Document:

Filed by Bowne Pure Compliance

Exhibit 4.1

FORM OF WARRANT

THIS WARRANT HAS NOT BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933, AS
AMENDED (THE “SECURITIES ACT”), OR APPLICABLE STATE SECURITIES LAWS. THE WARRANT MAY NOT BE SOLD, OFFERED
FOR SALE, TRANSFERRED, PLEDGED OR OTHERWISE DISPOSED OF UNLESS IT HAS BEEN REGISTERED UNDER THOSE LAWS OR UNLESS THE
COMPANY HAS RECEIVED AN OPINION OF COUNSEL SATISFACTORY TO IT THAT SUCH DISPOSITION IS IN COMPLIANCE WITH THE
SECURITIES ACT AND ANY APPLICABLE STATE SECURITIES LAWS.

Right to Purchase
                         
Shares

of Common Stock of Tri-Isthmus Group, Inc.

TRI-ISTHMUS GROUP, INC.

Common Stock Purchase Warrant

TRI-ISTHMUS GROUP, INC., a Delaware corporation (the
“Company”), hereby certifies that, for value received,
                              
(the “Holder”) is entitled, subject to the terms set forth below, to purchase from the Company at
any time on or before 5:00 p.m., Pacific Daylight Time, on July 18, 2008 (the “Expiration
Date”) Fifteen Thousand (15,000) fully paid and nonassessable shares of common stock of the Company, par
value $0.01 per share (the “Common Stock”), at a purchase price per share equal to the Purchase
Price, as defined herein. The number of such shares of Common Stock and the Purchase Price are subject to adjustment as
provided in this Warrant. The initial purchase price for shares subject to this Warrant will be 50/100 Dollars ($0.50)
per share (the “Initial Purchase Price”), and will be adjusted from time to time as provided herein.
The Initial Purchase Price or, if such price has been adjusted, the price per share of Common Stock as last adjusted
pursuant to the terms hereof is referred to as the “Purchase Price” herein.

1. Exercise of Warrant. This Warrant may be
exercised by the Holder hereof in full at any time until the Expiration Date by surrender of this Warrant and the
subscription form annexed hereto (duly executed by the Holder), to the Company, and by making payment in cash or by
certified or official bank check payable to the order of the Company, in the amount obtained by multiplying
(i) the number of shares of Common Stock subject to the Warrant by (ii) the Purchase Price then in effect.

1

 

2. Delivery of Stock Certificates, etc., on
Exercise. As soon as practicable after the exercise of this Warrant, the Company will cause to be issued in the
name of and delivered to the Holder hereof a certificate for the number of fully paid and nonassessable shares of
Common Stock (or Other Securities) to which the Holder shall be entitled on such exercise, plus, in lieu of any
fractional share to which the Holder would otherwise be entitled, cash equal to such fraction multiplied by the then
current fair market value (as reasonably determined by the Company) of one full share, together with any other stock or
other securities or property (including cash, where applicable) to which the Holder is entitled upon such exercise.
“Other Securities” shall mean any stock (other than Common Stock) and other securities of the
Company or any other person (corporate or otherwise) which the Holder at any time shall be entitled to receive, or
shall have received, on the exercise of this Warrant, in lieu of or in addition to Common Stock, or which at any time
shall be issuable or shall have been issued in exchange for or in replacement of Common Stock or Other Securities
pursuant to Sections 3 or 4.

3. Adjustment.

(a) Initial Purchase Price; Subsequent Adjustment of
Price and Number of Purchasable Shares. The Initial Purchase Price will be adjusted from time to time as provided
below. Upon each adjustment of the Purchase Price, the Holder will thereafter be entitled to purchase, at the Purchase
Price resulting from such adjustment, the number of shares of Common Stock obtained by multiplying the Purchase Price
in effect immediately before such adjustment by the number of shares of Common Stock purchasable pursuant to this
Warrant immediately before such adjustment and dividing the product by the Purchase Price resulting from such
adjustment.

(b) Adjustment for Stock Splits and Combinations.
If the Company at any time or from time to time after the date of this Warrant effects a subdivision of the outstanding
shares of Common Stock, by stock split or otherwise, the Purchase Price then in effect immediately before that
subdivision shall be proportionately decreased; and, conversely, if the Company at any time or from time to time after
the date of this Warrant combines the outstanding shares of Common Stock, by reverse stock split or otherwise, the
Purchase Price then in effect immediately before that combination shall be proportionately increased. Any adjustment
under this Section 3(b) shall become effective at the close of business on the date the subdivision or combination
becomes effective.

2

2

 

(c) Adjustment for Certain Dividends and
Distributions. In the event the Company at any time or from time to time after the date of this Warrant either
makes, or fixes a record date for the determination of holders of Common Stock entitled to receive, a dividend or other
distribution payable in additional shares of Common Stock, then and in each such event the Purchase Price then in
effect shall be decreased as of the time of such issuance or, in the event such a record date is fixed, as of the close
of business on such record date, by multiplying the Purchase Price then in effect by a fraction (1) the numerator
of which is the total number of shares of Common Stock issued and outstanding immediately prior to the time of such
issuance on the close of business on such record date, and (2) the denominator of which shall be (i) the
total number of shares of Common Stock issued and outstanding immediately prior to the time of such issuance or the
close of business on such record date plus (ii) the number of shares of Common Stock issuable in payment of such
dividend or distribution; provided, however, that if such record date is fixed and such dividend is not
fully paid or if such distribution is not fully made on the date fixed therefor, the Purchase Price shall be recomputed
accordingly as of the close of business on such record date or date fixed therefor and thereafter the Purchase Price
shall be adjusted pursuant to this Section 3(c) as of the time of actual payment of such dividend or distribution.
For purposes of the foregoing formula, “the total number of shares of Common Stock issued and outstanding”
on a particular date shall include shares of Common Stock issuable upon conversion of stock or securities convertible
into Common Stock and the exercise of warrants, options or rights for the purchase of Common Stock which are
outstanding on such date.

(d) Adjustments for Other Dividends and
Distributions. In the event the Company at any time or from time to time after the date of this Warrant makes, or
fixes a record date for the determination of holders of Common Stock entitled to receive, a dividend or other
distribution payable in securities of the Company other than shares of Common Stock, then and in each such event,
provision shall be made so that the Holder shall receive upon exercise hereof, in addition to the number of shares of
Common Stock receivable thereupon, the amount and kind of securities of the Company which it would have received had
this Warrant been exercised for Common Stock as of the date of such event and had it thereafter, during the period from
the date of such event to and including the date of exercise, retained such securities receivable by it as aforesaid
during such period, subject to all other adjustments called for during such period under this Section 3 with
respect to the rights of the Holder.

(e) Adjustment for Recapitalization, Reclassification,
or Exchange. If the Common Stock issuable upon the exercise of this Warrant is changed into the same or a different
number of shares of any class or classes of stock of the Company, whether by recapitalization, reclassification or
other exchange (other than a subdivision or combination of shares, or a stock dividend or a reorganization, merger,
consolidation or sale of assets, provided for elsewhere in this Section 3), then and in any such event the Holder
shall have the right thereafter to exercise this Warrant to purchase the kind and amount of stock and other securities
and property receivable upon such recapitalization, reclassification or other exchange by holders of the number of
shares of Common Stock which might have been purchased under this Warrant immediately prior to such recapitalization,
reclassification or other exchange, all subject to further adjustment as provided herein.

3

3

 

(f) Reorganizations, Mergers, Consolidations or Sales
of Assets. If at any time or from time to time there is a capital reorganization of the Common Stock (other than a
subdivision or combination of shares or a stock dividend or a recapitalization, reclassification or other exchange of
shares, provided for elsewhere in this Section 3 or a merger or consolidation of the Company with or into another
corporation, or the sale of all or substantially all of the Company’s assets to any other person), then, as a
part of such capital reorganization, provision shall be made so that the Holder shall thereafter be entitled to receive
upon exercise of this Warrant the number of shares of stock or other securities or property of the Company, or of the
successor corporation resulting from such capital reorganization, to which a holder of the number of shares of Common
Stock deliverable upon such exercise would have been entitled on such capital reorganization. In any such case,
appropriate adjustment shall be made in the application of the provisions of this Section 3 with respect to the
rights of the Holder after the capital reorganization to the end that the provisions of this Section 3 (including
the number of shares deliverable upon exercise of this Warrant) shall continue to be applicable after that event and
shall be as nearly equivalent to the provisions hereof as may be practicable.

(g) Certificate of Adjustment. Upon the occurrence
of each adjustment or readjustment of the Purchase Price and/or the number of shares of Common Stock subject to this
Warrant, the Company at its expense shall promptly compute such adjustment or readjustment in accordance with the terms
hereof, and shall prepare and furnish to the Holder a certificate setting forth such adjustment or readjustment and
showing in detail the facts upon which such adjustment or readjustment is based.

4. Exercise upon Reorganization, Consolidation,
Merger, etc. In case at any time or from time to time, the Company intends to (a) effect a reorganization,
(b) consolidate with or merge into any other person, (c) sell or transfer all or substantially all of its
properties or assets to any other person, (d) dissolve, (e) consummate an initial public offering of its
securities; or if the Company is sold through the sale of its capital stock, then, notwithstanding any other provision
of this Warrant, in each such case, as a condition of such reorganization, consolidation, merger, sale, dissolution,
conveyance, or offering the Company shall give at least ten (10) days’ notice to the Holder of such pending
transaction whereby the Holder shall have the right to exercise this Warrant prior to any such reorganization,
consolidation, merger, sale, dissolution, conveyance or offering. Any exercise of this Warrant pursuant to notice under
this Section shall be conditioned upon the closing of such reorganization, consolidation, merger, sale, dissolution,
conveyance or offering which is the subject of the notice and the exercise of this Warrant shall not be deemed to have
occurred until immediately prior to the closing of such transaction.

5. Further Assurances. The Company
will take all action that may be necessary or appropriate in order that the Company may validly and legally issue fully
paid and nonassessable shares of Common Stock, free from all taxes, liens and charges with respect to the issue
thereof, on the exercise of all or any portion of this Warrant from time to time outstanding.

4

4

 

6. Notices of Record Date, etc. In the
event of:

(a) any taking by the Company of a record of the holders
of any class of securities for the purpose of determining the holders thereof who are entitled to receive any dividend
on, or any right to subscribe for, purchase or otherwise acquire any shares of stock of any class or any other
securities or property, or to receive any other right, or

(b) any capital reorganization of the Company, any
reclassification or recapitalization of the capital stock of the Company or any transfer of all or substantially all of
the assets of the Company to or the sale, consolidation or merger of the Company with, to or into any other person, or

(c) any voluntary or involuntary dissolution, liquidation
or winding up of the Company;

then and in each such event the Company will mail or cause to be mailed to the
Holder, at least ten (10) days prior to such record date, a notice specifying (i) the date on which any such
record is to be taken for the purpose of such dividend, distribution or right, and stating the amount and character of
such dividend, distribution or right, (ii) the date on which any such reorganization, reclassification,
recapitalization, transfer, consolidation, merger, dissolution, liquidation or winding up is to take place, and the
time, if any is to be fixed, as of which the holders of record of Common Stock (or Other Securities) shall be entitled
to exchange their shares of Common Stock (or Other Securities) for securities or other property deliverable on such
reorganization, reclassification, recapitalization, transfer, consolidation, merger, dissolution, liquidation or
winding up, and (iii) the amount and character of any stock or other securities, or rights or options with respect
thereto, proposed to be issued or granted, the date of such proposed issue or grant and the persons or class of persons
to whom such proposed issue or grant is to be offered or made.

7. Reservation of Stock, etc., Issuable on Exercise
of Warrants. The Company will at all times reserve and keep available out of its authorized but unissued shares
of capital stock, solely for issuance and delivery on the exercise of this Warrant, a sufficient number of shares of
Common Stock (or Other Securities) to effect the full exercise of this Warrant and the exercise, conversion or exchange
of any other warrant or security of the Company exercisable for, convertible into, exchangeable for or otherwise
entitling the Holder to acquire shares of Common Stock (or Other Securities), and if at any time the number of
authorized but unissued shares of Common Stock (or Other Securities) shall not be sufficient to effect such exercise,
conversion or exchange, the Company shall take such action as may be necessary to increase its authorized but unissued
shares of Common Stock (or Other Securities) to such number as shall be sufficient for such purposes.

8. Transfer of Warrant. This Warrant cannot
be transferred without the prior written consent of the Company, which consent shall not be unreasonably withheld;
provided, however, the Holder may transfer this Warrant to any of its affiliates without such consent so
long as such transfer complies with all applicable securities laws.

5

5

 

9. No Rights as a Stockholder. This Warrant
shall not entitle the Holder hereof to any voting rights or other rights as a stockholder of the Company.

10. Notices, etc. All notices which are
required to be given pursuant to this Warrant shall be in writing and shall be delivered by certified mail, return
receipt requested, first class postage prepaid, or sent by overnight express or similarly recognized overnight delivery
with receipt acknowledged or by facsimile, with a copy thereof sent by one of the other means. Notices shall be deemed
to have been given at the time delivered and shall be addressed as follows or to such other address as a party may
designate by proper notice hereunder.

	 	 	 	 
	 	If to Holder:	 	To the address set forth on the first page hereof.
	 	 	 	 
	 	If to the Company:	 	Tri-Isthmus Group, Inc.

149 South Barrington Ave., Suite 808

Los Angeles, California 90049

Attn.: David Hirschhorn

11. Securities Laws. By acceptance of this
Warrant, the Holder hereby represents to the Company that this Warrant is being acquired for investment for the
Holder’s own account, not as a nominee or agent, and not with a view to the resale or distribution thereof, and
that the Holder has no present intention of selling, granting any participation in, or otherwise distributing this
Warrant or the Common Stock issuable upon exercise of this Warrant. By acceptance of this Warrant, the Holder further
represents that the Holder does not presently have any contract, undertaking, agreement or arrangement with any person
to sell, transfer or grant participations to such person or to any third person, with respect to this Warrant or the
Common Stock issuable upon exercise of this Warrant. The Holder is an “accredited investor” as the term is
defined in Rule 501(a) of Regulation D promulgated under the Securities Act and has sufficient knowledge and
experience in finance and business that it is capable of evaluating the risks and merits of its investment in the
shares subject to this Warrant and the Holder is able financially to bear the risks thereof. The Holder understands
that the sale and issuance of this Warrant and the Common Stock issuable upon exercise of this Warrant have not been
registered under the Securities Act, by reason of a specific exemption from the registration provisions of the
Securities Act which depends upon, among other things, the bona fide nature of the investment intent and the accuracy
of the Holder’s representations as expressed herein. The Holder further recognizes and acknowledges that because
the sale and issuance of this Warrant and the Common Stock issuable upon exercise of this Warrant are unregistered,
they may not be eligible for resale, and may only be resold in the future pursuant to an effective registration
statement under the Securities Act and any applicable state securities laws, or pursuant to a valid exemption from such
registration requirements and that the Holder must, therefore, bear the economic risk of such investment indefinitely.

6

6

 

12. Legend. Unless theretofore registered
for resale under the Securities Act, each certificate for shares of Common Stock issued upon exercise of this Warrant
shall bear the following or a similar legend:

THE SHARES REPRESENTED BY THIS CERTIFICATE
HAVE NOT BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933, AS AMENDED (THE “SECURITIES ACT”), OR ANY
APPLICABLE STATE SECURITIES LAWS. THE SECURITIES HAVE BEEN ACQUIRED FOR INVESTMENT AND MAY NOT BE RESOLD, TRANSFERRED
OR ASSIGNED IN THE ABSENCE OF AN EFFECTIVE REGISTRATION STATEMENT FOR THE SECURITIES UNDER THE SECURITIES ACT OR AN
OPINION OF COUNSEL REASONABLY ACCEPTABLE TO THE COMPANY THAT SUCH DISPOSITION IS IN COMPLIANCE WITH THE SECURITIES ACT
AND ANY APPLICABLE STATE SECURITIES LAWS.

13. Miscellaneous. This Warrant and any
terms hereof may be changed, waived, discharged or terminated only by an instrument in writing signed by the party
against which enforcement of such change, waiver, discharge or termination is sought. This Warrant shall be construed
and enforced in accordance with and governed by the internal laws of the State of Delaware, without regard to conflict
of laws principles. The headings in this Warrant are for purposes of reference only, and shall not limit or otherwise
affect any of the terms hereof. The invalidity or unenforceability of any provision hereof shall in no way affect the
validity or enforceability of any other provision.

* * *

7

7

 

IN WITNESS WHEREOF, the Company has caused this Warrant to be
executed on its behalf by one of its officers thereunto duly authorized as of July
     , 2007.

TRI-ISTHMUS GROUP, INC.

By:                                                                             

DAVID HIRSCHHORN, CEO

 

8

8

 

FORM OF SUBSCRIPTION

TRI-ISTHMUS GROUP, INC.

(To be signed only on
exercise of Warrant)

TO: TRI-ISTHMUS GROUP, INC.

1. The undersigned Holder of the attached original,
executed Warrant of Tri-Isthmus Group, Inc., a Delaware corporation (the “Company”), hereby elects
to exercise its purchase right under such Warrant with respect to
                             
(                         )
shares (the “Exercise Shares”) of Common Stock (as defined in the Warrant), constituting all the
shares of Common Stock subject to the Warrant.

2. The undersigned Holder is hereby paying the aggregate
purchase price for such the Exercise Shares (i) by the enclosed certified or official bank check payable in
United States dollars to the order of the Company in the amount of
$                     ,
or (ii) by wire transfer of United States funds to the account of the Company in the amount of
$                           ,
which transfer has been made before or simultaneously with the delivery of this Form of Subscription pursuant to the
instructions of the Company.

3. Please issue a stock certificate or certificates
representing the Exercise Shares in the name of the undersigned Holder.

Dated:                                               

	 	 	 	                                                                       

Signature of Holder

9Exhibit 4(a)

Protective
Life Insurance Company

 

PROTECTIVE LIFE INSURANCE COMPANY / P.O. BOX 2606 /
BIRMINGHAM, ALABAMA 35202

A STOCK COMPANY

 

Master Contract Application

Group Flexible Premium Deferred Modified Guaranteed Annuity Contract

 

The
Trustee of the Protective Life MGA Trust hereby applies to Protective Life
Insurance Company for a Group Flexible Premium Deferred Modified Guaranteed
Annuity master contract to be issued in Des Moines, Iowa.

 

 

	
  Patty
  Ashbaugh, as Trustee, for Bankers Trust Company, N.A.

  	
   

  	
   

  
	
  Name

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
  Vice
  President

  	
   

  	
   

  
	
  Title

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
  /s/ Patty
  Ashbaugh

  	
   

  	
   

  
	
  Signature

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
  1/7/04

  	
  140321837

  	
   

  	
   

  
	
  Date

  	
  Trust
  Number

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
  Protective
  Life MGA Trust

  	
   

  	
   

  
	
  Name
  of Trust

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
  ProSaver Platinum MGA

  	
   

  	
   

  
	
  Name
  of Product

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
  IPD-2084

  	
   

  	
   

  
	
  Policy
  Form #

  	
   

  	
   

  

 

	
  GMA-2084

  	
   

  	
  12/03

  

 

 

PROTECTIVE LIFE INSURANCE COMPANY

P. O. BOX 2606

BIRMINGHAM,
ALABAMA 35202

 

ENDORSEMENT

 

The Contract or Certificate to which this Endorsement is attached is
amended as of its effective date, as follows:

 

If you cancel this Contract during the first ten days after you first
receive it according to the “Right to Return” provision of the face page of
the Contract, the amount we return to you will equal the Account Value on the
date we receive your written cancellation request, adjusted by the Market Value
Adjustment.

 

For the purpose of determining the Market Value Adjustment during the
ten day cancellation period, we will identify a Treasury Rate each day. The
current Treasury Rate (“C” in the Market Value Adjustment formula on the
Schedule of this Contract) will be the Treasury Rate identified on the date we
receive your written cancellation request.

 

	
  Signed for the Company as of the Effective Date.

  	
   

  
	
   

  	
   

  
	
  PROTECTIVE LIFE INSURANCE COMPANY

  	
   

  
	
   

  	
   

  
	
  /s/ Deborah J. Long

  	
   

  
	
  Deborah J. Long

  	
   

  
	
  Secretary

  	
   

  

 

	
  IPD-2092V

  	
   

  	
  7/99

  

 

 

CERTIFICATE

 

Individual Certificate issued under the Group Modified
Guaranteed Annuity Contract

Account Value is subject to a Market Value Adjustment

Non-Participating

 

This Certificate is a summary of your rights under the Group Modified
Guaranteed Annuity Contract (“Contract”) identified on the Schedule. This
Certificate is subject to all provisions of the Contract, whether or not
summarized in this Certificate. The Contract alone governs the rights of the
parties. A copy of the Contract will be furnished on request.

 

Protective Life Insurance Company certifies that the person named as
Participant on the Schedule is a Participant under the Contract.

 

YOU HAVE THE RIGHT TO RETURN THIS CONTRACT. You may cancel
this Contract within twenty days after you receive it by returning the Contract
to our Home Office or to our Agent, with a written request for cancellation.
The Contract will be as though it had never been issued. We will promptly
return any Annuity Deposit made.

 

	
   

  	
   

  	
   

  
	
  /s/ Deborah J. Long

  	
   

  	
  /s/ John D. Johns

  
	
  Deborah J. Long

  	
   

  	
  John D. Johns

  
	
  Secretary

  	
   

  	
  President

  

 

 

PROTECTIVE LIFE INSURANCE COMPANY

P.O. Box 2606

Birmingham, Alabama 35202

(205) 879-9230

(A Stock Insurance Company)

 

	
  Form No. IPD-2084

  	
   

  	
  12/97

  

 

 

CONTRACT

 

	
  Patty
  Ashbaugh, as Trustee for Bankers Trust Company, N. A.

  	
   

  
	
  Contract
  Holder

  	
   

  
	
   

  	
   

  
	
  140321837

  	
  January 7, 2004

  
	
  Trust
  Account #

  	
  Contract
  Effective Date

  

 

Separate Account

The
assets supporting this Contract are held in a Separate Account. All values will
be determined as provided in the Contract, without regard to the actual
investment performance of the Separate Account.

 

Surrender Charge

The
Surrender Charge is equal to the Surrender Charge Percentage indicated below,
applied to the amount of each full or partial surrender requested less any
amount available under the “Interest
Withdrawal” provision of the Certificate at the time of the
surrender.

 

	
  Number of Completed Years

  in a Guaranteed Period

  	
   

  	
  Surrender Charge

  Percentage

  	
   

  
	
  0

  	
   

  	
  6

  	
  %

  
	
  1

  	
   

  	
  6

  	
  %

  
	
  2

  	
   

  	
  5

  	
  %

  
	
  3

  	
   

  	
  4

  	
  %

  
	
  4

  	
   

  	
  3

  	
  %

  
	
  5

  	
   

  	
  2

  	
  %

  
	
  6

  	
   

  	
  1

  	
  %

  
	
  7+

  	
   

  	
  0

  	
  %

  

 

Market Value Adjustment

The
Market Value Adjustment is equal to the Market Value Adjustment Percentage
indicated below, applied to the amount of each full or partial surrender
requested less any amount available under the “Interest
Withdrawal” provision of the Certificate at the time of the
surrender.

 

Market Value Adjustment Percentage = (C - I + 0.25%) x
(N/12), where:

 

C =
the Treasury Rate currently established for the same term as the Guaranteed
Period from which the surrender is being made;

 

I = the
Treasury Rate initially established for the Guaranteed Period from which the
surrender is being made;

 

N = The
number of months remaining in the Guaranteed Period from which the surrender is
being made.

 

The
Treasury Rate is the annual effective interest rate credited to United States
Treasury instruments, as published by a nationally recognized source. On the
fifteenth day and the last day of each month, the Company will identify a
Treasury Rate for each Guaranteed Period. The method used by the Company to
determine the Treasury Rates under this Contract shall be consistent and is
binding upon any Participant, Annuitant and Beneficiary.

 

2

 

INDEX

 

	
  Schedule

  	
  2

  
	
  Definitions

  	
  4

  
	
  General Provisions

  	
  5

  
	
  Control Provisions

  	
  7

  
	
  Premium Taxes

  	
  8

  
	
  Surrenders - Termination

  	
  8

  
	
  Interest Credited and Guaranteed Periods

  	
  9

  
	
  Annuity Options

  	
  9

  
	
  Annuity Tables

  	
  10

  

 

3

 

DEFINITIONS

 

Account Value - The sum of all Sub-Account Values.

 

Annuitant - Annuity payments may depend upon the continuation of the life of a
person. That person is called an Annuitant and is named on the Schedule.

 

Annuity - A series of predetermined periodic payments.

 

Annuity Commencement Date - The date on which annuity payments begin.
This date is indicated on the Schedule.

 

Annuity Deposit(s) - Annuity Deposits (less Premium Taxes, if
applicable) made and allocated to the Guaranteed Period(s) you select
under this Certificate. Each Annuity Deposit and each allocation to a
Guaranteed Period must be at least $10,000. We reserve the right to limit the
amount of your Annuity Deposits. Only one Certificate will be issued regardless
of the number of Annuity Deposits you make.

 

Beneficiary - The person entitled to receive the benefits under this Certificate, if
any, upon the death of any Participant.

 

Primary - The person named to receive the death benefits upon any Participant’s
death. Upon the death of any Participant, the surviving Participant, if any,
will become the Primary Beneficiary.

 

Contingent - The person named to receive the death benefits if the Primary
Beneficiary is not living at the time of a Participant’s death. If no
Beneficiary designation is in effect or if no Beneficiary is living at the time
of a Participant’s death, the Estate of the deceased Participant will be the
Beneficiary.

 

Irrevocable - An irrevocable Beneficiary is one whose consent is needed to change
the Beneficiary designation, or to exercise certain other rights.

 

Certificate - The individual Certificate issued by the Company to a Participant. Your
Certificate summarizes the provisions of the Contract.

 

Certificate Date - The date shown on the Schedule and on which this Certificate takes
effect. Certificate Years are measured from the Certificate Date.

 

Contract - The Group Modified Guaranteed Annuity Contract under which this
Certificate has been issued.

 

Guaranteed Period - The period for which either an Initial or Subsequent Guaranteed Interest
Rate will be credited to a Sub-Account under a Contract. Guaranteed Periods
will be designated as being either “Initial” or “Subsequent”.

 

Home Office - 2801 Highway South, Birmingham, Alabama.

 

4

 

Initial Guaranteed
Interest Rate - The
effective rate of interest, calculated after daily compounding of interest has
been taken into account, which is used in determining the interest credited to
a Sub-Account under this Certificate during the Initial Guaranteed Period. This
rate is specified on the Schedule.

 

Market Value
Adjustment - The
adjustment made to a Sub-Account Value when a full or partial surrender is
requested prior to the end of an Initial or Subsequent Guaranteed Period. The
Market Value Adjustment is explained on the Schedule.

 

Net Account Value - The sum of all Net Sub-Account Values.

 

Net Sub-Account Value
- The
Sub-Account Value after application of the Market Value Adjustment and
deductions for any Surrender Charges and applicable Premium Taxes.

 

Participant - The person(s) named in the Schedule,
herein referred to as “you” or “your”.

 

Sub-Account - Each Annuity Deposit will be allocated to one
or more Sub-Accounts as directed by the Participant. Each Sub-Account will
correspond to a specified Guaranteed Period and guaranteed interest rate
selected by the Participant.

 

Sub-Account Value - The amount equal to that part of the Annuity
Deposit allocated by a Participant to a Sub-Account or any amount transferred
to a Sub-Account or Sub-Accounts at the end of a Guaranteed Period increased by
all interest credited and decreased by amounts due to previous full or partial
surrenders (including Surrender Charges, Market Value Adjustments, and Premium
Taxes thereon) and previous interest withdrawals. The Sub-Account Value of each
Sub-Account under this Certificate must be at least $10,000 at all times.

 

Subsequent Guaranteed
Interest Rate - The
effective rate of interest, calculated after daily compounding of interest has
been taken into account, which is established by the Company for any applicable
Subsequent Guaranteed Period.

 

Surrender Charge - A Surrender Charge, if applicable, is
deducted from any Sub-Account Value from which a full or partial surrender is
made prior to the end of an Initial or Subsequent Guaranteed Period. The
Surrender Charge is explained on the Schedule.

 

Writing - A written form satisfactory to the Company
and filed at the Home Office of the Company in Birmingham, Alabama. All
correspondence should be sent to P.O. Box 2606, Birmingham, Alabama 35202.

 

GENERAL PROVISIONS

 

Entire Contract

The
Contract, this Certificate and any endorsements attached hereto, and the
Application, a copy of which is attached, constitute the entire contract. A
Certificate is a summary of the Contract.

 

5

 

Modification

No
change or waiver of the terms of this Contract is valid unless made by us, in
Writing, and approved by our President, Vice President, or Secretary. We
reserve the right to change the provisions of the Contract and this Certificate
issued under the Contract to conform to any applicable laws, regulations or
rulings issued by a governmental agency.

 

Error in Age or Sex

Questions
in the Application concern the Annuitant’s date of birth and sex. If the date
of birth or sex given is not correct, the benefits under this Contract shall be
adjusted to the amount which would have been payable at the correct age and
sex. If we made any underpayments on account of any misstatement, the amount of
any underpayment shall be immediately paid in one sum. Any overpayments made
shall be deducted from the current or succeeding payments due under the
Contract.

 

Assignment

Upon
notice to us, you may assign your rights under this Contract. The assignment
must be in Writing and filed with us. We assume no responsibility for the
validity of any assignment. Any claim under any assignment shall be subject to
proof of interest and the extent of the assignment.

 

Settlement

Any
payment by us under this Contract is payable at our Home Office. The
Participant may elect to apply settlement proceeds, including any full or
partial surrender proceeds or the death benefit, to any payout option offered
by us for such payments at the time the election is made.

 

Facility of Payment

If
the Annuitant or Beneficiary is incapable of giving a valid receipt for any
payment, we may make such payment to whomever has assumed his or her care and
principal support. Any such payment shall fully discharge us to the extent of
that payment.

 

Proof of Age

Proof
of age is required before the first payment under an Annuity Option involving
lifetime payments.

 

Annual Reports

We
will send you a report at least once per year showing your Account Value,
Sub-Account Values and interest credited.

 

Annuity Commencement Date Changes

Upon
thirty days notice in Writing, you may change the Annuity Commencement Date.
The proposed Annuity Commencement Date you select cannot be before the end of
any Guaranteed Period or later than the Certificate Year closest to the Annuitant’s
85th birthday.

 

6

 

Protection of Proceeds

To
the extent permitted by law, no benefits payable under this Certificate will be
subject to the claims of creditors of any payee.

 

CONTROL PROVISIONS

 

Annuitant

The
Participant may change the Annuitant prior to the Annuity Commencement Date.
The request must be in Writing. Once it is received and acknowledged at our
Home Office, any change will relate back to and take effect on the date the
request was signed. The Annuitant is the “Payee” for the purposes of the
Annuity Table.

 

Beneficiary

The
Beneficiary will be as shown in the Application. You may change the Beneficiary
at any time. To make a change, we must receive a written request satisfactory
to us at our Home Office. If the Beneficiary has been designated irrevocably,
however, such designation cannot be changed or revoked without the
Beneficiary’s written consent. Any such change will relate back to and take
effect on the date the request was signed. We will not be liable for any
payment we make before such request has been received and acknowledged at our
Home Office. Any payment which has become due to an Annuitant and has not been
paid prior to his or her death shall be paid to the Primary Beneficiary, if
living; otherwise to the Contingent Beneficiary.

 

Death of the Annuitant or Participant

If
an Annuitant is not a Participant and dies prior to the Annuity Commencement
Date, the Participant first named on the Application will become the new
Annuitant unless the Participant designates otherwise. If any Participant is
not a natural person, the death or change of the Annuitant will be treated as
the death of a Participant. If any Participant dies while this Certificate is
in force prior to the Annuity Commencement Date, a Death Benefit will be
payable to the Beneficiary.

 

Death Benefit

The
Death Benefit will be determined as of the date due proof of death is received
by the Company. If a claim for the Death Benefit is received at our Home Office
within 6 months of the date of death, the Death Benefit will equal the greater
of: (1) the Account Value, less applicable Premium Taxes; or (2) the
Net Account Value. If a claim is received past 6 months after the date of
death, the Death Benefit will equal the Net Account Value. If any Participant
of this Certificate is not a natural person, upon the change of the Annuitant,
the Death Benefit will equal the Net Account Value. Only one Death Benefit is
payable under this Certificate, even though the Certificate may continue beyond
a Participant’s death.

 

The
Death Benefit may be taken in one sum immediately. In all events, the entire
Death Benefit, including any interest accrued thereon, must be distributed
within five years of the date of death unless:

 

7

 

(a)                                  it is payable over the life
of the Beneficiary with distributions beginning within one year of the date of
death; or

 

(b)                                 it is payable over a period
not extending beyond the life expectancy of the Beneficiary with distributions
beginning within one year of the date of death; or

 

(c)                                  the deceased Participant’s
spouse is the Beneficiary and, in lieu of receiving the Death Benefit,
continues the Certificate and becomes the new Participant.

 

If
the deceased Participant’s spouse continues the Certificate and becomes the new
Participant, upon such spouse’s death, a Death Benefit will become payable to
the new Beneficiary (determined at the time of the spouse’s death). the Death
Benefit, including any interest accrued thereon must be distributed within five
years of the spouse’s death.

 

PREMIUM TAXES

 

Premium
Taxes (including any related retaliatory taxes, if any) will be deducted, if
applicable. Premium Taxes may be deducted, as provided under applicable law,
from the Annuity Deposit when received, upon full or partial surrender, or from
the amount applied to effect an Annuity at the time the annuity payments
commence. Premium Taxes may also be deducted from the Death Benefit.

 

SURRENDERS - TERMINATION

 

Full
surrenders may be made at any time. Partial surrenders may only be made if each
remaining Sub-Account Value is at least $10,000. You must specify the
Sub-Accounts from which the partial surrender is to be made. If the Sub-Account
specified has the same Guaranteed Period as any other Sub-Account, the partial
surrender must come from the Sub-Account with the shortest time remaining in
the Guaranteed Period.

 

Surrender
Charges and Market Value Adjustments will not apply to full or partial
surrenders made at the end of an Initial or Subsequent Guaranteed Period. The
Surrender Value will equal the Sub-Account Value on this date. A request for a
surrender at the end of an Initial or Subsequent Guaranteed Period must be
received in Writing within twenty days prior to the end of such an Initial and
Subsequent Guaranteed Period.

 

The
Surrender Value will be calculated by the Company using the following formula:

 

(A - S - M - P), where:

 

A = the amount of the full or
partial surrender;

S = the amount of Surrender
Charge;

M = the amount of the Market
Value Adjustment;

P = the amount of unpaid Premium
Taxes, if any.

 

The
Company may defer payment of any partial or full surrender for the period
permitted by law. In no event will this deferral of payment exceed 6 months
from the date of receipt of the election to surrender partially or fully.

 

8

 

Interest Withdrawals

If
you notify the Company in Writing at any time during the current Certificate
Year, the Company will send you all or a portion of the interest credited
during the prior Certificate Year. You may only make one withdrawal during a
Certificate Year. No Surrender Charge or Market Value Adjustment will be
imposed on such interest withdrawals.

 

INTEREST CREDITED AND GUARANTEED PERIODS

 

The
portion of each Annuity Deposit allocated to a Sub-Account will earn interest
at the Initial Guaranteed Interest Rate for each Certificate Year during the
Initial Guaranteed Period selected for that Sub-Account. A Guaranteed Period is
the period of years for which a rate of interest is guaranteed. You may select
from any Guaranteed Period offered by the Company under the Contract at the
time the Annuity Deposit or transfer is made. However, Guaranteed Periods
cannot extend beyond the Annuity Commencement Date.

 

You
may not transfer a Sub-Account Value to any existing or new Sub-Account(s) prior
to the end of the Sub-Account’s Guaranteed Period. At the end of any Guaranteed
Period a Subsequent Guaranteed Period will begin. Unless you elect a different
duration from among those then offered by us within twenty days prior to the
end of the previous Guaranteed Period, your Sub-Account Value will be
automatically transferred to a Subsequent Guaranteed Period of either (1) the
same duration as your previous Guaranteed Period if then offered by us; or (2) the
shortest duration then offered by us which is closest to the same duration as
your previous Guaranteed Period.

 

Your
Sub-Account Value at the beginning of any Subsequent Guaranteed Period will be
equal to your Sub-Account Value at the end of the Guaranteed Period just
ending. The Sub-Account Value will earn interest at the Subsequent Guaranteed
Interest Rate for each Certificate Year in the Subsequent Guaranteed Period. At
your request within twenty days prior to the end of any Guaranteed Period, the
Company will notify you of the then effective Subsequent Guaranteed Interest
Rate. The actual Subsequent Guaranteed Interest Rate will be determined at the
beginning of the Subsequent Guaranteed Period.

 

ANNUITY OPTIONS

 

Annuity Benefit

If
the Annuitant is alive on the Annuity Commencement Date and unless directed
otherwise, the Company will apply the Net Account Value according to the
Annuity Option elected.

 

You
may elect to have all or a part of the Net Account Value applied on the Annuity
Commencement Date under any of the Annuity Options described below. In the
absence of an election, the Net Account Value will be applied on the Annuity
Commencement Date under Option 2 - Life Income with Payments for a 10 Year
Guaranteed Period. Elections of any of these options must be made in Writing to
the Company at least 30 days prior to the date such election is to become
effective.

 

9

 

If
the Annuitant or Participant dies on or after the Annuity Commencement Date,
any remaining payments will be distributed at least as rapidly as under the
method of distribution being used at the time of death.

 

Annuity Options

 

Option 1 - Payment For a Fixed Period. Equal monthly
payments will be made for any period of not less than 5 nor more than 30 years.
The amount or each payment depends on the total amount applied, the period
selected and the monthly payment rates we are using when the first payment is
due.

 

Option 2 - Life Income with Payments for a Guaranteed Period.
Equal monthly payments are based on the life of the named Annuitant.
Payments will continue for the lifetime of that person with payments guaranteed
for 10 or 20 years. Payments stop at the end of the selected guaranteed period
or when the named person dies, whichever is later.

 

Option 3 - Payments of a Fixed Amount. Equal monthly
payments will be for an agreed fixed amount. The amount of each payment may not
be less than $10 for each $1,000 applied. Interest will be credited each month
on the unpaid balance and added to it. This interest will be at a rate set by
us, but not less than an effective interest rate of 4% per year. Payments
continue until the amount we hold runs out. The last payment will be for the
balance only.

 

Minimum Amounts - We reserve the right to pay
the total amount of this Certificate in one lump sum, if less than $5,000. If
monthly payments are less than $100, we may make payments quarterly,
semi-annually, or annually, at our option.

 

All
elected Annuity Options must comply with current Federal and state statutes and
Internal Revenue Service Regulations. If we have available, at the time an
Annuity Option is elected, options or rates on a more favorable basis than
those guaranteed, the higher benefits shall apply.

 

ANNUITY TABLES

 

The
attached Annuity Tables show the dollar amount of the monthly payments for each
$1,000 applied. The tables are based on the 1983 Individual Annuitant Mortality
Table A projected 4 years with interest at 4% per annum. One year will be
deducted from the attained age of the Annuitant for every three completed years
beyond the year 1987.

 

Individual Certificate issued under the Group
Modified Guaranteed Annuity Contract

Account Value is subject to a Market Value Adjustment

Non-Participating

 

	
  IPD-2084

  	
   

  	
  12/97

  

 

10

 

MINIMUM MONTHLY PAYMENT RATES FOR
EACH $1,000 APPLIED

 

	
  OPTION 1 TABLE

  	
   

  	
  OPTION 2 TABLE

  	
   

  
	
  Payments for a

  	
   

  	
  Life Income with Payments

  	
   

  
	
  Fixed Period

  	
   

  	
  for a Guaranteed Period

  	
   

  
	
  Years

  	
   

  	
  Monthly

  	
   

  	
  Age of

  	
   

  	
  10 Years

  	
   

  	
  20 Years

  	
   

  
	
  Female

  	
   

  	
  Payment

  	
   

  	
  Payee

  	
   

  	
  Male

  	
   

  	
  Female

  	
   

  	
  Male

  	
   

  	
  Female

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  5

  	
   

  	
  18.32

  	
   

  	
  59

  	
   

  	
  5.29

  	
   

  	
  4.83

  	
   

  	
  4.98

  	
   

  	
  4.68

  	
   

  
	
  6

  	
   

  	
  15.56

  	
   

  	
  60

  	
   

  	
  5.40

  	
   

  	
  4.92

  	
   

  	
  5.04

  	
   

  	
  4.74

  	
   

  
	
  7

  	
   

  	
  13.59

  	
   

  	
  61

  	
   

  	
  5.51

  	
   

  	
  5.01

  	
   

  	
  5.10

  	
   

  	
  4.81

  	
   

  
	
  8

  	
   

  	
  12.12

  	
   

  	
  62

  	
   

  	
  5.63

  	
   

  	
  5.10

  	
   

  	
  5.17

  	
   

  	
  4.88

  	
   

  
	
  9

  	
   

  	
  10.97

  	
   

  	
  63

  	
   

  	
  5.75

  	
   

  	
  5.21

  	
   

  	
  5.24

  	
   

  	
  4.95

  	
   

  
	
  10

  	
   

  	
  10.06

  	
   

  	
  64

  	
   

  	
  5.88

  	
   

  	
  5.32

  	
   

  	
  5.30

  	
   

  	
  5.02

  	
   

  
	
  11

  	
   

  	
  9.31

  	
   

  	
  65

  	
   

  	
  6.02

  	
   

  	
  5.43

  	
   

  	
  5.37

  	
   

  	
  5.09

  	
   

  
	
  12

  	
   

  	
  8.69

  	
   

  	
  66

  	
   

  	
  6.16

  	
   

  	
  5.55

  	
   

  	
  5.43

  	
   

  	
  5.17

  	
   

  
	
  13

  	
   

  	
  8.17

  	
   

  	
  67

  	
   

  	
  6.31

  	
   

  	
  5.68

  	
   

  	
  5.49

  	
   

  	
  5.24

  	
   

  
	
  14

  	
   

  	
  7.72

  	
   

  	
  68

  	
   

  	
  6.47

  	
   

  	
  5.82

  	
   

  	
  5.55

  	
   

  	
  5.31

  	
   

  
	
  15

  	
   

  	
  7.34

  	
   

  	
  69

  	
   

  	
  6.63

  	
   

  	
  5.97

  	
   

  	
  5.60

  	
   

  	
  5.38

  	
   

  
	
  16

  	
   

  	
  7.00

  	
   

  	
  70

  	
   

  	
  6.79

  	
   

  	
  6.12

  	
   

  	
  5.65

  	
   

  	
  5.45

  	
   

  
	
  17

  	
   

  	
  6.71

  	
   

  	
  71

  	
   

  	
  6.96

  	
   

  	
  6.28

  	
   

  	
  5.70

  	
   

  	
  5.51

  	
   

  
	
  18

  	
   

  	
  6.64

  	
   

  	
  72

  	
   

  	
  7.13

  	
   

  	
  6.45

  	
   

  	
  5.74

  	
   

  	
  5.58

  	
   

  
	
  19

  	
   

  	
  6.21

  	
   

  	
  73

  	
   

  	
  7.31

  	
   

  	
  6.63

  	
   

  	
  5.78

  	
   

  	
  5.64

  	
   

  
	
  20

  	
   

  	
  6.00

  	
   

  	
  74

  	
   

  	
  7.48

  	
   

  	
  6.81

  	
   

  	
  5.82

  	
   

  	
  5.69

  	
   

  
	
  21

  	
   

  	
  5.81

  	
   

  	
  75

  	
   

  	
  7.66

  	
   

  	
  7.00

  	
   

  	
  5.85

  	
   

  	
  5.74

  	
   

  
	
  22

  	
   

  	
  5.64

  	
   

  	
  76

  	
   

  	
  7.84

  	
   

  	
  7.20

  	
   

  	
  5.88

  	
   

  	
  5.78

  	
   

  
	
  23

  	
   

  	
  5.49

  	
   

  	
  77

  	
   

  	
  8.02

  	
   

  	
  7.40

  	
   

  	
  5.90

  	
   

  	
  5.82

  	
   

  
	
  24

  	
   

  	
  5.35

  	
   

  	
  78

  	
   

  	
  8.20

  	
   

  	
  7.60

  	
   

  	
  5.92

  	
   

  	
  5.85

  	
   

  
	
  25

  	
   

  	
  5.22

  	
   

  	
  79

  	
   

  	
  8.37

  	
   

  	
  7.81

  	
   

  	
  5.94

  	
   

  	
  5.88

  	
   

  
	
  26

  	
   

  	
  5.10

  	
   

  	
  80

  	
   

  	
  8.54

  	
   

  	
  8.10

  	
   

  	
  5.96

  	
   

  	
  5.91

  	
   

  
	
  27

  	
   

  	
  5.00

  	
   

  	
  81

  	
   

  	
  8.70

  	
   

  	
  8.21

  	
   

  	
  5.97

  	
   

  	
  5.93

  	
   

  
	
  28

  	
   

  	
  4.90

  	
   

  	
  82

  	
   

  	
  8.85

  	
   

  	
  8.41

  	
   

  	
  5.98

  	
   

  	
  5.95

  	
   

  
	
  29

  	
   

  	
  4.80

  	
   

  	
  83

  	
   

  	
  8.99

  	
   

  	
  8.59

  	
   

  	
  5.98

  	
   

  	
  5.96

  	
   

  
	
  30

  	
   

  	
  4.72

  	
   

  	
  84

  	
   

  	
  9.12

  	
   

  	
  8.77

  	
   

  	
  5.99

  	
   

  	
  5.97

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  &
  over

  	
   

  	
  9.25

  	
   

  	
  8.93

  	
   

  	
  5.99

  	
   

  	
  5.98

  	
   

  

 

Rates
for monthly payments for ages not shown in the above tables will be calculated
on the same basis as those shown and may be obtained from us. The basis for
these calculations is the 1983 Individual Annuitant Mortality Table A projected
4 years with interest at 4% per annum.

 

	
  IPD-2084

  	
  12/97

  

 

11

 

	
  

  	
  Annuity Application

  	
   

  	
  Protective Life Insurance
  Company

  3-1 IPD P.O. Box 10648

  Birmingham, Alabama 35202-0648

  
	
   

  	
   

  	
   

  	
   

  
	
  Owner/Participant Name, Street, City, State,
  Zip Code

  	
   

  	
   

  Male

  Female

   

  	
   

  Birthdate (Mo./Day/Yr.)  

  Tax ID/Social Security No.

   

  
	
  Joint Owner/Participant (if any) Name, Street,
  City, State, Zip Code

  	
   

  	
   

  Male

  Female

   

  	
   

  Birthdate (Mo./Day/Yr.)  
 Tax ID/Social
  Security No.

   

  
	
   

  	
   

  	
   

  	
   

  
	
  Annuitant (if other than Owner/Participant) Name, Street,
  City, State, Zip Code

  	
   

  	
   

  Male

  Female

   

  	
   

  Birthdate (Mo./Day/Yr.)  
 Tax ID/Social
  Security No.

  
	
   

  	
   

  	
   

  	
   

  
	 
	
  Primary Beneficiary Name, Address,
  Relationship & Percentage 

  	
   

  	
  Plan Type - Check Only One (See instructions on back.) 

  	 

	 
	
  Tax ID/Social Security No.

  	
  Non-Qualified

  CD Transfer

  IRA Transfer

  IRA

  ROTH IRA

  	
  1035 Exchange

  IRA Rollover

  IRA Direct Rollover  

  TSA Direct
  Rollover 

  	 

	 
	
   

  	
   

  	
   

  	
   

  	 

	 
	
  Contingent Beneficiary Name, Address,
  Relationship & Percentage 

  	
   

  	
  Replacement:  
 Do you have an
  existing annuity contract or life insurance policy?

                                                                Yes o No o

   

  Will this annuity change or replace any existing annuity
  contract or life insurance policy?

                                                                Yes o No o

  	 

	 
	
  Tax ID/Social Security No.

  	
   

  	
  (If yes, indicate company name and policy # in Special
  Remarks section on back.)

  	 

								

 

	
  TOTAL ANNUITY DEPOSIT $ 

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  3-Yr. $ 

  	
   

  	
   

  	
  4 Yr. $ 

  	
   

  	
   

  	
  5-Yr. $ 

  	
   

  	
   

  	
  6-Yr.$

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  7-Yr. $ 

  	
   

  	
   

  	
  8 Yr. $ 

  	
   

  	
   

  	
  9-Yr. $ 

  	
   

  	
   

  	
  10-Yr. $

  	
   

  
	
   

  	
   

  	
   

  
	
  I (we) authorize Protective Life to automatically
  transfer each Guaranteed Period(s) at renewal to the       Guaranteed
  Period. If the Subsequent Guaranteed Period is not available due to my (our)
  age, I (we) elect to renew to the longest Guaranteed Period available. I (we)
  may change my (our) election at any time prior to the expiration of the
  current Guaranteed Period.

  
	
   

  	
   

  	
   

  
	
  Rate Lock: Available for 1035 Exchanges, Direct Transfers and
  Direct Rollovers. See information on back. 

  
	
  Yes, please lock-in my rate for 60 days. The
  estimated amount of my exchange/transfer is $

  	
   

  	
  .

  
	
  No, please give me the rate in effect when my
  money is received at Protective Life.  

  
	
   

  	
   

  	
   

  
	
  Other Protective Life Annuities: Have you purchased
  other Protective Life Annuities this calendar
  year?     Yes  o  No o

  
	
   

  	
   

  	
   

  
	
  AUTHORIZATION AND ACKNOWLEDGMENT: I (We) declare to the best
  of my (our) knowledge and belief that all of the answers herein are complete
  and true. I (We) agree that this Application shall be part of my (our)
  Certificate/Contract issued by the Company. If this Application is declined,
  the Company will have no liability except to return the Annuity Deposit. 

  
	
   

  	
   

  	
   

  
	
  I (We) understand that this Contract/Certificate
  contains a Market Value Adjustment.

  
														

 

	
   

  	
   

  	
   

  
	
  Signed At:

  	
   

  	
  Date:  

  	
   

  
	
   

  	
   

  	
   

  
	
  Signature of

  Owner/Participant

  	
   

  	
   

  	
  Signature of

  Joint Owner/Participant

  	
   

  
	
   

  	
   

  	
   

  
	
  Signature of

  Annuitant: (if other than Owner)

  	
   

  	
  Witness:

  	
   

  
												

 

An annuity contract is not a
deposit or obligation of, or guaranteed by any bank or financial institution.
It is not insured by the Federal Deposit Insurance Corporation or any other
government agency and is subject to investment risk, including the possible
loss of principal.

 

	
  IPD-2081

  	
   

  	
  5/03

  

 

 

Special Remarks:

 

AGENT REPORT

 

I certify that I
have given a current Prospectus to the owner(s) named
on this application.                              o Yes   o No

 

To the best of my
knowledge and belief, the annuity being applied for o does o does not
replace or change any other annuity or insurance.

 

	
  Agent’s

  Signature:

  	
   

  	
   

  	
  Print

  Agent Name:

  	
   

  
	
   

  	
   

  	
   

  
	
  Broker/Dealer Name (if
  applicable)

  	
   

  	
   

  	
  Protective Life

  Agent Number:

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  Branch:

  	
   

  	
   

  	
  Phone No:

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Client Account No. (if
  applicable)

  	
   

  	
   

  	
  Agent Social Security No:.

  	
   

  
														

 

IMPORTANT INFORMATION REGARDING RATE LOCK

 

If “yes” is selected, and the money is received within 60 days from the date the
application is received, you will receive the rate in effect on that date,
regardless of whether the rate goes up or down. If the money is received after
the 90 day period, you will receive the rate in effect on the date the money is
received by Protective Life.

 

EXPLANATION OF PLAN TYPES

 

Non-Qualified - Money which did not
originate in an IRA, TSA, Pension, Profit Sharing, or 401K Plan.

 

1035
Exchange - The tax free exchange of a non-qualified annuity or life
insurance contract for one issued by another insurance company.

 

CD Transfer - The direct transfer of
non-qualified proceeds from a maturing certificate of deposit into an annuity.

 

IRA Rollover - The deposit of qualified
funds originating from the distribution of proceeds from an IRA, IRA Rollover,
TSA,

 

Pension, Profit Sharing, or 401K
Plan. The rollover must be made within 60 days after the distribution. If
taxes were withheld, out of pocket money may be added to make up the full
distribution amount.

 

IRA
Transfer - The direct transfer of IRA funds originating from the
distribution of assets in an IRA. These distributions/deposits are not reported
to the IRS.

 

Direct
IRA Rollover - The direct rollover of qualified funds originating from
the distributions of assets in a TSA, Pension, Profit Sharing, or 401K plan
into an IRA Rollover. These distributions/deposits are reported to the IRS.
This method avoids mandatory withholding taxes.

 

IRA (indicate
contribution & tax year in SPECIAL REMARKS) - Use for annual IRA
contributions.

 

TSA
Direct Rollover - The direct rollover or transfer of assets distributed from
a 403 (b) plan into another 403 (b) program. These
distributions/deposits are reported to the IRS. This method avoids mandatory
withholding taxes.

 

Send Application To:

 

	
  Regular Mail:

  	
  Overnight Mail:

  
	
  IPD Annuity Services 3-1 IPD 

  	
  IPD Annuity Services 3-1 IPD 

  
	
  Protective Life Insurance
  Company 

  	
  Protective Life Insurance Company 

  
	
  P.O. Box 10648

  	
  2801 Highway 280 South 

  
	
  Birmingham, AL 35202-0648

  	
  Birmingham, AL 35223

  

 

	
  IPD-2081

  	
   

  	
  5/03

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