Document:

EXHIBIT 4(G)

 EXHIBIT 4(g) 

FORM OF POLICY RIDER (RETIREMENT INCOME CHOICE 2.0) 

 

 
 GUARANTEED LIFETIME WITHDRAWAL BENEFIT 

This rider is issued as a part of the policy to which it is attached. All provisions of the policy that do not conflict with this rider apply to this rider.
In the event of any conflict between the provisions of this rider and the provisions of the policy, the provisions of this rider shall prevail over the provisions of the policy. 

The purpose of the guaranteed living withdrawal benefit provided under this rider is to provide a stream of income payments to the Owner. 

You may cancel this rider on or before midnight of the thirtieth calendar day after You receive it and no Rider Fees will be assessed. 

This rider provides a minimum withdrawal benefit that guarantees, upon election, a series of withdrawals from the policy equal to the Withdrawal Percentage
shown below applied to the Withdrawal Base. The Withdrawal Base is established for the sole purpose of determining the minimum withdrawal benefit and is not used in calculating the cash surrender value or other guaranteed benefits. 

Rider Data Specification 
  

													
		  		  	 	  	 	  		 	 	  	
		  	 Policy Number:
	  	 	  		  	123456	 		  	
		  	 Rider Date:
	  	 	  		  	03/11/2015	 		  	
		  	 Growth Rate Percentage:
	  	 	  		  	5.50%	 		  	
				 		 	
		  	 Rider Fee Percentages*:
	  		  	 	  		 	 	  	
		  	 Designated Allocation Group A:
	  	 	  		  	1.45%	 		  	
		  	 Designated Allocation Group B:
	  	 	  		  	1.10%	 		  	
		  	 Designated Allocation Group C:
	  	 	  	 	  	0.70%	 		  	
						 	
		  		  		  	 	  		 	 	  	
		  	 Annuitant:
	  	 	  		  	John Doe	 		  	
			 				 
		  	 Annuitant’s Issue Age/Sex:
	  	 	  		  	65   /  Male	 	 	  	
		  		  		  	 	  		 		  	

  

	*	The Rider Fee is also a maximum Rider Fee for the life of the rider, provided there are no automatic step-ups. When an automatic step-up is utilized, the maximum Rider Fee would not be more than [0.75%] greater than the rider fee percentages shown above. 

 Designated
Allocations: If You elect this rider, 100% of Your Policy Value must be in one or more of the Designated Investment Options (or any other option authorized for use with this rider). The Designated Investment Options available may change with an
upgrade or prior approval of the New York State Department of Financial Services. 
 You can generally transfer between the Designated Investment Options as
permitted under Your policy; however, You cannot make transfers as provided for in the policy to a non-designated investment option (or any other option not authorized for use with this rider) while this rider is in force. If You wish to make a
transfer to a non-designated investment option, this rider must be terminated, as described in Article IV, prior to making the transfer. You will be notified if there are any changes to the Designated Investment Options. 

Guaranteed Lifetime Withdrawal Benefit: The withdrawal percentage is determined by the attained age and is used to determine the Rider Withdrawal
Amount as described in Article III. The withdrawal percentages are shown in the table below: 
  

																	
	 	 	 	  	 Attained Age
	  	 	  	 	  	 	  	 Withdrawal
Percentage
	  	 	  	 
		 		  		  		  		  		  		  		  	
	 	 	 	  	59 - 64	  	 	  	 	  	 	  	4.00%	  	 	  	
	 	 		  	65 -  79	  		  	 	  		  	5.00%	  		  	
	 	 	 	  	80 +	  	 	  	 	  	 	  	6.00%	  	 	  	

  

  

					
	NIC14 RGMB480515(IS)(NY)	 	(1)	 	(Income-Single)

 ARTICLE I 

DEFINITIONS: 
 Terms used that are not defined in this
rider shall have the same meaning as those in Your policy. 
 Designated Investment Options 

Investment Options authorized for use with this rider and identified by us as Designated Investment Options. 

Excess Withdrawal 
 The excess of a Gross Partial
Withdrawal over the Rider Withdrawal Amount remaining prior to the withdrawal, if any. 
 Gross Partial Withdrawal 

The amount that will be deducted from Your Policy Value as a result of each partial withdrawal. 

Rider Anniversary 
 The anniversary of the rider date.

 Rider Fee 
 The fee charged for the benefits under
this rider. The fee will be charged on each Rider Quarterversary by the Company. 
 Rider Monthiversary 

The same day of the month as the rider date, or the next business day if our Administrative Office or the New York Stock Exchange is closed. If a certain
date does not exist in a given month, the first day of the following month will be used. 
 Rider Quarter 

Each three-month period beginning on the rider date. 
 Rider
Quarterversary 
 For each Rider Quarter, the same day of the month as the rider date, or the next business day if our Administrative Office or the New
York Stock Exchange is closed. If a certain date does not exist in a given month, the first day of the following month will be used. 
 Rider Withdrawal
Amount 
 The maximum amount that can be withdrawn from the policy each Rider Year without causing an Excess Withdrawal under the terms of this rider and
thus reducing the Withdrawal Base. This amount will change if the Withdrawal Base changes. 
 Rider Year 

Each twelve-month period following the rider date. 

Withdrawal Base 
 The amount used to calculate the
Rider Withdrawal Amount and the Rider Fee. This amount has no cash value and cannot be taken as a lump sum. 
 

ARTICLE II 
 RIDER FEES 

The Rider Fee is deducted on each Rider Quarterversary. The fee is calculated at issue and at the beginning of each Rider Quarter for the upcoming quarter. The
rider fee percentage will not change during the first five Rider Years, and will only change thereafter due to an automatic step-up. You will be notified of any increase in the rider fee percentage. A portion of this fee will also be deducted when
the rider is terminated based on the number of days that have elapsed since the previous Rider Quarterversary. 

  

					
	NIC14 RGMB480515(IS)(NY)		(2)		(Income-Single)

 ARTICLE II CONTINUED 

The fee will be adjusted for new deposits, transfers among Designated Investment Options and Excess Withdrawals made during the Rider Quarter. 

Fees will be calculated on the day the rider is issued and at the beginning of each Rider Quarter. They will be deducted automatically from each subaccount on
a pro rata basis on each Rider Quarterversary. The annual fee percentages for each designated allocation group are shown on page 1, in the Rider Data Specification section. 

The quarterly fee is calculated as follows: 
 Multiply
(1) by (2) divided by (3) multiplied by (4). 
  

	1)	Withdrawal Base; 

  

	2)	Product of each designated allocation group rider fee percentage and the applicable designated allocation group value summed together; 

 

	3)	Total Policy Value; 

  

	4)	Number of days remaining in the Rider Quarter divided by the number of days within the applicable Rider Year. 

Please see the Appendix attached to this rider which illustrates how the Rider Fee is calculated. 

ARTICLE III 
 GUARANTEED LIFETIME WITHDRAWAL
BENEFIT 
 Under this rider, we guarantee that You can receive up to the Rider Withdrawal Amount each Rider Year, regardless of the Policy Value, (first
as withdrawals from Your Policy Value and, if necessary, as payments from us) until the Annuitant’s death. 
 The withdrawal percentage is determined
by the attained age (age at last birthday) of the Annuitant at the time of the first withdrawal of any amount from the Policy Value taken on or after the Rider Anniversary following the Annuitant’s [59th] birthday. Once the withdrawal percentage is established, it may only be changed by an upgrade or automatic step-up and redetermined at that time. Upon automatic step-up, the withdrawal percentage
will be reset based on the attained age at the time of the automatic step-up. The withdrawal percentages are shown in the table in the Rider Data Specification section. 

If the Annuitant is not yet
[59] on the Rider Date, the withdrawal percentage will be zero until the Rider Anniversary following the Annuitant’s [59th] birthday. Withdrawals prior to age 59 1/2 will be subject to
the IRS 10% early withdrawal penalty. 
 Withdrawals will reduce the Policy Value and death benefit of the policy to which this rider is attached. If
the Policy Value equals zero, You cannot make subsequent Premium Payments and all other policy features, benefits and guarantees are no longer available. Also, if the Policy Value equals zero, You will need to request payments by selecting the
amount and frequency in accordance with the policy provisions to which this rider attaches, equal to the Rider Withdrawal Amount. Once the payment amount and frequency are established, they cannot be changed and no additional withdrawals will be
allowed. 
 We guarantee that You may withdraw up to the Rider Withdrawal Amount each year regardless of the Policy Value until the Annuitant’s death.

 Example 
 Assume You
are the Owner and Annuitant and begin taking withdrawals at age 80 and Your Withdrawal Base is $100,000. Assuming a withdrawal percentage of 6%, You could withdraw up to $6,000 each Rider Year for the rest of Your life (assuming that You do not
withdraw more than $6,000 in any one Rider Year). 
 Any amount You withdraw in excess of the Rider Withdrawal Amount may impact the Withdrawal Base on a
greater than dollar-for-dollar basis. 
 The Guaranteed Lifetime Withdrawal
Benefit can only be taken as a withdrawal benefit and it does not increase the Policy Value. 

  

					
	NIC14 RGMB480515(IS)(NY)		(3)		(Income-Single)

 ARTICLE III CONTINUED 

ISSUE AGE AND SURVIVAL 
 The benefits under this rider
depend on the Annuitant being alive at the time of withdrawal and the amount of the benefit depends on the attained age of the Annuitant. Reasonable proof of survival and the date of birth may be required by the Company. 

If the Annuitant’s age has been misstated, this rider’s fees and benefits will be adjusted to the amounts which would have been calculated for the
correct age. However, if this rider would not have been issued had the age not been misstated, the rider is treated as if it never existed, and any fees charged for this rider would be returned. If withdrawals under the provisions of the rider have
already commenced and the misstatement caused the Rider Withdrawal Amount to be overstated, any withdrawal in excess of the correct Rider Withdrawal Amount will be considered an Excess Withdrawal and will impact the Withdrawal Base and Rider
Withdrawal Amount. If overpayments occurred when the sum of the accumulated values in all the subaccounts was zero, the amount of that overpayment will be deducted from one or more future payments until this amount is paid in full. 

RIDER WITHDRAWAL AMOUNT 
 The Rider Withdrawal Amount will
be equal to the greater of 1) and 2), where: 
  

	1)	is the withdrawal percentage multiplied by the Withdrawal Base; 

  

	2)	is an amount equal to the minimum required distribution amount, if any. Prior to the 1st Rider Anniversary, this amount is based on the Policy Value on the rider date. After this time, the minimum required distribution
is calculated based on the rules established by the IRS. The minimum required distribution may only be used if all of the following are true: 

  

	 	A)	the policy to which this rider is attached is a tax-qualified policy for which IRS minimum required distributions are required, 

  

	 	B)	the minimum required distributions do not start prior to the Annuitant’s attained age 70 1/2, 

  

	 	C)	the minimum required distributions are based on either the Uniform Lifetime table or the Joint Life and Last Survivor Expectancy table, 

 

	 	D)	the minimum required distributions are based on age of the living Annuitant. The minimum required distributions can not be based on the age of someone who is deceased, 

 

	 	E)	the minimum required distributions are based only on the policy to which this rider is attached, and 

  

	 	F)	the minimum required distributions are only for the current Rider Year. Amounts carried over from past Rider Years are not considered. 

If any of the above are not true, then 2) is equal to zero and it is not available as a Rider Withdrawal Amount. 

If You withdraw less than the Rider Withdrawal Amount in a Rider Year, the unused portion cannot be carried over to the next Rider Year. 

Surrender charges may apply if Your Rider Withdrawal Amount exceeds Your surrender charge-free amount. 

WITHDRAWAL BASE 
 The Withdrawal Base is used to calculate
the Rider Withdrawal Amount. On the rider date, the initial Withdrawal Base is equal to the Policy Value (less any applicable premium enhancements if the rider is added in the first Policy Year). During any Rider Year, the Withdrawal Base is
increased by subsequent Premium Payments (not including premium enhancements, if any), and is reduced for Excess Withdrawals. 
 On each Rider Anniversary,
the Withdrawal Base will be set to the greatest of: 
  

	 	1)	The current Withdrawal Base; 

  

	 	2)	The Policy Value on the Rider Anniversary; 

  

	 	3)	The highest Policy Value on a Rider Monthiversary for the current Rider Year; and 

  

	 	4)	The current Withdrawal Base immediately prior to Rider Anniversary processing increased by the growth rate percentage. 

Item 3) above will be zero if there have been any Excess Withdrawals in the current Rider Year. Item 4) above will be zero after the [10th] Rider
Anniversary or if there have been any withdrawals in the current Rider Year. 

  

					
	NIC14 RGMB480515(IS)(NY)		(4)		(Income-Single)

 ARTICLE III CONTINUED 

AUTOMATIC STEP-UP FEATURE 
 The rider receives an automatic
step-up on the Rider Anniversary if the Withdrawal Base is set equal to the Policy Value or the highest Policy Value on a Rider Monthiversary. This feature does not require the termination of the existing rider. This rider will continue with the
same rider date and features. The Rider Fee may change and the withdrawal percentages may increase due to an automatic step-up, but there will be no increase in the rider fee percentage during the first five Rider Years. Following the fifth Rider
Anniversary, the rider fee percentage may be increased if there is an automatic step-up, but will not exceed the maximum rider fee percentages described in the Rider Data Specification section. 

You have the right to reject an automatic step-up within [30] days following a Rider Anniversary, if the rider fee percentage
increases. If You reject an automatic step-up, You must notify us in a manner which is acceptable to us, however You are eligible for future automatic step-ups. Changes as a result of the automatic step-up feature will be reversed. Any increase in
the Rider Fee or withdrawal percentages will also be reversed. 
 WITHDRAWAL BASE ADJUSTMENTS 

Gross Partial Withdrawals, taken in a Rider Year, less than or equal to the Rider Withdrawal Amount will not reduce the Withdrawal Base. Excess Withdrawals
will reduce the Withdrawal Base by the withdrawal base adjustment which may be more than the dollar amount of the Excess Withdrawal. The withdrawal base adjustment is the greater of 1) and 2), where: 

 

	1)	is the Excess Withdrawal amount; and 

  

	2)	is the result of (A multiplied by B), divided by C, where: 

  

	 	A)	is the Excess Withdrawal; 

  

	 	B)	is the Withdrawal Base prior to the Excess Withdrawal amount; and 

  

	 	C)	is the Policy Value after the Rider Withdrawal Amount has been withdrawn, but prior to the withdrawal of the Excess Withdrawal amount. 

ARTICLE IV 
 CONTINUATION 

In the case of spousal joint Owners where one spouse is the Annuitant, if the spouse who is not the Annuitant dies and the surviving spouse is the sole
beneficiary, the rider continues with the same rider values. In the case of spousal joint Owners where one spouse is the Annuitant, if the spouse who is the Annuitant dies, this rider will terminate. 

In the case of non-spousal joint Owners where an Owner who is not the Annuitant dies, the surviving Owner (who is also the sole designated beneficiary) may
elect to receive lifetime income payments under this rider instead of receiving any benefits applicable to the policy. The lifetime income payments must begin no later than 1 year after the Owner’s death and will be equal to the Rider
Withdrawal Amount divided by the number of payments made per year. Once the payments begin, no additional Premium Payments will be accepted and no additional withdrawals will be paid. 

ANNUITIZATION 
 On the maximum Annuity Commencement Date,
as described in Your policy, You will have the option to receive lifetime income payments that are no less than Your Rider Withdrawal Amount each year. This option will also guarantee that the sum of all income payments received over time will equal
or exceed the Policy Value on the maximum Annuity Commencement Date. If the Annuitant should die before the sum of all income payments received equals or exceeds the Policy Value on the maximum Annuity Commencement Date, the Annuitant’s
beneficiary will receive a final payment equal to the difference. 

  

					
	NIC14 RGMB480515(IS)(NY)		(5)		(Income-Single)

 RIDER UPGRADE 

You may elect, in writing, to upgrade the Withdrawal Base to the Policy Value within [30] days after the [fifth] Rider Anniversary and every [fifth] Rider Anniversary thereafter, subject to the issue age restrictions on the new rider. If an upgrade is selected, this rider will terminate and a new rider with
the same features will be issued with a new rider date. The new rider will have its own growth rate percentage and rider fee percentages which may not be the same as this rider’s percentages. 

At the time of upgrade, the Rider Withdrawal Amount will be recalculated based on the new Withdrawal Base. 

The new rider date will be the date the Company receives all information necessary, at our Home Office, in a written form acceptable to the Company, to
process the upgrade. 
 TERMINATION 
  

	This	rider will terminate upon the earliest of: 

  

	1)	the date the policy to which this rider is attached terminates; 

  

	2)	the date of the Annuitant’s death; 

  

	3)	the date You elect to upgrade (as described in Article IV of this rider); 

  

	4)	the date You elect to receive annuity payments under Your policy; 

  

	5)	the date You notify us in writing of Your intention to terminate this rider (this date must be within [30] days after the [fifth] Rider Anniversary and every [fifth] Rider Anniversary thereafter); and 

 

	6)	the date any of Your Policy Value is not invested in one of the Designated Investment Options. 

 Termination of
the rider will result in the loss of all benefits provided by the rider. After termination, rider fees will no longer be assessed. 
 REPORTS TO OWNER

 We will give You a report at least once each Policy Year. Before You are eligible to receive the Rider Withdrawal Amount, the report will direct You
to contact the Company for information regarding Your Rider Withdrawal Amount. After You are eligible for Your Rider Withdrawal Amount, this amount will be included in the report. 

Signed for us at our home office. 
  

 

  

					
	NIC14 RGMB480515(IS)(NY)		(6)		(Income-Single)

 APPENDIX 

The quarterly fee is calculated as follows: 

Multiply (1) by (2) divided by (3) multiplied by (4) where: 
  

	1)	Withdrawal Base; 

  

	2)	Product of each designated allocation group rider fee percentage and the applicable designated allocation group value summed together; 

 

	3)	Total policy value; 

  

	4)	Number of days in the rider quarter divided by the number of days within the applicable rider year. 

 The fee
adjustment for additional premium payments and excess withdrawals is calculated as follows: 
 Multiply (1) by (2) divided by (3) multiplied
by (4) where: 
  

	1)	Withdrawal base change (i.e. withdrawal base after the transaction minus the withdrawal base before the transaction) 

  

	2)	Product of each designated allocation group rider fee percentage and the applicable designated allocation group value, summed together 

 

	3)	Total transaction amount 

  

	4)	Number of days remaining in the rider quarter divided by the number of days within the applicable rider year 

The fee adjustment for fund transfers is calculated as follows: 

Multiply (1) by (2) divided by (3) multiplied by (4) where: 
  

	1)	Withdrawal base; 

  

	2)	Product of each designated allocation group rider fee percentage and the applicable designated allocation group value summed together; 

 

	3)	Total policy value; 

  

	4)	Number of days remaining in the rider quarter divided by the number of days within the applicable rider year. 

The following two examples use assumed fees and values listed in the table below. The assumed rider year is not a leap year. 

 

													
	 Designated Allocation Group
	  	Fee	 	 	Initial
Policy Value	 	  	Additional Premium
Used in Example 2	 
	 Group A
	  	 	2.50	% 	 	$	50,000	  	  	$	5,000	  
	 Group B
	  	 	2.40	% 	 	$	30,000	  	  	$	3,000	  
	 Group C
	  	 	2.30	% 	 	$	20,000	  	  	$	2,000	  

 Example 1: Calculation at rider issue for first quarter fee assuming an initial withdrawal base of $100,000. 

= 100,000 * [(50,000*0.0250) + (30,000*0.0240) + (20,000*0.0230)] / 100,000 * (91/365) 

= 100,000 * (1,250 + 720 + 460) / 100,000 * (91/365) 

= 100,000 * 2,430/100,000 * (91/365) 

= 2,430 * (91/365) 
 = $605.84

 Example 2: Calculation for first quarter fee assuming initial withdrawal base from Example 1 above, plus adjustment for additional premium payment
of $10,000 made with 20 days remaining in the first rider quarter (invested as shown above). The withdrawal base change and total transaction amount equal $10,000. 

Fee adjustment as follows: 
 = 10,000 *
[(5,000*0.0250) + (3,000*0.0240) + (2,000*0.0230)] / 10,000 * (20/365) 
 = 10,000 * (125 + 72 + 46) / 10,000 * (20/365) 

= 10,000 * 243/10,000 * (20/365) 

= 243 * (20/365) 
 = $13.32 

Total fee assessed on first rider quarterversary (assuming no further rider fee adjustments): 

= 13.32 + 605.84 
 = $619.16 

  

					
	NIC14 RGMB480515(IS)(NY)	 	(A-1)	 	(Income-Single)

 The following three examples use assumed fees and values listed in the table below. The assumed rider year is not
a leap year. 
  

																	
	 Designated Allocation Group
	  	Fee	 	 	Policy Value	 	  	Partial Withdrawal
Used in Example 4	 	  	Fund Transfer
Used in Example 5	 
	 Group A
	  	 	2.50	% 	 	$	49,000	  	  	$	-5,000	  	  	$	-5,000	  
	 Group B
	  	 	2.40	% 	 	$	29,000	  	  	$	-3,000	  	  	$	3,000	  
	 Group C
	  	 	2.30	% 	 	$	19,000	  	  	$	-2,000	  	  	$	2,000	  

 Example 3: Calculation for second quarter fee at beginning of second rider quarter, assuming withdrawal base of
$110,000 and policy value of $97,000 invested as above. 
 = 110,000 * [(49,000*0.0250) + (29,000*0.0240) + (19,000*0.0230)] / 97,000 *
(91/365) 
 = 110,000 * (1,225 + 696 + 437) / 97,000 * (91/365) 

= 110,000 * 2,358/97,000 * (91/365) 

= 2,674.02 * (91/365) 
 = $666.67

 Example 4: Calculation for second quarter fee assuming beginning values as in Example 3 above, plus adjustment for partial withdrawal of $10,000
taken with 40 days remaining in the second rider quarter. Assumes withdrawal percentage of 5%, policy value of $97,000 prior to the transaction and change in withdrawal base as follows: 

Rider Withdrawal Amount (RWA) = Withdrawal Base * Withdrawal Percentage = 110,000 * .05 = $5,500 

Excess Withdrawal = Difference between assumed withdrawal amount and RWA = 10,000 - 5,500 = $4,500 

Withdrawal Base Adjustment = Max (Excess Withdrawal, Excess Withdrawal * Withdrawal Base prior to withdrawal / Policy Value after RWA has been withdrawn but
before excess withdrawal) = Max [4,500, 4,500 * 110,000 / (97,000-5,500)] = Max (4,500, 5,409.84) = $5,409.84 
 Fee adjustment as follows: 

= -5,409.84 * [(5,000*0.0250) + (3,000*0.0240) + (2,000*0.0230)] / 10,000 * (40/365) 

= -5,409.84 * (125 + 72 + 46) / 10,000 * (40/365) 

= -5,409.84 * 243/10,000 * (40/365) 

= -131.46 * (40/365) 
 = $-14.41

 Total fee assessed on second rider quarterversary (assuming no further rider fee adjustments): 

= 666.67 - 14.41 
 = $652.26 

The new Withdrawal Base = $110,000 - $5,409.84 = $104,590.16 

Example 5: Calculation for fund transfer occurring during second quarter with 25 days remaining in the rider quarter, assuming beginning values as in
Example 3 and withdrawal adjustment as in Example 4 above. 
 Withdrawal Base = $104,590.16 and assumed policy value of $90,000. Fund transfer amount of
$5,000 as allocated in table above. 
 Fee adjustment as follows: 

= 104,590.16 * [(-5,000*0.0250) + (3,000*0.0240) + (2,000*0.0230)] / 90,000 * (25/365) 

= 104,590.16 * (-125 + 72 + 46) / 90,000 * (25/365) 

= 104,590.16 * -7/90,000 * (25/365) 

= -8.13 * (25/365) 
 = $-0.56 

Total fee assessed on second rider quarterversary (assuming no further rider fee adjustments): 

= 652.26 - 0.56 
 = $651.70 

  

					
	NIC14 RGMB480515(IS)(NY)	 	(A-2)	 	(Income-Single)

 

 
 GUARANTEED LIFETIME WITHDRAWAL BENEFIT 

This rider is issued as a part of the policy to which it is attached. All provisions of the policy that do not conflict with this rider apply to this rider.
In the event of any conflict between the provisions of this rider and the provisions of the policy, the provisions of this rider shall prevail over the provisions of the policy. 

The purpose of the guaranteed living withdrawal benefit provided under this rider is to provide a stream of income payments to the Owner. 

You may cancel this rider on or before midnight of the thirtieth calendar day after You receive it and no Rider Fees will be assessed. 

This rider provides a minimum withdrawal benefit that guarantees, upon election, a series of withdrawals from the policy equal to the Withdrawal Percentage
shown below applied to the Withdrawal Base. The Withdrawal Base is established for the sole purpose of determining the minimum withdrawal benefit and is not used in calculating the cash surrender value or other guaranteed benefits. 

Rider Data Specification 
  

													
					 		 				 		
			 Policy Number:
		 				123456				
			 Rider Date:
		 				03/11/2015				
			 Growth Rate Percentage:
		 				5.50%				
				 		 	
			 Rider Fee Percentages*:
				 				 		
			 Designated Allocation Group A:
		 				1.45%				
			 Designated Allocation Group B:
		 				1.10%				
			 Designated Allocation Group C:
		 				0.70%				
											 		
			 Annuitant:
		 				John Doe				
			 				 
			 Annuitant’s Issue Age/Sex:
		 				65 / Male				
			 Annuitant’s Spouse:
		 				Jane Doe				
			 Annuitant’s Spouse’s Issue Age/Sex:
		 				65  /  Female		 		
							 						

  

	*	The Rider Fee is also a maximum Rider Fee for the life of the rider, provided there are no automatic step-ups. When an automatic step-up is utilized, the maximum Rider Fee would not be more than [0.75%] greater than the
rider fee percentages shown above. 

 Designated Allocations: If You elect this rider, 100% of your Policy Value must be in one or more
of the Designated Investment Options (or any other option authorized for use with this rider). The Designated Investment Options available may change with an upgrade or prior approval of the New York State Department of Financial Services. 

You can generally transfer between the Designated Investment Options as permitted under Your policy; however, You cannot make transfers as provided for in the
policy to a non-designated investment option (or any other option not authorized for use with this rider) while this rider is in force. If You wish to make a transfer to a non-designated investment option, this rider must be terminated, as described
in Article IV, prior to making the transfer. You will be notified if there are any changes to the Designated Investment Options. 

  

					
	NIC14 RGMB480515(IJ)(NY)		(1)		(Income-Joint)

 RIDER DATA SPECIFICATION CONTINUED 

Guaranteed Lifetime Withdrawal Benefit: The withdrawal percentage is determined by the attained age and is used to determine the Rider Withdrawal Amount
as described in Article III. The withdrawal percentages are shown in the table below: 
  

																	
	 	 	 	  	 Attained Age
	 	 	  	 	 	 	 	 Withdrawal
Percentage
	 	 	  	 
	    	 		  		 		  		 		 		 		  	
	 	 	 	  	59 - 64	 	 	  	 	 	 	 	3.50%	 	 	  	
	 	 		  	65 - 79	 		  	 	 		 	4.50%	 		  	
	 	 	 	  	80 +	 	 	  	 	 	 	 	5.50%	 	 	  	

 ARTICLE I 
 The
Annuitant’s spouse as of the rider date is hereafter referred to as the Annuitant’s spouse. As it pertains to the benefits of this rider, the Annuitant’s spouse cannot be changed. The Annuitant’s spouse must be the sole primary
beneficiary and/or a joint Owner. The only living Owners allowed on the policy to which this rider is attached are the Annuitant and the Annuitant’s spouse. 

DEFINITIONS: 
 Terms used that are not defined in this
rider shall have the same meaning as those in Your policy. 
 Designated Investment Options 

Investment Options authorized for use with this rider and identified by us as Designated Investment Options. 

Excess Withdrawal 
 The excess of a Gross Partial
Withdrawal over the Rider Withdrawal Amount remaining prior to the withdrawal, if any. 
 Gross Partial Withdrawal 

The amount that will be deducted from Your Policy Value as a result of each partial withdrawal. 

Rider Anniversary 
 The anniversary of the rider date.

 Rider Fee 
 The fee charged for the benefits under
this rider. The fee will be charged on each Rider Quarterversary by the Company. 
 Rider Monthiversary 

The same day of the month as the rider date, or the next business day if our Administrative Office or the New York Stock Exchange is closed. If a certain date
does not exist in a given month, the first day of the following month will be used. 
 Rider Quarter 

Each three-month period beginning on the rider date. 
 Rider
Quarterversary 
 For each Rider Quarter, the same day of the month as the rider date, or the next business day if our Administrative Office or the New
York Stock Exchange is closed. If a certain date does not exist in a given month, the first day of the following month will be used. 
 Rider Withdrawal
Amount 
 The maximum amount that can be withdrawn from the policy each Rider Year without causing an Excess Withdrawal under the terms of this rider and
thus reducing the Withdrawal Base. This amount will change if the Withdrawal Base changes. 
 Rider Year 

Each twelve-month period following the rider date. 

Withdrawal Base 
 The amount used to calculate the
Rider Withdrawal Amount and the Rider Fee. This amount has no cash value and cannot be taken as a lump sum. 

  

					
	NIC14 RGMB480515(IJ)(NY)	 	(2)	 	(Income-Joint)

 ARTICLE II 

RIDER FEES 
 The Rider Fee is deducted on each Rider
Quarterversary. The fee is calculated at issue and at the beginning of each Rider Quarter for the upcoming quarter. The rider fee percentage will not change during the first five Rider Years, and will only change thereafter due to an automatic
step-up. You will be notified of any increase in the rider fee percentage. A portion of this fee will also be deducted when the rider is terminated based on the number of days that have elapsed since the previous Rider Quartersary. 

The fee will be adjusted for new deposits, transfers among Designated Investment Options and Excess Withdrawals made during the Rider Quarter. 

Fees will be calculated on the day the rider is issued and at the beginning of each Rider Quarter. They will be deducted automatically from each subaccount on
a pro rata basis on each Rider Quarterversary. The annual fee percentages for each designated allocation group are shown on page 1, in the Rider Data Specification section. 

The quarterly fee is calculated as follows: 
 Multiply
(1) by (2) divided by (3) multiplied by (4). 
  

	1)	Withdrawal Base; 

  

	2)	Product of each designated allocation group rider fee percentage and the applicable designated allocation group value summed together; 

 

	3)	Total Policy Value; 

  

	4)	Number of days remaining in the Rider Quarter divided by the number of days within the applicable Rider Year. 

Please see the Appendix attached to this rider which illustrates how the Rider Fee is calculated. 

ARTICLE III 
 GUARANTEED LIFETIME WITHDRAWAL
BENEFIT 
 Under this rider, we guarantee that You can receive up to the Rider Withdrawal Amount each Rider Year, regardless of the Policy Value, (first
as withdrawals from Your Policy Value and, if necessary, as payments from us) until the Annuitant’s or the Annuitant’s spouse’s death, whichever is later. 

The withdrawal percentage is determined by the attained age (age at last birthday) of the younger of the living spouses at the time of the first withdrawal of
any amount from the Policy Value taken on or after the Rider Anniversary following the younger of the living spouse’s
[59th] birthday. Once the withdrawal percentage is established, it may only be changed by an upgrade or automatic step-up and redetermined at that time. Upon automatic step-up, the withdrawal percentage
will be reset based on the attained age of the younger of the living spouses at the time of the automatic step-up. The withdrawal percentages are shown in the table in the Rider Data Specification section. 

If the younger of the Annuitant and the Annuitant’s spouse is not yet [59] on the rider date, the withdrawal percentage will be zero until
the Rider Anniversary following the younger of the living spouse’s [59th] birthday. Withdrawals prior to age 59 1/2 will be subject to the IRS 10% early withdrawal penalty. 

Withdrawals will reduce the Policy Value and death benefit of the policy to which this rider is attached. If the Policy Value equals zero, You cannot make
subsequent Premium Payments and all other policy features, benefits and guarantees are no longer available. Also, if the Policy Value equals zero, You will need to request payments by selecting the amount and frequency in accordance with the policy
provisions to which this rider attaches, equal to the Rider Withdrawal Amount. Once the payment amount and frequency are established, they cannot be changed and no additional withdrawals will be allowed. 

We guarantee that you may withdraw up to the rider withdrawal amount each year regardless of the policy value until the annuitant’s death. 

Example 
 Assume the
younger of the annuitant and the annuitant’s spouse is 65 and withdrawals begin and your Withdrawal Base is $100,000. Assuming a withdrawal percentage of 4.50%, you could withdraw up to $4,500 each rider year until the annuitant’s or the
annuitant’s spouse’s death, which ever is later (assuming that you do not withdraw more than $4,500 in any one Rider Year). 

  

					
	NIC14 RGMB480515(IJ)(NY)		(3)		(Income-Joint)

 ARTICLE III CONTINUED 

Any amount you withdraw in excess of the rider withdrawal amount may impact the withdrawal base on a greater than dollar-for-dollar basis. 
 The Guaranteed Lifetime Withdrawal Benefit can only be taken as a withdrawal benefit
and it does not increase the policy value. 
 ISSUE AGE AND SURVIVAL 

The benefits under this rider depend on the Annuitant or Annuitant’s spouse being alive at the time of withdrawal and the amount of the benefit depends on
the attained age of the Annuitant and Annuitant’s spouse. Reasonable proof of survival and the date of birth may be required by the Company. 
 If the
younger of the spouses’ ages has been misstated, this rider’s fees and benefits will be adjusted to the amounts which would have been calculated for the correct age. However, if this rider would not have been issued had the age not been
misstated, the rider is treated as if it never existed, and any fees charged for this rider would be returned. If withdrawals under the provisions of the rider have already commenced and the misstatement caused the Rider Withdrawal Amount to be
overstated, any withdrawal in excess of the correct Rider Withdrawal Amount will be considered an Excess Withdrawal and will impact the Withdrawal Base and Rider Withdrawal Amount. If overpayments occurred when the sum of the accumulated values in
all the subaccounts was zero, the amount of that overpayment will be deducted from one or more future payments until this amount is paid in full. 

RIDER WITHDRAWAL AMOUNT 
 The Rider Withdrawal Amount will
be equal to the greater of 1) and 2), where: 
  

	1)	is the withdrawal percentage multiplied by the Withdrawal Base; 

  

	2)	is an amount equal to the minimum required distribution amount, if any. Prior to the 1st Rider Anniversary, this amount is based on the Policy Value on the rider date. After this time, the minimum required distribution
is calculated based on the rules established by the IRS. The minimum required distribution may only be used if all of the following are true: 

  

	 	A)	the policy to which this rider is attached is a tax-qualified policy for which IRS minimum required distributions are required, 

  

	 	B)	the minimum required distributions do not start prior to the Annuitant’s attained age 70 1/2, 

  

	 	C)	the minimum required distributions are based on either the Uniform Lifetime table or the Joint Life and Last Survivor Expectancy table, 

 

	 	D)	the minimum required distributions are based on age of the living Annuitant or the Annuitant’s spouse if the Annuitant is deceased. The minimum required distributions can not be based on the age of someone who is
deceased, 

  

	 	E)	the minimum required distributions are based only on the policy to which this rider is attached, and 

  

	 	F)	the minimum required distributions are only for the current Rider Year. Amounts carried over from past Rider Years are not considered. 

If any of the above are not true, then 2) is equal to zero and it is not available as a Rider Withdrawal Amount. 

If You withdraw less than the Rider Withdrawal Amount in a Rider Year, the unused portion cannot be carried over to the next Rider Year. 

Surrender charges may apply if your Rider Withdrawal Amount exceeds Your surrender charge-free amount. 

WITHDRAWAL BASE 
 The Withdrawal Base is used to calculate
the Rider Withdrawal Amount. On the rider date, the initial Withdrawal Base is equal to the Policy Value (less any applicable premium enhancements if the rider is added in the first Policy Year). During any Rider Year, the Withdrawal Base is
increased by subsequent Premium Payments (not including premium enhancements, if any), and is reduced for Excess Withdrawals. 

  

					
	NIC14 RGMB480515(IJ)(NY)		(4)		(Income-Joint)

 ARTICLE III CONTINUED 

On each Rider Anniversary, the Withdrawal Base will be set to the greatest of: 
  

	 	1)	The current Withdrawal Base; 

  

	 	2)	The Policy Value on the Rider Anniversary; 

  

	 	3)	The highest Policy Value on a Rider Monthiversary for the current Rider Year; and 

  

	 	4)	The current Withdrawal Base immediately prior to Rider Anniversary processing increased by the growth rate percentage. 

Item 3) above will be zero if there have been any Excess Withdrawals in the current Rider Year. Item 4) above will be zero after the [10th] Rider Anniversary or if there have been any withdrawals in the current Rider Year. 

AUTOMATIC STEP-UP FEATURE 
 The rider receives an
automatic step-up on the Rider Anniversary if the Withdrawal Base is set equal to the Policy Value or the highest Policy Value on a Rider Monthiversary. This feature does not require the termination of the existing rider. This rider will continue
with the same rider date and features. The Rider Fee may change and the withdrawal percentages may increase due to an automatic step-up, but there will be no increase in the rider fee percentage during the first five Rider Years. Following the fifth
Rider Anniversary, the rider fee percentage may be increased if there is an automatic step-up, but will not exceed the maximum rider fee percentages described in the Rider Data Specification section. 

You have the right to reject an automatic step-up within [30] days following a Rider Anniversary, if the rider fee percentage
increases. If You reject an automatic step-up, You must notify us in a manner which is acceptable to us, however You are eligible for future automatic step-ups. Changes as a result of the automatic step-up feature will be reversed. Any increase in
the Rider Fee or withdrawal percentages will also be reversed. 
 WITHDRAWAL BASE ADJUSTMENTS 

Gross Partial Withdrawals, taken in a Rider Year, less than or equal to the Rider Withdrawal Amount will not reduce the Withdrawal Base. Excess Withdrawals
will reduce the Withdrawal Base by the withdrawal base adjustment which may be more than the dollar amount of the Excess Withdrawal. The withdrawal base adjustment is the greater of 1) and 2), where: 

 

	1)	is the Excess Withdrawal amount; and 

  

	2)	is the result of (A multiplied by B), divided by C, where: 

  

	 	A)	is the Excess Withdrawal; 

  

	 	B)	is the Withdrawal Base prior to the Excess Withdrawal amount; and 

  

	 	C)	is the Policy Value after the Rider Withdrawal Amount has been withdrawn, but prior to the withdrawal of the Excess Withdrawal amount. 

ARTICLE IV 
 CONTINUATION 

In the case of spousal joint Owners where one spouse is the Annuitant, if the spouse who is not the Annuitant dies and the surviving spouse is the sole
beneficiary, the rider continues with the same rider values. In the case of spousal joint Owners where one spouse is the Annuitant, if the spouse who is the Annuitant dies and the surviving spouse is the sole beneficiary, the rider continues with
the same rider values until the death of the surviving spouse. 
 ANNUITIZATION 

On the maximum Annuity Commencement Date, as described in Your policy, You will have the option to receive lifetime income payments that are no less than Your
Rider Withdrawal Amount each year. This option will also guarantee that the sum of all income payments received over time will equal or exceed the Policy Value on the maximum Annuity Commencement Date. If the Annuitant or Annuitant’s spouse
should die before the sum of all income payments received equals or exceeds the Policy Value on the maximum Annuity Commencement Date, the Annuitant’s beneficiary will receive a final payment equal to the difference. 

  

					
	NIC14 RGMB480515(IJ)(NY)		(5)		(Income-Joint)

 ARTICLE IV CONTINUED 

RIDER UPGRADE 
 You may elect, in writing, to upgrade the
Withdrawal Base to the Policy Value within [30] days after the [fifth] Rider Anniversary and every [fifth] Rider Anniversary thereafter, subject to the issue age
restrictions on the new rider. If an upgrade is selected, this rider will terminate and a new rider with the same features will be issued with a new rider date. The new rider will have its own growth rate percentage and rider fee percentage which
may not be the same as this rider’s percentages. 
 At the time of upgrade the Rider Withdrawal Amount will be recalculated based on the new
Withdrawal Base. 
 The new rider date will be the date the Company receives all information necessary, at our Home Office, in a written form acceptable to
the Company, to process the upgrade. 
 TERMINATION 

This rider will terminate upon the earliest of: 
  

	1)	the date the policy to which this rider is attached terminates; 

  

	2)	the later of the Annuitant’s or Annuitant’s spouse’s death; 

  

	3)	the date You elect to upgrade (as described in Article IV of this rider); 

  

	4)	the date You elect to receive annuity payments under Your policy; 

  

	5)	the date You notify us in writing of Your intention to terminate this rider (this date must be within [30] days after the [fifth] Rider Anniversary and every [fifth] Rider Anniversary thereafter); and 

 

	6)	the date any of Your Policy Value is not invested in one of the Designated Investment Options. 

 Termination of
the rider will result in the loss of all benefits provided by the rider. After termination, rider fees will no longer be assessed. 
 REPORTS TO OWNER

 We will give You a report at least once each Policy Year. Before You are eligible to receive the Rider Withdrawal Amount, the report will direct You
to contact the Company for information regarding Your Rider Withdrawal Amount. After You are eligible for Your Rider Withdrawal Amount, this amount will be included in the report. 

Signed for us at our home office. 
  

			
	

		

  

					
	NIC14 RGMB480515(IJ)(NY)		(6)		(Income-Joint)

 APPENDIX 

The quarterly fee is calculated as follows: 

Multiply (1) by (2) divided by (3) multiplied by (4) where: 
  

	1)	Withdrawal Base; 

  

	2)	Product of each designated allocation group rider fee percentage and the applicable designated allocation group value summed together; 

 

	3)	Total policy value; 

  

	4)	Number of days in the rider quarter divided by the number of days within the applicable rider year. 

 The fee
adjustment for additional premium payments and excess withdrawals is calculated as follows: Multiply (1) by (2) divided by (3) multiplied by (4) where: 
  

	1)	Withdrawal base change (i.e. withdrawal base after the transaction minus the withdrawal base before the transaction) 

  

	2)	Product of each designated allocation group rider fee percentage and the applicable designated allocation group value summed together 

 

	3)	Total transaction amount 

  

	4)	Number of days remaining in the rider quarter divided by the number of days within the applicable rider year 

The fee adjustment for fund transfers is calculated as follows: 
  

	Multiply	(1) by (2) divided by (3) multiplied by (4) where: 

  

	1)	Withdrawal base; 

  

	2)	Product of each designated allocation group rider fee percentage and the applicable designated allocation group value summed together; 

 

	3)	Total policy value; 

  

	4)	Number of days remaining in the rider quarter divided by the number of days within the applicable rider year. 

The following two examples use assumed fees and values listed in the table below. The assumed rider year is not a leap year. 

 

													
	 Designated

Allocation Group
	 	Fee	 	 	Initial
Policy Value	 	 	Additional Premium
Used in Example 2	 
	Group A	 	 	2.50	% 	 	$	50,000	  	 	$	5,000	  
	Group B	 	 	2.40	% 	 	$	30,000	  	 	$	3,000	  
	Group C	 	 	2.30	% 	 	$	20,000	  	 	$	2,000	  

 Example 1: Calculation at rider issue for first quarter fee assuming an initial withdrawal base of $100,000. 

= 100,000 * [(50,000*0.0250) + (30,000*0.0240) + (20,000*0.0230)] / 100,000 * (91/365) 

= 100,000 * (1,250 + 720 + 460) / 100,000 * (91/365) 

= 100,000 * 2,430/100,000 * (91/365) 

= 2,430 * (91/365) 
 = $605.84

 Example 2: Calculation for first quarter fee assuming initial withdrawal base from Example 1 above, plus adjustment for additional premium payment
of $10,000 made with 20 days remaining in the first rider quarter (invested as shown above). The withdrawal base change and total transaction amount equal $10,000. 

Fee adjustment as follows: 
 = 10,000 *
[(5,000*0.0250) + (3,000*0.0240) + (2,000*0.0230)] / 10,000 * (20/365) 
 = 10,000 * (125 + 72 + 46) / 10,000 * (20/365) 

= 10,000 * 243/10,000 * (20/365) 

= 243 * (20/365) 
 = $13.32 

Total fee assessed on first rider quarterversary (assuming no further rider fee adjustments): 

= 13.32 + 605.84 
 = $619.16
 

  

					
	NIC14 RGMB480515(IJ)(NY)	 	(A-1)	 	(Income-Joint)

 The following three examples use assumed fees and values listed in the table below. The assumed rider year is not
a leap year. 
  

																	
	 Designated Allocation Group
	  	Fee	 	 	Policy Value	 	  	Partial Withdrawal
Used in Example 4	 	  	Fund Transfer
Used in Example 5	 
	 Group A
	  	 	2.50	% 	 	$	49,000	  	  	$	-5,000	  	  	$	-5,000	  
	 Group B
	  	 	2.40	% 	 	$	29,000	  	  	$	-3,000	  	  	$	3,000	  
	 Group C
	  	 	2.30	% 	 	$	19,000	  	  	$	-2,000	  	  	$	2,000	  

 Example 3: Calculation for second quarter fee at beginning of second rider quarter, assuming withdrawal base of
$110,000 and policy value of $97,000 invested as above. 
 = 110,000 * [(49,000*0.0250) + (29,000*0.0240) + (19,000*0.0230)] / 97,000 *
(91/365) 
 = 110,000 * (1,225 + 696 + 437) / 97,000 * (91/365) 

= 110,000 * 2,358/97,000 * (91/365) 

= 2,674.02 * (91/365) 
 = $666.67

 Example 4: Calculation for second quarter fee assuming beginning values as in Example 3 above, plus adjustment for partial withdrawal of $10,000
taken with 40 days remaining in the second rider quarter. Assumes withdrawal percentage of 5%, policy value of $97,000 prior to the transaction and change in withdrawal base as follows: 

Rider Withdrawal Amount (RWA) = Withdrawal Base * Withdrawal Percentage = 110,000 * .05 = $5,500 

Excess Withdrawal = Difference between assumed withdrawal amount and RWA = 10,000 - 5,500 = $4,500 

Withdrawal Base Adjustment = Max (Excess Withdrawal, Excess Withdrawal * Withdrawal Base prior to withdrawal / Policy Value after RWA has been withdrawn but
before excess withdrawal) = Max [4,500, 4,500 * 110,000 / (97,000-5,500)] = Max (4,500, 5,409.84) = $5,409.84 
 Fee adjustment as follows: 

= -5,409.84 * [(5,000*0.0250) + (3,000*0.0240) + (2,000*0.0230)] / 10,000 * (40/365) 

= -5,409.84 * (125 + 72 + 46) / 10,000 * (40/365) 

= -5,409.84 * 243/10,000 * (40/365) 

= -131.46 * (40/365) 
 = $-14.41

 Total fee assessed on second rider quarterversary (assuming no further rider fee adjustments): 

= 666.67 - 14.41 
 = $652.26 

The new Withdrawal Base = $110,000 - $5,409.84 = $104,590.16 

Example 5: Calculation for fund transfer occurring during second quarter with 25 days remaining in the rider quarter, assuming beginning values as in
Example 3 and withdrawal adjustment as in Example 4 above. 
 Withdrawal Base = $104,590.16 and assumed policy value of $90,000. Fund transfer amount of
$5,000 as allocated in table above. 
 Fee adjustment as follows: 

= 104,590.16 * [(-5,000*0.0250) + (3,000*0.0240) + (2,000*0.0230)] / 90,000 * (25/365) 

= 104,590.16 * (-125 + 72 + 46) / 90,000 * (25/365) 

= 104,590.16 * -7/90,000 * (25/365) 

= -8.13 * (25/365) 
 = $-0.56 

Total fee assessed on second rider quarterversary (assuming no further rider fee adjustments): 

= 652.26 - 0.56 
 = $651.70 

  

					
	NIC14 RGMB480515(IJ)(NY)	 	(A-2)	 	(Income-Joint)

 

 
 GUARANTEED LIFETIME WITHDRAWAL WITH DEATH BENEFIT OPTION 

This rider is issued as a part of the policy to which it is attached. All provisions of the policy that do not conflict with this rider apply to this rider.
In the event of any conflict between the provisions of this rider and the provisions of the policy, the provisions of this rider shall prevail over the provisions of the policy. 

The purpose of the guaranteed living withdrawal benefit provided under this rider is to provide a stream of income payments to the Owner. 

You may cancel this rider on or before midnight of the thirtieth calendar day after You receive it and no Rider Fees will be assessed. 

This rider provides a minimum withdrawal benefit that guarantees, upon election, a series of withdrawals from the policy equal to the Withdrawal Percentage
shown below applied to the Withdrawal Base. The Withdrawal Base is established for the sole purpose of determining the minimum withdrawal benefit and is not used in calculating the cash surrender value or other guaranteed benefits. 

Rider Data Specification 
  

													
		 		 	 	 	 	  		 	 	  	
		 	 Policy Number:
	 	 	 		  	123456	 		  	
		 	 Rider Date:
	 	 	 		  	03/11/2015	 		  	
		 	 Growth Rate Percentage:
	 	 	 		  	5.50%	 		  	
				 		 	
		 	 Rider Fee Percentages*:
	 		 	 	  		 	 	  	
		 	 Designated Allocation Group A:
	 	 	 		  	1.85%	 		  	
		 	 Designated Allocation Group B:
	 	 	 		  	1.50%	 		  	
		 	 Designated Allocation Group C:
	 	 	 		  	1.10%	 		  	
		 		 		 	 	  		 	 	  	
		 	 Annuitant:
	 	 	 		  	John Doe	 		  	
			 				 
		 	 Annuitant’s Issue Age/Sex:
	 	 	 		  	65  /  Male	 	 	  	
		 		 		 	 	  		 		  	

  

	*	The Rider Fee is also a maximum Rider Fee for the life of the rider, provided there are no automatic step-ups. When an automatic step-up is utilized, the maximum Rider Fee would not be more than [0.75%] greater than the rider fee percentages shown above. 

 Designated
Allocations: If You elect this rider, 100% of Your Policy Value must be in one or more of the Designated Investment Options (or any other option authorized for use with this rider). The Designated Investment Options available may change with an
upgrade or prior approval of the New York State Department of Financial Services. 
 You can generally transfer between the Designated Investment Options as
permitted under Your policy; however, You cannot make transfers as provided for in the policy to a non-designated investment option (or any other option not authorized for use with this rider) while this rider is in force. If You wish to make a
transfer to a non-designated investment option, this rider must be terminated, as described in Article IV, prior to making the transfer. You will be notified if there are any changes to the Designated Investment Options. 

Guaranteed Lifetime Withdrawal Benefit: The withdrawal percentage is determined by the attained age and is used to determine the Rider Withdrawal
Amount as described in Article III. The withdrawal percentages are shown in the table below: 
  

																	
	 	 	 	  	 Attained Age
	  	 	  	 	  	 	  	 Withdrawal
Percentage
	  	 	  	 
		 		  		  		  		  		  		  		  	
	 	 	 	  	59 - 64	  	 	  	 	  	 	  	4.00%	  	 	  	
	 	 		  	65 -  79	  		  	 	  		  	5.00%	  		  	
	 	 	 	  	80 +	  	 	  	 	  	 	  	6.00%	  	 	  	

  

					
	NIC14 RGMB480515(AS)(NY)	 	(1)	 	(Income/Death-Single)

 ARTICLE I 

DEFINITIONS: 
 Terms used that are not defined in this
rider shall have the same meaning as those in Your policy. 
 Designated Investment Options 

Investment Options authorized for use with this rider and identified by us as Designated Investment Options. 

Excess Withdrawal 
 The excess of a Gross Partial
Withdrawal over the Rider Withdrawal Amount remaining prior to the withdrawal, if any. 
 Gross Partial Withdrawal 

The amount that will be deducted from Your Policy Value as a result of each partial withdrawal. 

Rider Anniversary 
 The anniversary of the rider date.

 Rider Fee 
 The fee charged for the benefits under
this rider. The fee will be charged on each Rider Quarterversary by the Company. 
 Rider Monthiversary 

The same day of the month as the rider date, or the next business day if our Administrative Office or the New York Stock Exchange is closed. If a certain date
does not exist in a given month, the first day of the following month will be used. 
 Rider Quarter 

Each three-month period beginning on the rider date. 
 Rider
Quarterversary 
 For each Rider Quarter, the same day of the month as the rider date, or the next business day if our Administrative Office or the New
York Stock Exchange is closed. If a certain date does not exist in a given month, the first day of the following month will be used. 
 Rider Withdrawal
Amount 
 The maximum amount that can be withdrawn from the policy each Rider Year without causing an Excess Withdrawal under the terms of this rider and
thus reducing the Withdrawal Base. This amount will change if the Withdrawal Base changes. 
 Rider Year 

Each twelve-month period following the rider date. 

Withdrawal Base 
 The amount used to calculate the
Rider Withdrawal Amount and the Rider Fee. This amount has no cash value and cannot be taken as a lump sum. 
 ARTICLE II 

RIDER FEES 
 The Rider Fee is deducted on each Rider
Quarterversary. The fee is calculated at issue and at the beginning of each Rider Quarter for the upcoming quarter. The rider fee percentage will not change during the first five Rider Years, and will only change thereafter due to an automatic
step-up. You will be notified of any increase in the rider fee percentage. A portion of this fee will also be deducted when the rider is terminated based on the number of days that have elapsed since the previous Rider Quarterversary. 

The fee will be adjusted for new deposits, transfers among Designated Investment Options and Excess Withdrawals made during the Rider Quarter. 

Fees will be calculated on the day the rider is issued and at the beginning of each Rider Quarter. They will be deducted automatically from each subaccount on
a pro rata basis on each Rider Quarterversary. The annual fee percentages for each designated allocation group are shown on page 1, in the Rider Data Specification section. 
  

  

					
	NIC14 RGMB480515(AS)(NY)		(2)		(Income/Death-Single)

 ARTICLE II CONTINUED 

The quarterly fee is calculated as follows: 
 Multiply
(1) by (2) divided by (3) multiplied by (4). 
  

	1)	Withdrawal Base; 

  

	2)	Product of each designated allocation group rider fee percentage and the applicable designated allocation group value, summed together; 

 

	3)	Total Policy Value; 

  

	4)	Number of days remaining in the Rider Quarter divided by the number of days within the applicable Rider Year. 

Please see the Appendix attached to this rider which illustrates how the Rider Fee is calculated. 

ARTICLE III 
 GUARANTEED LIFETIME WITHDRAWAL
BENEFIT 
 Under this rider, we guarantee that You can receive up to the Rider Withdrawal Amount each Rider Year, regardless of the Policy Value, (first
as withdrawals from Your Policy Value and, if necessary, as payments from us) until the Annuitant’s death. 
 The withdrawal percentage is determined
by the attained age (age at last birthday) of the Annuitant at the time of the first withdrawal of any amount from the Policy Value taken on or after the Rider Anniversary following the Annuitant’s [59th] birthday. Once the withdrawal percentage is established, it may only be changed by an upgrade or automatic step-up and redetermined at that time. Upon automatic step-up, the withdrawal percentage
will be reset based on the attained age at the time of automatic step-up. The withdrawal percentages are shown in the table in the Rider Data Specification section. 

If the Annuitant is not yet
[59] on the rider date, the withdrawal percentage will be zero until the Rider Anniversary following the Annuitant’s [59th] birthday. Withdrawals prior to age 59 1/2 will be subject to
the IRS 10% early withdrawal penalty. 
 Withdrawals will reduce the Policy Value and death benefit of the policy to which this rider is attached. If
the Policy Value equals zero, You cannot make subsequent Premium Payments and all other policy features, benefits and guarantees are no longer available. Also, if the Policy Value equals zero, You will need to request payments by selecting the
amount and frequency in accordance with the policy provisions to which this rider attaches, equal to the Rider Withdrawal Amount. Once the payment amount and frequency are established, they cannot be changed and no additional withdrawals will be
allowed. 
 We guarantee that You may withdraw up to the Rider Withdrawal Amount each year regardless of the Policy Value until the Annuitant’s death.

 Example 
 Assume You
are the Owner and Annuitant and begin taking withdrawals at age 75 and Your Withdrawal Base is $100,000. Assuming a withdrawal percentage of 5%, You could withdraw up to $5,000 each Rider Year for the rest of Your life (assuming that You do not
withdraw more than $5,000 in any one Rider Year). 
 Any amount You withdraw in excess of the Rider Withdrawal Amount may impact the Withdrawal Base on a
greater than dollar-for-dollar basis. 
 The Guaranteed Lifetime Withdrawal Benefit can only be taken as a withdrawal benefit and it does not increase the
Policy Value. 
 ISSUE AGE AND SURVIVAL 
 The benefits
under this rider depend on the Annuitant being alive at the time of withdrawal and the amount of the benefit depends on the attained age of the Annuitant. Reasonable proof of survival and the date of birth may be required by the Company. 

If the Annuitant’s age has been misstated, this rider’s fees and benefits will be adjusted to the amounts which would have been calculated for the
correct age. However, if this rider would not have been issued had the age not been misstated, the rider is treated as if it never existed, and any fees charged for this rider would be returned. If withdrawals under the provisions of the rider have
already commenced and the misstatement caused the Rider Withdrawal Amount to be overstated, any withdrawal in excess of the correct Rider Withdrawal Amount will be considered an Excess Withdrawal and will impact the Withdrawal Base and Rider
Withdrawal Amount. If overpayments occurred when the sum of the accumulated values in all the subaccounts was zero, the amount of that overpayment will be deducted from one or more future payments until this amount is paid in full. 

  

					
	NIC14 RGMB480515(AS)(NY)		(3)		(Income/Death-Single)

 ARTICLE III CONTINUED 

RIDER WITHDRAWAL AMOUNT 
 The Rider Withdrawal Amount will
be equal to the greater of 1) and 2), where: 
  

	1)	is the withdrawal percentage multiplied by the Withdrawal Base; 

  

	2)	is an amount equal to the minimum required distribution amount, if any. Prior to the 1st Rider Anniversary, this amount is based on the Policy Value on the rider date. After this time, the minimum required distribution
is calculated based on the rules established by the IRS. The minimum required distribution may only be used if all of the following are true: 

  

	 	A)	the policy to which this rider is attached is a tax-qualified policy for which IRS minimum required distributions are required, 

  

	 	B)	the minimum required distributions do not start prior to the Annuitant’s attained age 70 1/2, 

  

	 	C)	the minimum required distributions are based on either the Uniform Lifetime table or the Joint Life and Last Survivor Expectancy table, 

 

	 	D)	the minimum required distributions are based on age of the living Annuitant. The minimum required distributions can not be based on the age of someone who is deceased, 

 

	 	E)	the minimum required distributions are based only on the policy to which this rider is attached, and 

  

	 	F)	the minimum required distributions are only for the current Rider Year. Amounts carried over from past Rider Years are not considered 

If any of the above are not true, then 2) is equal to zero and it is not available as a Rider Withdrawal Amount. 

If You withdraw less than the Rider Withdrawal Amount in a Rider Year, the unused portion cannot be carried over to the next Rider Year. 

Surrender charges may apply if Your Rider Withdrawal Amount exceeds Your surrender charge-free amount. 

WITHDRAWAL BASE 
 The Withdrawal Base is used to calculate
the Rider Withdrawal Amount. On the rider date, the initial Withdrawal Base is equal to the Policy Value (less any applicable premium enhancements if the rider is added in the first Policy Year). During any Rider Year, the Withdrawal Base is
increased by subsequent Premium Payments (not including premium enhancements, if any), and is reduced for Excess Withdrawals. 
 On each Rider Anniversary,
the Withdrawal Base will be set to the greatest of: 
  

	 	1)	The current Withdrawal Base; 

  

	 	2)	The Policy Value on the Rider Anniversary; 

  

	 	3)	The highest Policy Value on a Rider Monthiversary for the current Rider Year; and 

  

	 	4)	The current Withdrawal Base immediately prior to Rider Anniversary processing increased by the growth rate percentage. 

Item 3) above will be zero if there have been any Excess Withdrawals in the current Rider Year. Item 4) above will be zero after the [10th] Rider Anniversary or if there have been any withdrawals in the current Rider Year. 

AUTOMATIC STEP-UP FEATURE 
 The rider receives an
automatic step-up on the Rider Anniversary if the Withdrawal Base is set equal to the Policy Value or the highest Policy Value on a Rider Monthiversary. This feature does not require the termination of the existing rider. This rider will continue
with the same rider date and features. The Rider Fee may change and the withdrawal percentages may increase due to an automatic step-up, but there will be no increase in the rider fee percentage during the first five Rider Years. Following the fifth
Rider Anniversary, the rider fee percentage may be increased if there is an automatic step-up, but will not exceed the maximum rider fee percentages described in the Rider Data Specification section. 

You have the right to reject an automatic step-up within [30] days following a Rider Anniversary, if the rider fee percentage
increases. If You reject an automatic step-up, You must notify us in a manner which is acceptable to us, however You are eligible for future automatic step-ups. Changes as a result of the automatic step-up feature will be reversed. Any increase in
the Rider Fee or withdrawal percentages will also be reversed. 

  

					
	NIC14 RGMB480515(AS)(NY)		(4)		(Income/Death-Single)

 ARTICLE III CONTINUED 

WITHDRAWAL BASE ADJUSTMENTS 
 Gross Partial Withdrawals,
taken in a Rider Year, less than or equal to the Rider Withdrawal Amount will not reduce the Withdrawal Base. Excess Withdrawals will reduce the Withdrawal Base by the withdrawal base adjustment which may be more than the dollar amount of the
Excess Withdrawal. The withdrawal base adjustment is the greater of 1) and 2), where: 
  

	1)	is the Excess Withdrawal amount; and 

  

	2)	is the result of (A multiplied by B), divided by C, where: 

  

	 	A)	is the Excess Withdrawal; 

  

	 	B)	is the Withdrawal Base prior to the Excess Withdrawal amount; and 

  

	 	C)	is the Policy Value after the Rider Withdrawal Amount has been withdrawn, but prior to the withdrawal of the Excess Withdrawal amount. 

RIDER DEATH BENEFIT 
 Upon the Annuitant’s death, we
will pay an additional death benefit amount equal to the excess, if any, of the rider death benefit over the greater of the base policy death benefit or the guaranteed minimum death benefit, if applicable, and this rider will then terminate. The
rider death benefit on the rider date is equal to the Policy Value (less any premium enhancements, if the rider is added in the first Policy Year). The rider death benefit after the rider date is equal to the rider death benefit on the rider date
plus any premiums (not including premium enhancements, if any) added after the rider date less any rider death benefit adjustments. 
 The rider death
benefit does not reset due to the automatic step-up. 
 RIDER DEATH BENEFIT ADJUSTMENTS 

Cumulative Gross Partial Withdrawals, taken in a Rider Year, up to the Rider Withdrawal Amount will reduce the rider death benefit by the same amount (dollar
for dollar). Excess Withdrawals will reduce the rider death benefit by the greater of: 
  

	1)	the Excess Withdrawal amount; and 

  

	2)	the result of (A divided by B), multiplied by C, where: 

  

	 	A)	is the Excess Withdrawal; 

  

	 	B)	is the Policy Value after the Rider Withdrawal Amount has been withdrawn, but prior to the Excess Withdrawal; and 

  

	 	C)	is the rider death benefit after the Rider Withdrawal Amount has been withdrawn, but prior to the Excess Withdrawal. 

ARTICLE IV 
 CONTINUATION 

In the case of spousal joint Owners where one spouse is the Annuitant, if the spouse who is not the Annuitant dies and the surviving spouse is the sole
beneficiary, the rider continues with the same rider values. No additional death benefit will be paid under this rider at this time. In the case of spousal joint Owners where one spouse is the Annuitant, if the spouse who is the Annuitant dies, this
rider will terminate. 
 In the case of non-spousal joint Owners where an Owner who is not the Annuitant dies, the surviving Owner (who is also the sole
designated beneficiary) may elect to receive lifetime income payments under this rider instead of receiving any benefits applicable to the policy. The lifetime income payments must begin no later than 1 year after the Owner’s death and will be
equal to the Rider Withdrawal Amount divided by the number of payments made per year. Once the payments begin, no additional Premium Payments will be accepted and no additional withdrawals will be paid. If these payments are elected but the
Annuitant dies before the rider death benefit equals zero, the Annuitant’s beneficiary will receive a death benefit equal to the rider death benefit. 

ANNUITIZATION 
 On the maximum Annuity Commencement Date,
as described in Your policy, You will have the option to receive lifetime income payments that are no less than Your Rider Withdrawal Amount each year. This option will also guarantee that the sum of all income payments received over time will equal
or exceed the greater of the Policy Value or the rider death benefit on the maximum Annuity Commencement Date. If the Annuitant should die before the sum of all income payments received equals or exceeds the greater of the Policy Value or the rider
death benefit on the maximum Annuity Commencement Date, the Annuitant’s beneficiary will receive a final payment equal to the difference. 

  

					
	NIC14 RGMB480515(AS)(NY)		(5)		(Income/Death-Single)

 ARTICLE IV CONTINUED 

RIDER UPGRADE 
 You may elect, in writing, to upgrade the
Withdrawal Base to the Policy Value within [30] days after the [fifth] Rider Anniversary and every [fifth] Rider Anniversary thereafter, subject to the issue age
restrictions on the new rider. If an upgrade is selected, this rider will terminate and a new rider with the same features will be issued with a new rider date. The new rider will have its own growth rate percentage and rider fee percentage which
may not be the same as this rider’s percentages. 
 At the time of upgrade, the rider death benefit will also be upgraded to the Policy Value
and the Rider Withdrawal Amount will be recalculated based on the new Withdrawal Base. 
 The new rider date will be the date the Company receives all
information necessary, at our Home Office, in a written form acceptable to the Company, to process the upgrade. 
 TERMINATION 

This rider will terminate upon the earliest of: 
  

	1)	the date the policy to which this rider is attached terminates; 

  

	2)	the date of the Annuitant’s death; 

  

	3)	the date You elect to upgrade (as described in Article IV of this rider); 

  

	4)	the date You elect to receive annuity payments under Your policy; 

  

	5)	the date You notify us in writing of Your intention to terminate this rider (this date must be within [30] days after the [fifth] Rider Anniversary and every [fifth] Rider Anniversary thereafter); and 

 

	6)	the date any of Your Policy Value is not invested in one of the Designated Investment Options. 

 Termination of
the rider will result in the loss of all benefits provided by the rider. After termination, rider fees will no longer be assessed. 
 REPORTS TO OWNER

 We will give You a report at least once each Policy Year. Before You are eligible to receive the Rider Withdrawal Amount, the report will direct You
to contact the Company for information regarding Your Rider Withdrawal Amount. After You are eligible for Your Rider Withdrawal Amount, this amount will be included in the report. 

Signed for us at our home office. 
  

			
	

		

	SECRETARY		PRESIDENT

  

					
	NIC14 RGMB480515(AS)(NY)		(6)		(Income/Death-Single)

 APPENDIX 

The quarterly fee is calculated as follows: 

Multiply (1) by (2) divided by (3) multiplied by (4) where: 
  

	1)	Withdrawal Base; 

  

	2)	Product of each designated allocation group rider fee percentage and the applicable designated allocation group value summed together; 

 

	3)	Total policy value; 

  

	4)	Number of days in the rider quarter divided by the number of days within the applicable rider year. 

 The fee
adjustment for additional premium payments and excess withdrawals is calculated as follows: 
 Multiply (1) by (2) divided by (3) multiplied
by (4) where: 
  

	1)	Withdrawal base change (i.e. withdrawal base after the transaction minus the withdrawal base before the transaction); 

  

	2)	Product of each designated allocation group rider fee percentage and the applicable designated allocation group value summed together; 

 

	3)	Total transaction amount; 

  

	4)	Number of days remaining in the rider quarter divided by the number of days within the applicable rider year. 

The fee adjustment for fund transfers is calculated as follows: 

Multiply (1) by (2) divided by (3) multiplied by (4) where: 
  

	1)	Withdrawal base; 

  

	2)	Product of each designated allocation group rider fee percentage and the applicable designated allocation group value summed together; 

 

	3)	Total policy value; 

  

	4)	Number of days remaining in the rider quarter divided by the number of days within the applicable rider year. 

The following two examples use assumed fees and values listed in the table below. The assumed rider year is not a leap year. 

 

													
	 Designated

Allocation Group
	  	Fee	 	 	Initial
Policy Value	 	  	Additional Premium
Used in Example 2	 
	 Group A
	  	 	2.50	% 	 	$	50,000	  	  	$	5,000	  
	 Group B
	  	 	2.40	% 	 	$	30,000	  	  	$	3,000	  
	 Group C
	  	 	2.30	% 	 	$	20,000	  	  	$	2,000	  

 Example 1: Calculation at rider issue for first quarter fee assuming an initial withdrawal base of $100,000. 

= 100,000 * [(50,000*0.0250) + (30,000*0.0240) + (20,000*0.0230)] / 100,000 * (91/365) 

= 100,000 * (1,250 + 720 + 460) / 100,000 * (91/365) 

= 100,000 * 2,430/100,000 * (91/365) 

= 2,430 * (91/365) 
 = $605.84

 Example 2: Calculation for first quarter fee assuming initial withdrawal base from Example 1 above, plus adjustment for additional premium payment
of $10,000 made with 20 days remaining in the first rider quarter (invested as shown above). The withdrawal base change and total transaction amount equal $10,000. 

Fee adjustment as follows: 
 = 10,000 *
[(5,000*0.0250) + (3,000*0.0240) + (2,000*0.0230)] / 10,000 * (20/365) 
 = 10,000 * (125 + 72 + 46) / 10,000 * (20/365) 

= 10,000 * 243/10,000 * (20/365) 

= 243 * (20/365) 
 = $13.32 

Total fee assessed on first rider quarterversary (assuming no further rider fee adjustments): 

= 13.32 + 605.84 
 = $619.16 

  

					
	NIC14 RGMB480515(AS)(NY)	 	(A-1)	 	(Income/Death-Single)

 The following three examples use assumed fees and values listed in the table below. The assumed rider year is not
a leap year. 
  

																	
	 Designated

Allocation Group
	  	Fee	 	 	Policy Value	 	  	Partial Withdrawal
Used in Example 4	 	  	Fund Transfer
Used in Example 5	 
	 Group A
	  	 	2.50	% 	 	$	49,000	  	  	$	-5,000	  	  	$	-5,000	  
	 Group B
	  	 	2.40	% 	 	$	29,000	  	  	$	-3,000	  	  	$	3,000	  
	 Group C
	  	 	2.30	% 	 	$	19,000	  	  	$	-2,000	  	  	$	2,000	  

 Example 3: Calculation for second quarter fee at beginning of second rider quarter, assuming withdrawal base of
$110,000 and policy value of $97,000 invested as above. 
 = 110,000 * [(49,000*0.0250) + (29,000*0.0240) + (19,000*0.0230)] / 97,000 *
(91/365) 
 = 110,000 * (1,225 + 696 + 437) / 97,000 * (91/365) 

= 110,000 * 2,358/97,000 * (91/365) 

= 2,674.02 * (91/365) 
 = $666.67

 Example 4: Calculation for second quarter fee assuming beginning values as in Example 3 above, plus adjustment for partial withdrawal of $10,000
taken with 40 days remaining in the second rider quarter. Assumes withdrawal percentage of 5%, policy value of $97,000 prior to the transaction and change in withdrawal base as follows: 

Rider Withdrawal Amount (RWA) = Withdrawal Base * Withdrawal Percentage = 110,000 * .05 = $5,500 

Excess Withdrawal = Difference between assumed withdrawal amount and RWA = 10,000 - 5,500 = $4,500 

Withdrawal Base Adjustment = Max (Excess Withdrawal, Excess Withdrawal * Withdrawal Base prior to withdrawal / Policy Value after RWA has been withdrawn but
before excess withdrawal) = Max [4,500, 4,500 * 110,000 / (97,000-5,500)] = Max (4,500, 5,409.84) = $5,409.84 
 Fee adjustment as follows: 

= -5,409.84 * [(5,000*0.0250) + (3,000*0.0240) + (2,000*0.0230)] / 10,000 * (40/365) 

= -5,409.84 * (125 + 72 + 46) / 10,000 * (40/365) 

= -5,409.84 * 243/10,000 * (40/365) 

= -131.46 * (40/365) 
 = $-14.41

 Total fee assessed on second rider quarterversary (assuming no further rider fee adjustments): 

= 666.67 - 14.41 
 = $652.26 

The new Withdrawal Base = $110,000 - $5,409.84 = $104,590.16 

Example 5: Calculation for fund transfer occurring during second quarter with 25 days remaining in the rider quarter, assuming beginning values as in
Example 3 and withdrawal adjustment as in Example 4 above. 
 Withdrawal Base = $104,590.16 and assumed policy value of $90,000. Fund transfer amount of
$5,000 as allocated in table above. 
 Fee adjustment as follows: 

= 104,590.16 * [(-5,000*0.0250) + (3,000*0.0240) + (2,000*0.0230)] / 90,000 * (25/365) 

= 104,590.16 * (-125 + 72 + 46) / 90,000 * (25/365) 

= 104,590.16 * -7/90,000 * (25/365) 

= -8.13 * (25/365) 
 = $-0.56 

Total fee assessed on second rider quarterversary (assuming no further rider fee adjustments): 

= 652.26 - 0.56 
 = $651.70 

  

					
	NIC14 RGMB480515(AS)(NY)	 	(A-2)	 	(Income/Death-Single)

 

 
 GUARANTEED LIFETIME WITHDRAWAL WITH DEATH BENEFIT OPTION 

This rider is issued as a part of the policy to which it is attached. All provisions of the policy that do not conflict with this rider apply to this rider.
In the event of any conflict between the provisions of this rider and the provisions of the policy, the provisions of this rider shall prevail over the provisions of the policy. 

The purpose of the guarantee living withdrawal benefit provided under this rider is to provide a stream of income payments to the Owner. 

You may cancel this rider on or before midnight of the thirtieth calendar day after You receive it and no Rider Fees will be assessed. 

This rider provides a minimum withdrawal benefit that guarantees, upon election, a series of withdrawals from the policy equal to the Withdrawal Percentage
shown below applied to the Withdrawal Base. The Withdrawal Base is established for the sole purpose of determining the minimum withdrawal benefit and is not used in calculating the cash surrender value or other guaranteed benefits. 

Rider Data Specification 
  

													
					 		 				 		
			 Policy Number:
		 				123456				
			 Rider Date:
		 				03/11/2015				
			 Growth Rate Percentage:
		 				5.50%				
				 		 	
			 Rider Fee Percentages*:
				 				 		
			 Designated Allocation Group A:
		 				1.80%				
			 Designated Allocation Group B:
		 				1.45%				
			 Designated Allocation Group C:
		 				1.05%				
											 		
			 Annuitant:
		 				John Doe				
			 				 
			 Annuitant’s Issue Age/Sex:
		 				65 / Male				
			 Annuitant’s Spouse:
		 				Jane Doe				
			 Annuitant’s Spouse’s Issue Age/Sex:
		 				65  /  Female		 		
							 						

  

	*	The Rider Fee is also a maximum Rider Fee for the life of the rider, provided there are no automatic step-ups. When an automatic step-up is utilized, the maximum Rider Fee would not be more than [0.75%] greater than the rider fee percentages shown above. 

 Designated
Allocations: If You elect this rider, 100% of Your Policy Value must be in one or more of the Designated Investment Options (or any other option authorized for use with this rider). The Designated Investment Options available may change with an
upgrade or prior approval of the New York State Department of Financial Services. 
 You can generally transfer between the Designated Investment Options as
permitted under Your policy; however, You cannot make transfers as provided for in the policy to a non-designated investment option (or any other option not authorized for use with this rider) while this rider is in force. If You wish to make a
transfer to a non-designated investment option, this rider must be terminated, as described in Article IV, prior to making the transfer. You will be notified if there are any changes to the Designated Investment Options. 

  

					
	NIC14 RGMB480515(AJ)(NY)		(1)		(Income/Death-Joint)

 RIDER DATA SPECIFICATION CONTINUED 

Guaranteed Lifetime Withdrawal Benefit: The withdrawal percentage is determined by the attained age and is used to determine the Rider Withdrawal Amount
as described in Article III. The withdrawal percentages are shown in the table below: 
  

																	
	 	 	 	 	 Attained Age
	  	 	 	 	 	 	  	Withdrawal
Percentage	 	 	  	 
		 		 		  		 		 		  		 		  	
		 	 	 		  	 	 		 	 	  		 	 	  	
		 		 	 59 - 64
	  	 	 		 		  	3.50%	 	 	  	
		 		 	 65 - 79
	  	 	 		 		  	4.50%	 	 	  	
		 		 	 80 +
	  	 	 		 		  	5.50%	 	 	  	
		 	 	 		  	 	 		 	 	  		 	 	  	

 ARTICLE I 
 The
Annuitant’s spouse as of the rider date is hereafter referred to as the Annuitant’s spouse. As it pertains to the benefits of this rider, the Annuitant’s spouse cannot be changed. The Annuitant’s spouse must be the sole primary
beneficiary and/or a joint Owner. The only living Owners allowed on the policy to which this rider is attached are the Annuitant and the Annuitant’s spouse. 

DEFINITIONS: 
 Terms used that are not defined in this
rider shall have the same meaning as those in Your policy. 
 Designated Investment Options 

Investment Options authorized for use with this rider and identified by us as Designated Investment Options. 

Excess Withdrawal 
 The excess of a Gross Partial
Withdrawal over the Rider Withdrawal Amount remaining prior to the withdrawal, if any. 
 Gross Partial Withdrawal 

The amount that will be deducted from Your Policy Value as a result of each partial withdrawal. 

Rider Anniversary 
 The anniversary of the rider date.

 Rider Fee 
 The fee charged for the benefits under
this rider. The fee will be charged on each Rider Quarterversary by the Company. 
 Rider Monthiversary 

The same day of the month as the rider date, or the next business day if our Administrative Office or the New York Stock Exchange is closed. If a certain date
does not exist in a given month, the first day of the following month will be used. 
 Rider Quarter 

Each three-month period beginning on the rider date. 
 Rider
Quarterversary 
 For each Rider Quarter, the same day of the month as the rider date, or the next business day if our Administrative Office or the New
York Stock Exchange is closed. If a certain date does not exist in a given month, the first day of the following month will be used. 
 Rider Withdrawal
Amount 
 The maximum amount that can be withdrawn from the policy each Rider Year without causing an Excess Withdrawal under the terms of this rider and
thus reducing the Withdrawal Base. This amount will change if the Withdrawal Base changes 
 Rider Year 

Each twelve-month period following the rider date. 

Withdrawal Base 
 The amount used to calculate the
Rider Withdrawal Amount and the Rider Fee. This amount has no cash value and cannot be taken as a lump sum. 

  

					
	NIC14 RGMB480515(AJ)(NY)	 	(2)	 	(Income/Death-Joint)

 ARTICLE II 

RIDER FEES 
 The Rider Fee is deducted on each Rider
Quarterversary. The fee is calculated at issue and at the beginning of each Rider Quarter for the upcoming quarter. The rider fee percentage will not change during the first five Rider Years, and will only change thereafter due to an automatic
step-up. You will be notified of any increase in the rider fee percentage. A portion of this fee will also be deducted when the rider is terminated based on the number of days that have elapsed since the previous Rider Quarterversary. 

The fee will be adjusted for new deposits, transfers among Designated Investment Options and Excess Withdrawals made during the Rider Quarter. 

Fees will be calculated on the day the rider is issued and at the beginning of each Rider Quarter. They will be deducted automatically from each subaccount on
a pro rata basis on each Rider Quarterversary. The annual fee percentages for each designated allocation group are shown on page 1 in the Rider Data Specification section. 

The quarterly fee is calculated as follows: 
 Multiply
(1) by (2) divided by (3) multiplied by (4). 
  

	1)	Withdrawal Base; 

  

	2)	Product of each designated allocation group rider fee percentage and the applicable designated allocation group value summed together; 

 

	3)	Total Policy Value; 

  

	4)	Number of days remaining in the Rider Quarter divided by the number of days within the applicable Rider Year. 

Please see the Appendix attached to this rider which illustrates how the Rider Fee is calculated. 

ARTICLE III 
 GUARANTEED LIFETIME WITHDRAWAL
BENEFIT 
 Under this rider, we guarantee that You can receive up to the Rider Withdrawal Amount each Rider Year, regardless of the Policy Value, (first
as withdrawals from Your Policy Value and, if necessary, as payments from us) until the Annuitant’s or the Annuitant’s spouse’s death, whichever is later. 

The withdrawal percentage is determined by the attained age (age at last birthday) of the younger of the living spouses at the time of the first withdrawal of
any amount from the Policy Value taken on or after the Rider Anniversary following the younger of the living spouse’s
[59th] birthday. Once the withdrawal percentage is established, it may only be changed by an upgrade or automatic step-up and redetermined at that time. Upon
automatic step-up, the withdrawal percentages will be reset based on the attained age of the younger of the living spouses at the time of the automatic step-up. The withdrawal percentages are shown in the table in the Rider Data Specification
section. 
 If the younger of the Annuitant and the Annuitant’s spouse is not yet
[59] on the rider date, the withdrawal percentage will be zero until the Rider Anniversary following the younger of the living spouse’s [59th] birthday. Withdrawals prior to age 59 1/2 will be subject to the IRS 10% early withdrawal penalty. 

Withdrawals will reduce the Policy Value and death benefit of the policy to which this rider is attached. If the Policy Value equals zero, You cannot make
subsequent Premium Payments and all other policy features, benefits and guarantees are no longer available. Also, if the Policy Value equals zero, You will need to request payments by selecting the amount and frequency in accordance with the policy
provisions to which this rider attaches, equal to the Rider Withdrawal Amount. Once the payment amount and frequency are established, they cannot be changed and no additional withdrawals will be allowed. 

We guarantee that you may withdraw up to the rider withdrawal amount each year regardless of the policy value until the annuitant’s death. 

  

					
	NIC14 RGMB480515(AJ)(NY)		(3)		(Income/Death-Joint)

 ARTICLE III CONTINUED 

Example 
 Assume the
younger of the annuitant and the annuitant’s spouse is 65 and withdrawals begin and your Withdrawal Base is $100,000. Assuming a withdrawal percentage of 4.50%, you could withdraw up to $4,500 each rider year until the annuitant’s or the
annuitant’s spouse’s death, which ever is later (assuming that you do not withdraw more than $4,500 in any one Rider Year). 
 Any amount you
withdraw in excess of the rider withdrawal amount may impact the withdrawal base on a greater than dollar-for-dollar basis. 

The Guaranteed Lifetime Withdrawal Benefit can only be taken as a withdrawal benefit and it does not increase the policy value 

ISSUE AGE AND SURVIVAL 
 The benefits under this rider
depend on the Annuitant or Annuitant’s spouse being alive at the time of withdrawal and the amount of the benefit depends on the attained age of the Annuitant and Annuitant’s spouse. Reasonable proof of survival and the date of birth may
be required by the Company. 
 If the younger of the spouses’ ages has been misstated, this rider’s fees and benefits will be adjusted to the
amounts which would have been calculated for the correct age. However, if this rider would not have been issued had the age not been misstated, the rider is treated as if it never existed, and any fees charged for this rider would be returned. If
withdrawals under the provisions of the rider have already commenced and the misstatement caused the Rider Withdrawal Amount to be overstated, any withdrawal in excess of the correct Rider Withdrawal Amount will be considered an Excess Withdrawal
and will impact the Withdrawal Base and Rider Withdrawal Amount. If overpayments occurred when the sum of the accumulated values in all the subaccounts was zero, the amount of that overpayment will be deducted from one or more future payments until
this amount is paid in full. 
 RIDER WITHDRAWAL AMOUNT 

The Rider Withdrawal Amount will be equal to the greater of 1) and 2), where: 
  

	1)	is the withdrawal percentage multiplied by the Withdrawal Base; 

  

	2)	is an amount equal to the minimum required distribution amount, if any. Prior to the 1st Rider Anniversary, this amount is based on the Policy Value on the rider date. After this time, the minimum required distribution
is calculated based on the rules established by the IRS. The minimum required distribution may only be used if all of the following are true: 

  

	 	A)	the policy to which this rider is attached is a tax-qualified policy for which IRS minimum required distributions are required, 

  

	 	B)	the minimum required distributions do not start prior to the Annuitant’s attained age 70 1/2, 

  

	 	C)	the minimum required distributions are based on either the Uniform Lifetime table or the Joint Life and Last Survivor Expectancy table, 

 

	 	D)	the minimum required distributions are based on age of the living Annuitant or the Annuitant’s spouse if the Annuitant is deceased. The minimum required distributions can not be based on the age of someone who is
deceased, 

  

	 	E)	the minimum required distributions are based only on the policy to which this rider is attached, and 

  

	 	F)	the minimum required distributions are only for the current Rider Year. Amounts carried over from past Rider Years are not considered. 

If any of the above are not true, then 2) is equal to zero and it is not available as a Rider Withdrawal Amount. 

If You withdraw less than the Rider Withdrawal Amount in a Rider Year, the unused portion cannot be carried over to the next Rider Year. 

Surrender charges may apply if Your Rider Withdrawal Amount exceeds Your surrender charge-free amount. 

WITHDRAWAL BASE 
 The Withdrawal Base is used to calculate
the Rider Withdrawal Amount. On the rider date, the initial Withdrawal Base is equal to the Policy Value (less any applicable premium enhancements if the rider is added in the first Policy Year). During any Rider Year, the Withdrawal Base is
increased by subsequent Premium Payments (not including premium enhancements, if any), and is reduced for Excess Withdrawals. 

  

					
	NIC14 RGMB480515(AJ)(NY)		(4)		(Income/Death-Joint)

 ARTICLE III CONTINUED 

On each Rider Anniversary, the Withdrawal Base will be set to the greatest of: 
  

	 	1)	The current Withdrawal Base; 

  

	 	2)	The Policy Value on the Rider Anniversary; 

  

	 	3)	The highest Policy Value on a Rider Monthiversary for the current Rider Year; and 

  

	 	4)	The current Withdrawal Base immediately prior to Rider Anniversary processing increased by the growth rate percentage. 

Item 3) above will be zero if there have been any Excess Withdrawals in the current Rider Year. Item 4) above will be zero after the [10th] Rider Anniversary or if there have been any withdrawals in the current Rider Year. 

AUTOMATIC STEP-UP FEATURE 
 The rider receives an
automatic step-up on the Rider Anniversary if the Withdrawal Base is set equal to the Policy Value or the highest Policy Value on a Rider Monthiversary. This feature does not require the termination of the existing rider. This rider will continue
with the same rider date and features. The Rider Fee may change and withdrawal percentages may increase due to an automatic step-up, but there will be no increase in the rider fee percentage during the first five Rider Years. Following the fifth
Rider Anniversary, the rider fee percentage may be increased if there is an automatic step-up, but will not exceed the maximum rider fee percentages described in the Rider Data Specification section. 

You have the right to reject an automatic step-up within [30] days following a Rider Anniversary, if the rider fee percentage
increases. If You reject an automatic step-up, You must notify us in a manner which is acceptable to us, however You are eligible for future automatic step-ups. Changes as a result of the automatic step-up feature will be reversed. Any increase in
the Rider Fee or withdrawal percentages will also be reversed. 
 WITHDRAWAL BASE ADJUSTMENTS 

Gross Partial Withdrawals, taken in a Rider Year, less than or equal to the Rider Withdrawal Amount will not reduce the Withdrawal Base. Excess Withdrawals
will reduce the Withdrawal Base by the withdrawal base adjustment which may be more than the dollar amount of the Excess Withdrawal. The withdrawal base adjustment is the greater of 1) and 2), where: 

 

	1)	is the Excess Withdrawal amount; and 

  

	2)	is the result of (A multiplied by B), divided by C, where: 

  

	 	A)	is the Excess Withdrawal; 

  

	 	B)	is the Withdrawal Base prior to the Excess Withdrawal amount; and 

  

	 	C)	is the Policy Value after the Rider Withdrawal Amount has been withdrawn, but prior to the withdrawal of the Excess Withdrawal amount. 

RIDER DEATH BENEFIT 
 Upon the later of the Annuitant or
the Annuitant’s spouse’s death, we will pay an additional death benefit amount equal to the excess, if any, of the rider death benefit over the greater of the base policy death benefit or the guaranteed minimum death benefit, if
applicable, and this rider will then terminate. The rider death benefit on the rider date is equal to the Policy Value (less any premium enhancements, if the rider is added in the first Policy Year). The rider death benefit after the rider date is
equal to the rider death benefit on the rider date plus any premiums (not including premium enhancements, if any) added after the rider date less any rider death benefit adjustments. 

The rider death benefit does not reset due to the automatic step-up. 

RIDER DEATH BENEFIT ADJUSTMENTS 
 Cumulative Gross Partial
Withdrawals, taken in a Rider Year, up to the Rider Withdrawal Amount will reduce the rider death benefit by the same amount (dollar for dollar). Excess Withdrawals will reduce the rider death benefit by the greater of: 

 

	1)	the Excess Withdrawal amount; and 

  

	2)	the result of (A divided by B), multiplied by C, where: 

  

	 	A)	is the Excess Withdrawal; 

  

	 	B)	is the Policy Value after the Rider Withdrawal Amount has been withdrawn, but prior to the Excess Withdrawal; and 

  

	 	C)	is the rider death benefit after the Rider Withdrawal amount has been withdrawn, but prior to the Excess Withdrawal. 

  

					
	NIC14 RGMB480515(AJ)(NY)		(5)		(Income/Death-Joint)

 ARTICLE IV 

CONTINUATION 
 In the case of spousal joint Owners where
one spouse is the Annuitant, if the spouse who is not the Annuitant dies and the surviving spouse is the sole beneficiary, the rider continues with the same rider values. No additional death benefit will be paid under this rider at this time. In the
case of spousal joint Owners where one spouse is the Annuitant, if the spouse who is the Annuitant dies and the surviving spouse is the sole beneficiary, the rider continues with the same rider values until the death of the surviving spouse. 

ANNUITIZATION 
 On the maximum Annuity Commencement Date,
as described in Your policy, You will have the option to receive lifetime income payments that are no less than Your Rider Withdrawal Amount each year. This option will also guarantee that the sum of all income payments received over time will equal
or exceed the greater of the Policy Value or the rider death benefit on the maximum Annuity Commencement Date. If the Annuitant or Annuitant’s spouse should die before the sum of all income payments received equals or exceeds the greater of the
Policy Value or the rider death benefit on the maximum Annuity Commencement Date, the Annuitant’s beneficiary will receive a final payment equal to the difference. 

RIDER UPGRADE 
 You may elect, in writing, to upgrade the
Withdrawal Base to the Policy Value within [30] days after the [fifth] Rider Anniversary and every [fifth] Rider Anniversary thereafter, subject to the issue age
restrictions on the new rider. If an upgrade is selected, this rider will terminate and a new rider with the same features will be issued with a new rider date. The new rider will have its own growth rate percentage and rider fee percentage which
may not be the same as this rider’s percentages. 
 At the time of upgrade, the rider death benefit will also be upgraded to the Policy Value
and the Rider Withdrawal Amount will be recalculated based on the new Withdrawal Base. 
 The new rider date will be the date the Company receives all
information necessary, at our Home Office, in a written form acceptable to the Company, to process the upgrade. 
 TERMINATION 

This rider will terminate upon the earliest of: 
  

	1)	the date the policy to which this rider is attached terminates; 

  

	2)	the later of the Annuitant’s or Annuitant’s spouse’s death; 

  

	3)	the date You elect to upgrade (as described in Article IV of this rider); 

  

	4)	the date You elect to receive annuity payments under Your policy; 

  

	5)	the date You notify us in writing of Your intention to terminate this rider (this date must be within [30] days after the [fifth] Rider Anniversary and every [fifth] Rider Anniversary thereafter); and 

 

	6)	the date any of Your Policy Value is not invested in one of the Designated Investment Options. 

 Termination of
the rider will result in the loss of all benefits provided by the rider. After termination, rider fees will no longer be assessed. 
 REPORTS TO OWNER

 We will give You a report at least once each Policy Year. Before You are eligible to receive the Rider Withdrawal Amount, the report will direct You
to contact the Company for information regarding Your Rider Withdrawal Amount. After You are eligible for Your Rider Withdrawal Amount, this amount will be included in the report. 

Signed for us at our home office. 
  

			
	

		

	 SECRETARY
		PRESIDENT

  

					
	NIC14 RGMB480515(AJ)(NY)		(6)		(Income/Death-Joint)

 APPENDIX 

The quarterly fee is calculated as follows: 

Multiply (1) by (2) divided by (3) multiplied by (4) where: 
  

	1)	Withdrawal Base; 

  

	2)	Product of each designated allocation group rider fee percentage and the applicable designated allocation group value summed together; 

 

	3)	Total policy value; 

  

	4)	Number of days in the rider quarter divided by the number of days within the applicable rider year. 

 The fee
adjustment for additional premium payments and excess withdrawals is calculated as follows: 
 Multiply (1) by (2) divided by (3) multiplied
by (4) where: 
  

	1)	Withdrawal base change (i.e. withdrawal base after the transaction minus the withdrawal base before the transaction) 

  

	2)	Product of each designated allocation group rider fee percentage and the applicable designated allocation group value summed together 

 

	3)	Total transaction amount 

  

	4)	Number of days remaining in the rider quarter divided by the number of days within the applicable rider year 

The fee adjustment for fund transfers is calculated as follows: 
  

	Multiply	(1) by (2) divided by (3) multiplied by (4) where: 

  

	1)	Withdrawal base; 

  

	2)	Product of each designated allocation group rider fee percentage and the applicable designated allocation group value summed together; 

 

	3)	Total policy value; 

  

	4)	Number of days remaining in the rider quarter divided by the number of days within the applicable rider year. 

The following two examples use assumed fees and values listed in the table below. The assumed rider year is not a leap year. 

 

													
	 Designated Allocation Group
	  	Fee	 	 	Initial
Policy Value	 	  	Additional Premium
Used in Example 2	 
	 Group A
	  	 	2.50	% 	 	$	50,000	  	  	$	5,000	  
	 Group B
	  	 	2.40	% 	 	$	30,000	  	  	$	3,000	  
	 Group C
	  	 	2.30	% 	 	$	20,000	  	  	$	2,000	  

 Example 1: Calculation at rider issue for first quarter fee assuming an initial withdrawal base of $100,000. 

= 100,000 * [(50,000*0.0250) + (30,000*0.0240) + (20,000*0.0230)] / 100,000 * (91/365) 

= 100,000 * (1,250 + 720 + 460) / 100,000 * (91/365) 

= 100,000 * 2,430/100,000 * (91/365) 

= 2,430 * (91/365) 
 = $605.84

 Example 2: Calculation for first quarter fee assuming initial withdrawal base from Example 1 above, plus adjustment for additional premium payment
of $10,000 made with 20 days remaining in the first rider quarter (invested as shown above). The withdrawal base change and total transaction amount equal $10,000. 

Fee adjustment as follows: 
 = 10,000 *
[(5,000*0.0250) + (3,000*0.0240) + (2,000*0.0230)] / 10,000 * (20/365) 
 = 10,000 * (125 + 72 + 46) / 10,000 * (20/365) 

= 10,000 * 243/10,000 * (20/365) 

= 243 * (20/365) 
 = $13.32 

Total fee assessed on first rider quarterversary (assuming no further rider fee adjustments): 

= 13.32 + 605.84 
 = $619.16 

  

					
	NIC14 RGMB480515(AJ)(NY)	 	(A-1)	 	 (Income/Death-Joint)

 The following three examples use assumed fees and values listed in the table below. The assumed rider year is not
a leap year. 
  

																	
	 Designated Allocation Group
	  	Fee	 	 	Policy Value	 	  	Partial Withdrawal
Used in Example 4	 	  	Fund Transfer
Used in Example 5	 
	 Group A
	  	 	2.50	% 	 	$	49,000	  	  	$	-5,000	  	  	$	-5,000	  
	 Group B
	  	 	2.40	% 	 	$	29,000	  	  	$	-3,000	  	  	$	3,000	  
	 Group C
	  	 	2.30	% 	 	$	19,000	  	  	$	-2,000	  	  	$	2,000	  

 Example 3: Calculation for second quarter fee at beginning of second rider quarter, assuming withdrawal base of
$110,000 and policy value of $97,000 invested as above. 
 = 110,000 * [(49,000*0.0250) + (29,000*0.0240) + (19,000*0.0230)] / 97,000 *
(91/365) 
 = 110,000 * (1,225 + 696 + 437) / 97,000 * (91/365) 

= 110,000 * 2,358/97,000 * (91/365) 

= 2,674.02 * (91/365) 
 = $666.67

 Example 4: Calculation for second quarter fee assuming beginning values as in Example 3 above, plus adjustment for partial withdrawal of $10,000
taken with 40 days remaining in the second rider quarter. Assumes withdrawal percentage of 5%, policy value of $97,000 prior to the transaction and change in withdrawal base as follows: 

Rider Withdrawal Amount (RWA) = Withdrawal Base * Withdrawal Percentage = 110,000 * .05 = $5,500 

Excess Withdrawal = Difference between assumed withdrawal amount and RWA = 10,000 - 5,500 = $4,500 

Withdrawal Base Adjustment = Max (Excess Withdrawal, Excess Withdrawal * Withdrawal Base prior to withdrawal / Policy Value after RWA has been withdrawn but
before excess withdrawal) = Max [4,500, 4,500 * 110,000 / (97,000-5,500)] = Max (4,500, 5,409.84) = $5,409.84 
 Fee adjustment as follows: 

= -5,409.84 * [(5,000*0.0250) + (3,000*0.0240) + (2,000*0.0230)] / 10,000 * (40/365) 

= -5,409.84 * (125 + 72 + 46) / 10,000 * (40/365) 

= -5,409.84 * 243/10,000 * (40/365) 

= -131.46 * (40/365) 
 = $-14.41

 Total fee assessed on second rider quarterversary (assuming no further rider fee adjustments): 

= 666.67 - 14.41 
 = $652.26 

The new Withdrawal Base = $110,000 - $5,409.84 = $104,590.16 

Example 5: Calculation for fund transfer occurring during second quarter with 25 days remaining in the rider quarter, assuming beginning values as in
Example 3 and withdrawal adjustment as in Example 4 above. 
 Withdrawal Base = $104,590.16 and assumed policy value of $90,000. Fund transfer amount of
$5,000 as allocated in table above. 
 Fee adjustment as follows: 

= 104,590.16 * [(-5,000*0.0250) + (3,000*0.0240) + (2,000*0.0230)] / 90,000 * (25/365) 

= 104,590.16 * (-125 + 72 + 46) / 90,000 * (25/365) 

= 104,590.16 * -7/90,000 * (25/365) 

= -8.13 * (25/365) 
 = $-0.56 

Total fee assessed on second rider quarterversary (assuming no further rider fee adjustments): 

= 652.26 - 0.56 
 = $651.70 

  

					
	NIC14 RGMB480515(AJ)(NY)	 	(A-2)	 	(Income/Death-Joint)EX-10.17

 Exhibit 10.17 

SEVERANCE AGREEMENT 
 This
Severance Agreement (“Agreement”) is entered into and effective as of January 6, 2014 (“Effective Date”), by and between USMD Holdings, Inc.
(“Company”) and Carolyn Jones (“Employee”). 
 Recitals 

WHEREAS, Company acknowledges and wishes to reward the valuable contributions Employee has made and will continue to make to the success of
the Company; and 
 WHEREAS, Company understands and acknowledges that Employee possesses skills and knowledge instrumental to the
successful conduct of the Company’s business; and 
 WHEREAS, Company is willing to enter into this Agreement with Employee in order to
better ensure itself of access to the continued services of Employee both before and after a Change in Control (defined below). 
 NOW,
THEREFORE, for and in consideration of the mutual covenants and agreements set forth herein and for other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties to this Agreement hereby agree as
follows: 
 1. Term. The term of this Agreement shall commence on the Effective Date and shall terminate on the actual
date on which Employee’s employment with Company terminates. 
 2. Operation of Agreement. On the Effective Date,
this Agreement shall supercede any other agreement, if any, between the Company and Employee that would provide Employee the right to receive severance benefits in connection with the termination of Employee’s employment. 

3. Certain Definitions. As used in this Agreement, the following terms shall have the meanings set forth below: 

(a) “Accrued Obligations” shall mean any vested amounts or benefits owing to Employee under the Company’s
otherwise applicable employee benefit plans and programs. 
 (b) “Base Salary” shall mean
Employee’s annualized base salary as in effect from time to time as reflected in the Company’s regular payroll records. Base Salary shall not include any portion of any bonus compensation for time periods which have not concluded as
of the Date of Termination. 
 (c) “Change in Control” shall mean the consummation of a transaction or a
series of the transactions in which more than fifty percent (50%) of the shares of stock of the Company are sold, transferred or conveyed. 

(d) “Change in Control Date” means the date on which a Change in Control occurs. 

 (e) “Date of Termination” shall mean 

(1) In the case of a termination for which a Notice of Termination is required, the date of receipt of such Notice of
Termination or, if later, the date specified therein, and 
 (2) In all other cases, the actual date on which Employee’s
employment terminates. 
 (f) “Earned Salary” shall mean Employee’s Base Salary earned, but
unpaid, through Employee’s Date of Termination. 
 (g) “Notice of Termination” shall mean a written
notice given, in the case of a Termination for Cause, within 45 days of the Company’s having actual knowledge of the events giving rise to such termination, and in the case of a Termination for Good Reason, within 45 days of Employee’s
having actual knowledge of the events giving rise to such termination. Any such Notice of Termination shall: 
 (1)
Indicate the specific termination provision in this Agreement relied upon, 
 (2) Set forth in reasonable detail the facts
and circumstances claimed to provide a basis for termination of Employee’s employment under the provision so indicated, 

(3) If the Date of Termination is other than the date of receipt of such notice, specify the Date of Termination (which date
shall be not more than 30 days after the giving of such notice), and 
 (4) Be delivered prior to the expiration of the term
of this Agreement. 
 (h) “Termination for Cause” shall mean a termination of Employee’s employment by
the Company due to the occurrence of any of the following: 
 (1) Employee’s continued failure to substantially perform
Employee’s duties and responsibilities after written demand for substantial performance is delivered by the Company specifically identifying the manner in which the Company believes Employee has not substantially performed Employee’s
duties and responsibilities; 
 (2) Employee’s engaging in an act or acts of misconduct which result in, or are intended
to result in, material damage to the Company’s business or reputation; 
 (3) Employee’s material violation of, or
failure to comply with, any material written policy of the Company which specifically provides that Employee may be dismissed (or Employee’s employment terminated) as a consequence of any such violation or failure to comply, or 

 (4) Employee’s conviction of (or plea of guilty or nolo contendere to
a charge of) any felony, or any crime or misdemeanor involving moral turpitude or financial misconduct. 
 (i)
“Termination for Good Reason” shall mean a termination of Employee’s employment by Employee due to the occurrence of any of the following, without the express written consent of Employee: 

(1) The assignment to Employee of any duties materially inconsistent in any material adverse respect with Employee’s
position, authority or responsibilities as in effect immediately prior such assignment or change; 
 (2) A material reduction
in Employee’s Base Salary in effect immediately prior to such reduction; 
 (3) Any failure by the Company, other than
an insubstantial or inadvertent failure remedied by the Company promptly after receipt of notice thereof given by Employee, to provide Employee with the agreed on annual Base Salary for Employee; or 

(4) If, not later than the Change in Control Date, any successor in interest to the Company shall have failed to agree in
writing to assume and perform this Agreement as required by paragraph 7(f) hereof. 
 4. Termination of Employment. Employee
acknowledges that this Agreement is not an employment agreement between Company and Employee and Employee remains an “at will” employee of the Company. Nothing in this Agreement shall be construed in any way to limit the
right of the Company to terminate Employee’s employment, with or without cause, or for Employee to terminate Employee’s employment with the Company, with or without reason; provided, however, that the Company and Employee must
nonetheless comply with any duty or obligation such party has at law or under any other agreement between the parties. 
 5. Amounts
Payable Upon Termination of Employment. 
 (a) Cause and Voluntary Termination. During the term of this Agreement,
if Employee’s employment is terminated by the Company in a Termination for Cause or voluntarily by Employee (other than in a Termination for Good Reason), the Company shall pay Employee: 

(1) The Earned Salary as soon as practicable, but in no event more than 30 days, following Employee’s Date of
Termination; and 
 (2) The Accrued Obligations in accordance with the terms of the applicable plan, program, policy or
arrangement. 

 (b) Termination for Good Reason or Not for Cause. During the term of this
Agreement, if Employee terminates Employee’s employment in a Termination for Good Reason, or the Company terminates Employee’s employment for any reason other than those described in paragraph 5(a) above, the Company shall pay or shall
provide to Employee the following benefits and compensation: 
 (1) The Earned Salary, as soon as practicable, but in no
event more than 30 days, following Employee’s Date of Termination; 
 (2) The Accrued Obligations, in accordance with
applicable law and the provisions of any applicable plan, program, policy or practice; and 
 (3) A Separation Payment equal
to (i) three months of Employee’s Base Salary on the date of termination if the date of termination occurs during the first two years after the commencement of Employee’s employment with the Company, or alternatively (ii) a
Separation payment equal to six months of Employee’s Base Salary on the date of termination if the date of termination occurs more than two years after the commencement of Employee’s employment with the Company; provided that if Employee
terminates employment for good reason based on a material change in Employee’s Base Salary, then Employee’s Base Salary for such purpose shall be considered the Base Salary immediately prior to such change. The Separation Payment shall be
paid over the ensuing three (with respect to subsection (i) above) or six (with respect to subsection (ii) above) month period following the expiration of the revocation period stated in the release agreement described in paragraph 5(c)
below in accordance with the usual and customary payroll practices of Employer. 
 (c) Payments Contingent on Release. The
Separation Payment payable under paragraph 5(b) shall be subject to, and contingent upon, Employee providing the Company with a signed release agreement, satisfactory to the Company, releasing the Company and all affiliates of any and all claims,
charges and causes of action the Employee may have arising out of or relating in any way to the Employee’s employment by the Company and its affiliated companies and the termination of such employment. 

(d) Transfer. For purposes of this Agreement, a transfer of employment from the Company to substantially equivalent
employment with an affiliate of the Company shall not constitute a termination of employment and shall not entitle Employee to a Separation Payment. 

6. Employee Covenants. 

(a) Acknowledgement of Access. Employee hereby acknowledges that in connection with Employee’s employment with the
Company, Employee has received, and will continue to receive, various information regarding the Company and its business, operations and affairs. All such information, to the extent not publicly available other than as a result of a disclosure
by Employee in violation of this Agreement, is referred to herein as the “Nonpublic Information.” 

 (b) Agreement to Keep Confidential. Employee hereby agrees that, from and
after the Effective Date and continuing until three (3) years following Employee’s Date of Termination, Employee will keep all Nonpublic Information confidential and will not, without the prior written consent of the Chairman of the
Company, disclose any Nonpublic Information in any manner whatsoever or use any Nonpublic Information other than in connection with the performance of Employee’s services to the Company; provided, however, that the provisions of this
paragraph 6(b) shall not prevent Employee from: 
 (1) Disclosing any Nonpublic Information to any other employee of the
Company or to any representative or agent of the Company (such as an independent accountant, engineer, attorney or financial advisor) when such disclosure is reasonably necessary or appropriate (in Employee’s judgment) in connection with the
performance by Employee of Employee’s duties and responsibilities, 
 (2) Disclosing any Nonpublic Information as
required by applicable law, rule, regulation or legal process (but only after compliance with the provisions of subparagraph (c) of this paragraph), or 

(3) Disclosing any information about this Agreement and Employee’s other compensation arrangement to Employee’s
spouse, financial advisors or attorneys, or to enforce any of Employee’s rights under this Agreement. 
 (c) Commitment to Seek
Protective Order. If Employee is requested pursuant to, or required by, applicable law, rule, regulation or legal process to disclose any Nonpublic Information, Employee will notify Company promptly so that the Company may seek a
protective order or other appropriate remedy or, in the Company’s sole discretion, waive compliance with the terms of this subparagraph, and Employee will fully cooperate in any attempt by the Company to obtain any such protective order or
other remedy. If no such protective order or other remedy is obtained, or the Company waives compliance with the terms of this paragraph, Employee will furnish or disclose only that portion of the Nonpublic Information as is legally required
and will exercise all reasonable efforts to obtain reliable assurance that confidential treatment will be accorded the Nonpublic Information that is so disclosed. 

7. Miscellaneous Provisions. 

(a) Arbitration. Except to the extent provided in paragraph 7(b), any dispute or controversy arising under or in connection
with this Agreement shall be resolved by binding arbitration. The arbitration shall be held in Dallas, Texas and except to the extent inconsistent with this Agreement, shall be conducted in accordance with the Expedited Employment Arbitration
Rules of the American Arbitration Association then in effect at the time of the arbitration, and otherwise in accordance with principles which would be applied by a court of law or equity. The arbitrator shall be acceptable to both the Company
and Employee. If the parties cannot agree on an acceptable arbitrator, the dispute shall be heard by a panel of three arbitrators, one appointed by each of the parties and the third appointed by the other two arbitrators. 

 (b) Equitable Relief Available. Employee acknowledges that remedies at law may
be inadequate to protect the Company against any actual or threatened breach of the provisions of paragraph 6 by Employee. Accordingly, without prejudice to any other rights or remedies otherwise available to the Company, Employee agrees that
the Company shall have the right to equitable and injunctive relief to prevent any breach of the provisions of paragraph 6, as well as to such damages or other relief as may be available to the Company by reason of any such breach as does occur.

 (c) Breach Not a Defense. The representations and covenants on the part of Employee contained in paragraph 6 shall be
construed as ancillary to and independent of any other provision of this Agreement, and the existence of any claim or cause of action of Employee against the Company or any officer, director, stockholder or representative of the Company, whether
predicated on this Agreement or otherwise, shall not constitute a defense to the enforcement by the Company of the covenants on the part of Employee contained in paragraph 6. 

(d) Notices. Any Notice of Termination or other communication called for by the terms of this Agreement shall be in writing
and either delivered personally or by registered or certified mail (postage prepaid and return receipt requested) and shall be deemed given when received at the following addresses (or at such other address for a party as shall be specified by like
notice): 
  

			
	If to the Company:        		USMD Holdings, Inc.
			6333 North State Highway 161, Ste. 200
			Irving, Texas 75038
			Attn: General Counsel
		
	If to Employee:		Carolyn Jones
			P. O. Box 261117
			Plano, Texas 75026

 (e) Assignment. Except pursuant to an assumption by a successor described in paragraph
7(f), the rights and obligations of the Company pursuant to this Agreement may not be assigned, in whole or in part, by the Company to any other person or entity without the express written consent of Employee. The rights and obligations of
Employee pursuant to this Agreement may not be assigned, in whole or in part, by Employee to any other person or entity without the express written consent of the Chairman of the Company. 

(f) Successors. This Agreement shall be binding on, and shall inure to the benefit of, the Company, Employee and their
respective successors, permitted assigns, personal and legal representatives, executors, administrators, heirs, distributees, devisees and legatees, as applicable. Company shall require any successor (whether direct or indirect) to all or
substantially all of the business or assets of Company under any Change in Control (whether by purchase of securities, merger, consolidation, sale of assets or otherwise), to expressly assume and agree to perform the obligations to be performed by
the Company under this Agreement in the same manner and to the same extent that the Company would be required to perform if no such succession had taken place. 

 (g) Amendments and Waivers. No provision of this Agreement may be amended or
otherwise modified, and no right of any party to this Agreement may be waived, unless such amendment, modification or waiver is agreed to in a written instrument signed by Employee and Company. No waiver by either party hereto of, or compliance
with, any condition or provision of this Agreement to be performed by the other party hereto shall be deemed a waiver of similar or dissimilar provisions or conditions at the same or at any prior or subsequent time. 

(h) Complete Agreement. This Agreement replaces and supersedes all prior agreements, if any, among the parties with respect
to the payments to be made to Employee upon termination of employment and the provisions of this Agreement constitute the complete understanding and agreement among the parties with respect to the subject matter hereof. 

(i) Governing Law. This Agreement is being made and executed in, and is intended to be performed in, the State of
Texas and shall be governed, construed, interpreted and enforced in accordance with the substantive laws of the State of Texas without regard to its conflict of laws principles. 

(j) Counterparts. This Agreement may be executed in several counterparts, each of which shall be deemed to be an original,
but all of which together will constitute one and the same agreement. 
 (k) Construction. The captions of the
paragraphs, subparagraphs and sections of this Agreement have been inserted as a matter of convenience of reference only and shall not affect the meaning or construction of any of the terms or provisions of this Agreement. Unless otherwise
specified, references in this Agreement to a “paragraph,” “subparagraph”, “section,” “subsection,” or “schedule” shall be considered to be
references to the appropriate paragraph, subparagraph, section, subsection, or schedule, respectively, of this Agreement. As used in this Agreement, the term “including” shall mean “including, but not limited
to.” 
 (l) Validity and Severability. If any term or provision of this Agreement is held to be illegal,
invalid or unenforceable under the present or future laws effective during the term of this Agreement, (1) such term or provision shall be fully severable, (2) this Agreement shall be construed and enforced as if such term or provision had
never comprised a part of this Agreement and (3) the remaining terms and provisions of this Agreement shall remain in full force and effect and shall not be affected by the illegal, invalid or unenforceable term or provision or by its severance
from this Agreement. Furthermore, in lieu of such illegal, invalid or unenforceable term or provision, there shall be added automatically as a part of this Agreement, a term or provision as similar to such illegal, invalid or unenforceable term
or provision as may be possible and be legal, valid and enforceable. 
 [Remainder of Page Left Blank; Signature Page to Follow] 

 IN WITNESS WHEREOF, the parties have executed this Agreement effective as of the date first
written above. 
  

			
	Company:
	
	USMD Holdings, Inc.
		
	By:		 /s/ John House

			John House, M.D., Chairman and CEO
	
	Employee:
	
	 /s/ Carolyn Jones

	Carolyn Jones

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