Document:

Exhibit (4)(y)

 EXHIBIT (4)(y) 

FORM OF POLICY RIDER (INCOME LINK) 

					
	

	 		  	 Home Office:
 4333 Edgewood
Road N.E.
 Cedar Rapids, Iowa 52499

(319)355-8511

INCOME
LINKSM RIDER 

This rider is issued as a part of the policy (contract) to which it is attached. Policy refers to the individual policy if the rider is attached to an
individual annuity or the group certificate if the rider is attached to a group annuity. 
 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. 

 

			
	Rider Data Specification
		
	Policy Number:	  	12345
	Rider Date:	  	03/01/2010
	Initial Rider Fee Percentage:	  	0.90%
	Annuitant:	  	John Doe
		
	Annuitant’s Issue Age/Sex:	  	35 / Male
	Annuitant’s Spouse:	  	Jane Doe
	Annuitant’s Spouse’s Issue Age/Sex:	  	35 / Female

  

 
 ARTICLE I

 You may cancel this rider prior to the close of business before midnight of the thirtieth calendar day after you received it and no
rider fee will be assessed. 
 If you elect this rider, 100% of your policy value must be in one or more of the designated investment
options. 
 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 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. 
 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. 

Income
LinkSM Rider Start Date 

The date of the first Income
LinkSM rider systematic withdrawal after election of the
withdrawal option. 
  

					
	RGMB 39 0110	  	(1)	  	(Income-Joint)

 ARTICLE I CONTINUED 

 

 Income
LinkSM Rider Systematic Withdrawal 

The rider withdrawal amount paid to you based on your election of a withdrawal option and frequency, and designated by us as an 

Income
LinkSM rider systematic withdrawal. 

Income
LinkSM Rider Withdrawal Year 

Each twelve-month period beginning on the Income
LinkSM rider start date. 

Rider Anniversary 
 The anniversary of
the rider date. 
 Rider Fee 

The fee charged for the benefits under this rider. The fee may be assessed on the last day of a rider quarter, or the next business day if the New York
Stock Exchange is closed. 
 Rider Monthiversary 

The same day of the month as the rider date, or the next business day if the New York Stock Exchange is closed. 

Rider Quarter 
 Each three-month period
beginning on the rider date. 
 Rider Withdrawal Amount 

The maximum annual amount that can be withdrawn, through Income
LinkSM rider systematic withdrawals, from the policy each
Income LinkSM rider withdrawal year. 

Rider Year 
 Each twelve-month period
beginning on the rider date. 
 Valuation Period 

The period of time from one determination of the value of a subaccount to the next. Such determinations are made when the value of the assets and
liabilities of each subaccount is calculated. This is generally the close of business on each day on which the New York Stock Exchange is open. 

Withdrawal Base 
 The amount used to
calculate the rider withdrawal amount and the rider fee. This amount cannot be taken as a lump sum. 
 Withdrawal Base Adjustment

 The increase to the withdrawal base due to an automatic step-up or premium addition and/or the decrease resulting from
any withdrawal taken other than 1) the Income LinkSM rider
systematic withdrawal or 2) to satisfy a minimum required distribution systematic withdrawal. 
 ARTICLE II 

RIDER FEE 
 The rider fee is deducted on
each rider quarter in arrears. The fee is calculated and stored at issue and at each subsequent rider quarter for the upcoming quarter. It will be deducted automatically from each investment option on a pro rata basis at the end of each rider
quarter. The initial rider fee percentage is shown on page 1, in the Rider Data Specification section. The rider fee percentage will not change during the first rider year, 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 quarter. 

The stored fee will be adjusted if the withdrawal base is adjusted during the rider quarter. 

The quarterly fee is calculated as follows: 

Multiply (1) by (2) by (3). 
  

	1)	Withdrawal Base; 

  

	2)	Rider Fee Percentage; 

  

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

 

					
	RGMB 39 0110	  	(2)	  	(Income-Joint)

 ARTICLE III 

GUARANTEED LIFETIME WITHDRAWAL BENEFIT 

Under this rider, we guarantee that you can receive up to the rider withdrawal amount each Income
LinkSM rider withdrawal year, regardless of the policy
value, (either through withdrawals or payments, where payments are equal to the rider withdrawal amount if your policy value equals zero) until the annuitant’s or the annuitant’s spouse’s death, whichever is later. 

You can elect one of the withdrawal options shown in the table below: 

Withdrawal Options 

4.5% for 7 Income
LinkSM rider withdrawal years and 3.5% thereafter

 5.5% for 6 Income
LinkSM rider withdrawal years and 3.5% thereafter

 6.5% for 5 Income
LinkSM rider withdrawal years and 3.5% thereafter

 7.5% for 4 Income
LinkSM rider withdrawal years and 3.5% thereafter

 8.5% for 3 Income
LinkSM rider withdrawal years and 3.5% thereafter

 9.5% for 2 Income
LinkSM rider withdrawal years and 3.5% thereafter

 Once the withdrawal option is elected, you may choose when to begin receiving an Income
LinkSM rider systematic withdrawal. These withdrawals are
available with a frequency of monthly, quarterly, semi-annual, or annual and are based on the withdrawal option. Prior to the Income
LinkSM rider start date, you may change your frequency or
the withdrawal option. After the Income LinkSM rider start
date, the withdrawal option cannot be changed, however the Income
LinkSM rider systematic withdrawal frequency can be
changed and will go into effect the next Income LinkSM
rider withdrawal year. Withdrawals prior to age
59 1/2 may be subject to the 10% penalty tax.

 Withdrawals will reduce the policy value of the policy to which this rider is attached. If the policy value
reaches zero through an Income LinkSM rider systematic
withdrawal, you cannot make subsequent premium payments and all other policy features, benefits and guarantees are no longer available. Also, 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. 

SURVIVAL 
 The benefits under this rider
depend on the annuitant or annuitant’s spouse being alive at the time of withdrawal or guaranteed payment. Proof of survival may be required by the Company. 

RIDER WITHDRAWAL AMOUNT 

Before the Income
LinkSM rider start date, the rider withdrawal amount is
zero. On the Income LinkSM rider start date and the
beginning of each Income LinkSM rider withdrawal year
thereafter, the rider withdrawal amount is equal to the withdrawal option percentage multiplied by the withdrawal base. During any Income
LinkSM rider withdrawal year, the remaining rider
withdrawal amount may be adjusted (up or down) as described in the Withdrawal Base Adjustment section. 
 MINIMUM REQUIRED DISTRIBUTION 

 For a tax-qualified policy, a withdrawal may be taken to satisfy the IRS minimum required distribution as set forth herein
and will not cause an adjustment to the withdrawal base. You must be at least
70 1/2 years old and take your withdrawals
systematically as calculated using: 
  

	 	A)	the living annuitant’s age, or the annuitant’s spouse if the annuitant is deceased, 

 

	 	B)	the IRS Uniform Lifetime table or Joint Life and Survivor table, 

  

	 	C)	the policy value of the base policy to which this rider attaches, and 

  

	 	D)	amounts from the current calendar year (no carry-over from past years). 

Any withdrawal taken during a calendar year will reduce the amount needed to satisfy the minimum required distribution. These withdrawals may be
withdrawn without causing an adjustment to your withdrawal base, provided they are taken as systematic payouts as described below. 
  

					
	RGMB 39 0110	  	(3)	  	(Income-Joint)

 ARTICLE III CONTINUED 

 

 Before the Income
LinkSM rider start date, any minimum required
distribution, as calculated in this section, must be withdrawn using a systematic minimum required distribution payout option, which is a systematic payout of modal payments on an annualized basis with a final non-modal payment, if necessary. This
systematic payout option is available on a monthly, quarterly, semi-annual, or annual basis. Any change to the frequency will go into effect on the next systematic payout option anniversary. Once you stop a systematic payout option, you cannot start
a new one until one year from the date of the previous systematic payout option anniversary. 
 After the Income
LinkSM rider start date, any minimum required
distribution, as calculated in this section, must be withdrawn using the Income
LinkSM rider systematic minimum required distribution
payout option with a final non-modal payment, if necessary. 
 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 premium enhancements if the rider is added in the first policy year). During any Income
LinkSM rider withdrawal year, the withdrawal base is
increased or decreased by any withdrawal base adjustments. 
 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; or 

  

	 	3)	The highest policy value on a rider monthiversary for the current rider year. 

Item 3) above will be zero if there is a negative withdrawal base adjustment in the current rider year. 

AUTOMATIC STEP-UP FEATURE 
 The rider
withdrawal base 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. The remaining rider withdrawal amount will be increased by the same
percentage that the withdrawal base is increased due to the automatic step-up. This feature does not require the termination of the existing rider. This rider will continue with the same rider date and features. Following the first rider
anniversary, the rider fee percentage may be increased due to an automatic step-up, but will not increase more than 0.75% from the initial rider fee percentage shown on page 1. 

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 percentage will
also be reversed, and the withdrawal base will be set to the withdrawal base prior to the automatic step-up. 
 WITHDRAWAL BASE ADJUSTMENTS

 An Income
LinkSM rider systematic withdrawal or a minimum required
distribution systematic withdrawal will not reduce the withdrawal base. 
 The withdrawal base is increased by the dollar
amount of any premium additions (not including any premium enhancements) and by an automatic step-up as described in the Automatic Step-Up Feature section. Any withdrawal (other than the Income
LinkSM rider systematic withdrawal or a minimum required
distribution systematic withdrawal), will decrease the withdrawal base as described below. 
 The withdrawal base is reduced by the greater of
1) and 2), where: 
  

	1)	 is the amount of the withdrawal that is not an Income
LinkSM rider systematic withdrawal or a minimum required
distribution systematic withdrawal; and 

  

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

  

	 	A)	is the amount in 1 above; 

  

	 	B)	is the withdrawal base prior to the withdrawal; and 

  

	 	C)	is the policy value prior to the withdrawal. 

During any Income
LinkSM rider withdrawal year, if there is a withdrawal
base adjustment, the remaining rider withdrawal amount and the Income
LinkSM rider systematic withdrawal amount will increase or
decrease by the same percentage as the withdrawal base. 
  

					
	RGMB 39 0110	  	(4)	  	(Income-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 surviving spouse may elect to continue the policy and rider. 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, this rider continues 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. 
 OWNERSHIP AND ASSIGNMENT 

 Ownership changes or assignments of any policy to which this rider is attached must be approved by the Company. We reserve the right to
disapprove ownership changes or assignments in a non-discriminatory manner when involving an institutional investor, a settlement company or another similar organization. 

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 receive annuity payments under your policy; and 

  

	4)	the date you notify us in writing of your intention to terminate this rider (this date must be after the fifth rider anniversary). 

Termination of the rider will result in the loss of all benefits provided by the rider. 

Signed for us at our home office. 
  

					
	 /s/ Craig D. Vermie
	 		  	 /s/ Brenda Clancy

	SECRETARY	 		  	PRESIDENT

  

					
	RGMB 39 0110	  	(5)	  	(Income-Joint)

					
	

	 		  	 Home Office:
 4333 Edgewood
Road N.E.
 Cedar Rapids, Iowa 52499

(319)355-8511

INCOME
LINKSM RIDER 

This rider is issued as a part of the policy (contract) to which it is attached. Policy refers to the individual policy if the rider is attached to an
individual annuity or the group certificate if the rider is attached to a group annuity. 
 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. 

 

			
	Rider Data Specification
		
	Policy Number:	  	12345
	Rider Date:	  	03/01/2010
	Initial Rider Fee Percentage:	  	0.90%
	Annuitant:	  	John Doe
		
	Annuitant’s Issue Age/Sex:	  	35 / Male

  

 
 ARTICLE I

 You may cancel this rider prior to the close of business before midnight of the thirtieth calendar day after you received it and no
rider fee will be assessed. 
 If you elect this rider, 100% of your policy value must be in one or more of the designated investment
options. 
 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 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. 
 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. 

Income
LinkSM Rider Start Date 

The date of the first Income
LinkSM rider systematic withdrawal after election of the
withdrawal option. 
 Income
LinkSM Rider Systematic Withdrawal 

The rider withdrawal amount paid to you based on your election of a withdrawal option and frequency, and designated by us as an Income
LinkSM rider systematic withdrawal. 

 

					
	RGMB 39 0110	  	(1)	  	(Income-Single)

 ARTICLE I CONTINUED 

 

 Income
LinkSM Rider Withdrawal Year 

Each twelve-month period beginning on the Income
LinkSM rider start date. 

Rider Anniversary 
 The anniversary of
the rider date. 
 Rider Fee 

The fee charged for the benefits under this rider. The fee may be assessed on the last day of a rider quarter, or the next business day if the New York
Stock Exchange is closed. 
 Rider Monthiversary 

The same day of the month as the rider date, or the next business day if the New York Stock Exchange is closed. 

Rider Quarter 
 Each three-month period
beginning on the rider date. 
 Rider Withdrawal Amount 

The maximum annual amount that can be withdrawn, through Income
LinkSM rider systematic withdrawals, from the policy each
Income LinkSM rider withdrawal year. 

Rider Year 
 Each twelve-month period
beginning on the rider date. 
 Valuation Period 

The period of time from one determination of the value of a subaccount to the next. Such determinations are made when the value of the assets and
liabilities of each subaccount is calculated. This is generally the close of business on each day on which the New York Stock Exchange is open. 

Withdrawal Base 
 The amount used to
calculate the rider withdrawal amount and the rider fee. This amount cannot be taken as a lump sum. 
 Withdrawal Base Adjustment

 The increase to the withdrawal base due to an automatic step-up or premium addition and/or the decrease resulting from
any withdrawal taken other than 1) the Income LinkSM rider
systematic withdrawal or 2) to satisfy a minimum required distribution systematic withdrawal. 
 ARTICLE II 

RIDER FEE 
 The rider fee is deducted on
each rider quarter in arrears. The fee is calculated and stored at issue and at each subsequent rider quarter for the upcoming quarter. It will be deducted automatically from each investment option on a pro rata basis at the end of each rider
quarter. The initial rider fee percentage is shown on page 1, in the Rider Data Specification section. The rider fee percentage will not change during the first rider year, 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 quarter. 

The stored fee will be adjusted if the withdrawal base is adjusted during the rider quarter. 

The quarterly fee is calculated as follows: 

Multiply (1) by (2) by (3). 
  

	1)	Withdrawal Base; 

  

	2)	Rider Fee Percentage; 

  

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

 

					
	RGMB 39 0110	  	(2)	  	(Income-Single)

 ARTICLE III 

GUARANTEED LIFETIME WITHDRAWAL BENEFIT 

Under this rider, we guarantee that you can receive up to the rider withdrawal amount each Income
LinkSM rider withdrawal year, regardless of the policy
value, (either through withdrawals or payments, where payments are equal to the rider withdrawal amount if your policy value equals zero) until the annuitant’s death. 

You can elect one of the withdrawal options shown in the table below: 

Withdrawal Options 

5.0% for 7 Income
LinkSM rider withdrawal years and 4.0% thereafter

 6.0% for 6 Income
LinkSM rider withdrawal years and 4.0% thereafter

 7.0% for 5 Income
LinkSM rider withdrawal years and 4.0% thereafter

 8.0% for 4 Income
LinkSM rider withdrawal years and 4.0% thereafter

 9.0% for 3 Income
LinkSM rider withdrawal years and 4.0% thereafter

 10.0% for 2 Income
LinkSM rider withdrawal years and 4.0% thereafter

 Once the withdrawal option is elected, you may choose when to begin receiving an Income
LinkSM rider systematic withdrawal. These withdrawals are
available with a frequency of monthly, quarterly, semi-annual, or annual and are based on the withdrawal option. Prior to the Income
LinkSM rider start date, you may change your frequency or
the withdrawal option. After the Income LinkSM rider start
date, the withdrawal option cannot be changed, however the Income
LinkSM rider systematic withdrawal frequency can be
changed and will go into effect the next Income LinkSM
rider withdrawal year. Withdrawals prior to age
59 1/2 may be subject to the 10% penalty tax.

 Withdrawals will reduce the policy value of the policy to which this rider is attached. If the policy value
reaches zero through an Income LinkSM rider systematic
withdrawal, you cannot make subsequent premium payments and all other policy features, benefits and guarantees are no longer available. Also, 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. 

SURVIVAL 
 The benefits under this rider
depend on the annuitant being alive at the time of withdrawal or guaranteed payment. Proof of survival may be required by the Company. 

RIDER WITHDRAWAL AMOUNT 

Before the Income
LinkSM rider start date, the rider withdrawal amount is
zero. On the Income LinkSM rider start date and the
beginning of each Income LinkSM rider withdrawal year
thereafter, the rider withdrawal amount is equal to the withdrawal option percentage multiplied by the withdrawal base. During any Income
LinkSM rider withdrawal year, the remaining rider
withdrawal amount may be adjusted (up or down) as described in the Withdrawal Base Adjustment section. 
 MINIMUM REQUIRED DISTRIBUTION 

 For a tax-qualified policy, a withdrawal may be taken to satisfy the IRS minimum required distribution as set forth herein
and will not cause an adjustment to the withdrawal base. You must be at least
70 1/2 years old and take your withdrawals
systematically as calculated using: 
  

	 	A)	the living annuitant’s age, 

  

	 	B)	the IRS Uniform Lifetime table or Joint Life and Survivor table, 

  

	 	C)	the policy value of the base policy to which this rider attaches, and 

  

	 	D)	amounts from the current calendar year (no carry-over from past years). 

Any withdrawal taken during a calendar year will reduce the amount needed to satisfy the minimum required distribution. These withdrawals may be
withdrawn without causing an adjustment to your withdrawal base, provided they are taken as systematic payouts as described below. 
  

					
	RGMB 39 0110	  	(3)	  	(Income-Single)

 ARTICLE III CONTINUED 

 

 Before the Income
LinkSM rider start date, any minimum required
distribution, as calculated in this section, must be withdrawn using a systematic minimum required distribution payout option, which is a systematic payout of modal payments on an annualized basis with a final non-modal payment, if necessary. This
systematic payout option is available on a monthly, quarterly, semi-annual, or annual basis. Any change to the frequency will go into effect on the next systematic payout option anniversary. Once you stop a systematic payout option, you cannot start
a new one until one year from the date of the previous systematic payout option anniversary. 
 After the Income
LinkSM rider start date, any minimum required
distribution, as calculated in this section, must be withdrawn using the Income
LinkSM rider systematic minimum required distribution
payout option with a final non-modal payment, if necessary. 
 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 premium enhancements if the rider is added in the first policy year). During any Income
LinkSM rider withdrawal year, the withdrawal base is
increased or decreased by any withdrawal base adjustments. 
 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; or 

  

	 	3)	The highest policy value on a rider monthiversary for the current rider year. 

Item 3) above will be zero if there is a negative withdrawal base adjustment in the current rider year. 

AUTOMATIC STEP-UP FEATURE 
 The rider
withdrawal base 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. The remaining rider withdrawal amount will be increased by the same
percentage that the withdrawal base is increased due to the automatic step-up. This feature does not require the termination of the existing rider. This rider will continue with the same rider date and features. Following the first rider
anniversary, the rider fee percentage may be increased due to an automatic step-up, but will not increase more than 0.75% from the initial rider fee percentage shown on page 1. 

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 percentage will
also be reversed, and the withdrawal base will be set to the withdrawal base prior to the automatic step-up. 
 WITHDRAWAL BASE ADJUSTMENTS

 An Income
LinkSM rider systematic withdrawal or a minimum required
distribution systematic withdrawal will not reduce the withdrawal base. 
 The withdrawal base is increased by the dollar
amount of any premium additions (not including any premium enhancements) and by an automatic step-up as described in the Automatic Step-Up Feature section. Any withdrawal (other than the Income
LinkSM rider systematic withdrawal or a minimum required
distribution systematic withdrawal), will decrease the withdrawal base as described below. 
 The withdrawal base is reduced by the greater of
1) and 2), where: 
  

	1)	 is the amount of the withdrawal that is not an Income
LinkSM rider systematic withdrawal or a minimum required
distribution systematic withdrawal; and 

  

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

  

	 	A)	is the amount in 1 above; 

  

	 	B)	is the withdrawal base prior to the withdrawal; and 

  

	 	C)	is the policy value prior to the withdrawal. 

During any Income
LinkSM rider withdrawal year, if there is a withdrawal
base adjustment, the remaining rider withdrawal amount and the Income
LinkSM rider systematic withdrawal amount will increase or
decrease by the same percentage as the withdrawal base. 
  

					
	RGMB 39 0110	  	(4)	  	(Income-Single)

 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 surviving spouse may elect to continue the policy and rider. 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. 

OWNERSHIP AND ASSIGNMENT 
 Ownership
changes or assignments of any policy to which this rider is attached must be approved by the Company. We reserve the right to disapprove ownership changes or assignments in a non-discriminatory manner when involving an institutional investor, a
settlement company or another similar organization. 
 TERMINATION 

This rider will terminate upon the earliest of: 
  

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

  

	2)	the annuitant’s death; 

  

	3)	the date you elect to receive annuity payments under your policy; and 

  

	4)	the date you notify us in writing of your intention to terminate this rider (this date must be after the fifth rider anniversary). 

Termination of the rider will result in the loss of all benefits provided by the rider. 

Signed for us at our home office. 
  

					
	 /s/ Craig D. Vermie
	 		  	 /s/ Brenda Clancy

	SECRETARY	 		  	PRESIDENT

  

					
	RGMB 39 0110	  	(5)	  	(Income-Single)Restated Non-Employee Director Restricted Stock Plan

 Exhibit 10.1 

AMERISAFE, INC. 

2010 RESTATED NON-EMPLOYEE DIRECTOR RESTRICTED STOCK PLAN 

1. Purpose. The purpose of this 2010 Restated Non-Employee Director Restricted Stock Plan is to attract and retain qualified
individuals who are not employed by the Company to serve as Directors. 
 2. Definitions. As used in this Plan,

 (a) “Annual Grant” means a grant of Restricted Stock to a Non-Employee Director in accordance with Section 5 of
this Plan. 
 (b) “Annual Meeting” means the Company’s annual meeting of shareholders. 

(c) “Award” means any award of an Initial Grant or Annual Grant under this Plan. 

(d) “Award Agreement” means a written agreement between the Company and a Non-Employee Director setting forth the terms,
conditions and restrictions of the Award granted to the Non-Employee Director. 
 (e) “Board” means the Board of
Directors of the Company. 
 (f) “Change in Control” shall have the meaning provided in Section 6 of this Plan.

 (g) “Common Shares” means the shares of common stock, par value $0.01 per share, of the Company or any security
into which such Common Shares may be changed by reason of any transaction or event of the type referred to in Section 3(b) of this Plan. 

(h) “Company” means AMERISAFE, Inc., a Texas corporation. 

(i) “Date of Grant” means (i) with respect to an Initial Grant, the close of business on the date on which the
Non-Employee Director is first elected or appointed to the Board, and (ii) with respect to an Annual Grant, the date on which the Annual Meeting in any calendar year is first convened. 

(j) “Director” means a member of the Board. 

(k) “Effective Date” means June 15, 2010. 

(l) “Exchange Act” means the Securities Exchange Act of 1934, as amended, and the rules and regulations thereunder, as such
law, rules and regulations may be amended from time to time. 

 (m) “Incumbent Directors” means the individuals who, as of the Effective Date, are
Directors of the Company and any individual becoming a Director subsequent to the date thereof whose election, nomination for election by the Company’s shareholders, or appointment, was approved by a vote of at least two-thirds of the then
Incumbent Directors (either by a specific vote or by approval of the proxy statement of the Company in which such person is named as a nominee for Director, without objection to such nomination); provided, however, that an individual
shall not be an Incumbent Director if such individual’s election or appointment to the Board occurs as a result of an actual or threatened election contest (as described in Rule 14a-12(c) of the Exchange Act) with respect to the election
or removal of Directors or other actual or threatened solicitation of proxies or consents by or on behalf of a Person other than the Board. 

(n) “Initial Grant” means a grant of shares of Restricted Stock to a Non-Employee Director in accordance with Section 4 of
this Plan. 
 (o) “Market Value per Share” means, as of any particular date, (i) the closing sale price per
Common Share on that date (or if there are no sales on that date, on the next preceding trading date during which a sale occurred) as reported on the Nasdaq Stock Market LLC, or if the Common Shares are not then-traded on the Nasdaq Stock Market
LLC, the principal exchange on which the Common Shares are then trading, or (ii) if clause (i) does not apply, the fair value of the Common Shares as determined by the Board. 

(p) “Non-Employee Director” means each member of the Board from time to time who is not an employee of the Company or any of
its Affiliates. 
 (q) “Person” means any individual, entity or group (within the meaning of Section 13(d)(3) or
14(d)(2) of the Exchange Act). 
 (r) “Plan” means this 2010 Restated Non-Employee Director Plan. 

(s) “Restricted Stock” means Common Shares as to which neither the substantial risk of forfeiture nor the prohibition on
transfers referred to in Section 4 or Section 5 of this Plan has lapsed. 
 (t) “Subsidiary” means a
corporation, company or other entity (i) more than 50 percent of whose outstanding shares or other securities (representing the right to vote for the election of directors or other managing authority) are, or (ii) which does not have
outstanding shares or other securities (as may be the case in a partnership, limited liability company, business trust or other legal entity), but more than 50 percent of whose ownership interest representing the right generally to make decisions
for such entity is, now or hereafter, owned or controlled, directly or indirectly, by the Company. 
 (u) “Total
Disability” means the permanent or total disability of a Non-Employee Director, as determined by the Board in good faith. 

(v) “Voting Securities” means, at any time, (i) the securities entitled to vote generally in the election of Directors in
the case of the Company, or (ii) the securities entitled to 
  

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vote generally in the election of members of the board of directors or similar body in the case of another legal entity. 

3. Shares Available Under the Plan. 

(a) Subject to adjustment as provided in Section 3(b) of this Plan, the number of Common Shares that may be issued or transferred as
Restricted Stock and released from substantial risk of forfeiture thereof shall not exceed in the aggregate 100,000 Common Shares. Such shares may be authorized but unissued shares or treasury shares or a combination of the foregoing. 

(b) The number of shares available in Section 3(a) above shall be adjusted to account for shares relating to Awards that are
forfeited. The number and type of shares available in Section 3(a) shall also automatically be adjusted to reflect (a) any stock split, combination of shares, recapitalization or other change in the capital structure of the Company,
(b) any merger, consolidation, spin-off, split-off, spin-out, split-up, reorganization, partial or complete liquidation or other distribution of assets, issuance of rights or warrants to purchase securities, or (c) any other corporate
transaction or event having an effect similar to any of the foregoing. 
 4. Initial Grants 

(a) Without any further action of the Board, each person who is elected or appointed for the first time to be a Non-Employee Director
shall automatically receive an Initial Grant determined by dividing $30,000 (prorated as determined below in this Section 4(a)) by the Market Value per Share on the Date of Grant; provided, however, that the number of shares of
Restricted Stock shall be rounded downward such that no fractional share shall be issued. If any such person is so elected or appointed other than at an Annual Meeting, the Initial Grant shall be prorated for the number of whole months that such
Non-Employee Director will serve until the first anniversary of the immediately preceding Annual Meeting. 
 (b) Each Initial
Grant shall constitute an immediate transfer of the ownership of shares of Restricted Stock to the Non-Employee Director, entitling such Non-Employee Director to voting, dividend and other ownership rights, but subject to the substantial risk of
forfeiture and restrictions on transfer set forth in this Section 4. 
 (c) Each Initial Grant shall provide that the
shares of Restricted Stock covered by such Initial Grant shall be subject to a “substantial risk of forfeiture” until the first Annual Meeting after the Date of Grant. Each Initial Grant shall provide that the Non-Employee Director shall
forfeit the shares of Restricted Stock covered by such Initial Grant if such Non-Employee Director terminates his or her service with the Company while such shares of Restricted Stock are subject to a substantial risk of forfeiture. Notwithstanding
the foregoing, each such Initial Grant shall provide for the immediate lapse of such substantial risk of forfeiture in the event of (i) the Non-Employee Director’s death or Total Disability, or (ii) upon a Change in Control.

 (d) Each Initial Grant shall require that any and all dividends or other distributions (other than cash dividends) declared
or otherwise distributed thereon be subject to the same restrictions as the underlying Initial Grant. 
  

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 (e) Each Initial Grant shall provide that during the period for which such substantial risk
of forfeiture has not lapsed, the shares of Restricted Stock shall not be sold or otherwise transferred, other than by will or the laws of descent and distribution. 

(f) Each Initial Grant shall be evidenced by an Award Agreement, which shall contain such terms and provisions not inconsistent with this
Plan as the Board may approve. Unless otherwise directed by the Board, all certificates representing shares of Restricted Stock shall be held in custody by the Company until all restrictions thereon shall have lapsed, together with a stock power or
powers executed by the Non-Employee Director in whose name such certificates are registered, endorsed in blank. 
 5. Annual
Grants 
 (a) Commencing with the Annual Meeting in 2010, each Non-Employee Director who is then elected or is continuing as
a Non-Employee Director shall, without any further action of the Board, automatically receive an Annual Grant determined by dividing $30,000 by the Market Value per Share on the Date of Grant; provided, however, that the number of
shares of Restricted Stock shall be rounded downward such that no fractional share shall be issued. 
 (b) Each Annual Grant
shall constitute an immediate transfer of the ownership of shares of Restricted Stock to the Non-Employee Director, entitling such Non-Employee Director to voting, dividend and other ownership rights, but subject to the substantial risk of
forfeiture and restrictions on transfer set forth in this Section 5. 
 (c) Each Annual Grant shall provide that the shares
of Restricted Stock covered by such Annual Grant shall be subject to a “substantial risk of forfeiture” until the first Annual Meeting after the Date of Grant. Each Annual Grant shall provide that the Non-Employee Director shall forfeit
the shares of Restricted Stock covered by such Annual Grant if such Non-Employee Director terminates his or her service with the Company while such shares of Restricted Stock are subject to a substantial risk of forfeiture. Notwithstanding the
foregoing, each such Annual Grant shall provide for the immediate lapse of such substantial risk of forfeiture in the event of (i) the Non-Employee Director’s death or Total Disability, or (ii) upon a Change in Control. 

(d) Each Annual Grant shall provide that during the period for which such substantial risk of forfeiture has not lapsed, the shares of
Restricted Stock shall not be sold or otherwise transferred, other than by will or the laws of descent and distribution. 
 (e)
Each Annual Grant shall require that any and all dividends or other distributions (other than cash dividends) declared or otherwise distributed thereon be subject to the same restrictions as the underlying Annual Grant. 

(f) Each Annual Grant shall be evidenced by an Award Agreement, which shall contain such terms and provisions not inconsistent with this
Plan as the Board may approve. Unless otherwise directed by the Board, all certificates representing Restricted Stock shall be held in custody by the Company until all restrictions thereon shall have lapsed, together with a

  

 4 

 
stock power or powers executed by the Non-Employee Director in whose name such certificates are registered, endorsed in blank. 

6. Change in Control. For purposes of this Plan, except as may be otherwise defined in an Award Agreement, a “Change in
Control” shall mean the occurrence of any of the following events: 
 (a) the acquisition by any Person of beneficial
ownership (within the meaning of Rule 13d-3 promulgated under the Exchange Act) of 35% or more of the then outstanding Voting Securities of the Company; provided, however, that for purposes of this Section 6(a), the following
acquisitions shall not constitute a Change in Control: (A) any acquisition by the Company or a Subsidiary of Voting Securities, (B) any acquisition of Voting Securities by any employee benefit plan (or related trust) sponsored or
maintained by the Company or any Subsidiary or (C) any acquisition of Voting Securities by any Person pursuant to a Business Combination that complies with clauses (A), (B) and (C) of Section 6(c) below; 

(b) a majority of the Board ceases to be comprised of Incumbent Directors; 

(c) consummation of a reorganization, merger or consolidation, a sale or other disposition of all or substantially all of the assets of
the Company or other transaction (each, a “Business Combination”), unless, in each case, immediately following the Business Combination, (A) all or substantially all of the individuals and entities who were the beneficial owners of
Voting Securities immediately prior to the Business Combination beneficially own, directly or indirectly, more than 50% of the combined voting power of the then outstanding Voting Securities of the entity resulting from the Business Combination
(including, without limitation, an entity which as a result of such transaction owns the Company or all or substantially all of the Company’s assets either directly or through one or more subsidiaries), (B) no Person (other than the
Company, such entity resulting from the Business Combination, or any employee benefit plan (or related trust) sponsored or maintained by the Company, any Subsidiary or such entity resulting from the Business Combination) beneficially owns, directly
or indirectly, 35% or more of the combined voting power of the then outstanding Voting Securities of the entity resulting from the Business Combination; provided, however, that no Person will be treated for purposes of this
Section 6(c) as beneficially owning 35% or more of the Voting Securities of the entity resulting from the Business Combination solely as a result of the Voting Securities held in the Company prior to consummation of the Business Combination and
(C) at least a majority of the members of the board of directors of the entity resulting from the Business Combination were Incumbent Directors at the time of the execution of the initial agreement or of the action of the Board providing for
the Business Combination; or 
 (d) approval by the shareholders of the Company of a complete liquidation or dissolution of the
Company, except pursuant to a Business Combination that complies with clauses (A), (B) and (C) of Section 6(c) hereof. 

Notwithstanding anything to the contrary contained in this Section 6, a Person who holds 35% or more of the Voting Securities of the
Company on the Effective Date will not be deemed to have acquired 35% or more of the Voting Securities of the Company for purposes of Section 6(a) of this Plan (and as a result, such circumstance shall not constitute a Change in Control)

  

 5 

 
unless after the Effective Date such person acquires, in one or more transactions, additional Voting Securities of the Company representing 1% or more of the then outstanding Voting Securities of
the Company it being understood that an increase in the percentage of Voting Securities held by a Person as a result of (i) the exercise of any conversion or exchange right pursuant to any securities of the Company that were outstanding on the
Effective Date shall not be deemed to be an acquisition of Voting Securities by such Person, or (ii) the Company’s repurchase of Voting Securities of the Company is not an acquisition of Voting Securities by such Person. 

7. Fractional Shares. The Company shall not issue any fractional Common Shares pursuant to this Plan. 

8. Administration of the Plan. 

(a) This Plan shall be administered by the Board, which may from time to time delegate all or any part of its authority under this Plan to
a committee of the Board (or a subcommittee thereof). To the extent of any such delegation, references in this Plan to the Board shall be deemed to be references to such committee or subcommittee. 

(b) The interpretation and construction by the Board of any provision of this Plan or of any Award Agreement, and any determination by
the Board pursuant to any provision of this Plan or of any such Award Agreement, shall be final and conclusive. No member of the Board shall be liable for any such action or determination made in good faith. 

9. Amendment and Termination of Plan. The Board may from time to time and at any time amend or terminate the Plan in whole or in
part; provided, however, that any amendment (i) which must be approved by the shareholders of the Company in order to comply with applicable law or the rules of the principal exchange on which the Common Shares are traded or
quoted, or (ii) which would increase the benefits accruing to Non-Employee Directors, increase the aggregate number of Common Shares that may be issued under the Plan or materially modify the eligibility requirements for participating in the
Plan, shall not be effective unless and until the shareholders of the Company have approved such amendment. Notwithstanding anything to the contrary set forth in this Plan, in the event the common stock of the Company is no longer listed for trading
with a national securities exchange or the Nasdaq Stock Market LLC, then all future grants under this Plan shall be suspended until the Board shall take further action with respect thereto. 

10. Governing Law. All issues concerning construction, validity and interpretation of this Plan and all Awards granted hereunder
shall be governed by the law of the State of Texas, without regard to such state’s conflict of laws rules. 
 11.
General Provisions. 
 (a) Nothing in the Plan shall be deemed to create any obligation on the part of the Board to
nominate any Director for reelection by the Company’s shareholders or to limit the rights of the shareholders to remove any Director. 
  

 6 

 (b) All notices under this Plan shall be in writing, and if to the Company, shall be
delivered to the Secretary of the Company or mailed to its principal executive office addressed to the attention of the Secretary; and if to a Non-Employee Director, shall be delivered personally or mailed to the Non-Employee Director at the address
appearing on the records of the Company. Such addresses may be changed at any time by written notice to the other party. 
  

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