	 
	•	 	any member of Your immediate family including Your and/or Your Spouse’s:

	 	•	 	parents;
	 
	 	•	 	children (natural, step or adopted);
	 
	 	•	 	siblings;
	 
	 	•	 	grandparents; or
	 
	 	•	 	grandchildren.

Proof means Written evidence satisfactory to Us that a person has satisfied the
conditions and requirements for any benefit described in this certificate. When a claim is made for
any benefit described in this certificate,
Proof must establish:

	•	 	the nature and extent of the loss or condition;
	 
	•	 	Our obligation to pay the claim; and
	 
	•	 	the claimant’s right to receive payment.

Proof must be provided at the claimant’s expense.

					
	 	 	 	 	 
	 	 	 	 	 
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DEFINITIONS (continued)

Signed means any symbol or method executed or adopted by a person with the present intention
to authenticate a record, which is on or transmitted by paper or electronic media which is
acceptable to Us and
consistent with applicable law.

Spouse means Your lawful spouse.

Total Disability or Totally Disabled means that due to an injury or sickness:

	•	 	You are unable to perform the material duties of Your regular job; and
	 
	•	 	You are unable to perform any other job for which You are fit by education, training or
experience.

We, Us and Our mean MetLife.

Written or Writing means a record which is on or transmitted by paper or electronic
media which is acceptable to Us and consistent with applicable law.

You and Your mean an employee who is insured under the Group Policy for the insurance described in
this certificate.

					
	 	 	 	 	 
	 	 	 	 	 
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ELIGIBILITY PROVISIONS: INSURANCE FOR YOU

ELIGIBLE CLASS(ES)

All Full-Time employees of the Policyholder.

All Executives

You are eligible for insurance if You were Actively at Work and covered for insurance on the day
immediately preceding the date of Your retirement and have retired in accord with the
Policyholder’s retirement plan.
Please be aware that:

	•	 	references to Active Work and Actively at Work will not apply; and
	 
	•	 	end of employment will mean the end of the person’s status as a retiree, as stated in the
Policyholder’s retirement plan.

DATE YOU ARE ELIGIBLE FOR INSURANCE

You may only become eligible for the insurance available for Your eligible class as shown in
the SCHEDULE OF BENEFITS.

If You are
in an eligible class on January 1, 2006, You will be eligible for the
insurance described in this certificate on that date.

If You
enter an eligible class after January 1, 2006, You will be eligible for insurance
on the date You enter that class.

Previous Employment With The Policyholder

If You were employed by the Policyholder and insured by Us under a policy of group life
insurance when Your employment ended, You will not be eligible for life insurance under this Group
Policy if You are re-hired by the Policyholder within 2 years after such employment ended, unless
You surrender any individual policy of life
insurance to which You converted when Your employment ended.

The cash value, if any, of such surrendered insurance will be paid to You.

ENROLLMENT PROCESS

If You are eligible for insurance, You may enroll for such insurance by completing an
enrollment form.

DATE YOUR INSURANCE TAKES EFFECT

Rules for Noncontributory Insurance

When You complete the enrollment process for Noncontributory Insurance, such insurance
will take effect on the date You become eligible, provided You are Actively at Work on that date.

If You are not Actively at Work on the date the Noncontributory Insurance would otherwise take
effect, the benefit will take effect on the day You resume Active Work.

DATE YOUR INSURANCE ENDS

Your insurance will end on the earliest of:

	1.	 	the date the Group Policy ends; or
	 
	2.	 	the date insurance ends for Your class; or
	 
	3.	 	the end of the period for which the last premium has been paid for You; or

					
	 	 	 	 	 
	 	 	 	 	 
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ELIGIBILITY PROVISIONS: INSURANCE FOR YOU (continued)

	4.	 	for Executive Life Insurance, the last day of the calendar month in which Your employment
ends; Your employment will end if You cease to be Actively at Work in any eligible class,
except as stated in the section entitled CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT.
	 
	5.	 	for Executive Life Insurance, the last day of the month You retire in accordance with the
Policyholder’s retirement plan.

Please refer to the section entitled LIFE INSURANCE: CONVERSION OPTION FOR YOU for
information concerning the option to convert to an individual policy of life insurance if Your Life
Insurance ends.

In certain cases insurance may be continued as stated in the section entitled CONTINUATION OF
INSURANCE WITH PREMIUM PAYMENT.

					
	 	 	 	 	 
	 	 	 	 	 
	GCERT2000

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CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT

FOR FAMILY AND MEDICAL LEAVE

Certain leaves of absence may qualify under the Family and Medical Leave Act of 1993
(FMLA) for continuation of insurance. Please contact the Policyholder for information regarding
the FMLA.

AT YOUR OPTION: PORTABILITY

For purposes of this subsection the term “Portability Eligible Insurance” refers to Your
Executive Life Insurance.

Evidence of insurability will not be required to exercise this Portability Option. If
You choose not to exercise this Portability Option, Life Insurance benefits may be converted in
accordance with the section entitled LIFE INSURANCE: CONVERSION OPTION FOR YOU.

You may request in Writing during the Request Period specified below to continue
Portability Eligible Insurance if such insurance ends because:

	•	 	Your employment ends; or
	 
	•	 	You cease to be in a class that is eligible for such insurance.

If a request is made under this subsection, We will issue a new certificate of insurance
which will explain the new insurance benefits. The insurance benefits under the new certificate may
not be the same as those that ended under the Group Policy.

For Life Insurance

A request under this subsection may be made, if on the date of the request, the following
requirements are met:

	•	 	The Group Policy is in effect;
	 
	•	 	We have not received notice from the Policyholder of its intent to end the Group Policy;
	 
	•	 	No application has been made to convert the insurance that is to be continued to an individual
policy of life insurance as provided in the section entitled LIFE INSURANCE: CONVERSTION OPTION
FOR YOU; and
	 
	•	 	The person making the request resides in a jurisdiction that permits portability.

Request Period

To
continue Portability Eligible Insurance under a different group policy, We must receive a
completed request form within the Request Period described below.

If written notice of the option to continue Portability Eligible Insuarnce is given within 15
days before or after the date such insurance ends, the Request period begins on the date the
insurance ends and expires 31 days after such date.

If written notice of the option to continue Portability Eligible Insurance is given more
than 15 days after but within 90 days of the date such insurance ends, the Request Period begins on
the date the insurance ends and expires 45 days after the date of the notice.

If written notice of the option to continue Portability Eligible Insurance is not given within
90 days of the date such insurance ends, the Request Period begins on the date the insurance ends
and expires at the end of such 90 day period.

Amount of the New Certificate

					
	 	 	 	 	 
	 	 	 	 	 
	GCERT2000

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	 	22
	 	 

 

 

CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT (continued)

The maximum amount of Executive Life Insurance and Optional Life Insurance that may be
continued is $1,000,000

Premiums for the New Certificate.

When a request to continue Portability Eligible Insurance is made under this subsection, the
first premium must be paid during the Request Period. All premium payments must be made directly to
Us. When We issue the new certificate, We will also provide a schedule of premiums and payment
instructions.

Right to Convert Life Insurance Amounts Not Continued

Any amount of Life Insurance not continued under this subsection may be converted under the
section entitled LIFE INSURANCE: CONVERSION OPTION FOR YOU.

If You Die Within 31 Days of the Days of the date Portability Eligible Insurance ends
and an application for a new certificate is not received by Us during such period, We will
determine whether to pay insurance in accordance with the section entitled LIFE INSURANCE:
CONVERSION OPTION FOR YOU. If an application for a new certificate was received by Us during such
period, We will only pay benefits for the Portability Eligible Insurance applied for in accordance
with this subsection.

AT THE POLICYHOLDER’S OPTION

The Policyholder has elected to continue insurance by paying premiums for his employees
who cease Active Work in an eligible class for any of the reasons specified below;

	1.	 	if You cease Active Work due to injury or sickness contact the Policyholder to determine
if Your insurance can be continued and for how long;
	 
	2.	 	if You cease Active Work due to layoff contact the Policyholder to determine if Your
insurance can be continued and for how long;
	 
	3.	 	if You cease Active Work due to any other Policyholder approved leave of absence discuss
with the Policyholder at the time You receive approval to take the leave of absence whether Your
insurance can be continued and for how long.

At the end of any of the continuation periods listed above, Your insurance will be affected
as follows:

	•	 	if You resume Active Work in an eligible class at this time, You will continue to be insured
under the Group Policy;
	 
	•	 	if You do not resume Active Work in an eligible class at this time, Your employment will be
considered to end and Your insurance will end in accordance with the Date Your Insurance Ends
subsection of the section entitled ELIGIBILITY PROVISIONS: INSURANCE FOR YOU.

Option To Convert

In addition to the Continuation of Insurance options described above, You may have the
right to convert to a policy of individual life insurance. We urge You to read the
section entitled LIFE INSURANCE: CONVERSION OPTION FOR YOU.

					
	 	 	 	 	 
	 	 	 	 	 
	GCERT2000

coi-eport
	 	23
	 	 

 

 

EVIDENCE OF INSURABILITY

No evidence of insurability is required for the insurance described in this certificate.

					
	 	 	 	 	 
	 	 	 	 	 
	GCERT2000

eoi
	 	24
	 	 

 

 

LIFE INSURANCE: FOR YOU

If You die, Proof of Your death must be sent to Us. When We receive such Proof with the
claim, We will review the claim and, if We approve it, will pay the Beneficiary the Life Insurance
in effect on the date of Your death.

PAYMENT OPTIONS

We wil pay the Life Insurance in one sum. Other modes of payment may be available upon request. For
details, call Our toll free number shown on the Certificate Face Page.

					
	 	 	 	 	 
	 	 	 	 	 
	GCERT2000

I/ee
	 	25
	 	 

 

 

LIFE INSURANCE: CONVERSION OPTION FOR YOU

If Your Life Insurance ends or is reduced for any of the reasons stated below, You have
the option to buy an individual policy of life insurance (“new policy”) from Us during the
Application Period in accordance with the conditions and requirements of this section. This is
referred to as the “option to convert”. Evidence of Your insurability will not be required.

When You Will Have the Option to Convert

You will have the option to convert when:

	•	 	Your Life Insurance ends because:

	 	•	 	You cease to be in an eligible class for any reason, including disability;
	 
	 	•	 	Your employment ends for any reason, including disability; or
	 
	 	•	 	the Group Policy ends; or

	•	 	Your Life Insurance is reduced:

	 	•	 	on or after the date You attain age 60;
	 
	 	•	 	because You change from one eligible class to another; or
	 
	 	•	 	due to an amendment of the Group Policy.

If You opt not to convert a reduction in the amount of Your Life Insurance as described
above, You will not have the option to convert that amount at a later date.

Application Period

If You opt to convert Your Life Insurance for any of the reasons stated above, We
must receive a completed conversion application form from You within the Application Period
described below.

If You are given Written notice of the option to convert within 15 days before or after the
date Your Life Insurance ends, the Application Period begins on the date that such Life Insurance
ends and expires 31 days after such date.

If You are given Written notice of the option to convert more than 15 days after but
within 90 days of the date Your Life Insurance ends, the Application Period begins on the date such
Life Insurance ends and expires 45 days from the date of such notice.

If You are not given Written notice of the option to convert within 90 days after the date that
Life Insurance for You ends, the Application Period begins on the date Your Life Insurance ends and
expires at the end of such 90 day period.

Option Conditions

The option to convert is subject to these conditions:

	1.	 	Our receipt within the Application Period of:

	 	•	 	Your Written application for the new policy; and
	 
	 	•	 	the premium due for such new policy;

	2.	 	the premium rates for the new policy will be based on:

	 	•	 	Our rates then in use;
	 
	 	•	 	the form and amount of insurance;
	 
	 	•	 	Your class of risk; and
	 
	 	•	 	Your attained age when Your Life Insurance ends or is reduced;

	3.	 	if insurance ends due to Your Total Disability, the new policy may be on any form then
customarily offered by Us, at Your option, the new policy may be preceded by a one year term
policy;

					
	 	 	 	 	 
	 	 	 	 	 
	GCERT2000

co/l/ee
	 	26
	 	 

 

 

LIFE INSURANCE: CONVERSION OPTION FOR YOU (continued)

	4.	 	if insurance ends for other reasons or is reduced, the new policy may be on any form then
customarily offered by Us excluding term insurance, at Your option, the new policy
may be preceded by a one year term policy;
	 
	5.	 	the new policy will be issued without an accidental death and dismemberment benefit, a
continuation benefit, an accelerated benefit option, a waiver of
premium benefit or any other rider
or additional benefit; and
	 
	6.	 	the new policy will take effect on the 32nd day after the date Your Life Insurance ends or
is reduced; this will be the case regardless of the duration of the Application Period.

Maximum Amount of the New Policy

If Your Life Insurance ends due to the end of the Group Policy, the maximum amount of
insurance that You may elect for the new policy is:

	•	 	the amount of Your Life Insurance that ends under the Group Policy; less
	 
	•	 	the amount of life insurance for which You become eligible under any group policy within 45 days
after the date insurance ends under the Group Policy.

     If Your Life Insurance ends due to Your Total Disability, the maximum amount of insurance that
You may elect for the new policy is:

	•	 	the amount of Your Life Insurance that ends under the Group Policy; less
	 
	•	 	the amount of Your Life Insurance that is replaced within 45 days after the date insurance
ends under the Group Policy.

If Your Life Insurance ends for any other reason or is reduced, the maximum amount of
insurance that You may elect for the new policy is the amount of Your Life Insurance which ends
under the Group Policy.

If an Application For a New Policy For You Is Not Received By Us During the
Application Period and You Die During Such Period

If You die during the Application Period, Proof of Your death must be sent to Us. When We
receive such Proof with the claim, We will review the claim and if We approve it will pay the
Beneficiary the amount of Life Insurance to which you were entitled to convert.

This subsection only applies if an application for a new policy for You was not received by Us
during the Application Period. We will not pay insurance under both a new policy applied for during
the Application Period and this subsection.

					
	 	 	 	 	 
	 	 	 	 	 
	GCERT2000

co/l/ee
	 	27
	 	 

 

 

FILING A CLAIM

The Policyholder should have a supply of claim forms. Obtain a claim form from the
Policyholder and fill it out carefully. Return the completed claim form with the required Proof to
the Policyholder. The Policyholder will certify Your insurance under the Group Policy and send the
certified claim form and Proof to Us.

When We receive the claim form and Proof, We will review the claim and, if We approve it, We will
pay benefits subject to the terms and provisions of this certificate and the Group Policy.

CLAIMS FOR LIFE INSURANCE BENEFITS

When
a claimant files a claim for Life Insurance benefits, Proof should be sent to Us as
soon as is reasonably possible after the death of an insured.

					
	 	 	 	 	 
	 	 	 	 	 
	GCERT2000

claim
	 	28
	 	 

 

 

GENERAL PROVISIONS

Assignment

You may assign Your Life Insurance rights and benefits under the Group Policy as a gift or as
a viatical assignment as described below. In this case, We will recognize the assignee(s) under
such assignment as owner(s) of Your right, title and interest for such Insurance in the Group
Policy if:

	1.	 	a Written form satisfactory to Us, affirming this assignment, has been completed;
	 
	2.	 	the Written form has been Signed by You and the assignee(s);
	 
	3.	 	the Policyholder acknowledges that Your Life Insurance being assigned is in force on the
life of the assignor; and
	 
	4.	 	the Written form is delivered to Us for recording.

You may have made an irrevocable assignment under a group policy that the Group Policy
replaces. In this case, We will recognize the assignee(s) under such assignment as owners of Your
right, title and interest under the Group Policy if:

	1.	 	a Written form satisfactory to Us, affirming this assignment, has been completed;
	 
	2.	 	the Written form has been Signed by You, the assignee(s) and the Policyholder; and
	 
	3.	 	the Written form is delivered to Us for recording.

Beneficiary

You may designate a Beneficiary in Your application or enrollment form. You may change Your
Beneficiary at any time. To do so, You must send a Signed and dated, Written request to the
Policyholder using a form satisfactory to Us. Your Written request to change the Beneficiary must
be sent to the Policyholder within 30 days of the date You Sign such request.

You do not need the Beneficiary’s consent to make a change. When We receive the change, it
will take effect as of the date You Signed it. The change will not apply to any payment made in
good faith by Us before We receive the change.

If two or more Beneficiaries are designated and their shares are not specified, they will
share the insurance equally.

If there is no Beneficiary designated or no surviving designated Beneficiary at Your
death, We may determine the Beneficiary to be one or more of the following who survive You:

	1.	 	Your Spouse;
	 
	2.	 	Your child(ren);
	 
	3.	 	Your parent(s);or
	 
	4.	 	Your sibling(s); or
	 
	5.	 	Your estate.

Instead of making payment to any of the above, we may pay Your estate. Any payment made
in good faith will discharge our liability to the extent of such payment.

Entire Contract

Your insurance is provided under a contract of group insurance with the Policyholder.
The entire contract with the Policyholder is made up of the following:

	1.	 	the Group Policy and its Exhibits, which include the certificate(s);
	 
	2.	 	the Policyholder’s application; and

					
	 	 	 	 	 
	 	 	 	 	 
	GCERT2000

gp/rev
	 	29
	 	 

 

 

GENERAL PROVISIONS (continued)

	3.	 	any amendments and/or endorsements to the Group Policy.

Incontestability: Statements Made by You

Any statement made by You will be considered a representation and not a warranty. We will not
use such statement to contest life insurance, reduce benefits or defend a claim unless the
following requirements are met:

	1.	 	the statement is in a Written application or enrollment form;
	 
	2.	 	You have Signed the application or enrollment form; and
	 
	3.	 	a copy of the application or enrollment form has been given to You or Your Beneficiary.

We will not use Your statements which relate to insurability to contest life insurance
after it has been in force for 2 years during Your life. In addition, We will not use such
statements to contest an increase or benefit addition to such insurance after the increase or benefit
has been in force for 2 years during Your life.

Misstatement of Age

If Your age is misstated, the correct age will be used to determine if insurance is in
effect and, as appropriate, We will adjust the benefits and/or premiums.

Conformity with Law

If the terms and provisions of this certificate do not conform to any applicable law,
this certificate shall be interpreted to so conform.

Autopsy

We have the right to make a reasonable request for an autopsy where permitted by law. Any
such request will set forth the reasons We are requesting the autopsy.

Gender

Male pronouns will be read as female where applicable.

					
	 	 	 	 	 
	 	 	 	 	 
	GCERT2000

gp/rev
	 	30
	 	 

 

 

THIS IS THE END OF THE CERTIFICATE.

THE FOLLOWING IS ADDITIONAL INFORMATION.

 

 

ERISA INFORMATION

NAME AND ADDRESS OF EMPLOYER AND PLAN ADMINISTRATOR

GOLDMAN, SACHS & CO.

180 Maiden Lane, 24th Floor

New York, NY 10038

EMPLOYER IDENTIFICATION NUMBER: 03-5108880

	 	 	 	 	 
	PLAN NUMBER

	 	COVERAGE
	 	PLAN NAME
	 
	 	 	 	 
	502

	 	All Coverages
	 	Goldman, Sachs & Co.

TYPE OF ADMINISTRATION

The above
listed benefits are insured by Metropolitan Life Insurance Company (“MetLife”).

MetLife is liable for all life insurance.

AGENT FOR SERVICE OF LEGAL PROCESS

For disputes arising under the Plan, service of legal process may be made upon the Plan
administrator at the above address. For disputes arising under those portions of the Plan insured
by MetLife, service of legal process may be made upon MetLife at one of its local offices, or upon
the supervisory official of the Insurance Department in the state in which you reside.

ELIGIBILITY FOR INSURANCE; DESCRIPTION OR SUMMARY OF BENEFITS

Your MetLife certificate describes the eligibility requirements for insurance provided by MetLife
under the Plan. It also includes a detailed description of the insurance provided by MetLife under
the Plan.

PLAN TERMINATION OR CHANGES

The group policy sets forth those situations in which the Employer and/or MetLife have the rights
to end the policy.

The Employer reserves the right to change or terminate the plan at any time. Therefore, there
is no guarantee that you will be eligible for the insurance described herein for the duration of
your employment. Any such action will be taken only after careful consideration.

Your consent or the consent of your beneficiary is not required to terminate, modify, amend, or
change the Plan.

In the event Your insurance ends in accord with the “Date Your Insurance Ends”
subsection of Your certificate, you may still be eligible to receive benefits. The
circumstances under which benefits are available are described in Your MetLife certificate.

 

 

CONTRIBUTIONS

No contribution is required for Executive Life Insurance.

The total premium rate for insurance provided under the Plan by MetLife is set by MetLife.

PLAN YEAR

The Plan’s fiscal records are kept on a Plan year basis beginning each January 1st and
ending on the following December 31st.

Qualified Domestic Relations Orders/Qualified Medical Child Support Orders

You and your beneficiaries can obtain, without charge, from the Plan Administrator a copy of
any procedures governing Qualified Domestic Relations Orders (QDRO) and Qualified Medical Child
Support Orders (QMCSO).

CLAIMS INFORMATION

Procedures for Presenting Claims for Life Benefits

All claim forms needed to file for benefits under the group insurance program can be obtained
from the Employer who will also be ready to answer questions about the insurance benefits and to
assist you or, if applicable, the claimant in filing claims. The instructions on the claim form
should be followed carefully. This will expedite the processing of the claim. Be sure all questions
are answered fully.

Routine Questions

If there is any question about a claim payment, an explanation may be requested from the
employer who is usually able to provide the necessary information.

CLAIM SUBMISSION

In submitting claims for life benefits (“Benefits”), the claimant must complete the
appropriate claim form and submit the required proof as described in the certificate.

Claim forms must be submitted in accordance with the instructions on the claim form.

Initial Determination

After MetLife receives your claim for Benefits, MetLife will review your claim and notify you
of its decision to approve or deny your claim.

Such notification will be provided to you within a reasonable period, not to exceed 90 days from
the date we received your claim, unless MetLife notifies you within that period that there are
special circumstances requiring an extension of time of up to 90 additional days.

If MetLife denies your claim in whole or in part, the notification of the claims decision will
state the reason why your claim was denied and reference the specific Plan provision(s) on which
the denial is based. If the claim is denied because MetLife did not receive sufficient information,
the claims decision will describe the additional information needed and explain why such
information is needed. The notification will also include a description of the Plan review
procedures and time limits, including a statement of your right to bring a civil action if
your claim is denied after an appeal.

Appealing the Initial Determination

In the event a claim has been denied in whole or in part, you or, if applicable, your
beneficiary can request a review of your claim by MetLife. This request for review should be
sent in writing to Group Insurance Claims

 

 

Review at the address of MetLife’s office which processed the claim within 60 days after
you or, if applicable, your beneficiary received notice of denial of the claim. When requesting a
review, please state the reason you or, if applicable, your beneficiary believe the claim was
improperly denied and submit in writing any written comments, documents, records or other
information you or, if applicable, your beneficiary deem appropriate. Upon your written request,
MetLife will provide you free of charge with copies of relevant documents, records and other
information.

MetLife will re-evaluate all the information, will conduct a full and fair review of the
claim, and you or, if applicable, your beneficiary will be notified of the decision. Such
notification will be provided within a reasonable period not to exceed 60 days from the date we
received your request for review, unless MetLife notifies you within that period that there are
special circumstances requiring an extension of time of up to 60 additional days.

If MetLife denies the claim on appeal, MetLife will send you a final written decision
that states the reason(s) why the claim you appealed is being denied, references any specific Plan
provision(s) on which the denial is based, any voluntary appeal procedures offered by the Plan, and
a statement of your right to bring a civil action if your claim is denied after an appeal. Upon
written request, MetLife will provide you free of charge with copies of documents, records and
other information relevant to your claim.

Discretionary Authority of Plan Administrator

and Other Plan Fiduciaries

In carrying out their respective responsibilities under the Plan, the Plan administrator
and other Plan fiduciaries shall have discretionary authority to interpret the terms of the Plan
and to determine eligibility for and entitlement to Plan benefits in accordance with the terms of
the Plan. Any interpretation or determination made pursuant to such discretionary authority shall
be given full force and effect, unless it can be shown that the interpretation or determination was
arbitrary and capricious.

STATEMENT OF ERISA RIGHTS

The following statement is required by federal law and regulation.

As a participant in the Plan, you are entitled to certain rights and protections under the Employee
Retirement Income Security Act of 1974 (ERISA). ERISA provides that all participants shall
be entitled to:

Receive Information About Your Plan and Benefits

Examine, without charge, at the Plan administrator’s office and at other specified
locations, all Plan documents, including insurance contracts and a copy of the latest annual
report (Form 5500 Series) filed by the Plan with the U.S. Department of Labor and available at
the Public Disclosure Room of the Employee Benefits Security Administration.

Obtain, upon written request to the Plan Administrator, copies of documents governing the
operation of the Plan, including insurance contracts and copies of the latest annual report (Form
5500 Series) and updated summary plan descriptions. The administrator may make a reasonable
charge for the copies.

Receive a summary of the Plan’s annual financial report. The Plan Administrator is
required by law to furnish each participant with a copy of this summary annual report.

Prudent Actions by Plan Fiduciaries

In addition to creating rights for Plan participants, ERISA imposes duties upon the people
who are responsible for the operation of the employee benefit plan. The people who operate
your Plan, called “fiduciaries” of the Plan, have a duty to do so prudently and in the interest
of you and other Plan participants and beneficiaries.

No one, including your employer or any other person, may fire you or otherwise
discriminate against you in any way to prevent you from obtaining a welfare benefit or
exercising your rights under ERISA.

Enforce Your Rights

 

 

If your claim for a welfare benefit is denied or ignored in whole or in part, you have a
right to know why this was done, to obtain copies of documents relating to the decision without
charge, and to appeal any denial, all within certain time schedules.

Under ERISA, there are steps you can take to enforce the above rights. For instance, if you
request a copy of Plan documents or the latest annual report and do not receive them within 30
days, you may file suit in a Federal court. In such a case, the court may require the Plan
administrator to provide the materials and pay you up to $110 a day until you receive the
materials, unless the materials were not sent because of reasons beyond the control of the
administrator. If you have a claim for benefits which is denied or ignored, in whole or in
part, you may file suit in a state or Federal court.

In addition, if you disagree with the Plan’s decision or lack thereof concerning the
qualified status of a domestic relations order or a medical child support order, you may file
suit in a Federal court.

If it should happen that Plan fiduciaries misuse the Plan’s money, or if you are discriminated
against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or
you may fie suit in a Federal court.

The court will decide who should pay court costs and legal fees. If you are successful, the court
may order the person you have sued to pay these costs and fees.

If you lose, the court may order you to pay these costs and fees; for example, if it finds
your claim is frivolous.

Assistance with Your Questions

If you have any questions about your Plan, you should contact the Plan administrator. If
you have any questions about this statement or about your rights under ERISA, or if you need
assistance in obtaining documents from the Plan administrator, you should contact the nearest office
of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone
directory of the Division of Technical Assistance and Inquiries, Employee Benefits Security
Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C
20210. You may also obtain certain publications about your rights and responsibilities under
ERISA by calling the publications hotline of the Employee Benefits Security Administration.

FUTURE OF THE PLAN

It is hoped that the Plan will be continued indefinitely, but GOLDMAN, SACHS & CO. reserves
the right to change or terminate the Plan in the future. Any such action would be taken only after
careful consideration.

The Board of Directors of GOLDMAN, SACHS & CO. shall be empowered to amend or terminate the Plan or
any benefit under the Plan at any time.EX-10.2

 

Exhibit 10.2

SE III-NY

Mailing Address: 700 Newport Center Drive • Newport Beach, CA 92660

FLEXIBLE PREMIUM VARIABLE UNIVERSAL LIFE INSURANCE

	•	 	Death Benefit Payable on
Death if the Insured Dies

Before The Maturity Date
	 
	•	 	Accumulated Value Less
Policy Debt Payable if the
Insured Lives Until the
Maturity Date
	 
	•	 	Adjustable Face Amount
	 
	•	 	Benefits May Vary Based on
Investment Experience
	 
	•	 	Non-Participating

READ YOUR POLICY CAREFULLY. This is a legal contract between
you, the Owner and us, Pacific Life & Annuity Company, a stock insurance
company. We agree to pay the benefits of this policy according to its
provisions. The consideration for this policy is the application for it, a copy
of which is attached, and payment of the premiums.

PREMIUMS ARE FLEXIBLE, SUBJECT TO MINIMUMS REQUIRED TO
KEEP THE POLICY IN FORCE. VARIABLE ACCOUNT VALUES MAY
INCREASE OR DECREASE DEPENDING UPON VARIABLE ACCOUNT
INVESTMENT EXPERIENCE. THERE IS NO GUARANTEED VARIABLE
ACCOUNT VALUE. POLICY LOAN VALUE IS LESS THAN ONE
HUNDRED PERCENT (100%) OF THE POLICY’S CASH SURRENDER
VALUE.

THE METHOD FOR DETERMINING THE DEATH BENEFIT IS
DESCRIBED IN THE DEATH BENEFIT SECTION OF THIS POLICY.
THE AMOUNT OF THE DEATH BENEFIT MAY BE FIXED OR
VARIABLE ACCORDING TO THE DEATH BENEFIT OPTION
SELECTED AND MAY INCREASE OR DECREASE. THE DURATION
THIS POLICY REMAINS IN FORCE MAY VARY, DEPENDING ON THE
PREMIUMS PAID AND THE INVESTMENT EXPERIENCE OF THE
VARIABLE ACCOUNTS.

Free Look Right — You may return this policy within ten (10) days after you
receive it. To do so, deliver or mail it to us or to our agent. This policy will
be deemed void from the beginning and we will refund the premiums paid.

Signed for Pacific Life & Annuity Company,

	 	 	 
	
	 	
	President and Chief Executive Officer
	 	Secretary

NOTE: IT IS POSSIBLE THAT THE COVERAGE WILL LAPSE IF THE ACCUMULATED VALUE IS INSUFFICIENT TO
PAY THE CHARGES ASSESSED ON A MONTHLY PAYMENT DATE. BECAUSE THE ACCUMULATED VALUE MAY BE BASED ON THE
INVESTMENT RESULTS OF THE VARIABLE ACCOUNTS, THE PAYMENT OF THE INITIAL AND PLANNED PREMIUMS MAY
NOT BE ADEQUATE TO GUARANTEE THAT THE POLICY WILL REMAIN IN FORCE. IF THE POLICY DOES NOT REMAIN IN
FORCE, THERE WILL BE NO DEATH BENEFIT OR ACCUMULATED VALUE.

This is a generic sample policy. Certain states may require specific policy and/or rider language, which is not included. Some riders
may not be available in all states.

P03SE3-NY

 

700 Newport Center Drive • Newport Beach, CA 92660

 

READ YOUR POLICY CAREFULLY. This is a legal contract
between you, the Owner, and us, Pacific Life & Annuity
Company, a stock insurance company. We agree to pay the benefits
of this policy according to its provisions. The consideration
for this policy is the application for it, a copy of which is
attached, and payment of the premiums.

PREMIUMS ARE FLEXIBLE, SUBJECT TO MINIMUMS REQUIRED TO KEEP
THE POLICY IN FORCE. VARIABLE ACCOUNT VALUES ARE NOT GUARANTEED,
AND MAY INCREASE OR DECREASE DEPENDING UPON VARIABLE ACCOUNT
INVESTMENT EXPERIENCE. POLICY LOAN VALUE IS LESS THAN ONE
HUNDRED PERCENT (100%) OF THE POLICY’S CASH SURRENDER
VALUE.

THE METHOD FOR DETERMINING THE DEATH BENEFIT IS DESCRIBED IN
THE DEATH BENEFIT SECTION OF THIS POLICY. THE AMOUNT OF THE
DEATH BENEFIT MAY BE FIXED OR VARIABLE ACCORDING TO THE DEATH
BENEFIT OPTION SELECTED AND MAY INCREASE OR DECREASE. THE
DURATION THIS POLICY REMAINS IN FORCE MAY VARY, DEPENDING ON THE
PREMIUMS PAID AND THE INVESTMENT EXPERIENCE OF THE VARIABLE
ACCOUNTS.

FREE LOOK RIGHT — You may return this policy within
10 days after you receive it. To do so, deliver or mail it
to us or to our agent. This policy will then be deemed void from
the beginning and we will refund the premiums paid.

Signed for Pacific Life Insurance Company,

	 	 	 	 	 
	
    
    
    

    	 	 		 
	
    
    Chairman and Chief Executive Officer
    

    	 	 	Secretary	 

FLEXIBLE PREMIUM VARIABLE UNIVERSAL LIFE INSURANCE

		
	• 	
    Death Benefit Payable On The Death Of The Insured While The
    Policy Is In Force
	 
	• 	
    Net Cash Surrender Value Payable Upon Surrender While The Policy
    Is In Force
	 
	• 	
    Adjustable Face Amount
	 
	• 	
    Benefits May Vary Based On Investment Experience
	 
	• 	
    Non-Participating

SE3-NY

	 	 	 	 	 	 	 	 	 
	
    
    POLICY NUMBER:
    

    	 	 	 	
    OWNER(S):
    	 	 	 	 
	
    
    POLICY DATE:
    

    	 	
    JAN 01, 2006
    	 	 	 	 	 	 
	
    
    RISK CLASSIFICATION:
    

    	 	 	 	
    INSURED:
    	 	 	 	 
	 	 	 	 	
    AGE ON POLICY DATE:
    	 	 	 	 
	 	 	 	 	
    INITIAL FACE AMOUNT:
    	 	$	2,500,000.00	 

NOTE: IT IS POSSIBLE THAT COVERAGE WILL LAPSE IF THE ACCUMULATED
VALUE IS INSUFFICIENT TO PAY THE CHARGES ASSESSED ON A MONTHLY
PAYMENT DATE. BECAUSE THE ACCUMULATED VALUE MAY BE BASED ON THE
INVESTMENT RESULTS OF THE VARIABLE ACCOUNTS, THE PAYMENT OF
INITIAL AND PLANNED PREMIUMS MAY NOT BE ADEQUATE TO GUARANTEE
THAT THE POLICY WILL REMAIN IN FORCE. IF THE POLICY DOES NOT
REMAIN IN FORCE, THERE WILL BE NO DEATH BENEFIT OR ACCUMULATED
VALUE.

103SE3-NY

 

 

POLICY SPECIFICATIONS

BASIC POLICY – FLEXIBLE PREMIUM VARIABLE
UNIVERSAL LIFE INSURANCE

PREMIUMS: PLANNED PERIODIC PREMIUM PAYMENT – $

DEATH BENEFIT QUALIFICATION TEST:

		
	 	
    CASH VALUE ACCUMULATION TEST 

     (THIS ELECTION IS IRREVOCABLE FOR THE LIFE OF THE CONTRACT)

DEATH BENEFIT OPTION: B

INTEREST ON THE FIXED OPTIONS AND ON THE LOAN ACCOUNT IS
GUARANTEED TO BE NOT LESS THAN 3.00% ANNUALLY FOR THE FIRST
10 POLICY YEARS AND 3.30% THEREAFTER. ANY EXCESS INTEREST
RATE DECLARED BY US AT THE BEGINNING OF EACH POLICY YEAR WILL BE
GUARANTEED UNTIL THE END OF THAT YEAR. BEFORE SUCH DECLARATION,
EXCESS AMOUNTS ARE NOT GUARANTEED, THERE IS NO EXCESS INTEREST
PAID ON THE LOAN ACCOUNT. SUBJECT TO POLICY GUARANTEES, WE HAVE
THE RIGHT TO CHANGE THE INTEREST CREDITED TO THE FIXED OPTIONS
AND THE COST OF INSURANCE AND OTHER CHARGES DEDUCTED, WHICH MAY
REQUIRE MORE PREMIUM TO BE PAID THAN WAS ILLUSTRATED OR THE
ACCUMULATED VALUE TO BE LESS THAN WAS ILLUSTRATED.

	 	 	 
	
    
    PREMIUM LOAD:
    

    	 	
    SEE POLICY CHARGE SPECIFICATIONS
    PAGE
    
	
    
    ADMINISTRATIVE CHARGE:
    

    	 	
    SEE POLICY CHARGE SPECIFICATIONS
    PAGE
    
	
    
    WITHDRAWAL FEE:
    

    	 	
    $ 25.00
    
	
    
    SURRENDER CHARGE:
    

    	 	
    SEE POLICY CHARGE SPECIFICATIONS
    PAGE
    
	
    
    M&E RISK CHARGE RATE:
    

    	 	
    SEE POLICY CHARGE SPECIFICATIONS
    PAGE
    

WE HAVE THE RIGHT TO CHANGE THE AMOUNT OF COST OF INSURANCE OR
OTHER EXPENSE CHARGES DEDUCTED UNDER THE POLICY WHICH MAY
REQUIRE MORE PREMIUM TO BE PAID THAN WAS ILLUSTRATED OR THE CASH
VALUES MAY BE LESS THAN THOSE ILLUSTRATED.

THE POLICY MAY NOT CONTINUE UNTIL THE DEATH OF THE INSURED EVEN
IF PLANNED PREMIUMS ARE PAID DUE TO CHANGES IN THE CURRENT
INTEREST RATE CREDITED, INVESTMENT PERFORMANCE OF THE SEPARATE
ACCOUNT, CHANGES IN THE CURRENT EXPENSE LOAD OR COST OF
INSURANCE THAT WERE ILLUSTRATED, LOANS AND PARTIAL WITHDRAWAL
ACTIVITY OR CHANGES IN DEATH BENEFIT OPTIONS.

	 	 	 	 	 
	
    
    POLICY NUMBER:
    

    	 	 	 	
    OWNER (S):
    
	
    
    POLICY DATE:
    

    	 	
    JAN 01, 2006
    	 	
    INSURED:
    
	 	 	 	 	
    AGE ON POLICY DATE:
    
	 	 	 	 	
    INITIAL FACE AMOUNT: $2,500,000.00
    

NOTE: IT IS POSSIBLE THAT COVERAGE WILL LAPSE IF THE ACCUMULATED
VALUE IS INSUFFICIENT TO PAY THE CHARGES ASSESSED ON A MONTHLY
PAYMENT DATE. BECAUSE THE ACCUMULATED VALUE MAY BE BASED ON THE
INVESTMENT RESULTS OF THE VARIABLE ACCOUNTS, THE PAYMENT OF
INITIAL AND PLANNED PREMIUMS MAY NOT BE ADEQUATE TO GUARANTEE
THAT THE POLICY WILL REMAIN IN FORCE. IF THE POLICY DOES NOT
REMAIN IN FORCE, THERE WILL BE NO DEATH BENEFIT OR ACCUMULATED
VALUE.

 

 

POLICY NUMBER:    

POLICY SPECIFICATIONS

TABLE OF INSURANCE CHARGES — BASIC POLICY

GUARANTEED MAXIMUM MONTHLY COST OF INSURANCE RATES PER
$1.00 OF COVERAGE APPLICABLE TO BASIC POLICY COVERING THE RATES BELOW INCLUDE A 5-YEAR GUARANTEE OF OUR CURRENT RATES AS OF THE ISSUE DATE.

	 	 	 	 	 	 	 	 	 	 	 
	AGE	 	MONTHLY RATE	 	AGE	 	MONTHLY RATE	 	AGE	 	MONTHLY RATE
	 	 	 	 	 	 	 	 	 	 	 

 

 

DEFINITIONS

In this
section, we define certain terms used throughout this policy. Other terms may be defined in
other parts of the policy. Defined terms are usually capitalized for emphasis.

Age
- means the Insured’s Age to the nearest birthday as of the Policy Date, increased by the number
of complete policy years elapsed.

Code - is the U.S. Internal Revenue Code, as amended, and the rules and regulations issued
thereunder.

Evidence
of Insurability - is information, including medical information,
satisfactory to us that is
used to determine insurability and the Insured’s risk class.

Face Amount - is used in determining the death benefit under this policy, including any increases
or decreases. The Face Amount is shown in the Policy Specifications.

Fixed Options - consist of the Fixed Account and the Fixed LT Account, which are part of our
general account.

Free Look Transfer Date - is 15 days after the policy is issued, or if later, the date all
requirements necessary to place the policy in force are delivered to the Home Offce.

Home Ofice - means our Life Insurance Operations Center.

Insured - is the person insured under this policy. The Insured is shown in the Policy
Specifications as the Covered Person.

Investment Options - consist of the Variable Accounts and the Fixed Options.

Monthly Payment Date - is the day each month on which certain policy charges are deducted from the
Accumulated Value. This first Monthly Payment Date is the Policy Date. Later Monthly Payment Dates
occur each month after the Policy Date on the same day of the month as the Policy Date.

Net Premium - is the premium we receive reduced by any Premium Load.

PL&A, the Company, we, our, ours and us - refer to Pacific Life & Annuity Company.

Policy
Date - is shown on page 3. Policy months, quarters, years and
anniversaries are measured from
this date.

Policy Debt - is the sum of outstanding policy loans plus accrued Loan Interest.

Policy
Specifications - is a section of your policy containing information generally unique to your
policy.

Separate Account -is the Pacific Select Exec Separate Account, which is a separate account of ours
that consists of subaccounts, also called Variable Accounts. Each Variable Account may invest its
assets in a separate class of shares of a designated investment company or companies.

Valuation Date - is each day required by applicable law and currently includes each day the New
York Stock Exchange is open for trading and our Home Office is open. If any transaction or event is
scheduled to occur on a day that is not a Valuation Date, such transaction or event will be deemed
to occur on the next following Valuation Date unless otherwise specified.

Valuation Period - is the period of time between successive Valuation Dates.

	 	 	 
	P03SE3-NY

	 	Page 5

 

 

Variable
Account - is a subaccount of a separate account of ours in which assets are segregated from
assets in our general account and from assets in other subaccounts.
Premiums and Accumulated Value
under this policy may be allocated to a Variable Account for variable accumulation.

Written
Request - is a request in writing, signed by you, and received by us at our Home Office,
containing such information that we need to act on the request.

You, your or Owner - refer to the Owner of this policy.

OWNER AND BENEFICIARY

Owner
- The Owner of this policy is as shown in the Policy Specifications or in a later Written
Request. If you change the Owner, the change is effective on the date
the Written Request is signed,
subject to our receipt of it. If there are two or more Owners, they will own this contract as joint
tenants with right of survivorship.

Assignment - You may assign this policy by Written Request, subject to the following. An assignment
will take place only when recorded at our Home Office. When recorded,
the assignment will take effect
as of the date the Written Request was signed. Any rights created by
the assignment will be subject to
any payments made or actions taken by us before we record the change. We will not be responsible for
the validity of any assignment.

Beneficiary
- The beneficiary is named by you in the application to receive the death benefit proceeds.
The beneficiary may be one or more persons. If the beneficiary is more than one person, they will share
the death benefit proceeds equally or as you may otherwise specify by Written Request. The interest of
any beneficiary will be subject to any assignment. If you have named a contingent beneficiary, that
person becomes the beneficiary if the beneficiary dies before the Insured. A beneficiary may not, at
or after the Insured’s death, assign, transfer or encumber any
benefit payable. To the extent allowed
by law, policy benefits will not be subject to the claims of any creditor of any beneficiary.

You may make a change of beneficiary by Written Request on a form provided by us while the Insured
is living. The change will take place as of the date the request is signed. Any rights created by the
change will be subject to any payments made or actions taken by us before the Written Request is
received. You may designate a permanent beneficiary whose rights under the policy cannot be changed
without his or her written consent.

The
interest of a beneficiary who does not survive to receive payment will pass to the surviving
beneficiaries in proportion to their share in the proceeds, unless otherwise provided. If no
beneficiaries survive to receive payment, the death proceeds will
pass to the Owner, or the Owner’s
estate if the Owner does not survive to receive payment.

PREMIUMS

Premiums - This policy will not be in force until the initial premium is paid. The initial premium
is
payable either at our Home Office or to our agent. Additional premiums, if any, are payable in
advance at our Home Office. At your request, a premium receipt signed by one of our officers will be
given to you. No premium may be less than $50. Premiums may be paid at any time before the insured
attains age 100, subject to the premium limitations shown later in this section.

Planned
Premium - is the amount of premium you plan to pay. It is shown in the Policy Specifications
and may be changed by Written Request. Payment of the Planned Premium does not guarantee that the
policy will continue in force, nor does failure to pay the Planned Premium, in itself, cause the
policy to enter the Grace Period and be in danger of lapse (see the
Grace Period an Lapse
provision).

	 	 	 
	P03SE3-NY

	 	Page 6

 

 

Premium Allocation Before the Free Look Transfer Date - Any Net Premium received before the Free
Look Transfer Date will be allocated to the Money Market Variable Account on the Policy Date or, if
later, the date the premium is received and accepted by us. On the
Free Look Transfer Date, the
Accumulated Value in the Money Market Variable Account will be allocated to the Investment Options
according to the premium allocation specified in the application or your most recent instructions
received by us, if any.

Premium
Allocation On or After the Free Look Transfer Date - Any Net Premium received by us on or
after the Free Look Transfer Date will be allocated to the Investment Options according to the
premium allocation specified in the application or your most recent instructions received by us, if
any.

Premium
Limitation - We will not accept premiums after the Insured attains Age 100 (except as needed
to keep the policy from lapsing), although you may make a loan repayment at any time. (The policy
provisions regarding loans, partial withdrawals and transfers among
funds remain applicable after the
Insured attains Age 100.) We reserve the right to require Evidence of Insurability, satisfactory to
us, for any unscheduled premium payment that would result in an immediate increase in the
difference between the death benefit and the Accumulated Value.

Guideline
Premium Limitation - This subsection applies only if you have elected the Guideline
Premium Test as the Death Benefit Qualification Test. In order for this policy to be treated as
life insurance under the Code, the sum of the premiums paid less a portion of any withdrawals, as
defined in the Code, may not exceed the greater of:

	•	 	The Guideline Single Premium; or
	 
	•	 	The sum of the annual Guideline Level Premiums to the date of payment.

The Guideline Premiums are shown in the Policy Specifications. The Guideline Premiums may change
whenever there is a change in the Face Amount of insurance or in other policy benefits. Any such
Guideline Premium change will be shown in a supplemental schedule that we will send to you at the
time of the change.

The Guideline Premiums are determined by the rules, which apply to this policy as set forth in the
Code. The Guideline Premiums will be adjusted to conform to any changes in the Code. In the event
that a premium payment would exceed such revised limits, we reserve the right to refund the excess
payment to you, provided that we may not refuse any premium payment necessary to keep this policy
in force. Further, we reserve the right to make distributions from the policy to the extent we deem
it necessary to continue to qualify this policy as life insurance under the Code.

DEATH BENEFIT

Death Benefit - This policy provides a death benefit on the death of the Insured while this policy
is in force. This section describes how the death benefit is calculated. On the date of death, the
death benefit is the larger of:

	•	 	The death benefit as calculated under the Death Benefit Option in effect; or
	 
	•	 	The Minimum Death Benefit calculated under the Death Benefit
Qualification Test elected.

Death Benefit Options - You elect the Death Benefit Option in the application. The Death Benefit
Option for this policy appears in the Policy Specifications. The Death Benefit Options are
explained below.

	•	 	Option A — The death benefit equals the Face Amount.
	 
	•	 	Option B — The death benefit equals the Face Amount plus the Accumulated Value at death.
	 
	•	 	Option C — The death benefit equals the Face Amount plus the sum of the premiums paid minus the
sum of any withdrawals taken and any other distribution of the Accumulated Value to the date of
death. If the sum of the withdrawals is greater than the sum of the premiums paid, then the death
benefit will be less than the Face Amount.

	 	 	 
	P03SE3-NY

	 	Page 7

 

 

Change
of Death Benefit Option - The Death Benefit Option may be changed
to Option A or B upon
Written Request at a maximum of once per year. Changes to Option C
are not permitted. After any
such change, the Face Amount will be that amount which results in the
death benefit after the change
being equal to the death benefit before the change. For this purpose, death benefit is the amount
calculated under the Death Benefit Options, disregarding the Minimum
Death Benefit. The change will
be effective on the Monthly Payment Date on or next following the day we receive your Written
Request at our Home Office. If an option change causes a decrease in
Face Amount, and there have been
prior increases in Face Amount, the original Face Amount and any increases will be decreased in
reverse order.

Death
Benefit Qualification Test - In order for your policy to be classified as life insurance under
the Code, it must satisfy one of two Death Benefit Qualification Tests. Unless you have elected
otherwise, the Death Benefit Qualification Test for this policy is the Guideline Premium Test. The
Death Benefit Qualification Test for this policy appears in the Policy
Specifications. It may not be
changed for the life of the contract. The two Death Benefit Qualification Tests are explained in
this subsection.

1. Cash
Value Accumulation Test (CVAT) - The Minimum Death Benefit will be the amount required for
this policy to be deemed “life insurance” according to the Code, but not less than 101% of the
Accumulated Value.

2. Guideline
Premium Test (GPT) - The Minimum Death Benefit at any time is the Accumulated Value
multiplied by the death benefit percentage for the Age of the Insured as shown in the following
table.

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Death Benefit	 	 	 	Death Benefit	 	 	 	Death Benefit	 	 	 	Death Benefit
	Age	 	Percentage	 	Age	 	Percentage	 	Age	 	Percentage	 	Age	 	Percentage
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	0-40

41

42

43

44

45

46

47

48

49
	 	250%

243

236

229

222

215

209

203

197

191
	 	50

51

52

53

54

55

56

57

58

59
	 	185%

178

171

164

157

150

146

142

138

134
	 	60

61

62

63

64

65

66

67

68

69
	 	130%

128

126

124

122

120

119

118

117

116
	 	70

71

72

73

74

75-90

91

92

93

Over 93
	 	115%

113

111

109

107

105

104

103

102

101

Death
Benefit Proceeds - The death benefit proceeds are the actual amount payable if the Insured dies
while this policy is in force. The death benefit proceeds are equal
to the death benefit, as of the date
of the Insured’s death, less any Policy Debt and less any due and unpaid monthly deductions
occurring during a grace period.

We will
pay the death benefit proceeds to the beneficiary after we receive,
at our Home Office, due
proof of the Insured’s death (certified copies of the death
certificate or, if unavailable, other legal
documentation which we accept) and information sufficient to identify the beneficiary. The death
benefit proceeds paid are subject to the conditions and adjustments defined in other policy
provisions, such as General Provisions, Withdrawals, Policy Loans,
and Timing of Payments and
Transfers. We will pay interest on Death Benefit Proceeds from the
date of death to the date payment
is made at a rate of interest not less than the guaranteed interest
rate used for the Fixed Account
under this policy. If state law requires payment of a greater amount
of interest, we will pay that
amount.

Face
Amount Change - Subject to our approval, the Owner may change the Face Amount if such
request is made:

	•	 	during the lifetime of the Insured;
	 
	•	 	no more often than once in any policy year; and
	 
	•	 	on your Written Request while this policy is in force.

	 	 	 
	P03SE3-NY

	 	Page 8

 

 

Face Amount Increase - An unscheduled increase in Face Amount is subject to evidence of insurability
and will be effective on the first Monthly Payment Date on or following the date all applicable
conditions are met. A supplemental schedule of benefits and premiums will be issued. This schedule
will include:

	•	 	the risk class;
	 
	•	 	the effective date;
	 
	•	 	the M&E Risk Charges;
	 
	•	 	the Surrender Charges;
	 
	•	 	the guaranteed Cost of Insurance Rates;
	 
	•	 	the amount of the increase and the total Face Amount after the increase; and
	 
	•	 	if the Guideline Premium Test is used, the new Guideline Premiums.

For any increase in Face Amount which arises from conversion of a term rider, we will waive the
Surrender Charges and M&E Risk Face Amount Charges that would otherwise apply for the increase.

Limits on Face Amount Increase - An increase in Face Amount will be allowed only if it results in a
death benefit increase no less than our minimum limit in effect on the date of the request. An
increase in Face Amount will not be allowed after the Insured attains Age 100. Also, an increase
will not be allowed if there has been a prior decrease in Face Amount, including any decrease which
occurred as a result of a Withdrawal.

Face Amount Decrease - Starting on the fifth policy anniversary, you may make a request to decrease
the Face Amount by an amount not less than the minimum we allow at such time. The effective date of
the decreased Face Amount will be the first Monthly Payment Date on or following the date we
receive your Written Request. We recommend you consult your tax advisor before requesting a
decrease in policy Face Amount. Upon approval of any unscheduled decrease, we will send you a
supplemental schedule of coverage, which will include the decreased Face Amount, the effective date
of the decrease and, if the Death Benefit Qualification is the Guideline Premium Test, the new
Guideline Premiums. If there have been prior increases in Face Amount, the original Face Amount and
any increase(s) in Face Amount will be decreased in reverse order.

The request for a decrease in the Face Amount will be subject to the Guideline Premium Limit as
defined in the Code. This may result in a refund of premiums and/or the distribution of Accumulated
Value in order to maintain compliance with such limit. Such request will not be allowed if the
resulting Guideline Premium limit could cause an amount in excess of the Net Cash Surrender Value
to be distributed from the policy.

Paid-Up Insurance - On each policy anniversary you have the option to use the Net Cash Surrender
Value to purchase guarantee fixed paid-up insurance on the life of the Insured. At the time of
conversion, the Net Cash Surrender Value will be transferred to our general account. The amount of
paid-up insurance is determined by applying the entire Net Cash Surrender Value as the net single
premium based upon the Insured’s Age and Risk Classification, 1980 CSO mortality and 3% interest. If
the amount of paid-up insurance so determined would exceed the death benefit of the policy
immediately prior to purchase of the paid-up insurance, we will apply only a portion of the Net
Cash Surrender Value to purchase paid-up insurance, and the remainder will be paid to you. In this
case, we will determine the amount of paid-up insurance so that the paid-up insurance plus the Net
Cash Surrender Value paid to you will equal the policy’s death benefit
immediately prior to the purchase of the paid-up insurance. This policy and any riders attached to
it will terminate at the time of conversion. Such paid-up insurance may be surrendered at any time,
with the cash surrender value being determined on the same basis.

Change in Benefits - Under the Guideline Premium Test, any change in policy or rider benefits will
require an adjustment to the Guideline Premium Limit. See the Tax Qualification as Life Insurance
subsection of the General Provisions section for details.

	 	 	 
	P03SE3-NY

	 	Page 9

 

 

'

ACCUMULATED VALUE

Accumulated Value - is defined on each Valuation Date and is the sum of the Fixed Accumulated Value
plus the Variable Accumulated Value plus the Loan Account.

Fixed
Accumulated Value - The Fixed Accumulated Value is the sum of the
Accumulated Value in each
Fixed Option. The Fixed Options consist of the Fixed Account and the Fixed LT Account.

This subsection describes how we calculate the Accumulated Value in each Fixed Option. We credit
interest on a daily basis, using a 365-day year, at a rate not less than an annual effective rate
of 3.0% in policy years 1-10 and 3.30% thereafter. At our discretion, we may credit a higher rate of
interest. Each Fixed Option may have its own unique rate. The interest rate in effect at the
beginning of the policy year will be effective for the duration of that year. The Accumulated Value
for each Fixed Option on any Valuation Date is the following, including interest on each:

	•	 	the Accumulated Value for the Fixed Option on the prior Monthly Payment Date;
	 
	•	 	plus the amount of any Net Premium received and allocated to the Fixed Option since the last
Monthly Payment Date;
	 
	•	 	plus the amount of any transfer to the Fixed Option, including transfers from the Loan Account,
since the last Monthly Payment Date;
	 
	•	 	minus the Monthly Deduction and other deductions due, if any, and assessed against the Fixed
Option; and
	 
	•	 	minus the amount of any withdrawals, or transfers from the Fixed Option, including transfers to
the Loan Account, since the last Monthly Payment Date.

Variable Accumulated Value - The Variable Accumulated Value is the sum of your policy’s Accumulated
Value in each Variable Account.

This subsection describes how we calculate your policy’s Accumulated Value in each Variable Account.
Assets in each Variable Account are divided into Accumulation Units, which are a measure of value
used for bookkeeping purposes. We credit your policy with Accumulation Units in each Variable
Account as a result of:

	•	 	the amount of any Net Premium received and allocated to the Variable Account; and
	 
	•	 	transfers of Accumulated Value to the Variable Account. including transfers from the Loan
Account.

We debit Accumulation Units in each Variable Account as a result of:

	•	 	transfers from the Variable Account, including transfers to the Loan Account;
	 
	•	 	Surrenders and withdrawals from the Variable Account; and
	 
	•	 	the monthly deduction and other deductions due, if any, and assessed against the Variable
Account.

To determine the number of Accumulation Units debited or credited for a transaction, we divide the
dollar amount of the transaction by the Unit Value of the affected Variable Account.

To determine your policy’s Accumulated Value in each Variable Account, we multiply the number of
Accumulation Units in the Variable Account by the Unit Value of the Variable Account. The
number of Accumulation Units in each Variable Account will not change because of subsequent changes
in Unit Value.

At the inception of each Variable Account the Unit Value was $10. The Unit Value of each Variable
Account is adjusted on each Valuation Date. To calculate the Unit Value of a Variable Account on any
Valuation Date, we multiply the Unit Value from the previous Valuation Date by the Net Investment
Factor. The Net Investment Factor for a Variable Account on any
Valuation Date is (a) minus (b),
divided by (c), where:

	 	 	 
	PO3SE3-NY

	 	Page 10

 

 

	(a)	 	is the Net Asset Value of the Variable Account as of the close of the business day, excluding
the impact of any policy transactions since the prior Valuation Date;
	 
	(b)	 	is the value of charges assessed by us since the prior Valuation Date for taxes attributable to
the operation of the Variable Account; and
	 
	(c)	 	is the Net Asset Value of the Variable Account as of the close of the previous Valuation Date.

The Net Asset Value of a Variable Account on any Valuation Date is the Net Asset Value per share for
the Variable Account on the Valuation Date multiplied by the number of shares in the Variable
Account on the Valuation Date. For each Variable Account, the Net Asset Value per share and the
number of shares outstanding are reported to us each Valuation Date by the investment company in
whose shares the Variable Account is invested.

Loan Account - The Loan Account is the amount set aside to secure Policy Debt. We will credit
interest to the Loan Account on a daily basis, using a 365-day year, and the daily equivalent of an
annual effective rate, which we guarantee to be at least 3.0% in policy years 1-10 and 3.30%
thereafter. At our discretion, we may credit a higher rate of interest on the Loan Account. The
amount in the Loan Account on any Valuation Date is the following, including interest on each:

	•	 	the amount in the Loan Account as of the end of the prior Monthly Payment Date;
	 
	•	 	plus any loan taken since the prior Monthly Payment Date; and
	 
	•	 	minus any loan amount repaid since the prior Monthly Payment Date.

On each policy anniversary, if the amount in the Loan Account exceeds policy debt, the excess will
be transferred from the Loan Account to the Investment Options according to your most recent premium
allocation instructions, and if policy debt exceeds the amount in the Loan Account, the excess will
be transferred from the Investment Options on a proportionate basis to the Loan Account.

POLICY CHARGES

Monthly Deduction - Before the Insured attains Age 100, a Monthly Deduction for a policy month is
due on each Monthly Payment Date and is equal to the sum of the following items:

	•	 	the monthly Cost of Insurance Charge;
	 
	•	 	the M&E Risk Charge;
	 
	•	 	the Administrative Charge; and
	 
	•	 	rider or benefit charges, if any.

Unless you have made a Written Request to the contrary, the Monthly Deduction will be charged on
the Monthly Payment Date proportionately to the Accumulated Value in each Investment Option.

After the Insured attains Age 100, there will be no Monthly Deduction.

Cost of Insurance Charge - Beginning on the Policy Date and monthly thereafter until the Insured
attains Age 100, there will be a monthly Cost of Insurance Charge applicable to the following:

	•	 	the initial Face Amount; plus
	 
	•	 	each increase in the Face Amount.

The monthly Cost of Insurance Charge for the death benefit payable under this policy equal to (1)
multiplied by (2), where:

	(1)	 	is the applicable monthly Cost of Insurance Rate; and
	 
	(2)	 	is the Net Amount at Risk.

If there have been increases of Face Amount, then the Net Amount at Risk will be proportionately
allocated to each increase according to the Face Amount of each increase in force as of the Monthly
Payment Date.

	 	 	 
	P03SE3-NY

	 	Page 11

 

 

Net Amount at Risk - The Net Amount at Risk is equal to the death benefit as of the most recent
Monthly Payment Date divided by the Monthly Guaranteed Interest Rate Factor, then reduced by the
Accumulated Value at the beginning of the policy month before the
Monthly Deduction is due. The
Monthly Guaranteed Interest Rate Factor is 1.002466.

Cost of Insurance Rates - The current monthly Cost of Insurance Rates will be determined by us.
These rates will not exceed the Guaranteed Maximum Monthly Cost of Insurance Rates shown in the
Policy Specifications. Cost of Insurance Rates will apply uniformly to all members of the same
class. Class is determined by a number of factors, including the Insured’s Age, Risk Classification,
death benefit, Policy Date and policy duration. Any changes in the Cost of Insurance Rates will
apply uniformly to all members of the same class. Guaranteed Maximum Cost of Insurance rates after
the initial 5-year guarantee are based on the 1980 Commissioner’s Standard Ordinary Mortality
Table.

M&E
Risk Charge - The Mortality and Expense Risk Charge (M&E Risk Charge) is to compensate us for
the risk we assume that mortality, expenses and other costs of providing your policy will be
greater than estimated. Beginning on the Policy Date and monthly thereafter until the Insured
attains Age 100, the M&E Risk Charge will be the sum of the M&E Risk Asset Charge and the M&E Risk
Face Amount Charge.

The
M&E Risk Asset Charge is a percentage of the Variable Accumulated Value. In the first 10 policy
years, the charge is 0.0625% (0.75% annually) of the first $25,000 of Variable Accumulated Value
plus a charge of 0.0292% (0.35% annually) of the Variable Accumulated Value above $25,000. After
the 10th policy year, the charge is 0.0375% (0.45% annually) of the first $25,000 of Variable
Accumulated Value plus a charge of 0.0042 (0.05% annually) of the Variable Accumulated Value above
$25,000. The percentages are also shown in the Policy Specifications.

The
M&E Risk Face Amount Charge is the amount shown in the Policy Specifications, and is based on
the Face Amount at policy issue. If there have been increases in the Face Amount, each increase will
have a corresponding M&E Risk Face Amount Charge related to the amount of the increase. These
charges will be specified in the supplemental schedule of benefits at the time of the increase.

Administrative Charge - Beginning on the Policy Date and monthly thereafter until the Insured
attains Age 100, there will be an Administrative Charge. The amount of the charge is shown in the
Policy Specifications.

Premium Load - A Premium Load will be charged each time that a premium is paid to cover certain
local, state and federal tax and certain sales and distribution costs. The Premium Load will equal the
premium paid multiplied by the Premium Load rate shown in the Policy Specifications. The Premium
Load associated with each premium will be immediately deducted from the premium paid. We reserve the
right to increase the Premium Load with respect to the charge for local, state and federal tax. We
will notify you of any such change.

Other Taxes - In addition to the charges imposed under Premium Load and elsewhere, we reserve the
right to make a charge for federal, state or local taxes that may be attributable to the Variable
Accounts or to our operations with respect to this policy if we incur any such taxes.

Change
In Policy Cost Factors - The Premium Load Rate, Administrative Charge, Cost of Insurance
Charge and Mortality and Expense Risk Charge may change from time to time subject to the maximums
shown in the Policy Specifications. In deciding whether to change any of these factors, We will
periodically consider factors such as Our expectations of future
mortality rates, investment earnings,
persistency experience, operating expenses, and Our costs associated with any applicable federal,
state, and local taxes to see if a change in Our assumptions is needed. Changes in these factors
will be by class. All changes will be determined only prospectively; that
is, We will not recoup prior losses or distribute prior gains by means of these changes.

	 	 	 
	P03SE3-NY

	 	Page 12

 

 

POLICY LAPSE AND REINSTATEMENT

Grace Period and Lapse - If the Accumulated Value less Policy Debt on a Monthly Payment Date
is sufficient to cover the Monthly Deduction due, the policy will continue in force. If the
Accumulated Value less Policy Debt on a Monthly Payment Date is not sufficient to cover the
Monthly Deduction due, a grace period of 61 days will be allowed for the payment of sufficient
premium to keep your policy in force.

The grace period begins on the Monthly Payment Date on which the insufficiency occurred
and ends 61 days thereafter. At the start of the grace period, we will notify you and any
assignee of record at the last known address. The notice will state the due date and the
amount of premium required for your policy to remain in force. A minimum of three times the
monthly deduction due when the insufficiency occurred, plus Premium Load, must be paid. There is no penalty
for paying a premium during
the grace period. Your policy will remain in force during the grace period. If sufficient premium is not
paid by the end of the grace period, a lapse will occur. Thirty-one days prior to lapse, we will
send you and any assignee of record a notice containing the lapse date and the required
premium to keep your policy in force. If the Insured dies during the grace period, the death
benefit proceeds will be reduced by any overdue charges. Upon lapse, the policy will
terminate with no value.

Reinstatement - If it has not been surrendered, this policy may be reinstated not more
than five years after the end of the grace period. To reinstate this policy you must provide
us with the following:

	•	 	A written application;
	 
	•	 	Evidence of Insurability;
	 
	•	 	Sufficient premium to cover all monthly deductions that were due and unpaid during the grace
period; plus
	 
	•	 	Sufficient premium to keep the policy in force for three months after the date of
reinstatement.

The effective date of the reinstated policy will be the first Monthly Payment Date on or
following the date we approve your reinstatement application. When this policy is reinstated, the
Accumulated Value will be equal to the Accumulated Value on the date of lapse subject to the
following. If the policy is reinstated on the first Monthly Payment Date following lapse, any
Policy Debt on the date of lapse will also be reinstated. If the policy is reinstated after
the first Monthly Payment Date following lapse, the
Accumulated Value will be reduced by the amount of any Policy Debt on the date of lapse and
the Policy debt will be extinguished, except that you may instruct us by Written Request to reinstate the
Policy Debt in such case. At reinstatement, the surrender charge will be that in effect at the
beginning of the grace period, and will then decrease each policy month thereafter according
to the successive month-by-month surrender charges shown in the Policy Specifications pages.

TRANSFERS

Transfers - After your initial Net Premium has been allocated according to your instructions
and while your policy is in force, you may, upon Written Request, transfer your Accumulated
Value, or a part of it, among the Investment Options as provided in this section. No
transfer may be made if the policy is in a grace period and the required premium has not been
paid.

We reserve the right:

	•	 	to limit the size of transfers so that each transfer is at least $500;
	 
	•	 	to limit the frequency of transfers (however, at least one transfer per quarter will be
allowed);
	 
	•	 	to require that the remaining balance in any account as a result of a
transfer be at least $500;
	 
	•	 	to assess a charge of $25 for each transfer exceeding 12 per policy year; and
	 
	•	 	to otherwise waive or reduce the restrictions on the transfer provisions described in this section.

					
	 	 	 	 	 
	 	 	 	 	 
	P03SE3-NY
	 	Page 13
	 	 

 

 

Transfers To The Fixed Options- Except during the first 18 policy months during which
transfers to the
Fixed Account are unlimited (see below), transfers to the Fixed Options may be made only during
the policy month preceding each policy anniversary.

Transfers
From The Fixed Account - You may transfer from the Fixed Account an amount up to
the greater of $5,000 or 25% of the Accumulated Value in the Fixed Account, but only one such
transfer may be made in any twelve-month period

Transfers From The Fixed LT Account - You may transfer from the Fixed LT Account an amount
up to the greater of $5,000 or 10% of the Accumulated Value in the Fixed LT Account, but only one
such transfer may be made in any twelve-month period.

Allocations To The fixed Options - We reserve the right to limit the aggregate amount so that
the amount allocated to the Fixed Account combined wit the Fixed LT
Account does not exceed
$1,000,000 during the most recent 12 months for all policies in which you have an ownership interest or
to which payments are made by the same payor. Policies that are MEC’s may not make any allocations
to the Fixed LT Account. Allocations include Net Premium payments, transfers and loan
repayments. Any excess over $1,000,000 will be allocated to your other Investment Options
according to your most recent instructions. We may increase the $1,000,000 limit at any
time at our sole discretion. You may contact us to find out if a higher limit is in effect.

Unlimited Transfer Into the Fixed Account Under Special Circumstances - You may
transfer from any Variable Account to the Fixed Options with no limitation, under the following
circumstances:

	•	 	For a period of time, as described below, after a material change in the investment policy
of that Variable Account; and
	 
	•	 	During the first 18 policy months as long as this policy is not in the grace period.

We will notify you if there is a material change in the investment policy of a Variable
Account. The notice will inform you of your options, including your option to transfer from
such Variable Account to the Fixed
Account within 60 days after (i) the effective date of the
material change or (ii) the date you receive the notice, whichever is later.

SURRENDER AND WITHDRAWAL OF VALUES

Surrender - Upon Written Request while the Insured is living you may surrender this policy for
its Net Cash Surrender Value. The policy will terminate on the date the request is received.

Surrender Charges - A Surrender Charge will be deducted from the Accumulated Value upon
surrender of the policy. The Surrender Charge is needed to help pay for costs such as underwriting,
policy issue and sales and distribution costs. The Surrender Charge varies each policy month
and is shown in the Table of Surrender Charges in the Policy Specifications.

If there have been increases in the Face Amount, each increase will have a corresponding
Surrender Charge related to the amount of the increase. At the time of the increase, we will send you
a supplemental schedule of benefits containing the Table of Surrender Charges for the
increase. If there have been decreases in the Face Amount, including decreases in Face Amount
due to withdrawals, the Surrender Charge will be unchanged as a result of such decrease in Face Amount.

Cash Surrender Value - The Cash Surrender Value is the Accumulated Value less any Surrender
Charge.

Net Cash Surrender Value - The Net Cash Surrender Value is the Cash Surrender Value less any
Policy Debt.

					
	 	 	 	 	 
	 	 	 	 	 
	P0sE3-NY
	 	Page 14
	 	 

 

 

Withdrawals - Upon Written Request on or after the first policy anniversary while the Insured
is living, you may withdraw a portion of the Net Cash Surrender Value of this policy. We
will deduct a withdrawal fee of $25 from the Accumulated Value for each withdrawal. The
withdrawal fee will be deducted from the Investment Options in the same proportion as the
withdrawal.

Withdrawals will be subject to the following conditions: The amount of each withdrawal
must be at least $500 and the Net Cash Surrender Value remaining after each withdrawal must
be at least $500. Also, if there is any Policy Debt at the time of each withdrawal, the amount
of the withdrawal is limited to the
excess, if any, of the Cash Surrender Value immediately prior to the withdrawal over the
result of the Policy Debt divided by 90%.

The amount of each withdrawal will be allocated proportionately to the Accumulated Value in
the Investment Options unless you request otherwise. If the Insured dies after the request
for a withdrawal is sent to us and prior to the withdrawal being effected, the amount of the
withdrawal will be deducted from the death benefit proceeds, which will be determined without
taking the withdrawal into account.

A withdrawal will affect the death benefit, depending on the Death Benefit Option you
have chosen. If your policy’s death benefit is greater than the Minimum Death Benefit, then the
withdrawal will reduce the death benefit by the amount of the withdrawal. However, if your policy’s
death benefit is equal to the Minimum Death Benefit, the withdrawal may cause the death benefit to
decrease by an amount greater than the amount of the withdrawal. For Death Benefit Option C,
if the sum of the withdrawals and other distributions from the policy is greater than the
premiums, the death benefit will be less than the Face Amount.

Withdrawals may also affect the Face Amount. A withdrawal will reduce the Face Amount, but
only for policies having Death Benefit Option A. In such case, a withdrawal in excess of the
difference between the Minimum Death Benefit and the Face Amount will reduce the Face
Amount by the amount of the excess. If a withdrawal requires a decrease in Face Amount and if
there have been prior increases in Face Amount, then the decrease will be applied proportionately
to the various coverage amounts. A withdrawal will never increase the Net Amount at Risk.

TIMING OF PAYMENTS AND TRANSFERS

Variable Accounts - With respect to allocations made to the Variable Accounts, we will
calculate values for surrenders, withdrawals, loans and, unless transfers are restricted,
transfers as of the end of the Valuation Date on or next following the day on which we receive your
instructions. For any portion of death benefit depending on the Variable Accumulated Value, we will
calculate such value as of the end of the Valuation Date on or next following the day on
which the Insured’s death occurs. We will pay such amounts and will process such transfers
within seven days after we receive all the information needed for the transaction. However,
we may postpone the calculation, payment or transfer of any amounts that are based on the
investment performance of the Variable Accounts, if:

	•	 	the New York Stock Exchange is closed on other than customary weekend and holiday closings;
or
	 
	•	 	an emergency exists, as determined by the SEC, as a result of which it is not reasonably
practicable to determine the value of the Account assets or to dispose of Account securities.

Fixed Options - With respect to allocations made to the Fixed Options, we may defer surrenders,
withdrawals, loans (except for loans to pay a premium on any policy issued by us), and
transfers from the Fixed Options, for up to six months after we receive your request.

Deferral - If we defer payment of surrenders, withdrawals or loans for more than 10
days after we receive your request, we will pay interest at the rate required by the state
in which this policy is delivered, but not less than an annual rate of 3%.

					
	 	 	 	 	 
	 	 	 	 	 
	P03SE3-NY
	 	Page 15
	 	 

 

 

INCOME BENEFITS

Income
Benefits - Surrender or withdrawal benefits may be used to buy a lifetime monthly
income as long as the monthly income is at least $100. Death benefits may be used to buy a
monthly income for the lifetime of the beneficiary. The monthly
income is guaranteed to continue for at least ten
years, unless another form of payment is requested. Under the automatic form of payment, if the income
recipient dies before the end of the ten-year period, payments will
continue to the end of the
ten-year period to a person designated by the income recipient in writing.

The purchase rates for the monthly income will be set periodically by the Company. However, under
the automatic form, the monthly income bought by each $1,000 of benefit amount will always be
at least as large as that shown below. Further, we guarantee that if you elect an income
benefit, it will be at least
equal to that of any single premium immediate annuity that we offer at the time of your
election.

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Monthly	 	 	 	 	 	 	Monthly	 	 	 	 	 	 	Monthly	 	 	 	 	 	 	Monthly	 	 	 	 	 	 	Monthly	 
	Age	 	Income	 	 	Age	 	 	Income	 	 	Age	 	 	Income	 	 	Age	 	 	Income	 	 	Age	 	 	Income	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	0-30
	 	 	3.09	 	 	 	40	 	 	 	3.37	 	 	 	50	 	 	 	3.81	 	 	 	60	 	 	 	4.54	 	 	 	70	 	 	 	5.78	 
	32
	 	 	3.14	 	 	 	42	 	 	 	3.44	 	 	 	52	 	 	 	3.93	 	 	 	62	 	 	 	4.73	 	 	 	72	 	 	 	6.11	 
	34
	 	 	3.19	 	 	 	44	 	 	 	3.52	 	 	 	54	 	 	 	4.06	 	 	 	64	 	 	 	4.95	 	 	 	74	 	 	 	6.48	 
	36
	 	 	3.24	 	 	 	46	 	 	 	3.61	 	 	 	56	 	 	 	4.20	 	 	 	66	 	 	 	5.20	 	 	 	75+	 	 	 	6.67	 
	38
	 	 	3.30	 	 	 	48	 	 	 	3.71	 	 	 	58	 	 	 	4.36	 	 	 	68	 	 	 	5.47	 	 	 	 	 	 	 	 	 

Monthly income amount for ages not shown are halfway between the two amounts for the
nearest two ages that are shown. Amounts shown are based on the Annuity 2000 table with
interest at 3.00%. We may require evidence of survival for incomes that last more than ten
years.

Other Income Options - Surrender, withdrawal or death benefits may be used under any other
payment plans that we make available at that time.

POLICY LOANS

Policy
Loans - You may obtain loans by Written Request on the sole security of the Loan Account
of this policy.

Loan Amount Available - The amount available for a loan is equal to 90% of Accumulated Value,
less any Policy Debt and also less and Surrender Charges that would be imposed if the policy were
surrendered on the date the loan is taken or, if greater, the result of (a x b/c)-d, where: a
is the Accumulation Value less 12 times the most recent monthly deduction; b = 1 plus the rate of
interest credited to the Loan Account at the time of the loan; c = 1 plus the rate of interest
charged on the loan at the time of the loan; and d = any existing Policy Debt. The amount of a loan
must be at least $200.

Loan Interest - Interest will accrue daily and is payable in arrears at the annual rate of
3.55%. Interest not paid when due will be added to the loan principal
and bear interest at the same
rate of interest.

Loan Account - When a loan is taken, an amount equal to the loan is transferred out of the
Accumulated Value in the Investment Options into the Loan Account to secure the loan. Unless you
request otherwise, loan amounts will be deducted from the Investment Options on a pro
rata basis, up to the amount available. We will credit interest to the Loan Account as
described in the Accumulated Value section.

On each policy anniversary, if the amount in the Loan Account exceeds Policy Debt, the excess
will be transferred from the Loan Account to the Investment Options according to your most recent
instructions.

					
	 	 	 	 	 
	 	 	 	 	 
	P03SE3-NY
	 	Page 16
	 	 

 

 

If Policy Debt exceeds the amount in the Loan Account. an amount equal to such excess
will be transferred from the Investment Options on a proportionate basis to the Loan Account.

Loan Repayment - Loans may be repaid at any time prior to lapse of this policy. An amount equal to
the portion of any loan repaid, but not more than the amount in the Loan Account, will be
transferred from the Loan Account to the Investment Options according to your most recent instructions.
We reserve the right to first transfer repayments from the Loan Account to each
Fixed Option up to the amount that was originally borrowed. Any excess over such amount will
be transferred to the Variable Accounts according to your most recent instructions.

Any payment we receive from you while you have a loan will be first considered a loan
repayment, unless you tell us in writing it is a premium payment.

SEPARATE ACCOUNT PROVISIONS

Separate Account - We established the Separate Account and maintain it under the laws
and regulations of Arizona and New York. The assets of the Separate Account shall be valued
at least as often as any policy benefits vary, but at least monthly. The Separate Account is
divided into subaccounts. called Variable Accounts. Income and realized and unrealized gains
and losses from the assets of each Variable Account are credited or charged against it without regard to our
other income, gains or losses. Assets may be put in our Separate Account to support this policy and other
variable life policies. Assets may be put in our Separate Account for other purposes, but not
to support contracts or policies other than variable life contracts or policies.

The assets of our Separate Account are our property. The portion of its assets equal to
the reserves and other policy liabilities with respect to our Separate Account will not be
chargeable with liabilities arising out of any other business we conduct. We may transfer assets of
a Variable Account in excess of the reserves and other liabilities with respect to that Variable
Account to another Variable Account or to our general account. All obligations arising under
the policy are general corporate obligations of ours.
We do not hold ourselves out to be trustees of the Separate Account assets.

Variable Accounts - Each Variable Account may invest its assets in a separate class of
shares of a designated investment company or companies. The Variable Accounts of our Separate
Account that were available for your initial allocations are shown in your application for
this policy. From time to time, we may make other Variable Accounts available to you. We will
provide you with written notice of all material details including investment objectives and
all charges.

We reserve the right, subject to compliance with the law
then in effect, to:

	•	 	change or add designated investment companies;
	 
	•	 	add, remove or combine Variable Accounts;
	 
	•	 	add, delete or make substitutions for the securities that are held or purchased by
the Separate Account or any Variable Account;
	 
	•	 	register or deregister any Variable Account under
the Investment Company Act of 1940;
	 
	•	 	change the classification of any Variable Account;
	 
	•	 	operate any Variable Account as a managed investment company or as a unit investment trust;
	 
	•	 	combine the assets of any Variable Account with other separate accounts or subaccounts of ours or our
affiliates;
	 
	•	 	transfer the assets of any Variable Account to other separate accounts or subaccounts of ours
or our affiliates;
	 
	•	 	run any Variable Account under the direction of a committee, board, or other group;
	 
	•	 	restrict or eliminate any voting rights of policy Owners with respect to any Variable
Account, or other persons who have voting rights as to any Variable Account;
	 
	•	 	change the allocations permitted under the policy;
	 
	•	 	terminate and liquidate any Variable Account; and
	 
	•	 	make any other change needed to comply with law.

					
	 	 	 	 	 
	 	 	 	 	 
	P03SE3-NY
	 	Page 17
	 	 

 

 

In spite of the above, we will not transfer any investment, or asset held for investment,
between separate accounts or between separate and other accounts, provided that the superintendent of the New
York Insurance Department may authorize transfers in circumstances where such transfers would not
be inequitable. If any of these changes result in a material change in the underlying
investment of a Variable Account of our Separate Account, we will notify you of such change.

Unless required by law or regulation, an investment policy may not be changed without our
consent. We will not change the investment policy of the Separate Account without the approval
of the Insurance Commissioner of the state of Arizona, our state of domicile, and without the approval of the
Insurance Department of the state of New York. The process for such approval is on file.

SUBSTITUTION OF INSURED

Benefit - Subject to our approval, you may request a substitution of the Insured under this
policy for a new Insured after the first policy year. We will require the following before
we substitute the Insured:

	•	 	The new Insured must submit Evidence of Insurability.
	 
	•	 	You must submit a written application for the substitution.

We may adjust the Face Amount, Accumulated Value and any policy fees and charges to reflect
the new Insured. A revised schedule of benefits will be sent to you outlining the benefits for the
new Insured. Riders on the new Insured will be added only with our consent and subject to our requirements
for those riders. If approved, the substitution will be effective on the next Monthly Payment
Date on or next following our approval.

With
respect to the substituted Insured, the incontestability and suicide exclusion periods
will begin on the substitution date, or any later reinstatement date. If the Substituted Insured
commits suicide, while sane or insane, within 2 years of the effective date of the
substitution, no death benefit proceeds will be paid. Instead, we will return the Net Cash
Surrender Value as of the Substitution Date, plus any premiums paid and less any loans and
Withdrawals taken, or any dividends paid in cash, all since the substitution date.

GENERAL PROVISIONS

Entire Contract - This policy is a contract between you and us. This policy, any
attached endorsements, benefits and riders and the attached copy of the initial application
are the entire contract, except as follows. Any written application for a change in policy
terms allowed by the policy after issue or written notice of exercise of policy options made
after the policy has been issued will also become part of the contract upon our acceptance of
such application or notice and our mailing of same to your address last known to us. Only an
authorized officer is permitted to change this contract or extend the time for paying premiums. Any
such change must be in writing.

All statements in the application shall be deemed representations and not warranties. We will not
use any statement to contest this policy or defend a claim on grounds of misrepresentation unless
the statement is in an application.

Incontestability - We will not contest this policy unless there was a material
misrepresentation in an application, including any reinstatement application. The policy will
terminate upon successful contest.
Except for failure to pay premiums, this policy cannot be contested after the expiration
of the following time periods:

	•	 	The initial Face Amount cannot be contested after the policy has been in force during the
Insured’s lifetime for two years from the later of the Policy Date or any reinstatement
date; and

					
	 	 	 	 	 
	 	 	 	 	 
	P03SE3-NY
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	•	 	An increase in the Face Amount, which was applied for and for which evidence of
insurability was required, cannot be contested after the increased amount has been in force
during the Insured’s lifetime for two years from the later of its effective date or any
reinstatement date; and
	 
	•	 	If this policy was issued under a term insurance conversion option, the convert amount cannot be
contested after the policy has been in force during the Insured’s lifetime for two years from
the later of the issue of the term policy or rider or any reinstatement date of the term
policy or of this policy.

Non-Participating - This policy will not share in any of our surplus earnings.

Juvenile Insured - If an Insured’s Age on the Policy Date is under 20, the Insured may apply
for Nonsmoker risk status on attaining Age 20. This option must be requested in writing and
accompanied by satisfactory evidence of nonsmoking.

Suicide
Exclusion - If the Insured dies by suicide within two years of the Policy Date, no
death benefit proceeds will be paid. Instead, we will return the sum
of the premiums paid, less the
sum of any Policy Debt and withdrawals. If the Insured dies by suicide within two years of the effective date
of any increase in the Face Amount which was applied for after the Policy Date, no benefit
will be paid with respect to such increase. Instead, we will refund the Cost of Insurance Charges made with respect to that increase.

If any insurance amount of this policy was issued under a term insurance conversion
option, the two-year period for excluding death by suicide for such amount does not star
anew, but is effective as of the issue date of the term policy or rider.

Misstatement - If it is discovered after the Insured dies that the Insured’s age was
misstated on the application, the death benefit will be adjusted so that the Net Amount at
Risk (NAR) after adjustment is the NAR before the adjustment multiplied by the ratio of the
incorrect Cost of Insurance (COI) rate to the correct COI rate. If the Minimum Death Benefit
after the adjustment is larger, the death benefit will be this larger amount.

Reports - A report will be mailed to you at the end of each policy year to your last
known address. This report will include the following information for the policy year:

	•	 	the Accumulated Value;
	 
	•	 	the Cash Surrender Value;
	 
	•	 	the current death benefit;
	 
	•	 	any Surrender Charges;
	 
	•	 	any existing Policy Debt;
	 
	•	 	transactions that occurred during the policy year;
	 
	•	 	changes in the Guideline Premiums, if applicable; and
	 
	•	 	any information required by law.

In addition to the above reports, an annual report will also be mailed to you. The
report will contain financial statements for the Separate Account and the designated
investment company or companies or other designated portfolio(s) in
which the Separate Account invests, the
latter of which will include a list of the portfolio securities of the investment company, as
required by the Investment Company Act of 1940, and of any other designated portfolio. We will also send any
other reports as required by federal securities law.

Policy Illustrations - Upon request we will give you an illustration of the future
benefits under this policy based upon both guaranteed and current cost factor assumptions.
However, if you ask us to do this more than once in any policy year, we reserve the right to
charge you a fee not to exceed $25 per request for this service. Illustrated benefits that
are not guaranteed, such as benefits based on the current cost factor assumptions, will vary
depending upon a number of factors, including but not limited to, changes in future
investment performance.

					
	 	 	 	 	 
	 	 	 	 	 
	P03SE3-NY
	 	Page 19
	 	 

 

 

Basis
of Values - A detailed statement showing how values are
determined has been filed with the state
insurance department, if required. All values are at least equal to the minimums
required by the law of the state in which this policy is delivered. The values are based on
the Commissioner’s 1980 Standard
Ordinary Mortality Table and interest at the rate of 3%, except for unisex issues which are
based on the 1980 CSO Table B and interest at the rate of 3%.

Ownership of Assets - We have the exclusive and absolute control of our assets, including
all assets in the Separate or Variable Accounts.

Tax Qualification as Life Insurance - This policy is intended to qualify as a life insurance
contract for federal tax purposes, and the death benefit under this policy is intended to
qualify for federal income tax exclusion. The policy, including any other rider, benefit or
endorsement, shall be interpreted to ensure
and maintain such tax qualification, despite any other provision to the contrary. We will not
accept a premium payment, which would cause the policy to fail to qualify as a life insurance
contract for federal tax purposes.

If at any time the premiums paid under the policy exceed the amount allowable for such tax
qualification,
the excess amount, including any associated investment gains or losses, shall be removed
from the policy as of the date of its payment, and any appropriate adjustment in the death
benefit shall be made as of such date. The excess amount, as determined under federal tax
law, including any associated investment gains or losses, shall be
refunded no later than 60
days after the end of the applicable contract year. For any such refund, any premium load
originally assessed will be refunded and no surrender charges will apply.

If this
excess amount is not refunded by the end of such 60-day period, the death benefit
shall be increased retroactively to the minimum extent necessary so that at no time is the death
benefit ever less than the amount necessary to ensure or maintain such tax qualification, and
the Accumulated Value will be reduced to reflect the increased Monthly Deductions as a result of
such death benefit increase.

If you request a decrease in policy or rider benefits, it may cause a reduction in any
applicable limitations on premiums or cash values for the policy under federal tax law. Such a
reduction in these limits may require us to make a distribution from the policy equal to the greatest amount by
which the premiums paid or cash values for the policy, as determined under federal tax law, exceed
any such reduced limits, in order to maintain the policy’s tax qualification. If such a
distribution is made, the distribution will be paid to you and the Accumulated Value will be
reduced by the amount of the distribution. However, no
request for a decrease in policy or rider benefits will be allowed to the extent that the
resulting reduction in such tax limits would require us to distribute more than the Net Cash Surrender Value for
the policy.

Continuation of coverage past Age 100 may disqualify insurance under this policy for
favorable tax treatment. You should consult your personal tax advisor.

MEC Status - MEC stands for Modified Endowment Contract. Unless you have given us Written
Notice to the contrary, the provisions of this MEC Status subsection apply. Under federal tax law,
if the funding of a life insurance contract occurs too rapidly, it
becomes a MEC and fails to
qualify for certain favorable treatment as a result. This policy is intended to qualify as a
life insurance contract that is not a MEC for federal tax purposes. This policy, including any
other rider, benefit or endorsement, shall be interpreted to prevent the policy from being
subject to such MEC treatment, despite any other provision to the
contrary. We will not accept a payment as premium or otherwise which would cause the policy to
become a MEC.

If at any time the amounts paid under the policy exceed the limit for avoiding such MEC
treatment, the excess amount, including any associated investment gains or losses, shall be removed
from the policy as of the date of its payment, and any appropriate adjustment in the death benefit shall be
made as of such date. The excess amount, as determined under federal tax law, including any associated
investment gains or losses, shall be refunded no later than 60 days after the end of the
applicable

					
	 	 	 	 	 
	 	 	 	 	 
	P03sE3-NY
	 	Page 20
	 	 

 

 

contract year. For any such refund, any premium load originally assessed will be refunded and
no surrender charges will apply.

If this excess amount is not refunded by the end of such 60-day period, the death
benefit shall be increased retroactively to the minimum extent necessary so that at no time is
the death benefit ever less than the amount necessary to avoid such MEC treatment, and the
Accumulated Value will be reduced to reflect the increased Monthly Deductions as a result of
such death benefit increase.

Any request that would change the death benefits under the policy and riders will not be
processed if the change would cause the policy to be treated as a MEC. Such changes include a
reduction in the Face Amount, a change in death benefit option, and a reduction in Face Amount due to a withdrawal.

Other Distributions of Accumulated Value - If the Net Amount at Risk ever exceeds three
times the original Face Amount, we reserve the right to make a distribution of Accumulated
Value to make the Net Amount at Risk equal three times the original Face Amount. In such case, the distribution
will be treated as a premium refund and no surrender charge will be imposed. By treating the distribution
as a premium refund, we mean that, in addition to the distribution of Accumulated Value, which
you will receive, we will also pay you an amount representing a return of premium load associated
with the distribution. The amount representing the return of premium load will be equal to the
reduction in Accumulated Value multiplied by (1/(1-premium load rate))-1, provided that
such amount can never exceed the total premium load paid under the policy.

Compliance - We reserve the right to make any change to the provisions of this policy to
comply with, or give you the benefit of, any Federal or state statute, rule, or regulation,
including but not limited to requirements for life insurance contracts under the Code or any
state. We will provide you with a copy of any such change, and file
such a change with the
insurance supervisory official of the state in which this policy is delivered. You have the
right to refuse any such change.

Termination - This policy terminates on the earliest of:

	•	 	the death of the insured;
	 
	•	 	lapse of the policy; or
	 
	•	 	surrender of the policy.

					
	 	 	 	 	 
	 	 	 	 	 
	P03SE3-NY
	 	Page 21
	 	 

 

 

INDEX

	 	 	 	 	 
	 	 	Page	 
	Accumulated Value
	 	 	10	 
	Administrative Charge
	 	 	12	 
	Age
	 	 	5	 
	Assignment
	 	 	6	 
	Basis of Values
	 	 	20	 
	Beneficiary
	 	 	6	 
	Cash Surrender Value
	 	 	14	 
	Cash Value Accumulation Test (CVAT)
	 	 	8	 
	Change in Policy Cost Factors
	 	 	12	 
	Change of Death Benefit Option
	 	 	8	 
	Code
	 	 	5	 
	Compliance
	 	 	21	 
	Cost of Insurance Charge
	 	 	11	 
	Cost of Insurance Rates
	 	 	12	 
	Death Benefit
	 	 	7	 
	Death Benefit Options
	 	 	7	 
	Death Benefit Proceeds
	 	 	8	 
	Death Benefit Qualification Test
	 	 	8	 
	Entire Contract
	 	 	18	 
	Evidence of Insurability
	 	 	5	 
	Face Amount
	 	 	5	 
	Face Amount Change
	 	 	8	 
	Face Amount Decrease
	 	 	9	 
	Face Amount Increase
	 	 	9	 
	Fixed Accumulated Value
	 	 	10	 
	Fixed Options
	 	 	5, 15	 
	Free Look Transfer Date
	 	 	5	 
	Grace Period
	 	 	13	 
	Guideline Premium Limitation
	 	 	7	 
	Guideline Premium Test (GPT)
	 	 	8	 
	Home Office
	 	 	5	 
	Income Benefits
	 	 	16	 
	Incontestability
	 	 	18	 
	Insured
	 	 	5	 
	Investment Options
	 	 	5	 
	Lapse
	 	 	13	 
	Limits on Face Amount Increase
	 	 	9	 
	Loan Account
	 	 	11, 16	 
	Loan Amount Available
	 	 	16	 
	Loan Interest
	 	 	16	 
	Loan Repayment
	 	 	17	 
	M&E Risk Charge
	 	 	12	 
	MEC Status
	 	 	20	 
	Misstatement
	 	 	19	 
	Modified Endowment Contract
	 	 	20	 
	Monthly Deduction
	 	 	11	 
	Monthly Payment Date
	 	 	5	 
	Mortality and Expense Risk Charge
	 	 	12	 
	Net Amount at Risk
	 	 	12	 
	Net Premium
	 	 	5	 
	Non-Participating
	 	 	19	 
	Owner
	 	 	6	 
	Paid-Up Insurance
	 	 	9	 
	Planned Premium
	 	 	6	 
	Policy Charges
	 	 	11	 
	Policy Date
	 	 	5	 
	Policy Debt
	 	 	5	 
	Policy Illustrations
	 	 	19	 
	Policy Loans
	 	 	16	 
	Policy Specifications
	 	 	5	 
	Premium Limitation
	 	 	7	 
	Premium Load
	 	 	12	 
	Premiums
	 	 	6	 
	Reinstatement
	 	 	13	 
	Reports
	 	 	19	 
	Separate Account
	 	 	5, 17	 
	Substitution of Insured
	 	 	18	 
	Suicide Exclusion
	 	 	19	 
	Surrender
	 	 	14	 
	Surrender Charges
	 	 	14	 
	Tax Qualification as Life Insurance
	 	 	20	 
	Termination
	 	 	21	 
	Transfers
	 	 	13	 
	Valuation Date
	 	 	5	 
	Valuation Period
	 	 	5	 
	Variable Account
	 	 	6	 
	Variable Accounts
	 	 	15, 17	 
	Variable Accumulated Value
	 	 	10	 
	Withdrawals
	 	 	15	 
	Written Request
	 	 	6	 

					
	 	 	 	 	 
	 	 	 	 	 
	P03SE3-NY
	 	Page 22
	 	 

 

 

ANNUAL RENEWABLE AND CONVERTIBLE TERM RIDER

Covered Person - As used in this rider,
the term “Covered Person” means any of
the persons covered under this rider on
the Policy Date. Covered Persons may be
deleted from or, with evidence of
insurability, added to this rider.
When this occurs, we will give you a
revised Policy Specifications page.

Benefit Amount- This rider
provides term insurance on any Covered
Person under this rider. This rider
has no cash value, but it affects the
cash value of the policy. The Benefit Amount is shown on the
Policy Specifications pages for each Covered Person.
Any reduction in Benefit Amount for any year
may require a reduction in Benefit
Amounts for future years. Any decrease
in the face amount of the policy to
which this rider is attached may
require a decrease in the Benefit
Amounts under this rider. We will pay
the Benefit Amount for this rider when we receive proof that
the death of a Covered Person occurred while
this rider was in force.

Cost of Insurance Charges - The Cost of
Insurance Charges for this rider
are calculated separately for each Covered
Person. The monthly Cost of Insurance Charge for any
Covered Person is equal to the product of the
applicable monthly cost of insurance rate times
the Benefit Amount for such Covered Person.
The cost of insurance rates are
based on a number of factors,
including the Covered
Person’s attained Age and risk class and
the duration of this rider. The current
monthly cost of insurance rates will be determined by us.
These rates will not exceed the
Guaranteed Maximum Monthly Cost of
Insurance Rates shown on the Policy
Specifications pages.

Renewal - Coverage under this rider
will be automatically renewed for each
Covered Person on each monthly payment date
for which there is an applicable Guaranteed
Maximum Monthly Cost of Insurance Rate shown
on the Policy Specifications pages.

Conversion - While this rider is in force or
upon termination of this policy by death of the
Insured, the Benefit Amount for
this rider may be converted to a new
policy on any Covered
Person’s life at any time before such Covered
Person becomes Age 65. This rider
may be converted during the first two
years it is in force regardless of the
Covered Person’s Age. The
Covered Person’s Benefit Amount
for this rider will be cancelled on
the new policy’s issue date.
The amount of insurance under the
new policy will be the same as the
Covered Person’s
Benefit Amount under this rider. A
lower amount may be selected as long as
it is not less than our regular minimum
limit at the time of conversion. The new
policy may be on the whole life or any
higher premium plan we regularly issue
at the time of conversion. It will be
issued in the same underwriting class and
contain the same restrictions, if any, as
this rider. It will be issued at our
published rates which apply at the
Covered Person’s Age on the
new policy’s issue date. Riders will not be
included in the new policy without
our consent at the time. If we are
waiving charges for this rider at the
Covered Person’s Age 65, and if this
rider is converted to a whole life
policy in the manner described above,
we will waive premiums under the new
policy while total disability continues
without interruption.

Effective Date - This rider is
effective on the policy date unless
otherwise stated. This rider will terminate
on the earliest of the following:

	•	 	on your written request;
	 
	•	 	on lapse or termination of this policy; or
	 
	•	 	when the last person covered by this rider becomes Age 80.

General Conditions - This rider is
part of the policy to which it is attached.
As applied to this rider, the periods
stated in this policy’s Incontestability and
Suicide provisions will start with this
rider’s effective date. This will also
apply to any increase in the Face
Amount applied for under this rider.
All terms of this policy that do not
conflict with this rider’s terms apply to
this rider.

Signed for Pacific Life & Annuity Company

	 	 	 
	
	 	
	President and Chief Executive Officer
	 	Secretary

R98-SPT-NY

 

 

ANNUAL RENEWABLE AND CONVERTIBLE TERM INSURANCE RIDER

Insured - As used in this rider, “Insured” means the individual covered under the policy.

Annual Renewable Term (ART) Face Amount - The ART Face Amount provided by this rider is shown in
the Policy Specifications.

Death Benefit Option - This rider provides term insurance on the Insured under this policy.
This rider has no cash value, but it affects the cash value of the policy. The death benefit
of the policy to which this rider
is attached is modified to include the ART Face Amount under this rider. It is now as
follows: The death benefit equals the greater of the Minimum Death Benefit or the death
benefit as calculated under one of the options below:

	•	 	Option A: The death benefit is the Face Amount of the policy plus the ART Face Amount;
	 
	•	 	Option B: The death benefit is the Face Amount of the policy plus the ART Face Amount plus the
Accumulated Value on the date of death;
	 
	•	 	Option C: The death benefit is the Face Amount of the
policy plus the ART Face Amount plus the sum of the premiums paid minus the sum of any withdrawals
taken and any other distribution of the Accumulated Value to the date of death. If the sum of the
withdrawals is greater than the sum of the premiums paid, then the death benefit will be less than
the Face Amount.

Changing the ART Face Amount - Subject to our approval, you may change the ART Face Amount
by Written Request during the lifetime of the Insured. Such request may be made not more than
once per policy year.

ART Face Amount Increases - You must provide evidence of insurability satisfactory to us
before any request for an increase in ART Face Amount becomes effective. An Administrative Charge
not to exceed $100 will be deducted from the policy’s Accumulated Value on the effective date of
any such increase in ART Face Amount. The effective date of the increase will be the first Monthly
Payment Date on or following the date all applicable conditions are met.

ART Face Amount Decreases - Any decrease in ART Face Amount that you request for any policy
year will first be applied against the most recent increase, if any, and then against
successively earlier increases, if any, and finally against the original ART Face Amount. The
effective date of the decrease will be the first Monthly Payment Date on or following the date we
receive your Written Request.

Cost of Insurance Charge - Beginning on the Policy Date and for every month thereafter, there
will be a charge equal to the Cost of Insurance Charge applicable to the following:

	•	 	the initial ART Face Amount; plus
	 
	•	 	each increase in the ART Face Amount.

The monthly Cost of Insurance Charge for the death benefit payable under this rider is (1)
multiplied by (2) where:

	(1)	 	is the applicable monthly Cost of Insurance Rate for
this rider; and
	 
	(2)	 	is the Net Amount at Risk attributed to the ART Face Amount.

The Net Amount at Risk for the policy is calculated by taking the total death benefit of the policy
divided by 1.002466 and subtracting the Accumulated Value at the beginning of the policy month
before the Monthly Deduction is due.

The Net Amount at Risk is allocated between the policy and this rider in proportion to
the Face Amounts of each as of the Monthly Payment Date.

					
	 	 	 	 	 
	 	 	 	 	 
	R98-ART-NY
	 	Page 1
	 	 

 

 

If there have been increases in the ART Face Amount, the Net Amount at Risk will be
proportionately allocated to each increase according to the Face
Amount of each increase in force
as of the Monthly Payment Date.

Cost of
Insurance Rates - The Cost of Insurance Rates are based on a number of factors,
including the Insured’s Age, Risk Classification and the policy duration. The current monthly Cost of
Insurance Rates will be determined by us. These rates will not exceed the Guaranteed Maximum
Monthly Cost of Insurance Rates shown in the Policy Specifications. Any changes in the Cost of
Insurance Rates will apply uniformly to all members of the same class
and based on changes in our
expectations of future mortality, persistency and expenses. Any such change will be
determined in accordance with procedures and standards on file with the Insurance Department
of the state of New York. Cost of insurance rates and other expense factors will be reviewed no
more frequently than annually and no less frequently than once every five years to determine
whether an adjustment is necessary.

The Cost of Insurance Rates used to calculate the Cost of Insurance Charges for an increase
in coverage necessary to meet the Guideline Minimum Death Benefit will be the same as shown in
the Policy Specifications.

M&E Risk Face Amount Charge - The M&E Risk Face Amount Charge for this rider is to compensate
us for the risk we assume that mortality, expenses and other costs associated with the rider
will be greater than estimated.

The amount of this charge will not exceed the monthly charges shown in the Policy
Specifications. We reserve the right to charge less than such amount. The amount of this charge is based on the
amount of insurance issued under this rider and any subsequent
increases as shown in the Policy
Specifications.

Withdrawals - The Withdrawals provision of the policy, to which this rider is attached,
is modified to include this rider. For the purpose of the Withdrawals provision, this rider is
treated the same as any other increase in the policy Face Amount. For further details, please
see the Withdrawals provision of your contract.

Conversion - Coverage under this rider is convertible to an increase in Face Amount of the
policy to which this rider is attached after 5 years from the effective date of the rider
coverage or at the Insured’s Age 80, if earlier. Cost of insurance rates for such conversion
amount will be those applicable for conversions. No evidence of insurability will be required.
The ART Face Amount will be cancelled on the effective date of the corresponding increase in
policy Face Amount.

Effective Date - This rider is effective on the Policy Date unless otherwise notified.

Termination - This rider will terminate on the earliest of the following:

	•	 	the Insured’s Age 80; or
	 
	•	 	your Written Request; or
	 
	•	 	lapse of the policy; or
	 
	•	 	conversion of this rider; or
	 
	•	 	termination of the policy.

General Conditions - This rider is part of the policy to which it is attached. As applied
to this rider, the periods stated in this policy’s Incontestability and Suicide provisions will
start with this rider’s effective date. This will also apply to any increase in the Face Amount under
this rider. All terms of this policy that do not conflict with this rider’s terms apply to
this rider.

Signed for Pacific Life & Annuity Company

	 	 	 
	

	 	
	President and Chief Executive Officer

	 	Secretary

					
	 	 	 	 	 
	 	 	 	 	 
	R98-ART-NY
	 	Page 2
	 	 

 

 

Mailing Address: 700 Newport Center Drive • Newport Beach, CA 92660

 

FLEXIBLE

PREMIUM

VARIABLE UNIVERSAL LIFE

INSURANCE

	•	 	Death Benefit Payable on Death if the Insured Dies Before The Maturity Date
	 
	•	 	Accumulated Value Less Policy Debt Payable if the Insured Lives Until the Maturity Date
	 
	•	 	Adjustable Face Amount
	 
	•	 	Benefits May Vary Based on Investment Experience
	 
	•	 	Non-Participating

 

 

                    CEBP

Pacific Life & Annuity Company

	 	 	 	 	 
	Mailing

Address

	 	Life Insurance Operations Center

P0 BOX 6520 Newport Beach, CA 92658-6520

(888) 595-6997
	 	

Executive Life Insurance Program

Agreement To Restrict Policy Owner’s Rights

	 	 	 	 	 	 
	 	 	 	 	 	 
	 	Proposed Insured

	 	 	Application/Policy Number	 
	 	 

	 	 	 	 
	 	 

	 	 	 	 
	 	 	 	 	 	 

			
	The Owner of the Policy is	 	
 

Goldman Sachs & Co. (the “Employer”) sponsors the Executive Life Insurance Program (the
“Plan”). The Owner participates in the Plan. Notwithstanding any other statements herein, Pacific
Life & Annuity Company (PL&A) is not a party to, nor the administrator of, the Plan. PL&A shall not
be charged with the knowledge of the terms of the Plan. Nothing in the foregoing shall be construed
as meaning that PL&A is not a party to or administrator of life insurance policies it issues, or
that it does not have knowledge of the terms of such policies.

PL&A
is directed by both the Owner and the Employer
to follow the sole direction of the
Owner as to the designation of and changes to the beneficiary(ies) for the total death
benefit of this policy. However, PL&A is further directed that, until PL&A receives written
instructions from Employer to the contrary, the exercise of
all other ownership rights shall
require the signature of only the Employer.

The Owner hereby designates the following individuals in the following order as beneficiaries
under the policy if there is no other designated beneficiary surviving at the Owner’s death:

	 	1.	 	The Owner’s spouse, if alive;
	 
	 	2.	 	The Owner’s child(ren) in equal shares, if there is no surviving spouse;
	 
	 	3.	 	The Owner’s parents, if there are no surviving children;
	 
	 	4.	 	The Owner’s siblings if there are no surviving parents; or
	 
	 	5.	 	The Owner’s estate.

	 	 	 	 	 	 	 	 	 	 	 	 	 
	Signed by Owner at

	 	 	 	, this
	 	 	 	day of
	 	  ,
	 	   .
	 

	 	 
	 	 	 	 
	 	 	 	 
	 	 
	 

	 	City/State
	 	 	 	Date
	 	 	 	Month
	 	Year

	 	 	 	 	 	 
	 	Owner’s Signature

	 	 	Date

	 
	 	Employer’s Signature

	 	 	Date

	 
	 

(Corporate seal, if appropriate):

     FOR
HOME OFFICE USE ONLY

     Recorded by Pacific Life & Annuity Company

	 	 	 	 	 	 	 	 	 
	Date:

	 	 	 	By:
	 	 	 	(Registrar)
	 

	 	 
	 	 	 	 	 	 

 

 

                    CEBP

PRODUCER: PROVIDE A PHOTOCOPY OF THIS SIGNED FORM TO ALL SIGNING PARTIES.

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