Document:

Exhibit

ANNUITY SCHEDULE PAGE

ANNUITY NUMBER: [001-00001]    ISSUE DATE:  [March 1, 2013]

TYPE OF BUSINESS:  [Non-Qualified]

OWNER:  [John Doe DCD FBO Jack Doe]               DATE OF BIRTH:              SEX:  

KEY LIFE:  [Jack Doe]        DATE OF BIRTH:  [October 21,1975]    SEX:  [Male]
 

ALLOCATION OF INITIAL PUCHASE PAYMENT

PURCHASE PAYMENT:  [$100,000.00]

VARIABLE SUB-ACCOUNT ALLOCATION PERCENTAGE:
[[VA Fund 1]                    10%]
[VA Fund 2]                    10%]
[VA Fund 3]                    10%]
[VA Fund 4]                    10%]
[VA Fund 5]                    10%]]

INDEX STRATEGY ALLOCATION PERCENTAGE:
[[Point to Point with Cap Index Strategy]        20%]
[Tiered Participation Rate Index Strategy]    20%]
[Step Rate Plus Index Strategy]            10%]]        
    
HOLDING ACCOUNT PERIOD: [30] Days from the Issue Date

PURCHASE PAYMENT AGE LIMITATION:  No Additional Purchase Payments accepted

MINIMUM ADDITIONAL PURCHASE PAYMENT:  Not applicable

MINIMUM ADDITIONAL PURCHASE PAYMENT UNDER AUTOMATIC PURCHASE PLANS:  Not applicable

WITHDRAWALS

MINIMUM WITHDRAWAL AMOUNT:  [$100]

MINIMUM SURRENDER VALUE AFTER A PARTIAL WITHDRAWAL:  [$2,000]

ALLOCATION OF ACCOUNT VALUE

MINIMUM VARIABLE SUB-ACCOUNT AMOUNT:  [$20]

MINIMUM INDEX STRATEGY AMOUNT:  [$2,000]

CHARGES

INSURANCE CHARGE:

MORTALITY AND EXPENSE RISK CHARGE: [

For Purchase Payments less than $1,000,000 the Insurance Charge is [X.XX%]
    

RILA-SCH-I-DCD(11/19)    

For Purchase Payments of $1,000,000 or more the Insurance Charge is reduced to [X.XX%]]

ADMINISTRATION CHARGE: [0.15%]
ANNUITY SCHEDULE PAGE (continued)

CONTINGENT DEFERRED SALES CHARGE:    NONE

ADVISORY FEES: We treat Advisory Fee payments as an expense of the Annuity and not a taxable distribution if (1) your Annuity is being used in conjunction with a “qualified” retirement plan (plans meeting the requirements of Sections 401, 403 or 408 of the Code) or (2) your non-qualified Annuity satisfies the requirements of Private Letter Ruling 201945005 (“PLR”) issued by the IRS to PALAC. In accordance with the PLR, Advisory Fee payments from your non-qualified Annuity are treated as an expense as long as your investment adviser attests to Prudential that the PLR requirements have been met, including that the advisory fees will not exceed [1.50]% of the Annuity’s Account Value in a calendar year. In relation to the Death Benefit, we will treat any Advisory Fees that are deducted as withdrawals that reduce the Death Benefit. 

ANNUITIZATION

LATEST AVAILABLE ANNUITY DATE:  Not applicable

EARLIEST AVAILABLE ANNUITY DATE:  Not applicable

MINIMUM ANNUITY PAYMENT:  Not applicable

MINIMUM SURRENDER VALUE AT ANNUITIZATION:  Not applicable

SEPARATE ACCOUNT(S):

VARIABLE SEPARATE ACCOUNT(S): [Prudential Annuities Life Assurance Corporation Variable Account B]

INDEX STRATEGIES SEPARATE ACCOUNT(S): [Prudential Annuities Life Assurance Corporation Index Strategies Separate Account]

RIDERS AND ENDORSEMENTS MADE A PART OF THE ANNUITY ON THE ISSUE DATE:
[Point to Point with Cap Index Strategy Endorsement
Tiered Participation Rate Index Strategy Endorsment
Step Rate Plus Index Strategy Endorsement]

RILA-SCH-I-DCD(11/19)    2Exhibit

PRUDENTIAL ANNUITIES LIFE ASSURANCE CORPORATION, PHOENIX, ARIZONA

RETURN OF PURCHASE PAYMENTS DEATH BENEFIT RIDER

ANNUITY NUMBER: [001-00001]                EFFECTIVE DATE: [Contract Issue Date]

This Rider is made part of your Annuity.  For purposes of this Rider, certain provisions of your Annuity are amended as described below.  If the terms of your Annuity and those of this Rider conflict, the provisions of this Rider shall control.  Should this Rider terminate, any amended or replaced Annuity provisions based on this Rider’s terms will revert to the provisions in the Annuity, except as may be provided below.  
This Rider will terminate upon assignment or a change in ownership of your Annuity unless the new assignee or Owner meets the qualifications specified in the Termination provision. This Rider may not be re-elected after it terminates. The benefit provided pursuant to the terms of this Rider is a “Return of Purchase Payments Death Benefit."  This Rider should be read in conjunction with any other Rider or Endorsement made a part of your Annuity. 

Definitions:  

Purchase Payment(s) :  A cash consideration in the currency of the United States of America given to us in exchange for the rights, privileges and benefits outlined in this Annuity reduced for any applicable fees, charges or Tax Charges.

Withdrawals:  Withdrawals of any type (including Partial Withdrawals) before the application of any Contingent Deferred Sales Charge or other charge applicable upon a Withdrawal.

Death Benefit: If we receive Due Proof of Death within a period of [1 year], beginning on the decedent’s date of death, the Death Benefit of the Annuity equals the greater of (a) and (b), where:

		
	(a)
	is the “Return of Purchase Payments Amount” described below; and

		
	(b)
	is the Account Value as described in the “Death Benefit” section of the Annuity.

If we do not receive Due Proof of Death within a period of [1 year], beginning on the decedent’s date of death, the Death Benefit of the Annuity equals (b) above.  We reserve the right to waive or extend, on a non-discriminatory basis, our right to enforce the Due Proof of Death period.  This right will only apply for purposes of determining the amount payable as a Death Benefit, and in no way restricts when a claim may be filed.

Return of Purchase Payments Amount:  Initially, this is an amount equal to the initial Purchase Payment on the Effective Date of this Rider.  Thereafter, on each Valuation Day, up to and including the date we receive Due Proof of Death, the Return of Purchase Payments Amount is increased by the amount of any additional Purchase Payments allocated to the Annuity on that day and reduced for any Withdrawal(s) by the ratio of the Withdrawal amount to the Account Value immediately prior to the Withdrawal. 

Other Death Benefit Provisions:  The provisions applicable to the Death Benefit described in your Annuity regarding eligibility, limits of applicability, methods of payment to Beneficiaries or any other provision regarding the Death Benefit, other than the method of calculation of the Death Benefit, continue to apply unless specifically indicated otherwise in this Rider.

Spousal Continuation:  If the Annuity is eligible for Spousal Continuation and Spousal Continuation occurs, upon Spousal Continuation the Account Value is increased, if necessary, to equal the greater of the (1) Return of  Purchase Payments Amount and (2) the Death Benefit described in the Annuity. Any increase to the Account Value resulting from such adjustment will be allocated to the Variable Sub-Accounts pro-rata or to the Holding Account if there is no Account Value in the Variable Sub-Accounts.  The spouse who continues the Annuity may transfer available Account Value to any of the Variable Sub-Accounts at any time or to a new Index Strategy on the next Index Anniversary Date. 
Following Spousal Continuation, any subsequent Death Benefit will be equal to the Account Value, including any increase described above.

Termination of this Rider and its Benefits:  Benefits pursuant to this Rider will terminate upon the first to occur of the following events:

		
	1)
	the date the Annuity’s Death Benefit is determined, unless the Annuity is eligible for Spousal Continuation and Spousal Continuation is elected;

		
	2)
	we process a request to change the Owner(s) (or Annuitant if entity owned) more than 60 days after the Effective Date, resulting in a change in the person(s) upon whose death a Death Benefit is determined, other than when the Annuity is jointly owned and one of the Owners remains the Owner;

		
	3)
	we process an assignment of the Annuity to which this Rider is made a part;

		
	4)
	if there is then any Account Value on the Annuity Date, or if earlier, the date we transfer all Account Value in order to begin annuity payments;

		
	5)
	the date we receive your request for full surrender;

 
		
	6)
	if your Account Value reduces to zero;

PRUDENTIAL ANNUITIES LIFE ASSURANCE CORPORATION

            []    
Secretary

RID-RILA-ROP(11/19)    1Exhibit

PRUDENTIAL ANNUITIES LIFE ASSURANCE CORPORATION, PHOENIX ARIZONA

MEDICALLY RELATED SURRENDER ENDORSEMENT

ANNUITY NUMBER: [001-00001]                EFFECTIVE DATE: [Contract Issue Date]

This Endorsement is made a part of your Annuity.  If the terms of your Annuity and those of this Endorsement conflict, the provisions of this Endorsement shall control.  The benefit provided pursuant to the terms of this Endorsement is a “Medically Related Surrender Benefit.”  There is no charge for the Medically Related Surrender Benefit.

Definitions:

Contingency Event:  A “Contingency Event” occurs if an Owner (an Annuitant, if the Annuity is owned by an entity) is:

		
	a)
	first confined in a Medical Care Facility after the Issue Date and while this Annuity is in force, remains confined for at least 90 consecutive days, and remains confined on the date we receive the Medically Related Surrender Request in Good Order at our Service Office; or

		
	b)
	first diagnosed as having a Fatal Illness after the Issue Date and while this Annuity is in force.  We may require a second or third medical opinion regarding such diagnosis, at our expense, by a Physician(s) chosen by us.  We may request the third medical opinion if the second opinion received conflicts with the first opinion.

Fatal Illness:  A condition:
		
	a)
	diagnosed by a Physician; and

		
	b)
	expected to result in death within 24 months after the diagnosis in 80% of the cases diagnosed with this condition.

Licensed Practical Nurse:  A person who is:
		
	a)
	A professional nurse legally designated “LPN” who, where licensing is required, holds a valid license according to the laws of the United States jurisdiction in which the nursing service is performed and is acting within the scope of that license; and

		
	b)
	not you, the Annuitant, or member of either your or the Annuitant’s family.

The term licensed practical nurse (LPN) shall include a licensed vocational nurse (LVN) and any other similarly designated nurse in those jurisdictions in which a professional nurse is designated as other than an LPN and for whom licensing is required.

Medical Care Facility:  A facility operated and licensed pursuant to laws of any United States jurisdiction providing medically necessary in-patient care, which is:
		
	a)
	prescribed by a Physician in writing;

		
	b)
	   recognized as a general hospital or long-term care facility by the proper authority of the United States jurisdiction in which it is located;

		
	c)
	recognized as a general hospital by the Joint Commission on the Accreditation of Hospitals; and

		
	d)
	certified as a hospital or long-term care facility; or 

		
	e)
	a nursing home licensed by the United States jurisdiction in which it is located and offers the services of a Registered Nurse (RN) or Licensed Practical Nurse (LPN) 24 hours a day that maintains control of all prescribed medications dispensed and daily medical records.

Physician:  A person who is:
		
	a)
	a professional physician who holds a valid license according to the laws of the United States jurisdiction in which the medical service is performed and is acting within the scope of that license; and

		
	b)
	not you, the Annuitant ,or member of either your or the Annuitant’s family.

Registered Nurse:  A person who is:
		
	a)
	a professional nurse legally designated “RN” who, where licensing is required, holds a valid license according to the laws of the United States jurisdiction in which the nursing service is performed and is acting within the scope of that license; and

		
	b)
	not you, the Annuitant, or member of either your or the Annuitant’s family.

MEDICALLY RELATED SURRENDER

Upon the occurrence of a Contingency Event prior to the Annuity Date, you may submit a request to our Service Office in Good Order to surrender all or part of your Annuity without application of any Contingent Deferred Sales Charge.  

If, as a result of your request for a partial withdrawal, the Surrender Value of your Annuity would be less than the Minimum Surrender Value after a Partial Withdrawal shown in the Annuity Schedule, we reserve the right to treat your request as a request for a full surrender.  

All Owners (the Annuitant, if your Annuity is owned by an entity) must be alive as of the date we pay the proceeds of such surrender request.  This benefit is available only if we agree to, and accept, your designation of the Owner (the Annuitant, if the Annuity is owned by an entity) prior to the occurrence of a Contingency Event.

This benefit is not available: 
		
	(i)
	if the Annuity has been assigned, or 

		
	(ii)
	on the portion, if any, of the amount of the Medically Related Surrender which, when added to the aggregate amount of Medically Related Surrenders you have previously taken under this Annuity and all other annuities issued to you by us or one of our affiliates, would exceed the Maximum Medically Related Surrender Amount shown below.  We reserve the right to waive, on a non-discriminatory basis, our right to enforce the Maximum Medically Related Surrender Amount.

Additional Purchase Payments may not be made after a Medically Related Surrender has been approved.  

Distributions under this Endorsement are subject to all reporting and withholding rules applicable to annuity distributions.

When we receive your completed Medically Related Surrender Request form, in Good Order, we will process it.  If we disapprove your request, we will notify you.

Maximum Medically Related Surrender Amount:  [$500,000]

Termination of this Endorsement:  Termination of this Endorsement is subject to the following rules:

		
	A.
	Termination due to Death:  This Endorsement terminates automatically as of the date the Annuity’s Death Benefit is determined, unless the Annuity is eligible for Spousal Continuation and Spousal Continuation occurs.

B.  Termination on the Annuity Date:  This Endorsement terminates automatically as of the Annuity Date.

C. Termination upon Surrender:  This Endorsement terminates upon surrender of the Annuity to which it is made a part.

PRUDENTIAL ANNUITIES LIFE ASSURANCE CORPORATION

[                     Secretary                   ]

END-RILA-MRS(11/19)     1

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