Document:

EXHIBIT 4(A)

 EXHIBIT (4)(a)
 FORM OF POLICY 

			
	

	 	 Home Office located at:
 440 Mamaroneck Avenue, Harrison, New York 10528
 Adm. Office located at:

4333 Edgewood Road N.E. Cedar Rapids, Iowa 52499
 (319) 355-8511

 Policy Number: 12345 

This is a legal contract between the Owner and Transamerica Financial Life Insurance Company, a Stock Company (Hereafter called the
Company, we, our or us.) The Company will provide annuity and other benefits as set out in this annuity policy, subject to its provisions. This annuity policy is delivered in, and is governed by the laws of, the State of New York.

 WE AGREE 

 

	 	•	 	 To provide annuity payments as set forth in Section 10 of this policy; 

 

	 	•	 	 To pay withdrawal benefits in accordance with Section 5 of this policy; 

 

	 	•	 	 To pay death proceeds in accordance with Section 9 of this policy. 

This contract permits the accumulation of funds on a tax-deferred basis and provides a periodic annuity payment for the life of the
Annuitant or for a certain period of time, or a combination of both. Payments start on the Annuity Commencement Date. 
 The
smallest annual rate of investment return that would have to be earned on the assets of the Separate Account so that the dollar amount of variable Annuity Payments will not decrease is 6.50%. 

Prior to the Annuity Commencement Date, a daily charge corresponding to an annual charge of no more than 1.85% for the Policy Value death
benefit option (2.05% for the Return of Premium death benefit option and 2.25% for the Annual Step-Up death benefit option), is applied by the Company to the assets of the Separate Account. The corresponding annual charge after the Annuity
Commencement Date is no more than 1.50% regardless of death benefit option elected prior to the Annuity Commencement Date. The amounts applicable to this policy are shown on the Policy Data page. In addition, a maximum annual Service Charge of $35
is assessed (prior to the Annuity Commencement Date only) on each Policy Anniversary. However, the Service Charge will not be deducted on a Policy

 Anniversary if, (1) the sum of all premium payments less the sum of all Withdrawals
taken equals or exceeds $50,000; or (2) the Policy Value equals or exceeds $50,000. 
 See the “Service Charge”
provision in Section 4 and the “Charges and Deductions” provision in Section 6 of this contract for more details. This contract is issued in consideration of the application and payment of the initial premium as provided. This
contract may be applied for and issued to qualify as a tax-qualified annuity under the applicable sections of the Internal Revenue Code. 
 20 DAY RIGHT TO CANCEL 
 You may cancel this policy by delivering or
mailing a written notice to us or Your agent. You must return the policy before midnight of the twentieth day after the day You receive it. Notice given by mail and return of the policy by mail are effective upon being mailed, properly addressed and
postage prepaid. We will return the Fixed Account premium and the Policy Value of the Separate Account including any fees and charges, within 10 days after we receive notice of cancellation and the returned policy. 

If this policy is a replacement of another policy, the Right to Cancel period is extended to 60 days and we will return the Fixed Account
premium and the Policy Value of the Separate Account, including any fees and charges, for this policy within 10 days after we receive notice of cancellation and the returned policy.

 

  
 Signed for us at our
home office. 

			
	
 

 SECRETARY
	  	
 

 PRESIDENT

 This policy is a legal contract between the Owner and the Company. 
 READ YOUR
POLICY CAREFULLY. 
 Flexible Premium Deferred Variable Annuity 

Income Payable At Annuity Commencement Date 
 Benefits Based On The Performance Of The Separate Account Are Variable And Are Not 

Guaranteed As To Dollar Amount And Will Increase Or Decrease In Value Based Upon 

Investment Experience (See Sections 6 and 10C) 
 Non-Participating 
 AFTER THE POLICY DATE, WE RESERVE THE RIGHT TO (I) REFUSE
PREMIUM PAYMENTS TO 
 THE FIXED ACCOUNT, AND (II) PROHIBIT TRANSFERS TO THE FIXED ACCOUNT 

  

					
	 AV1396 101 179 1003
	 		 	

 SECTION 1 – DEFINITIONS

 ANNUITANT - The person whose life annuity payments will be based on. 

ANNUITY COMMENCEMENT DATE - The Date the Annuitant will begin receiving payments from this policy. You may change the Annuity
Commencement Date at any time by giving us 30 days written notice. In no event can this date be later than the last day of the month following the month in which the Annuitant attains age 95. The Annuity Commencement Date may not be scheduled at
issue to be earlier than the first day of the calendar month coinciding with or next following the first Policy Anniversary. 

CASH VALUE - Amount defined in Section 5 that is available for partial or full Surrenders. 

CUMULATIVE EARNINGS - An amount equal to the Policy Value at the time a lump sum payout or systematic payout option payout is
made, minus the sum of all premium payments reduced by all prior partial Withdrawals deemed to have been from premium, if any. 

DISTRIBUTION - A Withdrawal or disbursement of funds from the Policy Value or Cash Value. Policy Value and Cash Value will be
reduced by any Distribution. 
 EARNINGS - The gains, if any, in the Policy Value. 

FIXED ACCOUNT GUARANTEED MINIMUM EFFECTIVE ANNUAL INTEREST RATE - The minimum guaranteed credited rate used to determine the Fixed
Account portion of Your Policy Value prior to the Annuity Commencement Date. This rate will apply for the life of the policy and is shown on the Policy Data page. 
 GAINS - Cumulative Earnings, if any, in the Policy Value. 
 HOSPITAL
- An institution which 1) is operated pursuant to the laws of the jurisdiction in which it is located, 2) operates primarily for the care and treatment of sick and injured persons on an inpatient basis, 3) provides 24—hour nursing service by or
under the supervision of registered graduate professional nurses, 4) is supervised by a staff of one or more licensed physicians, and 5) has medical, surgical and diagnostic facilities or access to such facilities. 

INCOME OPTIONS - Options through which the distribution of the Policy Value can be directed. 

INVESTMENT OPTIONS - The one-year Guaranteed Period Option of the Fixed Account the Dollar Cost Averaging Fixed Account Option,
and any of the Subaccounts of the Separate Account 
  

NURSING CARE - Care prescribed by a physician and performed or supervised by a registered graduate nurse. Such care includes
nursing and rehabilitation services available 24 hours. 

 NURSING FACILITY - A facility which 1) is operated pursuant to the laws of the
jurisdiction in which it is located, 2) provides care prescribed by a physician and performed or supervised by a registered graduate nurse on a 24 hour basis, or provides care designed essentially to help a person with the activities of daily living
that require the continuous attention of trained medical or paramedical personnel, and 3) is not other than incidentally, a hospital, a retirement home, a rest home, a community living center or a place mainly for the treatment of alcoholism, mental
illness, or drug abuse. 
 PAYEE - The person to whom annuity payments will be made. 

POLICY ANNIVERSARY - The anniversary of the Policy Date for each year the policy remains in force. 

POLICY DATE - The date shown on the Policy Data page of this policy and the date on which this policy becomes effective.

 POLICY VALUE - Amount defined in Section 4, that can be used to fund one of the Income Options. 

POLICY YEAR - The 12-month period following the Policy Date shown on the Policy Data page. The first Policy Year starts on the
Policy Date. Each subsequent year starts on the anniversary of the Policy Data 
 SEPARATE ACCOUNT - The separate
investment account(s) established by us, as described in Section 6. The investment performance of the Separate Account is independent of the performance of the general assets of the Company. 

SUBACCOUNT - A division of the Separate Account which invests in shares of one Portfolio. The investment performance of each
Subaccount is directly linked to the investment performance of the corresponding Portfolio, as described in Section 6. 

SURRENDER - A partial or full Withdrawal of funds from the Policy Value or Cash Value. 

WITHDRAWAL - A distribution of funds from the Policy Value or Cash Value. 

YOU, YOUR - The Owner of this policy. Unless otherwise specified on the Policy Data page. the Annuitant and the Owner shall be one
and the same person. If the Owner is a trust and the trust allows any person(s) other than the trustee to exercise ownership rights under the policy, then such person(s) must be named as the Annuitant, as applicable. The Owner, while living,
controls all rights and benefits under the policy. 

 

  

					
	 AV1396 101 179 1003
	 	Page 2	 	AVB1396

 SECTION 2 – POLICY DATA 

 

							
	POLICY NUMBER:	  	12345	  	ANNUITANT:	    	John Doe
				
	INITIAL PREMIUM	  		  		    	
	PAYMENT:	  	$5,000,00	  	ISSUE AGE/SEX:	    	35     /  Male
				
	POLICY DATE	  	February 1, 2011	  	OWNER(S):	    	John Doe
				
	ANNUITY	  		  		    	
	COMMENCEMENT	  		  		    	
	DATE:	  	March 31, 2071	  		    	
		  		  	DEATH BENEFIT	    	
		  		  	OPTION:	    	Policy Value
	BENEFICIARY:	  	Jane Doe	  		    	

 Initial Effective Annual Interest Rate Credited to the Fixed Account 1.50% 

Fixed Account Guaranteed Minimum Effective Annual Interest Rate:# 1.50% 
 # This
interest rate applies for the life of the policy. 
 After the policy date, we reserve the right to (l) refuse premium payments to the
Fixed Account and (II) prohibit transfers to the Fixed Account. 
 The credited interest rate for the Dollar Cost Averaging Fixed Account will
never be less than the Fixed Account Guaranteed Minimum Annual Interest Rate shown above. 
 The minimum initial premium payment is $5,000 for
nonqualified and $1,000 for qualified. 
 The maximum total premium payments which we will accept without prior approval is $1,000,000 for issue
ages 0 - 80, $500,000 for issue ages 81 and older. 
 Before the Annuity Commencement Date: 

Service Charge: Annual charge equal to the lesser of 2% of the Policy Value or $35. 

Mortality and Expense Risk Fee and Administrative Charge: 0.45% 
 After the Annuity Commencement Date: 
 Mortality and Expense Risk Fee and
Administrative Charge: 0.45% 

  

					
	AV1396 101 179 1003SP (PV) (R)	 	Page 3	 	

 SECTION 3 – PREMIUM PAYMENTS 

 

 PAYMENT OF PREMIUMS 
 Premium payments may be made any time while this policy is in force before the Annuity Commencement Date. You may start or stop, increase or decrease, or skip any premium payments. We reserve the right to
prohibit premium payments to the Fixed Account options described in Section 7 after the Policy Date. We will provide 30 days advance written notice of this decision. We will also provide timely written notification to You once any such
prohibition of premiums to the Fixed Account is no longer in effect 
 MAXIMUM AND MINIMUM PREMIUM PAYMENT 

The premium payments may not be more than the amount permitted by law if this is a tax–qualified annuity. The minimum initial premium
payment is $5,000. If this policy is being used as a tax–qualified annuity, the minimum initial premium is $1,000, except that no minimum initial premium payment will be required for 403(b) annuities The minimum subsequent premium payment we
will accept is $50. The maximum total premium payments which we will accept without prior Company approval is $1,000,000 for issue ages 0 – 80, $500,000 for issue ages 81 and older 

If premium payments are discontinued, the Policy Value at the cessation of premium payments will be held by us and the Fixed Account
portion of the policy will continue to be credited with at least the Fixed Account Guaranteed Minimum Effective Annual Interest Rate provided in this policy. We may declare a higher rate in advance, Any portion of the Policy Value that is allocated
to the Subaccounts of the Separate Account at the time premium payments are discontinued, will remain in those Subaccounts unless You transfer the value to another Subaccount or to the Fixed Account

 The values in the Subaccounts will change from business day to business day reflecting the
investment experience of the Subaccount On the Annuity Commencement Date we will distribute the Policy Value under one of the Income Options. 

PREMIUM PAYMENT DATE 

The premium payment date is the date on which the premium payment is credited to thepolicy. The initial premium payment less any
applicable premium taxes will be credited to the policy within two business days of receipt of the premium payment and the information needed. Subsequent additional premium payments will be credited to the policy as of the business day the premium
payment and required information are received A business day is any day that the New York Stock Exchange is open for trading. 
 ALLOCATION
OF PREMIUM PAYMENTS 
 Premium payments may be applied to various Investment Options, which we make available. For each
premium payment, You must indicate what percentage to allocate to various Investment Options. Each percent may be either zero or any whole number; however, the allocation among all accounts must total 100%. 

CHANGE OF ALLOCATION 

You may change the allocation of premium payments to various Investment Options by providing us notice containing the facts that we need.
Premium payments received after the date on which we receive Your notice will be applied on the basis of the new allocation. 
 PREMIUM TAXES

 The insurance laws of the State of New York as of 2011 do not allow the imposition of premium taxes on annuity ‘
considerations. Therefore, wherever reference is made in this annuity policy to the deduction of premium taxes, such deductions will not be made while the Owner is a resident of the State of New York, unless subsequent changes in New York’s
insurance laws provide otherwise. The amount of any applicable premium tax imposed on amounts relating to this annuity policy may be deducted from this annuity policy. For purposes of this annuity policy, premium taxes include retaliatory taxes or
similar taxes. 

 

  
 SECTION 4 –
POLICY VALUE 

 

 POLICY VALUE 
 On or before the Annuity Commencement Date, the Policy Value is equal to Your: 
  

	(a)	 premium payments; minus 

  

	(b)	 Gross Partial Withdrawals (as defined in Section 5); plus 

 

	(c)	 interest credited to the Fixed Account (see Section 7); plus 

 

	(d)	 accumulated gains, including the deduction of the Mortality and Expense Risk Fee and Administrative Charge, in the Separate Account (see
Section 6); minus 

	(e)	 accumulated losses including the deduction of the Mortality and Expense Risk Fee and Administrative Charge, in the Separate Account (see
Section 6); minus 

  

	(f)	 service charges, premium taxes, rider fees and transfer fees, if any. 

You may use the Policy Value on the Annuity Commencement Date to provide income under the General Payment Provisions in Section 10.

 SERVICE CHARGE 
 On each Policy Anniversary during any Policy Year before the Annuity Commencement Date, we reserve the right to assess a Service Charge up to $35 for policy administration expenses.

 

  

  

					
	 AV1396 101 179 1003
	 	Page 4	 	M1667R

 SECTION 4 – CONTINUED 

 

 The Service Charge will be deducted from each Subaccount in proportion to the portion of
Policy Value (prior to such charge) in each Subaccount In no event will the Service Charge exceed 2% of the Policy Value on the Policy Anniversary.

 The Service Charge will not be deducted on a Policy Anniversary if, (1) the sum of all
premium payments less the sum of all Withdrawals taken equals or exceeds $50,000; or (2) the Policy Value equals or exceeds $50,000.

 

  
 SECTION 5 –
CASH VALUE AND PARTIAL WITHDRAWALS 

 

 CASH VALUE 
 On or before the Annuity Commencement Date, the Cash Value is equal to the Policy Value. Information on the current amount of Your policy’s Cash Value is available upon request The Cash Value may be
partially withdrawn or will be paid in the event of a full Surrender of the policy. We must receive Your written partial Withdrawal or Surrender request before the Annuity Commencement Date. 

There is no Cash Value once Annuity payments have begun. 
 MINIMUM VALUES 
 Benefits available under this policy, including any paid up
annuity Cash Value or death benefits that may be available, are not less than those required by the insurance laws of the State of New York. Such benefits will be increased as interest is credited to the policy as described in the Fixed Account or
increased/decreased by Separate Account gains/losses. 
 PARTIAL WITHDRAWALS 

We may delay payment of the Cash Value from the Fixed Account for up to 6 months after we receive the request If payment of the Partial
Withdrawal or full Surrender is not made within 10 business days of our receipt of the request, we will pay interest on that amount from the date of receipt of the request to the date of payment as described in the Deferment provision in
Section 11. If the Owner dies after we receive the request but before the request is processed, the request will be processed before the death proceeds are determined. 
 The Gross Partial Withdrawal is the total amount which will be deducted from Your Policy Value as a result of each Partial Withdrawal. The Gross Partial Withdrawal equals the requested Partial Withdrawal.

 If no premium payments have been made for three Policy Years and any Partial Withdrawal reduces the Policy Value below
$2,000, we reserve the right to pay the full Policy Value and terminate the policy.

 For interest crediting purposes only, the oldest premium payment is considered to be
withdrawn first, then the interest associated with that premium payment If the amount withdrawn exceeds this amount the next oldest premium payment and its associated interest is considered to be withdrawn, and so on until the most recent premium
payment and its associated interest is considered to be withdrawn (i.e. Partial Withdrawals are made on a First–In, First–Out or FIFO basis). 
 Amounts also may be withdrawn under one of the options as described below. 
 LUMP SUM

 Beginning in the first Policy Year, partial withdrawals are available as lump sum distributions in one or more withdrawals
during a policy year. 
 The minimum withdrawal is $500. 
 SYSTEMATIC PAYOUT OPTION 
 Beginning in the first Policy Year, a Systematic
Payout Option (SF0) is available on a monthly, quarterly, semi–annual or annual basis At the time a SPO payout is made, such payout must be at least $50 and may not exceed the greater of A or B, divided by the number of payouts made per year
(e.g. 12 for monthly). 
  

	A	 is the Cumulative Earnings, if any, in the Policy Value; and 

 

	B	 is an amount equal to 10% of the premium payments. 

 Monthly and quarterly payouts must be sent through electronic funds transfer directly to a checking or savings account You may start or stop SPO payouts at any time; however, 30 days written notice is
required to stop SPO payouts. 
 Once You have elected a SPO, You must wait a minimum time before the first SPO payment 1 month
for monthly, 3 months for quarterly, 6 months for semi–annual, or 12 months for annual. Lf a Lump Sum or Partial Withdrawal distribution is taken in the same Policy Year when SPO payments are being taken, and the total Withdrawal would exceed
the greater of A or B above in that Policy Year, the SPO will be stopped. 

 

  

  

					
	 AV1396 101 179 1003
	 	Page 5	 	U1667R 

 SECTION 5 – CONTINUED 

 

 MINIMUM REQUIRED DISTRIBUTION 

For tax–qualified plans, Partial Withdrawals taken to satisfy minimum distribution requirements under Section 401 (a)(9) of the
Internal Revenue Code (IRC) are available. The amount available from this annuity with respect to the minimum distribution requirements is based solely on this policy. 
 Systematic minimum distributions must be at least $50 or a lump sum Distribution is available if minimum required distributions are less than $50. 
 NURSING CARE AND TERMINAL CONDITION WITHDRAWAL OPTION 
 Beginning in the
first Policy Year, if the Owner or Owners spouse (Annuitant or Annuitant’s spouse if the Owner is not a natural person) has been 1) confined in a hospital or nursing facility for 30 consecutive days or 2) diagnosed as having a terminal
condition and the confinement begins or diagnosis is made on or after the Policy Date, You may elect to withdraw all or a portion of the Policy Valua The minimum Withdrawal under this option is $1000. This option is available even during the Policy
Years other partial Withdrawal options were exercised prior to nursing care.

 For nursing care, we must receive each Withdrawal request and proof of eligibility with
each request no later than 90 days following the date that confinement has ceased, unless it can be shown that it was not reasonably possible to provide the notice and proof within the above time period and that the notice and proof were given as
soon as reasonably possible. However, in no event, except the absence of legal capacity, shall the notice and proof be provided later than one year following the date that confinement has ceased. Proof of confinement may be a physician’s
statement or a statement from a hospital or nursing facility administrator. 
 For a terminal condition, we must receive each
Withdrawal request and the applicable proof of eligibility no later than one year following diagnosis of the terminal condition. Proof of a terminal condition is required only with the initial Withdrawal request and must be furnished by the
Owner’s, Owner’s spouse’s, Annuitants, or Annuitant’s spouse’s physician, as applicable. 

 

  
 SECTION 6 –
SEPARATE ACCOUNT 

 

 SEPARATE ACCOUNT 
 We have established and will maintain one or more Separate Account(s), under the laws of the state of New York. Any realized or unrealized income, net gains and losses from the assets of the Separate
Account are credited to or charged against it without regard to our other income, gains or losses, Assets are put in the Separate Account for this policy, as well as for other variable annuity policies Any Separate Account may invest assets in
shares of one or more mutual fund portfolios, or in the case of a managed Separate Account direct investments in stocks or other securities as permitted by law. Fund shares refer to shares of underlying mutual funds or prorata ownership of the
assets held in a Subaccount of a managed Separate Account Fund shares are purchased, redeemed and valued on behalf of the Separate Account 
 The Separate Account is divided into Subaccounts. Each Subaccount invests exclusively in shares of one of the portfolios of an underlying fund. We reserve the right to add or remove any Subaccount of the
Separate Account. 

 The Separate Account meets the definition of a “Separate Account” under rule
0–1(e)(1) of the Investment Company Act of 1940 (the “1940 Act’). The assets of the Separate Account are our property. These assets will equal or exceed the reserves and other contract liabilities of the Separate Account. These assets
will not be chargeable with liabilities arising out of any other business we conduct We reserve the right, subject to regulations governing the Separate Account to transfer assets of a Subaccount, in excess of the reserves and other contract
liabilities with respect to that Subaccount, to another Subaccount or to our General Account. 
 We will determine the fair
market value of the assets of the Separate Account in accordance with a method of valuation, which we establish in good faith. Valuation Period means the period of time from one determination of the value of each Subaccount to the next. Such
determinations are made when the value of the assets and liabilities of each Subaccount is calculated This is generally the close of business on each day on which the New York Stock Exchange is open. In order to determine the value of an asset on a
day that is not a Business Day, the Company will use the value of that asset as of the end of the next Business Day on which trading takes place. 

 

 

  

					
	 AV1396 101 179 1003
	 	Page 6	 	V1545R

 SECTION 6 – CONTINUED 
  

 The Company will determine the value of the reserves for assets in the Separate Account at
the end of each Business Day. In order to determine the value of reserves for assets on a day that is not a Business Day, the Company will use the value of that asset as of the end of the prior Business Day on which trading took place. 

We also reserve the right (with prior authorization from the Superintendent) to transfer assets of the Separate Account which we
determine to be associated with the class of policies to which this policy belongs, to another Separate Account. If this type of transfer is made, the term Separate Account’, as used in the policy, shall then mean the Separate Account to which
the assets were transferred. 
 We also reserve the right when permitted by law to: 

 

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

 

	(b)	 manage the Separate Account under the direction of a committee at any time; 

 

	(c)	 restrict or eliminate any voting rights of policy Owners or other persons who have voting rights as to the Separate Account;

  

	(d)	 combine the Separate Account with one or more other Separate Accounts; 

 

	(e)	 create new Separate Accounts; 

  

	(f)	 add new Subaccounts to or remove existing Subaccounts from the Separate Account, or combine Subaccounts; and 

 

	(g)	 add new underlying mutual funds, remove existing mutual funds, or substitute a new fund for an existing fund. 

The Net Asset Value of a fund share is the per - share value calculated by the mutual fund or, in the case of a managed Separate Account,
by the Company. The Net Asset Value is computed by adding the value of the Subaccounts investments, cash and other assets, subtracting its liabilities, and then dividing by the number of shares outstanding. Net Asset Values of fund shares reflect
investment advisory fees and other expenses incurred in managing a mutual fund or a managed Separate Account. 
 CHANGE IN INVESTMENT
OBJECTIVE OR POLICY OF A MUTUAL FUND 
 If required by law or regulation, an investment policy of the Separate Account will
only be changed if approved by the appropriate insurance official of the state of New York or deemed approved in accordance with such law or regulation. If so required, the process for obtaining such approval is filed with the insurance official of
the state or district in which this policy is delivered. 

 CHARGES AND DEDUCTIONS 
 The Mortality and Expense Risk Fee and Administrative Charge is deducted both before and after the Annuity Commencement Date to compensate for changes in mortality and expenses not anticipated by the
mortality and administration charges guaranteed in the policy. Neither expenses actually incurred, other than taxes on the investment return, nor mortality actually experienced, shall adversely affect the dollar amount of variable benefits under the
policy. 
 The Service Charge is deducted prior to the Annuity Commencement Date only. 

If the Mortality and Expense Risk Fee and Administrative Charge is more than sufficient the Company will retain the balance as profit or
may reduce this fee in the future. 
 ACCUMULATION UNITS 
 The Policy Value in the Separate Account before the Annuity Commencement Date is represented by accumulation units. The dollar value of accumulation units for each Subaccount will change from business day
to business day reflecting the investment experience of the Subaccount. 
 Premium Payments allocated to and any amounts
transferred to the Subaccounts will be applied to provide accumulation units in those Subaccounts. The number of accumulation units purchased in a Subaccount will be determined by dividing the amount allocated to or transferred to that Subaccount,
by the value of an accumulation unit for that Subaccount on the premium payment or transfer date. 
 The number of accumulation
units withdrawn or transferred from the Subaccounts will be determined by dividing the amount withdrawn or transferred by the value of an accumulation unit for that Subaccount on the Withdrawal or transfer date. 

The value of an accumulation unit on any business day is determined by multiplying the value of that unit at the end of the immediately
preceding valuation period by the net investment factor for the valuation period. 
 The net investment factor used to calculate
the value of an accumulation unit in each Subaccount for the Valuation Period is determined by dividing (a) by (b) and subtracting (c) from the result where: 
  

 

  

					
	AV1396 101 179 1003	 	Page 7	 	VB1545R

 SECTION 6 - CONTINUED 
  

 

	(a)	is the result of: 

  

	 	(1)	 the net asset value of a fund share held in that Subaccount determined as of the end of the current valuation period; plus

  

	 	(2)	 the per share amount of any dividend or capital gain Distributions made by the fund for shares held in that Subaccount if the ex - dividend date
occurs during the valuation period; plus or minus 

  

	 	(3)	 a per share credit or charge for any taxes reserved for, which we determine to have resulted from the investment operations of that Subaccount

 

	(b)	 is the net asset value of a fund share held in that Subaccount determined as of the end of the immediately preceding valuation period.

  

	(c)	 is a factor representing the Mortality and Expense Risk Fee and Administrative Charge before the Annuity Commencement Date. This factor is less than
or equal to, on an annual basis, the percentage shown on the Policy Data Page of the daily net asset value of a fund share held in that Subaccount 

 Since the net investment factor may be greater or less than one, the accumulation unit value may increase or decrease.

 

  
 SECTION 7 –
FIXED ACCOUNT 

 

 FIXED ACCOUNT 
 The Fixed Account is comprised of a one - year Guaranteed Period Option and the Dollar Cost Averaging Fixed Option that we may choose to offer. Premium payments applied to and any amounts transferred to
the Fixed Account will reflect a fixed interest rate. The interest rates we set will be credited for increments of at least one year measured from each premium payment or transfer date. These rates will never be less than the Fixed Account
Guaranteed Minimum Effective Annual Interest Rate shown on the Policy Data page. 
 After the policy date, we reserve the right
to prohibit premium payments and/or transfers allocated to the Fixed Account described in this section. We will provide 30 days advance written notice of this decision. We will also provide timely written notification to You once any such
prohibition of premium payments and/or transfers is no longer in effect 
 Even if we are prohibiting premium payments or
transfers to the Fixed Account funds will still roll into a new one - year Guaranteed Period Option at the end of the expiring option’s guaranteed period 
 GUARANTEED PERIOD OPTION 
 We will offer the one - year Guaranteed Period
Option. The current interest rate we set for funds entering a Guaranteed Period Option (GPO) is guaranteed until the end of that option’s Guaranteed Period. At that time, the premium payment made or amount transferred into the GPO, less any
Withdrawals or transfers from that GPO, plus accrued interest will be rolled into a new one - year GPO or may be transferred to any Subaccount(s) within the Separate Account(s). 

You may choose the Investment Option(s) You want the funds transferred into by giving us a written notice within 30 days before the end
of the expiring option’s Guaranteed Period. However, any Guaranteed Period elected may not extend beyond the maximum Annuity Commencement Date defined in Section 11.

 In the absence of such election, the funds will be rolled into a new one - year GPO, You
will be mailed a notice of completion of any rollover with the new interest rate applicable. The new GPO will be deemed as accepted if we do not receive a written rejection within 30 days from the postmark date of the completion notice. 

When funds are withdrawn or transferred from the one - year GPO, the Policy Value associated with the oldest premium payment or rollover
is considered to be withdrawn/transferred first If the amount withdrawn/transferred exceeds the Policy Value associated with the oldest premium, the Policy Value associated with the next oldest premium payment or rollover is considered to be
withdrawn/transferred next and so on until the Policy Value associated with the most recent premium payment or rollover is considered to be withdrawn/transferred (this is a “First - In, First - Out” or FIFO basis). 

DOLLAR COST AVERAGING FIXED ACCOUNT OPTION 
 We may offer a Dollar Cost Averaging one - year (DCA) Fixed Account Option separate from the Guaranteed Period Option. This option will have a one - year interest rate guarantee. The current interest rate
we set for the DCA Fixed Account may differ from the rates credited on the one - year GPO in the Fixed Account In addition, the current interest rate we credit may vary on different portions of the DCA Fixed Account The credited interest rate will
never be less than the Fixed Account Guaranteed Minimum Effective Annual Interest Rate shown on Page 3. The DCA Fixed Account Option will only be available under a Dollar Cost Averaging program as described in Section 8.

 

  

					
	AV1396 101 179 1003	 	Page 8	 	L1141R

 SECTION 8 – TRANSFERS 

 

	A.	TRANSFERS BEFORE THE ANNUITY COMMENCEMENT DATE 

 Prior to the Annuity Commencement Date, You may transfer the value of the accumulation units from one Investment Option to another by providing us notice containing the facts that we need. 

Transfers of interest credited in the one–year GPO to other Investment Options are allowed on a “First–In,
First–Out” basis. Such transfers may be made monthly, quarterly, semi–annually, or annually. Each such transfer must be at least $50, 
 Transfers of Policy Value from the Separate Account are subject to a minimum of $500 or the entire Subaccount Policy Value, if less. However, if the remaining Subaccount Policy Value is less than $500, we
reserve the right to include that amount as part of the transfer. 
 We reserve the right to limit transfers to no more than 12
in any one Policy Year. Any transfers in excess of 12 per Policy Year may be charged a $1 0 per transfer fee. Transfers among multiple Investment Options will be treated as one transfer in determining the number of transfers that have occurred
We also reserve the right to prohibit transfers to the Fixed Account We may prohibit premium payments and/or transfers if the yield on investments at such time is not sufficient to support the statutory minimum interest rate guarantee and other
company expenses If we are prohibiting transfers to the Fixed Account we will provide 30 days advance written notice of this decision. You must indicate which Investment Option(s) to transfer the funds to while such prohibition is in effect We will
also provide timely written notification to You once any such prohibition of transfers is no longer in effect 
 The policy was
not designed for professional market timing organizations or other persons that use programmed, large, or frequent transfers. The use of such transfers may be disruptive to an underlying portfolio. We reserve the right to reject any transfer request
from any person in the interest of overall fund management or, if, in our judgment an underlying fund would be unable to invest effectively in accordance with its investment objectives and policies or would otherwise be potentially adversely
affected or if an underlying fund would reject our purchase order. We also reserve the right to revoke Your fax and electronic transfer privileges at any time without revoking all owners’ fax and electronic transfer privileges. 

DOLLAR COST AVERAGING OPTION 
 Prior to the Annuity Commencement Date, You may instruct us to automatically transfer a specified amount from the Money Market Subaccount, U.S. Government Securities

 Subaccount, or out of the Dollar Cost Averaging (DCA) Fixed Account Option to any other
Subaccount(s) of the Separate Account The automatic transfers can occur monthly or quarterly. 
 Transfers will continue until
the elected Subaccount or DCA Fixed Account value is depleted. The amount transferred each time must be at least $500. All transfers from the DCA account will be the same amount as the initial transfer. Changes to the Subaccounts to which these
transfers are allocated are not restricted. Transfers must be scheduled for at least 6, but not more than 24 months or for at least 4, but not more than 8 quarters each time the Dollar Cost Averaging program is started or restarted following
termination of the program for any reason. 
 Dollar Cost Averaging results in the purchase of more accumulation units when the
value of the accumulation unit is low, and fewer accumulation units when the value of the accumulation unit is high. However, there is no guarantee that the Dollar Cost Averaging program will result in higher Policy Values. 

Dollar Cost Averaging may be discontinued before its scheduled completion by sending written notice to us While Dollar Cost Averaging is
in effect Asset Rebalancing is not available If Dollar Cost Averaging is discontinued prior to the end of the scheduled period, all remaining funds in the Dollar Cost Averaging Fixed Account will be transferred at that time. Unless we are notified
otherwise, the funds remaining in the Dollar Cost Averaging Fixed Account will be transferred to the Subaccounts in the percentages currently indicated. 
 ASSET REBALANCING 
 Prior to the Annuity Commencement Date, You may instruct
us to automatically transfer amounts among the Subaccounts of the Separate Account on a regular basis to maintain a desired allocation of the Policy Value among the various Subaccounts offered. Rebalancing will occur on a monthly, quarterly,
semi–annual or annual basis, beginning on a date selected by You. You must select the percentage of the Policy Value desired in each of the various Subaccounts offered (totaling 100%). Any amounts in the Fixed Account are ignored for the
purposes of Asset Rebalancing. Rebalancing can be started, stopped or changed at any time. Asset Rebalancing is not available while Dollar Cost Averaging is in effect Rebalancing will cease as soon as we receive a request for any other transfer.

 

  

					
	 AV1396 101 179 1003
	 	Page 9	 	LB1141R

 SECTION 8 – CONTINUED 

 

	B.	TRANSFERS AFTER THE ANNUITY COMMENCEMENT DATE 

 After the Annuity Commencement Date, You may transfer the value of the variable annuity units from one Subaccount to another within the Separate Account or to the Fixed Account If You want to transfer the
value of the variable annuity units, You must provide a signed notice, containing the facts that we need. We reserve the right to limit transfers between the Subaccounts or to the Fixed Accounts to once per Policy Year

 The minimum amount which may be transferred is the lesser of $10 monthly income or the
entire monthly income of the variable annuity units in the Subaccount from which the transfer is being made. If the monthly income of the remaining units in a Subaccount is less than $10, we have the right to include the value of those variable
annuity units as part of the transfer 
 After the Annuity Commencement Date, no transfers may be made from the Fixed Account to
any other Investment Options. 

 

  
 SECTION 9 –
DEATH PROCEEDS 

 

	A.	DEATH PROCEEDS PRIOR TO ANNUITY COMMENCEMENT DATE 

 The amount of death proceeds will be the greater of (a) or (b) where: 
  

	(a)	 is the Policy Value on the date we receive due proof of death and an election of a method of settlement and; 

 

	(b)	 is the Guaranteed Minimum Death Benefit (GMDB), if any, plus any additional premium payments received, (less any Gross Partial Withdrawals) from the
date of death to the date of payment of death proceeds. 

 For purposes of this policy, due proof of death
means: 
  

	(a)	 a certified copy of the death certificate; or 

  

	(b)	 a certified copy of a decree of a court of competent jurisdiction as to a finding of death; and 

 

	(c)	 any other proof or other documents required by us. 

 If You have not selected a payment option by the date of death, the beneficiary may make such election within one year of the date we receive due proof of the Owner’s or Annuitant’s death as
described in C below. The beneficiary may elect to receive the death proceads as a lump sum payment or may use the death proceeds to provide any of the annuity Income Options described in Section 10. 

We will pay interest on death proceeds from the date of death to the date of payment at an annual interest rate of 1.5%, or the
guaranteed annual rate used for calculating settlement options, whichever is greater. 
  

	B.	GUARANTEED MINIMUM DEATH BENEFIT 

 The amount of the Guaranteed Minimum Death Benefit (GMDB) is based on the death benefit option shown on the Policy Data Page. You may not change the GMDB option after the policy is issued.

 Annual Step-Up Death Benefit 
 This GMDB is equal to: 
  

	(a)	 the step–up value as described below; plus 

  

	(b)	 any premium payments subsequent to the previous determination point minus 

 

	(c)	 any Adjusted Partial Withdrawals subsequent to the previous determination point. 

On the Policy Date. the step–up value is the Policy Value. On each Policy Anniversary (referred to as the determination points)
prior to the earlier of the date of death of the Annuitant or the Annuitant’s 8 1 st birthday, a comparison is made between (a) and (b), where (a) is the Policy Value at this point in time and (b) is the previous step–up
value, plus premium payments minus Adjusted Partial Withdrawals (as described below) made since the previous determination point The larger of (a) and (b) becomes the new step–up value. This step–up process stops at the earlier
of the date of death of the Annuitant or the Annuitant’s 81st birthday. The then current step–up value becomes the final step–up value. 
 Return of Premium Death Benefit 
 This GMDB is equal to the total premiums
paid for this policy, less any Adjusted Partial Withdrawals (as described below), as of the date of death. 
 Adjusted Partial Withdrawal

 A partial Withdrawal taken as provided in Section 5 will reduce the Guaranteed Minimum Death Benefit by an amount
referred to as the “Adjusted Partial Withdrawal”. The Adjusted Partial Withdrawal may be a different amount than the Gross Partial Withdrawal described in Section 5. If at the time of the partial Withdrawal, the Policy Value is
greater than the GMDB, the Adjusted Partial Withdrawal will equal the Gross Partial Withdrawal. 

 

  

					
	 AV1396 101 179 1003
	 	Page 10	 	D568R

 SECTION 9 – CONTINUED 

 

			
	 The Adjusted Partial Withdrawal formula is APW = GPW times (DP/PV) where:

		
	APW=	 	Adjusted Partial Withdrawal
	GPW=	 	Gross Partial Withdrawal
	DP=	 	 Death Proceeds prior to the Withdrawal (equal to the greater of PV and GMDB)

	PV=	 	Policy Value prior to the Withdrawal
	GMDB=	 	 Guaranteed Minimum Death Benefit prior to the Withdrawal

  

	C.	DEATH PRIOR TO ANNUITY COMMENCEMENT DATE 

 Payment of death proceeds depends upon the relationships between the Owner, Annuitant, and beneficiary as outlined below. 
 If there are surviving Owners, the surviving Owners automatically take the place of any beneficiary designation. 
  

	I.	Annuitant Death 

 When we have due proof that the Annuitant died before the Annuity Commencement Date, we will provide the death proceeds to the beneficiary. Interest upon the death proceeds will be computed daily at the
rate set forth in Section 9, A, above from the date of death to the date of payment and will be considered part of the total sum paid If no beneficiary is designated, the Owner or Owner’s estate will become the beneficiary. 

 

	 	a)	 When the beneficiary is the deceased Annuitant’s surviving spouse. The beneficiary may elect to continue this policy as Owner and
Annuitant rather than receiving the death proceeds If the policy is continued, an amount equal to the excess, if any, of the Guaranteed Minimum Death Benefit (if any) over the Policy Value will then be added to the Policy Value pro rata according to
the amount of Policy Value in each Investment Option at that time. This is a one–time only Policy Value adjustment applied at the time the policy is continued, and the Guaranteed Minimum Death Benefit previously selected will continue on as
applicable. If no election is received from the spouse following the Annuitants death, the policy will be continued with the surviving spouse as the Owner and Annuitant, 

If the beneficiary elects to have the death proceeds paid rather than continue the policy, the death proceeds must be
distributed pursuant to subsections b)(1) and (2) below, 
  

	 	b)	 When the beneficiary is an individual who is not the deceased Annuitant’s surviving spouse. The death proceeds must be
distributed: 

	 	(1)	 by the end of 5 years after the date of the deceased Annuitant’s death, or 

 

	 	(2)	 payments must begin no later than one year after the deceased Annuitants death and must be made for a period certain or for this beneficiary’s
lifetime, so long as any period certain does not exceed this beneficiary’s life expectancy (as defined by the Internal Revenue Code and regulations adopted under that Code). Election of this option must be made at least 60 days prior to the one
year anniversary of the Annuitants death, 

  

	 	c)	 When the beneficiary is not a natural person. The death proceeds may be paid in a lump sum or must be distributed within 5 years after the
Annuitants death. 

 In 1035 exchanges where there are joint Annuitants, the death proceeds will only be
payable upon the death of the surviving Annuitant, subject to the distribution rules described in section II. 
  

	II.	Owner Death 

 If the deceased Owner is also the Annuitant, Subsection Cl. “Annuitant Death” above applies. 
 If an Owner or joint Owner who is not an Annuitant dies prior to the Annuity Commencement Date and before the entire interest in the policy is distributed, the successor Owner as defined below will become
the new Owner, and no death proceeds are payable. The person or entity first listed below who is alive or in existence on the date of that death will become the successor Owner: 

 

	 	a)	 surviving Owner; 

  

	 	b)	 primary beneficiary; 

  

	 	c)	 contingent beneficiary; or 

  

	 	d)	 deceased Owner’s estate. 

 The successor Owner will need to take distributions according to a), b), or c) below: 
  

	 	a)	 If the sole successor Owner is the deceased Owner’s opposite–sex spouse, We will continue this policy with the successor Owner as the new
Owner, If no distribution option is elected by the deceased Owner’s same–sex spouse, the Policy Value will be distributed according to b) below. 

 

	 	b)	 If the successor Owner is an individual who is not the deceased Owner’s spouse, the Policy Value must be distributed:

 

  

					
	 AV1396 101 179 1003
	 	Page 11	 	DB568R

 SECTION 9 – CONTINUED 

 

	 	(1)	 by the end of 5 years after the date of the deceased Owner’s death, or 

 

	 	(2)	 payments must begin no later than one year after the deceased Owners death and must be made for a period certain or for the successor Owner’s
lifetime, so long as any period certain does not exceed the successor Owner’s life expectancy (as defined by the Internal Revenue Code and regulations adopted under that Code). Election of this option must be made at least 60 days prior to the
one year anniversary of the deceased Owner’s death. 

  

	c)	 If the successor Owner is not a natural person, the Policy Value may be paid in a lump sum, or must be distributed within 5 years after the
Owner’s death. 

	D.	DEATH ON OR AFTER THE ANNUITY COMMENCEMENT DATE 

 The death proceeds on or after the Annuity Commencement Date depend on the payment option selected. If any Owner dies on or after the Annuity Commencement Date, but before the entire interest in the
policy is distributed, the remaining portion of such interest in the policy will be distributed to the Owner’s beneficiary at least as rapidly as under the method of distribution being used as of the date of that Owner’s death. 

 

	E.	AN OWNER IS NOT AN INDIVIDUAL 

 In the case of a non tax–qualified annuity, if any Owner or beneficial Owner is not an individual, then for purposes of Section 72(s) of the Internal Revenue Code’s mandatory distribution
provisions in subsection C or D above, (1) the primary Annuitant will be treated as the Owner of the policy, and (2) if there is any change in the primary Annuitant, such a change will be treated as the death of the Owner.

 

  
 SECTION 10 –
ANNUITY PAYMENTS 

 

	A.	GENERAL PAYMENT PROVISIONS 

 Payment

 If this policy is in force on the Annuity Commencement Date, we will use the Fixed Account portion and/or the Separate
Account portion of the Policy Value to make annuity payments to the Annuitant under Option 2 and/or 3–V, respectively, with 10 years certain, or if elected, under one or more of the other options described in this section. However, the
option(s) elected must provide for lifetime income or income for a period of at least 60 months You will become the Annuitant at the Annuity Commencement Date. Payments will be made at 1, 3, 6 or 12–month intervals. We reserve the right to
change the frequency of payments to avoid making payments of less than $20.00. 
 Before the Annuity Commencement Date, if the
death proceeds become payable or if You Surrender this policy, we will pay any proceeds in one sum, or if elected, all or part of these proceeds may be placed under one or more of the options described in this section. If we agree, the proceeds may
be placed under some other method of payment instead. 
 Betterment of Rates 

The amounts shown in the tables on page 16–17 are the guaranteed amounts. Current amounts offered to individuals of the same class
may be obtained from us. Fixed annuity payments at the time of their commencement will not be less than those which would be provided by the application of the Policy Value to purchase any single consideration immediate annuity contract (as
described in Section 4223 (a)(1)(E) of the New York Insurance Law) offered by the Company at the time to the same class of Annuitant

 Adjusted Age 
 Payments under Options 2 and 4 and the first payment under Options 3–V and 5–V are determined based on the adjusted age of the Annuitant, The adjusted age is the Annuitant’s actual age on
the Annuitant’s nearest birthday, at the Annuity Commencement Date, adjusted as follows: 
  

					
	  	 	 Annuity
 Commencement Date
	  	 Adjusted Age

			
		 	 2011 – 2019
	  	Actual Age minus 1
		 	 2020 – 2026
	  	Actual Age minus 2
		 	 2027 – 2033
	  	Actual Age minus 3
		 	 2034 – 2040
	  	Actual Age minus 4
		 	 After 2040
	  	Actual Age minus 5

Election of Optional Method of Payment Before the Annuity Commencement Date You can elect or change an Income Option. You may elect in a
notice You sign which gives us the facts that we need, annuity payments that may be either variable, fixed, or a combination of both. If You elect a combination, You must also tell us what part of the policy proceeds on the Annuity Commencement Date
are to be applied to provide each type of payment (You must also specify which Subaccounts,) The amount of a combined payment will be the sum of the variable and fixed payments. Payments under a variable Income Option will reflect the investment
performance of the selected Subaccount of the Separate Account 

 

  

					
	 AV1396 101 179 1003
	 	Page 12	 	S1254R

 SECTION 10 – CONTINUED 

 

 Payee 
 Unless You specify otherwise, the Payee shall be the Annuitant, or the beneficiary as defined in the Beneficiary provision in Section 11. 

Proof of Age 
 We may require proof of the age of any person who has an annuity purchased under Options 2, 3–V. 4 and 5 –V of this section before we make the first payment 

Minimum Proceeds 
 If the Policy Value on the Annuity Commencement Date is less than $2,000, we reserve the right to pay the Policy Value as a lump sum instead of applying it to an income option. 

Premium Tax 
 The Insurance laws of the State of New York as of 2011 do not allow the imposition of premium taxes on the amount applied to a settlement option. Therefore, such deductions will not be made while the
Owner is a resident of the State of New York, unless subsequent changes in New York’s insurance laws provide otherwise. However, if the Owner becomes a non–resident of New York or if New York changes its insurance laws to allow the
imposition of premium taxes on the amount applied to a settlement option, we will deduct the applicable premium tax before applying the proceeds. 
 Supplementary Contract 
 Once proceeds become payable and an income option
has been selected, we will issue a supplementary contract to reflect the terms of the selected option. The contract will name the Payee(s) and will describe the payment schedule.

 B. FIXED INCOME OPTIONS 

Guaranteed Income Options 
 The fixed income option is determined by multiplying each $1,000 of policy proceeds allocated to a fixed income option by the amounts shown on pages 16 and 17 for the option You select Options 1 and 3 are
based on a guaranteed interest rate of 1.5%. Options 2 and 4 are based on a guaranteed interest rate of 1.5% and the ‘Annuity 2000” male, female mortality table projected for improvement using projection scale G (50% of the female scale G
factors were used, while 100% of the male scale G factors were used). The rates were projected dynamically using an assumed Annuity Commencement date of 2005. The “Annuity 2000” mortality rates are adjusted based on improvements in
mortality since 2000 to more appropriately reflect increased longevity. This is accomplished using a set of improvement factors referred to as projection scale C. 
 Option 1 – Income for a Specified Period We will make level payments only for the fixed period You choosa The duration of the payments may not exceed the Annuitant’s life expectancy, (as defined
by the Internal Revenue Code and regulations adopted under that code) nor be for a period of time that is less than 60 months. In the event of the death of the person receiving payments prior to the end of the fixed period elected, payments will be
continued to that person’s beneficiary. 

 

  

					
	 AV1396 101 179 1003
	 	Page 13	 	SB1254R

 SECTION 10 – CONTINUED 

 

 Option 2 – Life Income – You may choose between: 

 

	1.	 No Period Certain – We will make level payments only during the Annuitants lifetime. 

 

	2.	 10 Years Certain – We will make level payments for the longer of the Annuitants lifetime or ten years In the event of the death of the person
receiving payments prior to the end of the fixed period elected, payments will be continued to that persons beneficiary. 

  

	3.	 Guaranteed Return of Policy Proceeds – We will make level payments for the longer of the Annuitant’s lifetime or until the total dollar
amount of payments we made to You equals the amount applied to this option. 

 Option 2(1) is not available
for Adjusted Age(s) greater than 85. 
 If any life income settlement option with a period certain provides for installment
payments of the same amount at some ages for different periods certain, the Company will deem the election to have been made for the longest period certain which could have been elected for such age and amount 

Option 3 – Income of a Specified Amount Payments are made for any specified amount until the amount applied to this option, with
interest is exhausted This will be a series of level payments followed by a smaller final payment. In the event of the death of the person receiving payments prior to the time proceeds with interest are exhausted, payments will be continued to that
person’s beneficiary. 
 Option 4 – Joint and Survivor Annuity 

Payments are made during the joint lifetime of the Payee and a joint Payee of Your selection. Payments will be made as long as either
person is living. 
 Option 4 is not available for Adjusted Age(s) greater than 85. 

Current Income Options 
 The amounts shown in the tables on pages 16 and 1 7 are the guaranteed amounts. Current amounts offered to individuals of the same class may be obtained from us Any rates not shown in the Tables contained
in this annuity policy and which are available will be provided by the Company upon request.

 C. VARIABLE INCOME OPTIONS 

Variable Annuity Units 
 The policy proceeds You tell us to apply to a variable income option will be used to purchase variable annuity units in Your chosen Subaccounts The dollar value of variable annuity units in Your chosen
Subaccounts will increase or decrease reflecting the investment experience of Your chosen Subaccounts. The value of a variable annuity unit in a particular Subaccount on any business day is equal to (a) multiplied by (b) multiplied by (c),
where: 
  

	(a)	 is the variable annuity unit value for that Subaccount on the immediately preceding business day; 

 

	(b)	 is the net investment factor for that Subaccount for the Valuation Period; and 

 

	(c)	 is the Assumed Investment Return adjustment factor for the Valuation Period. 

The Assumed Investment Return adjustment factor for the valuation period is the product of discount factors of .99986634 per day to
recognize the 5.0% effective annual Assumed Investment Return. 
 The net investment factor used to calculate the value of a
variable annuity unit in each Subaccount for the Valuation Period is determined by dividing (a) by (b) and subtracting (c) from the result where: 
  

	(a)	 is the net result of: 

  

	 	(1)	 the net asset value of a fund share held in that Subaccount determined as of the end of the current valuation period; plus

  

	 	(2)	 the per share amount of any dividend or capital gain Distributions made by the fund for shares held in that Subaccount if the ex–dividend date
occurs during the Valuation Period; plus or minus 

  

	 	(3)	 a per share credit or charge for any taxes reserved for, which we determine to have resulted from the investment operations of the Subaccount

  

	(b)	 is the net asset value of a fund share held in that Subaccount determined as of the end of the immediately preceding Valuation Period.

  

	(c)	 is a factor representing the Mortality and Expense Risk Fee and Administrative Charge applicable after the Annuity Commencement Date. This factor is
less than or equal to, on an annual basis, the percentage shown on the Policy Data Page of the daily net asset value of a fund share held in the Separate Account for that Subaccount.

 

  

					
	 AV1396 101 179 1003
	 	Page 14	 	C937R

 SECTION 10 – CONTINUED 

 

 Determination of the First Variable Payment The amount of the first variable payment is
determined by multiplying each $1,000 of policy proceeds allocated to a variable income option by the amounts shown on pages 18 and 19 for the variable option You select The tables are based on a 5% effective annual Assumed Investment Return and the
“Annuity 2000’ male, and female mortality table projected for improvement using projection scale G (50% of the female scale G factors were used, while 100% of the male scale ci factors were used). The rates were projected dynamically using
an assumed Annuity Commencement date of 2005. The “Annuity 2000” mortality rates are adjusted based on improvements in mortality since 2000 to more appropriately reflect increased longevity. This is accomplished using a set of improvement
factors referred to as projection scale G. 
 Option 3–V – Life Income – You may choose between: 

 

	1.	 No Period Certain – Payments will be made during the lifetime of the Annuitant 

 

	2.	 10 Years Certain – Payments will be made for the longer of the Annuitant’s lifetime or ten years In the event of the death of the person
receiving payments prior to the end of the guarantee period for which the election was made, payments will be continued to that person’s beneficiary. 

 Option 3–VU) is not available for Adjusted Age(s) greater than 85.

 Option 5–V – Joint and Survivor Annuity: 

Payments are made as long as either the Annuitant or the joint Annuitant is living. 

Option 5–V is not available for Adjusted Age(s) greater than 85. 

Determination of Subsequent Variable Payments 
 The amount of each variable annuity payment after the first will increase or decrease according to the value of the variable annuity units which reflect the investment experience of the selected
Subaccounts. Each variable annuity payment after the first will be equal to the number of variable annuity units in the selected Subaccounts multiplied by the variable annuity unit value on the date the payment is made. The number of variable
annuity units in each selected Subaccount is determined by dividing the first variable annuity payment allocated to the Subaccount by the variable annuity unit value of that Subaccount on the Annuity Commencement Date. 

Once Annuity Payments begin, neither expenses actually incurred other than taxes on the investment return, nor mortality actually
experienced by the Company, shall adversely affect the dollar amount of Variable Annuity Payments to any Annuitant for whom such payments have commenced.

 

  

					
	 AV1396 101 179 1003
	 	Page 15	 	CB937R

 GUARANTEED FIXED INCOME OPTIONS ** 

The amounts shown in these tables are the guaranteed amounts for each $1,000 of the proceeds. Higher current amounts may be available at
the time of settlement. 
  

																																													
	 Option 1, Table I
	 	  	Option 2, Table II	 	  	Option 2, Table III	 	  	Option 2, Table IV	 
	 Number

of
 Years

Payable
	  	Amount of
Monthly
Installment	 	  	 	 	  	Monthly Installment
For Life No
Period
Certain	 	  	Monthly Installment For
Life 10 Years Certain	 	  	Monthly Installment For
Life Guaranteed
Return
of Policy Proceeds	 
	 	  	 	 	  	Age*	 	  	Male	 	  	Female	 	  	Unisex	 	  	Male	 	  	Female	 	  	Unisex	 	  	Male	 	  	Female	 	  	Unisex	 
		  				  	 	50	  	  	$	2.97	  	  	$	2.86	  	  	$	2.90	  	  	$	2.96	  	  	$	2.66	  	  	$	2.89	  	  	$	2.79	  	  	$	2.74	  	  	$	2.76	  
		  				  	 	51	  	  	 	3.04	  	  	 	2.92	  	  	 	2.96	  	  	 	3.02	  	  	 	2.91	  	  	 	2.94	  	  	 	2.84	  	  	 	2.79	  	  	 	2,80	  
		  				  	 	52	  	  	 	3.10	  	  	 	2.98	  	  	 	3.02	  	  	 	3.08	  	  	 	2.97	  	  	 	3.01	  	  	 	2.89	  	  	 	2.84	  	  	 	2.85	  
		  				  	 	53	  	  	 	3.18	  	  	 	3.05	  	  	 	3.09	  	  	 	3,15	  	  	 	3.03	  	  	 	3.07	  	  	 	2.94	  	  	 	2.89	  	  	 	2.90	  
	 5
	  	 	17.28	  	  	 	54	  	  	 	125	  	  	 	3.11	  	  	 	3.15	  	  	 	3.22	  	  	 	3.10	  	  	 	3.14	  	  	 	100	  	  	 	2.94	  	  	 	2.96	  
	 6
	  	 	14.51	  	  	 	55	  	  	 	3.33	  	  	 	3.18	  	  	 	3.23	  	  	 	3.30	  	  	 	3.17	  	  	 	3.21	  	  	 	3.06	  	  	 	3.00	  	  	 	3.02	  
	 7
	  	 	12.53	  	  	 	56	  	  	 	3.41	  	  	 	3.26	  	  	 	3.30	  	  	 	3.38	  	  	 	3.24	  	  	 	3.28	  	  	 	3.12	  	  	 	3.06	  	  	 	3.07	  
	 8
	  	 	11.04	  	  	 	57	  	  	 	3.50	  	  	 	3.34	  	  	 	3.39	  	  	 	3.46	  	  	 	3.32	  	  	 	3.36	  	  	 	3.18	  	  	 	3.12	  	  	 	114	  
	 9
	  	 	9.89	  	  	 	58	  	  	 	3.60	  	  	 	3.42	  	  	 	3.47	  	  	 	3.55	  	  	 	3.39	  	  	 	3.44	  	  	 	3.25	  	  	 	3.18	  	  	 	3.20	  
	 10
	  	 	8.96	  	  	 	59	  	  	 	3.69	  	  	 	3.51	  	  	 	3.58	  	  	 	3.65	  	  	 	3.48	  	  	 	3.53	  	  	 	3.32	  	  	 	3.25	  	  	 	3.27	  
	 11
	  	 	8.21	  	  	 	60	  	  	 	3.80	  	  	 	3.60	  	  	 	3.66	  	  	 	3.75	  	  	 	3.57	  	  	 	3.62	  	  	 	3.39	  	  	 	3.32	  	  	 	3.34	  
	 12
	  	 	7.58	  	  	 	61	  	  	 	3.91	  	  	 	3.70	  	  	 	3.76	  	  	 	3.85	  	  	 	3.66	  	  	 	3.72	  	  	 	3.46	  	  	 	3.39	  	  	 	3.41	  
	 13
	  	 	7.05	  	  	 	62	  	  	 	4.03	  	  	 	3.81	  	  	 	3.87	  	  	 	3.96	  	  	 	3.76	  	  	 	3.82	  	  	 	3.54	  	  	 	3.47	  	  	 	3.49	  
	 14
	  	 	6.59	  	  	 	63	  	  	 	4.16	  	  	 	3.92	  	  	 	3.99	  	  	 	4.07	  	  	 	3.87	  	  	 	3.93	  	  	 	3.83	  	  	 	3.55	  	  	 	3,57	  
	 15
	  	 	6.20	  	  	 	64	  	  	 	4.30	  	  	 	4.04	  	  	 	4.12	  	  	 	4.20	  	  	 	3.98	  	  	 	4.04	  	  	 	3.72	  	  	 	3.63	  	  	 	3.66	  
	 16
	  	 	5.85	  	  	 	65	  	  	 	4.45	  	  	 	4.16	  	  	 	4.25	  	  	 	4,32	  	  	 	4.09	  	  	 	4.16	  	  	 	3.81	  	  	 	3.72	  	  	 	3.75	  
	 17
	  	 	5.55	  	  	 	66	  	  	 	4.60	  	  	 	4.30	  	  	 	4.39	  	  	 	4.46	  	  	 	4.22	  	  	 	4.29	  	  	 	3.91	  	  	 	3.81	  	  	 	3.84	  
	 18
	  	 	5.27	  	  	 	67	  	  	 	4.77	  	  	 	4,45	  	  	 	4.54	  	  	 	4.60	  	  	 	4.35	  	  	 	4.42	  	  	 	4.01	  	  	 	3.91	  	  	 	3.94	  
	 19
	  	 	5.03	  	  	 	68	  	  	 	4.95	  	  	 	4.60	  	  	 	4.71	  	  	 	4.75	  	  	 	4.49	  	  	 	4.57	  	  	 	4.11	  	  	 	4.01	  	  	 	4.04	  
	 20
	  	 	4.81	  	  	 	69	  	  	 	5.14	  	  	 	4.77	  	  	 	4.88	  	  	 	4.90	  	  	 	4.64	  	  	 	4.71	  	  	 	4.23	  	  	 	4.12	  	  	 	4.15	  
		  				  	 	70	  	  	 	5.34	  	  	 	4.95	  	  	 	5.07	  	  	 	5.06	  	  	 	4.79	  	  	 	4.87	  	  	 	4.34	  	  	 	4.24	  	  	 	4.27	  
		  				  	 	71	  	  	 	5.56	  	  	 	5.15	  	  	 	5.27	  	  	 	5.22	  	  	 	4.95	  	  	 	5.03	  	  	 	4.47	  	  	 	4.36	  	  	 	4.39	  
		  				  	 	72	  	  	 	5.79	  	  	 	5.36	  	  	 	5.49	  	  	 	5.39	  	  	 	5.12	  	  	 	5.20	  	  	 	4.60	  	  	 	4.49	  	  	 	4.52	  
		  				  	 	73	  	  	 	6.03	  	  	 	5,59	  	  	 	5.72	  	  	 	5.56	  	  	 	5.30	  	  	 	5.38	  	  	 	4.73	  	  	 	4.62	  	  	 	4.66	  
		  				  	 	74	  	  	 	6.30	  	  	 	5.83	  	  	 	5.97	  	  	 	5.74	  	  	 	5.49	  	  	 	5.57	  	  	 	4.88	  	  	 	4.77	  	  	 	4.80	  
		  				  	 	75	  	  	 	6.58	  	  	 	6.10	  	  	 	6.24	  	  	 	5.93	  	  	 	5.68	  	  	 	5.76	  	  	 	5.03	  	  	 	4.92	  	  	 	4.95	  
		  				  	 	76	  	  	 	6.88	  	  	 	6.39	  	  	 	6.53	  	  	 	6.11	  	  	 	5.88	  	  	 	5.95	  	  	 	5.18	  	  	 	5.08	  	  	 	5.11	  
		  				  	 	77	  	  	 	7.20	  	  	 	6.70	  	  	 	6.85	  	  	 	6.30	  	  	 	6.09	  	  	 	6,15	  	  	 	5.35	  	  	 	5.25	  	  	 	5.28	  
		  				  	 	78	  	  	 	7.55	  	  	 	7.03	  	  	 	7.19	  	  	 	6.49	  	  	 	6.30	  	  	 	6.36	  	  	 	5.53	  	  	 	5.43	  	  	 	5.46	  
		  				  	 	79	  	  	 	7.92	  	  	 	7.40	  	  	 	7.55	  	  	 	6.68	  	  	 	8.51	  	  	 	656	  	  	 	5.71	  	  	 	5.61	  	  	 	5.64	  
		  				  	 	80	  	  	 	8.32	  	  	 	7.79	  	  	 	7.95	  	  	 	6.87	  	  	 	6.72	  	  	 	6.77	  	  	 	5.90	  	  	 	5.81	  	  	 	5.84	  
		  				  	 	81	  	  	 	8.75	  	  	 	822	  	  	 	8.38	  	  	 	7.06	  	  	 	6.93	  	  	 	6.97	  	  	 	6.11	  	  	 	602	  	  	 	6.05	  
		  				  	 	82	  	  	 	9.20	  	  	 	8.69	  	  	 	8.84	  	  	 	7.24	  	  	 	7.13	  	  	 	7.16	  	  	 	6.32	  	  	 	6.24	  	  	 	6.27	  
		  				  	 	83	  	  	 	9.69	  	  	 	9.19	  	  	 	9.34	  	  	 	7.41	  	  	 	7.33	  	  	 	7.36	  	  	 	6.55	  	  	 	6.48	  	  	 	6.50	  
		  				  	 	84	  	  	 	10.21	  	  	 	9.74	  	  	 	9.88	  	  	 	7.58	  	  	 	7.52	  	  	 	7.54	  	  	 	6.78	  	  	 	6.72	  	  	 	6.74	  
		  				  	 	85	  	  	 	10.77	  	  	 	10.33	  	  	 	10.46	  	  	 	7.74	  	  	 	7.69	  	  	 	7.71	  	  	 	7.03	  	  	 	6.98	  	  	 	7.00	  
		  				  	 	86	  	  				  				  				  	 	7.89	  	  	 	7.86	  	  	 	7.87	  	  	 	7.29	  	  	 	7.26	  	  	 	7.27	  
		  				  	 	87	  	  				  				  				  	 	8.03	  	  	 	8.01	  	  	 	8.01	  	  	 	7.57	  	  	 	7.54	  	  	 	7.55	  
		  				  	 	88	  	  				  				  				  	 	8.16	  	  	 	8.15	  	  	 	815	  	  	 	7.86	  	  	 	7.84	  	  	 	7.85	  
		  				  	 	89	  	  				  				  				  	 	8.28	  	  	 	8.27	  	  	 	8.27	  	  	 	8.17	  	  	 	8.15	  	  	 	8.16	  
		  				  	 	90	  	  				  				  				  	 	8.38	  	  	 	8.38	  	  	 	8.38	  	  	 	8.49	  	  	 	8.48	  	  	 	8.48	  
		  				  	 	91	  	  				  				  				  	 	8.48	  	  	 	8.48	  	  	 	8.48	  	  	 	8.83	  	  	 	8.82	  	  	 	8.83	  
		  				  	 	92	  	  				  				  				  	 	8.57	  	  	 	8.57	  	  	 	8,57	  	  	 	9.19	  	  	 	9.18	  	  	 	9.19	  
		  				  	 	93	  	  				  				  				  	 	8.65	  	  	 	8.64	  	  	 	8.65	  	  	 	9.58	  	  	 	9.56	  	  	 	9.57	  
		  				  	 	94	  	  				  				  				  	 	8.72	  	  	 	8.71	  	  	 	8.71	  	  	 	10.00	  	  	 	9.97	  	  	 	9.98	  
		  				  	 	95	  	  				  				  				  	 	8.78	  	  	 	8.77	  	  	 	8.77	  	  	 	10.45	  	  	 	10.40	  	  	 	10.42	  

  

	*	Adjusted Age as defined in Section 10.A. 

	**	The guaranteed fixed income amounts are based on a guaranteed interest rate of 1.5%. 

 Dollar amounts of monthly, quarterly, semi–annual and annual installments not shown in the above tables will be calculated on the same basis as those shown and may be obtained from the Company (if
the option is available based on Adjusted Age as described in Section 10). 

  

					
	 AV1396 101 179 1003
	 	Page 16	 	T1027R

 Fixed Income Option 4, Table V 

Monthly Installment For Joint and Full Survivor 
  

																													
	 Adjusted Age
 of
 Male

Annuitant*
	  	Adjusted Age of Female Annuitants	 
	  	15 Years
Less Than
Male	 	  	12 Years
Less Than
Male	 	  	9 Years
Less Than
Male	 	  	6 Years
Less Than
Male	 	  	3 Years
Less Than
Male	 	  	Same As
Male	 	  	3 Years
More Than
Male	 
	 50
	  	$	2.20	  	  	$	2.27	  	  	$	2.34	  	  	$	2.41	  	  	$	2.48	  	  	$	2.55	  	  	$	2.62	  
	 55
	  	 	2.35	  	  	 	2.44	  	  	 	2.52	  	  	 	2.61	  	  	 	2.71	  	  	 	2.80	  	  	 	2.88	  
	 60
	  	 	2.54	  	  	 	2.84	  	  	 	2.76	  	  	 	2.88	  	  	 	2.99	  	  	 	3.11	  	  	 	3.23	  
	 65
	  	 	2.77	  	  	 	2.91	  	  	 	3.06	  	  	 	3.22	  	  	 	3.38	  	  	 	3.54	  	  	 	3,69	  
	 70
	  	 	3.08	  	  	 	3.26	  	  	 	3.46	  	  	 	3.67	  	  	 	3.89	  	  	 	4,11	  	  	 	4.33	  
	 75
	  	 	3.47	  	  	 	3.72	  	  	 	3,99	  	  	 	4.29	  	  	 	4.60	  	  	 	4.93	  	  	 	5.24	  
	 80
	  	 	4.01	  	  	 	4.35	  	  	 	4.74	  	  	 	5.17	  	  	 	5.62	  	  	 	6.08	  	  	 	6.53	  
	 85
	  	 	4.75	  	  	 	5.25	  	  	 	5.81	  	  	 	6.44	  	  	 	7.09	  	  	 	7.75	  	  	 	8.36	  

 Monthly Installment
For Unisex Joint and Full Survivor 
  

																													
	 Adjusted Age
 of
 First

Annuitant*
	  	Adjusted Age of Joint Annuitant*	 
	  	15 Years
Less Than
First	 	  	12 Years
Less Than
First	 	  	9 Years
Less Than
First	 	  	6 Years
Less Than
First	 	  	3 Years
Less Than
First	 	  	Same As
First	 	  	3 Years
More Than
First	 
	 50
	  	$	2.20	  	  	$	2.27	  	  	$	2.34	  	  	$	2.41	  	  	$	2.48	  	  	$	2.55	  	  	$	2.61	  
	 55
	  	 	2.36	  	  	 	2.44	  	  	 	2.53	  	  	 	2.62	  	  	 	2.70	  	  	 	2.79	  	  	 	2.87	  
	 80
	  	 	2.55	  	  	 	2,65	  	  	 	2.76	  	  	 	2.88	  	  	 	2.99	  	  	 	3.10	  	  	 	3.20	  
	 65
	  	 	2.79	  	  	 	2.92	  	  	 	3.07	  	  	 	3.22	  	  	 	3.37	  	  	 	3,52	  	  	 	3.66	  
	 70
	  	 	3.10	  	  	 	3.28	  	  	 	3.47	  	  	 	3.67	  	  	 	3.88	  	  	 	4.09	  	  	 	4.28	  
	 75
	  	 	3.50	  	  	 	3.75	  	  	 	4.02	  	  	 	4.30	  	  	 	4.60	  	  	 	4.89	  	  	 	5.16	  
	 80
	  	 	4.06	  	  	 	4.40	  	  	 	4.78	  	  	 	5.19	  	  	 	5.62	  	  	 	6.04	  	  	 	6.44	  
	 85
	  	 	4.83	  	  	 	5.32	  	  	 	5.87	  	  	 	6.47	  	  	 	7.10	  	  	 	7,71	  	  	 	8.28	  

  

	*	Adjusted Age as defined in Section 10.A. 

Dollar amounts of monthly, quarterly, semi-annual, and annual installments not shown in the above tables will be calculated on the same basis as those
shown and may be obtained from the Company (if the option is available based on Adjusted Age as described in Section 10). 

  

					
	 AV1396 101 179 1003
	 	Page 17	 	TB1027R

 VARIABLE INCOME OPTIONS 

BASED ON ASSUMED INVESTMENT RETURN ** 
 The amounts shown in these tables are the initial payment amounts based on a 5.0% Assumed Investment Return for each $1,000 of the proceeds. 

 

																									
	 	  	Option 3-V, Table I	 	  	Option 3-V, Table II	 
	 	  	Monthly Installment for Life
No Period
Certain	 	  	Monthly Installment for Life
10 Years
Certain	 
	 Age*
	  	Male	 	  	Female	 	  	Unisex	 	  	Male	 	  	Female	 	  	Unisex	 
	 50
	  	$	5.07	  	  	$	4.93	  	  	$	4.98	  	  	$	5.04	  	  	$	4.92	  	  	$	4.95	  
	 51
	  	 	5.13	  	  	 	4.99	  	  	 	5.03	  	  	 	5.09	  	  	 	4.96	  	  	 	5.00	  
	 52
	  	 	5.19	  	  	 	5.04	  	  	 	5.08	  	  	 	5.15	  	  	 	5.01	  	  	 	5.05	  
	 53
	  	 	5.26	  	  	 	5.10	  	  	 	5.14	  	  	 	5.21	  	  	 	5.07	  	  	 	5.11	  
	 54
	  	 	5.33	  	  	 	5.16	  	  	 	5.21	  	  	 	5.27	  	  	 	5.12	  	  	 	5.17	  
	 55
	  	 	5.40	  	  	 	5.22	  	  	 	5.27	  	  	 	5.34	  	  	 	5.18	  	  	 	5.23	  
	 56
	  	 	5.48	  	  	 	5.29	  	  	 	5.35	  	  	 	5.41	  	  	 	5.25	  	  	 	5.30	  
	 57
	  	 	5.57	  	  	 	5.36	  	  	 	5.42	  	  	 	5.49	  	  	 	5.32	  	  	 	5.37	  
	 58
	  	 	5,66	  	  	 	5.44	  	  	 	5.50	  	  	 	5.57	  	  	 	5.39	  	  	 	5.44	  
	 59
	  	 	5.75	  	  	 	5.52	  	  	 	5.59	  	  	 	5.66	  	  	 	5.47	  	  	 	5.52	  
	 60
	  	 	5.85	  	  	 	5.61	  	  	 	5.68	  	  	 	5.75	  	  	 	5.55	  	  	 	5.61	  
	 61
	  	 	5.97	  	  	 	5,70	  	  	 	5.78	  	  	 	5.85	  	  	 	5.63	  	  	 	5.70	  
	 62
	  	 	6.09	  	  	 	5.81	  	  	 	5.89	  	  	 	5.95	  	  	 	5.72	  	  	 	5.79	  
	 63
	  	 	8.21	  	  	 	5.91	  	  	 	6.00	  	  	 	8.06	  	  	 	5.82	  	  	 	5.89	  
	 64
	  	 	8.35	  	  	 	6.03	  	  	 	6.13	  	  	 	8.17	  	  	 	5.92	  	  	 	6.00	  
	 65
	  	 	6.50	  	  	 	8.16	  	  	 	6.26	  	  	 	6.29	  	  	 	6,03	  	  	 	6.11	  
	 66
	  	 	6.66	  	  	 	8.29	  	  	 	6.40	  	  	 	6.42	  	  	 	6.15	  	  	 	6.23	  
	 67
	  	 	6.83	  	  	 	6.43	  	  	 	6.55	  	  	 	6.55	  	  	 	6.27	  	  	 	6,36	  
	 88
	  	 	7.01	  	  	 	6.59	  	  	 	6.71	  	  	 	6.89	  	  	 	6.40	  	  	 	6,49	  
	 69
	  	 	7.21	  	  	 	6.76	  	  	 	6.89	  	  	 	6.83	  	  	 	6.54	  	  	 	6,63	  
	 70
	  	 	7.41	  	  	 	6.94	  	  	 	7.08	  	  	 	6,98	  	  	 	6.69	  	  	 	6.77	  
	 71
	  	 	7.63	  	  	 	7.14	  	  	 	7.28	  	  	 	7.13	  	  	 	6.84	  	  	 	6.93	  
	 72
	  	 	7.87	  	  	 	7.35	  	  	 	7.50	  	  	 	7.28	  	  	 	7.00	  	  	 	7.09	  
	 73
	  	 	8.12	  	  	 	7.58	  	  	 	7.74	  	  	 	7.45	  	  	 	7.17	  	  	 	7.25	  
	 74
	  	 	8.39	  	  	 	7.83	  	  	 	8.00	  	  	 	7.61	  	  	 	7.34	  	  	 	7.42	  
	 75
	  	 	8.68	  	  	 	8.11	  	  	 	8.28	  	  	 	7.78	  	  	 	7.52	  	  	 	7.60	  
	 75
	  	 	8.99	  	  	 	8.40	  	  	 	8.58	  	  	 	7.95	  	  	 	7.71	  	  	 	7.78	  
	 77
	  	 	9.32	  	  	 	8.72	  	  	 	8.90	  	  	 	8.12	  	  	 	7.90	  	  	 	7.97	  
	 78
	  	 	9,88	  	  	 	9.07	  	  	 	9.25	  	  	 	8.29	  	  	 	8.09	  	  	 	8.16	  
	 79
	  	 	10.06	  	  	 	9.45	  	  	 	9.63	  	  	 	8.47	  	  	 	8.29	  	  	 	8.34	  
	 80
	  	 	10.47	  	  	 	9.85	  	  	 	10.04	  	  	 	8.64	  	  	 	8.48	  	  	 	8.53	  
	 81
	  	 	10.91	  	  	 	10.30	  	  	 	10.48	  	  	 	8.80	  	  	 	8,67	  	  	 	8.71	  
	 82
	  	 	11.38	  	  	 	10.78	  	  	 	10.96	  	  	 	8.97	  	  	 	8.86	  	  	 	8.89	  
	 83
	  	 	11.88	  	  	 	11.30	  	  	 	11.47	  	  	 	9.12	  	  	 	9.04	  	  	 	9.06	  
	 84
	  	 	12.42	  	  	 	11.87	  	  	 	12.03	  	  	 	9.27	  	  	 	9.21	  	  	 	9.23	  
	 85
	  	 	12.99	  	  	 	12.48	  	  	 	12.63	  	  	 	9.41	  	  	 	9.37	  	  	 	9.38	  
	 85
	  				  				  				  	 	9.54	  	  	 	9.51	  	  	 	9.52	  
	 87
	  				  				  				  	 	9.67	  	  	 	9.65	  	  	 	9.65	  
	 88
	  				  				  				  	 	9.78	  	  	 	9.77	  	  	 	9.77	  
	 89
	  				  				  				  	 	9.89	  	  	 	9.88	  	  	 	9.88	  
	 90
	  				  				  				  	 	9.98	  	  	 	9.98	  	  	 	9.98	  
	 91
	  				  				  				  	 	10.07	  	  	 	10.07	  	  	 	10.07	  
	 92
	  				  				  				  	 	10.15	  	  	 	10.15	  	  	 	10.15	  
	 93
	  				  				  				  	 	10.22	  	  	 	10.22	  	  	 	10.22	  
	 94
	  				  				  				  	 	10.28	  	  	 	10.28	  	  	 	10.28	  
	 95
	  				  				  				  	 	10.34	  	  	 	10.33	  	  	 	10.33	  

  

	*	Adjusted Age as defined in Section 10.A. 

	**	The discount factor per day which corresponds to the Assumed Investment Return of 5.0% is .99986634. 

Dollar amounts of monthly, quarterly, semi–annual, and annual installments not shown in the above tables will be calculated on the same basis as
those shown and may be obtained from the Company (if the option is available based on Adjusted Age as described in Section 10). 

  

					
	 AV1396 101 179 1003
	 	Page 18	 	H1313R

 Variable Income Option 5-V, Table Ill 

Monthly Installment For Joint and Full Survivor 
  

																													
	 Adjusted Age
 of
 Male

Annuitant*
	  	Adjusted Age of Female Annuitant*	 
	  	15 Years
Less Than
Male	 	  	12 Years
Less Than
Male	 	  	9 Years
Less Than
Male	 	  	6 Years
Less Than
Male	 	  	3 Years
Less Than
Male	 	  	Same As
Male	 	  	3 Years
More Than
Male	 
	 50
	  	$	4.37	  	  	$	4.42	  	  	$	4.46	  	  	$	4.51	  	  	$	4.56	  	  	$	4.62	  	  	$	4.67	  
	 55
	  	 	4.48	  	  	 	4.64	  	  	 	4.60	  	  	 	4.67	  	  	 	4.74	  	  	 	4.81	  	  	 	4.88	  
	 60
	  	 	4.62	  	  	 	4.70	  	  	 	4.79	  	  	 	4.88	  	  	 	4.98	  	  	 	5.08	  	  	 	5.18	  
	 65
	  	 	4.81	  	  	 	4.92	  	  	 	5.04	  	  	 	5.17	  	  	 	6.31	  	  	 	5.46	  	  	 	5.61	  
	 70
	  	 	5.07	  	  	 	5,23	  	  	 	5.40	  	  	 	5.59	  	  	 	5.79	  	  	 	6.00	  	  	 	6.22	  
	 75
	  	 	5.43	  	  	 	5.65	  	  	 	5.90	  	  	 	6.18	  	  	 	6.48	  	  	 	6.79	  	  	 	7.11	  
	 80
	  	 	5.94	  	  	 	6.26	  	  	 	6.63	  	  	 	7.04	  	  	 	7.49	  	  	 	7.95	  	  	 	8.40	  
	 85
	  	 	6.67	  	  	 	7.15	  	  	 	7.70	  	  	 	8.31	  	  	 	8.97	  	  	 	9.63	  	  	 	10.26	  

 Monthly Installment
For Unisex Joint and Full Survivor 
  

																													
	 Adjusted Age
 of
 First

Annuitant*
	  	Adjusted Age of Joint Annuitant*	 
	  	15 Years
Less Than
First	 	  	12 Years
Less Than
First	 	  	9 Years
Less Than
First	 	  	6 Years
Less Than
First	 	  	3 Years
Less Than
First	 	  	Same As
First	 	  	3 Years
More Than
First	 
	 50
	  	$	4.38	  	  	$	4.42	  	  	$	4.47	  	  	$	4.51	  	  	$	4.56	  	  	$	4.61	  	  	$	4.66	  
	 55
	  	 	4.48	  	  	 	4.54	  	  	 	4.60	  	  	 	4.67	  	  	 	4.73	  	  	 	4.80	  	  	 	4.87	  
	 60
	  	 	4.63	  	  	 	4.70	  	  	 	4.79	  	  	 	4.88	  	  	 	4.97	  	  	 	5.07	  	  	 	5.16	  
	 65
	  	 	4.82	  	  	 	4.93	  	  	 	5.05	  	  	 	5.17	  	  	 	5.30	  	  	 	5.44	  	  	 	5.57	  
	 70
	  	 	5.09	  	  	 	5.24	  	  	 	5.41	  	  	 	5.59	  	  	 	5.78	  	  	 	5.97	  	  	 	6.16	  
	 75
	  	 	5.46	  	  	 	5.68	  	  	 	5.93	  	  	 	6.19	  	  	 	6.47	  	  	 	6.75	  	  	 	7.03	  
	 80
	  	 	5.99	  	  	 	6.31	  	  	 	6.67	  	  	 	7.07	  	  	 	7.48	  	  	 	7.90	  	  	 	8.30	  
	 85
	  	 	6.75	  	  	 	7.23	  	  	 	7.76	  	  	 	8.35	  	  	 	8.97	  	  	 	9.59	  	  	 	10.17	  

  

																													
	 * Adjusted Age as defined in Section 10.A
	  				  				  				  				  				  				  			

 Dollar amounts of monthly, quarterly, semi—annual, and annual installments not shown in the above tables will
be calculated on the same basis as those shown and may be obtained from the Company (if the option is available based on Adjusted Age as described in Section 10). 

  

					
	 AV1396 101 179 1003
	 	Page 19	 	J1313R

 SECTION 11 – GENERAL PROVISIONS 

 

 THE ENTIRE CONTRACT 

The entire contract consists of this policy, the Policy Data page, endorsements, and riders, if any and the application signed by You, a
copy of which is attached hereto. No insertion in or other alteration of any written application can be made by any person other than the Owner without his or her written consent except that insertions may be made by the Company for administrative
purposes only in such manner as to clearly indicate that the insertions are not to be ascribed to the Owner. All statements in the application made by or under the authority of the applicant are representations and not warranties. Nothing is
incorporated by reference, unless a copy is endorsed upon or attached to the Policy. Nothing in the policy or any attached endorsements or riders thereto invalidates or impairs any right granted to the Owner by New York law or this policy.

 MODIFICATION OF POLICY 
 No change in this policy is valid unless made in writing by us and approved by one of our officers. No Registered Representative has authority to change or waive any provision of Your policy. 

TAX QUALIFICATION 
 This policy is intended to qualify as an annuity contract for federal income tax purposes. The provisions of this policy are to be interpreted to maintain such qualification, notwithstanding any other
provisions to the contrary. To maintain such tax qualification, we reserve the right to amend this policy to reflect any clarifications that may be needed or are appropriate to maintain such tax qualification or to conform this policy to any
applicable changes in the tax qualification requirements. Any such amendment will be filed with and approved by the New York Department of Insurance prior to use. We will send You a copy in the event of any such amendment If You refuse such an
amendment it must be by giving us written notice, and Your refusal may result in adverse tax consequences. 

NON-PARTICIPATING 
 This policy will not share in our surplus earnings. 
 AGE OR SEX CORRECTIONS

 If the age or sex of the Annuitant has been misstated, the benefits will be those, which the premiums paid, would have
purchased for the correct age and sex. If required by law to ignore differences in the sex of the Annuitant, the annuity payments will be determined using the unisex factors. 
 Any underpayment made by us will be paid with the next payment Any overpayment made by us will be deducted from future payments. Any underpayment or overpayment will include interest at 5% per year,
from the date of the wrong payment to the date of the adjustment 
 INCONTESTABILITY 

This policy shall be incontestable from the Policy Date.

 EVIDENCE OF SURVIVAL 

We have the right to require reasonable evidence that a person is alive if a payment is based on that person being alive. No payment will
be made until we receive the evidence. 
 SETTLEMENT 

Any payment by us under this policy is payable at our Home Office 

RIGHTS OF OWNER The Owner may, while the Annuitant is living: 

 

	 	1.	Assign this policy. 

  

	 	2.	Surrender the policy to us. 

  

	 	3.	Amend or modify the policy with our written consent. 

  

	 	4.	Receive annuity payments or name a Payee to receive the payments. 

  

	 	5.	Exercise, receive and enjoy every other right and benefit contained in the policy. 

The use of these rights may be subject to the consent of any assignee or irrevocable beneficiary; and of the spouse in a community or
marital property state. 
 Unless we have been notified of a community or marital property interest in this policy, we will rely
on our good faith belief that no such interest exists and will assume no responsibility for inquiry. 
 SUCCESSOR OWNER

 A successor Owner will be the new Owner as described in Section 9, C, II. 

CHANGE OF OWNERSHIP 
 In the case of a non-tax-qualified annuity, You can change the Owner of this policy, from yourself to a new Owner, in a notice You sign which gives us the facts that we need. When this change takes effect
all rights of ownership in this policy will pass to the new Owner. 
 A change of Owner will not be effective until it is
received by Us. After it has been received, the change will take effect as of the date You signed the notica However, if the Annuitant dies before the notice has been received, it will not be effective as to those proceeds we have paid before the
change was received by Us. 
 We may require that the change be endorsed in the policy. Changing the Owner does not change the
beneficiary or the Annuitant 
 A change of ownership may result in adverse tax consequences. 

ANNUITY COMMENCEMENT DATE 
 The Annuity Commencement Date is the date annuity payments begin. In no event can this date be later than the last day of the month following the month in which the Annuitant attains age 95. You may
change the Annuity Commencement Date at any time before the Annuity Commencement date by giving us 30 days’ written notice. The Annuity Commencement Date may not be scheduled at issue to be earlier than the first day of the calendar month
coinciding with or next following the first policy anniversary. 
  
  

 

 

  

					
	AV1396 101 179 1003	 	Page 20	 	 R313R

 SECTION 11 – CONTINUED 

 

 ASSIGNMENT 

 

	(a)	 In the case of a non tax-qualified annuity, this Policy may be assigned. The assignment must be in writing and received by us.

  

	(b)	 We assume no responsibility for the validity of any assignment Any claim made under an assignment shall be subject to proof of interest and the
extent of the assignment 

  

	(c)	 This policy may be applied for and issued to qualify as a tax-qualified annuity under certain sections of the Internal Revenue Code. Ownership of
this policy is then restricted so that it will comply with provisions of the Internal Revenue Code. 

Assignment of this policy may result in adverse tax consequences. 

BENEFICIARY 
 Death proceeds, when payable in accordance with Section 9, are payable to the designated beneficiary or beneficiaries. Such beneficiary(lies) must be named and may be changed without consent (unless
irrevocably designated or required by law) by notifying us in writing on a form acceptable to us. The change will take effect upon the date You sign it whether or not You are living when we receive it The notice must have been postmarked (or show
other evidence of delivery that is acceptable to us) on or before the date of death. Your most recent change of beneficiary notice will replace any prior beneficiary designations. No change will apply to any payment we made before the written notice
was received. If an irrevocable beneficiary dies, You may designate a new beneficiary. 
 You may direct that the beneficiary
shall not have the right to withdraw, assign or commute any sum payable under an option. In the absence of such election or direction, the beneficiary may change the manner of payment or make an election of any option. 

If any primary or contingent beneficiary dies before the Annuitant, that beneficiary’s interest in this policy ends with that
beneficiary’s death. Only those beneficiaries living at the time of the Annuitants death will be eligible to receive their share of the death proceeds. In the event no beneficiaries have been named or all beneficiaries have died before the
death proceeds become payable, the Owner(s) will become the beneficiary(ies) unless elected otherwise in accordance with Section 9. If both primary and contingent beneficiaries havebeen named, payment

 will be made to the named primary beneficiaries living at the time the death proceeds
become payable. If there is more than one beneficiary and You failed to specify their interest they will share equally. Payment will be made to the named contingent beneficiary(ies) only, if all primary beneficiaries have died before the death
proceeds become payable. If any primary beneficiary is alive at the time the death proceeds become payable, but dies before receiving their payment their share will be paid to their estate. 

PROTECTION OF PROCEEDS 
 Unless You so direct by filing written notice with us, no beneficiary may assign any payments under this policy before the same are due. To the extent permitted by law, no payments under this policy will
be subject to the claims of creditors of any beneficiary. 
 DEFERMENT 

We will pay any partial Withdrawals or Surrender proceeds from the Separate Account within 7 days after we receive all requirements that
we need. However, it may happen that the New York Stock Exchange is closed for trading (other than the usual weekend or holiday closings), or the Securities and Exchange Commission restricts trading or determines that an emergency exists. If so, it
may not be practical for us to determine the investment experience of the Separate Account In that case, we may defer transfers among the Subaccounts and to the Fixed Account and determination or payment of partial Withdrawals or Surrender proceeds,
until such time as is practical. 
 We may defer paying any partial Withdrawals or Surrender proceeds from the Fixed Account for
up to 6 months from the date we receive Your request If payment of the partial Withdrawal or full Surrender is not made within 10 business days of our receipt of the request, we will pay interest on that amount from the date of receipt of the
request to the date of payment, at an annual interest rate of 1.5%, or the guaranteed annual rate used for calculating settlement options, whichever is greater. If the Owner dies after the request is received, but before the request is processed,
the request will be processed before the death proceeds are determined. 

 

  

					
	 AV1396 101 179 1003
	 	Page 21	 	RB313R

 SECTION 11 – CONTINUED 

 

 ASSET ALLOCATION PORTFOLIOS 

The Company may, from time to time, offer one or more asset allocation underlying fund portfolios Each such asset allocation portfolio
seeks to achieve its investment objective by generally investing a substantial portion of its assets in a diversified combination of other underlying fund portfolios and mutual funds “(the underlying portfolios/funds).’ 

In seeking to achieve its investment objective, each asset allocation portfolio generally follows these investment strategies:
(1) under normal market conditions, each expects to adjust its investments in the underlying portfolios and funds to achieve its desired mix of assets in equities, bonds, and cash, cash equivalents, or money market instruments (the percentage
mix may vary at different times); (2) each asset allocation portfolio decides how much of its assets to allocate to each underlying portfolio and fund based on its outlook for the markets in which it invests, historical performance, global
markets current valuations, and other economic factors; (3) each seeks to periodically adjust its allocations to favor investments in those underlying portfolios and funds that are expected to provide the most favorable outlook for achieving
its investment objective; and (4) each asset allocation portfolio may also invest directly in government securities, short-term commercial paper, or other appropriate investments.

 Each such asset allocation portfolio expects to adjust its allocations to favor investments
that it believes will provide a favorable outlook for achieving its investment objective. It is not possible to predict the extent to which an asset allocation portfolio will be invested in a particular underlying portfolio or fund at any time.

 REPORTS TO OWNER 
 We will give You an annual report at least once each Policy Year. This report will show the number and value of the accumulation units held in each of the Subaccounts as well as the value of the Fixed
Account It will also give You the death benefit and method of determining the Cash Value, and any other facts required by law or regulation.

 

  

					
	 AV1396 101 179 1003
	 	Page 22	 	R639R

			
	
 

  
	  	Home Office located at;
	A Stock Company (Hereafter called the Company, we, our or us)	  	440 Mamaroneek Avenue, Harrison, New York 10528
		  	Adm. Office located at :
		  	4333 Edgewood Road N.E. Cedar Rapids, Iowa 52499
		  	(319) 355-8511

 INDEX 

 

					
	 	  	Page    	 
	 Accumulation Units
	  	 	7, 8	  
	 Age or Sex Corrections
	  	 	20	  
	 Annuity Commencement Date
	  	 	20	  
	 Annuity Payments
	  	 	12	  
	 Assignment
	  	 	21	  
	 Beneficiary
	  	 	21	  
	 Cash Value
	  	 	5	  
	 Contract
	  	 	20	  
	 Death Proceeds
	  	 	10,11,12	  
	 Definitions
	  	 	2	  
	 Dollar Cost Averaging Option
	  	 	9	  
	 Evidence of Survival
	  	 	20	  
	 Fixed Account
	  	 	8	  
	 Guaranteed Minimum Death Benefit
	  	 	10	  
	 Guaranteed Period Option
	  	 	8	  

					
	 	  	Page    	 
	Incontestability	  	 	20	  
	Income Option Tables	  	 	16,17,18,19	  
	Modification of Policy	  	 	20	  
	Non-participating	  	 	20	  
	Option to Change Annuity Commencement Date	  	 	20	  
	Partial Withdrawals	  	 	5	  
	Payee	  	 	13	  
	Payment of Premiums	  	 	4	  
	Policy Data Page	  	 	3	  
	Policy Value	  	 	4	  
	Proof of Age	  	 	13	  
	Protection of Proceeds	  	 	21	  
	Right to Cancel	  	 	1	  
	Rights of Owner	  	 	20	  
	Separate Account	  	 	6, 7	  
	Service Charge	  	 	4, 5	  
	Settlement	  	 	20	  
	Transfers	  	 	9, 10	  

 

  
 Flexible Premium
Deferred Variable Annuity 
 Income Payable At Annuity Commencement Date 

Benefits Based On The Performance Of The Separate Account Are Variable And Are Not 

Guaranteed As To Dollar Amount And Will Increase Or Decrease In Value Based Upon 

Investment Experience (See Sections 6 and 10C) 
 Non-Participating 
 AFTER THE POLICY DATE. WE RESERVE THE RIGHT TO (I) REFUSE
PREMIUM PAYMENTS TO 
 THE FIXED ACCOUNT, AND (II) PROHIBIT TRANSFERS TO THE FIXED ACCOUNT 

  

					
	 AV1396 101 179 1003
	 		 	Y1028REXHIBIT 4(B)

 EXHIBIT (4)(b) 

FORM OF ENDORSEMENT (DWS FUND FACILITATION FEE) 

			
	
 

  
	  	 Home Office located at:
 440 Mamaroneck Avenue, Harrison, New York 10528
 Adm. Office located at:

4333 Edgewood Road N.E. Cedar Rapids, Iowa 52499

(319) 355-8511

	A Stock Company (Hereafter called the Company, we, our or us)	  

 AMENDATORY ENDORSEMENT 

This Amendatory Endorsement is attached to and part of your policy. 
  

					
	 	  	Fund Facilitation Fee	 
	 DWS Alternative Asset Allocation Plus VIP
	  	 	0.19	% 
	 DWS Capital Growth VIP
	  	 	0.19	% 
	 DWS Dreman Small Mid Cap Value VIP
	  	 	0.19	% 
	 DWS Global Opportunities VIP
	  	 	0.19	% 
	 DWS Government & Agency Securities VIP
	  	 	0.19	% 
	 DWS High Income VIP
	  	 	0.19	% 
	 DWS Large Cap Value VIP
	  	 	0.19	% 
	 DWS Money Market VIP
	  	 	0.19	% 
	 DWS Small Mid Cap Growth VIP
	  	 	0.19	% 
	 DWS Strategic Income VIP
	  	 	0.19	% 

 If any of the above Subaccounts are
elected, a Fund Facilitation Fee would be charged in addition to any policy fees and charges, and will be used in the calculation of the net investment factor as described in the Accumulation Units provision of the policy. The Fund Facilitation Fee
will only be charged when money is allocated to one of the above Subaccounts and is guaranteed not to change during the life of the policy. The Fund Facilitation Fee is an annualized percentage taken from the daily net asset values of a fund share
held in that Subaccount. 
 This endorsement takes effect and expires concurrently with the policy to which it is attached and is subject to all
the terms and conditions of the policy not inconsistent herewith. 
 Signed for us at our home office. 

 

			
	
 

  
	  	
 

  

	SECRETARY	  	PRESIDENT

 AE 1288 0608 (NY)
(DWS)

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