Document:

Exhibit 4(h)

 EXHIBIT 4(h) 
 FORM OF POLICY RIDER 
 (RIM) 

					
	 

	 		 	 Home Office:

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

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

 RETIREMENT INCOME MAXSM RIDER 
 GUARANTEED LIFETIME WITHDRAWAL BENEFIT 
 This rider is issued as a part of
the policy to which it is attached. All provisions of the policy that do not conflict with this rider apply to this rider. In the event of any conflict between the provisions of this rider and the provisions of the policy, the provisions of this
rider shall prevail over the provisions of the policy. 
 The purpose of the guaranteed living benefit provided under this
rider is to provide security through a stream of income payments to the Owner. This rider will terminate upon assignment or change in ownership of the policy unless the new assignee or Owner meets the qualifications specified in the Termination
provision on page 5 of this rider. 
 You may cancel this rider before midnight of the thirtieth calendar day after You
receive it and no Rider Fees will be assessed. 
 Rider Data Specification 

 

			
	Policy Number:	  	 12345

	Rider Date:	  	 05/01/2013

	Growth Rate Percentage:	  	 5.00%

	Initial Rider Fee Percentage*:	  	 1.25%

	Annuitant:	  	 John Doe

		
	Annuitant’s Issue Age/Sex:	  	 35    /  Male

 *The initial rider fee percentage is also the maximum rider fee percentage for the life of the policy,
provided there are no automatic step-ups. When an automatic step-up is utilized, the maximum rider fee percentage will be 0.75% greater than the initial rider fee percentage shown above. 

Designated Allocations:  If You elect this rider, 100% of Your Policy Value must be in one or more of the Designated
Investment Options. 
 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. You will be notified if there are any changes to the Designated Allocations. 

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

									
		 		 		  	Withdrawal	 	
		 	Attained Age	 		  	Percentage	 	
					
		 	0 - 58	 		  	0.0%	 	
		 	59 - 64	 		  	4.3%	 	
		 	65 - 79	 		  	5.3%	 	
		 	80 +	 		  	6.3%	 	

  

					
	 ICC12 RGMB410513(IS)
	  	(1)	  	  
 (Income-Single)

 ARTICLE I 
 DEFINITIONS: 
 Terms used that are not defined in this rider shall have the same meaning as
those in Your policy. 
 Designated Investment Options 
 Investment Options authorized for use with this rider and identified by us as Designated Investment Options. 
 Excess Withdrawal 
 The excess of a Gross Partial Withdrawal over the Rider Withdrawal
Amount remaining prior to the withdrawal, if any. 
 Gross Partial Withdrawal 
 The amount which will be deducted from Your Policy Value as a result of each partial withdrawal. 

Rider Anniversary 
 The anniversary of
the rider date. 
 Rider Fee 

The fees charged for the benefits under this rider. The fees will be charged on a rider quarterly basis by the Company. 

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

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

The maximum amount that can be withdrawn from the policy each Rider Year without causing an Excess Withdrawal under the terms of this
rider and thus reducing the Withdrawal Base. This amount will change if the Withdrawal Base changes. 
 Rider Year 

Each twelve-month period following the rider date. 
 Withdrawal Base 
 The amount used to calculate the Rider Withdrawal
Amount and the Rider Fee. This amount cannot be taken as a surrender and is not payable as a death benefit. 
 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 and the maximum rider fee percentage are described 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. 

  

					
	 ICC12 RGMB410513(IS)
	  	(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 Rider Year, regardless of the Policy Value, (first as withdrawals from Your Policy Value and, if necessary, as payments from us) until the Annuitant’s death. 

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

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

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

ISSUE AGE AND SURVIVAL 

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

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

 

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

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

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

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

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

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

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

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

  

					
	 ICC12 RGMB410513(IS) 
	  	(3)	  	  
 (Income-Single)

 ARTICLE III CONTINUED 

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

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

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

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

	 	1)	 The current Withdrawal Base; 

	 	2)	 The Policy Value on the Rider Anniversary; 

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

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

Item 3) above will be zero if there have been any Excess Withdrawals in the current Rider Year. Item 4) above will be zero
after the 10th Rider Anniversary or if there have been any withdrawals in the current Rider Year. 
 AUTOMATIC STEP-UP FEATURE

 The rider receives an automatic step-up on the Rider Anniversary if the Withdrawal Base is set equal to the Policy Value
or the highest Policy Value on a Rider Monthiversary. This feature does not require the termination of the existing rider. This rider will continue with the same rider date and features. The Rider Fee and withdrawal percentages may be changed due to
an automatic step-up. Beginning with the first Rider Anniversary, the rider fee percentage may be increased if there is an automatic step-up, but will not exceed the maximum rider fee percentage described in the Rider Data Specification section.

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

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

 

	1)	 is the Excess Withdrawal amount; and 

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

 

	 	A)	 is the Excess Withdrawal; 

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

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

  

					
	 ICC12 RGMB410513(IS) 
	  	(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 rider continues with the same rider values. In the case of spousal joint Owners where one spouse is the Annuitant, if the spouse who is the
Annuitant dies, this rider will terminate. 
 In the case of non-spousal joint Owners where an Owner who is not the Annuitant
dies, the surviving Owner (who is also the sole designated beneficiary) may elect to receive lifetime income payments under this rider instead of receiving any benefits applicable to the policy. The lifetime income payments must begin no later than
1 year after the Owner’s death and will be equal to the Rider Withdrawal Amount divided by the number of payments made per year. Once the payments begin, no additional Premium Payments will be accepted and no additional withdrawals will be
paid. 
 ANNUITIZATION 
 On the maximum Annuity Commencement Date, as described in Your policy, You will have the option to receive lifetime income payments that are no less than Your Rider Withdrawal Amount each year.

 TERMINATION 
 This rider
will terminate upon the earliest of: 
  

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

	2)	 the date the policy to which this rider is attached is assigned or if the Owner is changed without our approval; 

	3)	 the date of the Annuitant’s death; 

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

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

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

Termination of the rider will result in the loss of all benefits provided by the rider. After termination, rider fees will no longer be
assessed. 
 REPORTS TO OWNER 
 We will give You a report at least once each Policy Year. Before You are eligible to receive the Rider Withdrawal Amount, the report will direct You to contact the Company for information regarding Your
Rider Withdrawal Amount. After You are eligible for Your Rider Withdrawal Amount, this amount will be included in the report. 

Signed for us at our home office. 
  

							
	 

 SECRETARY
	 		  	 

 PRESIDENT
	 	
	 		  	 	

  

					
	 ICC12 RGMB410513(IS) 
	  	(5)	  	  
 (Income-Single)

					
	 

	 		 	 Home Office:

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

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

 RETIREMENT INCOME MAXSM RIDER 
 GUARANTEED LIFETIME WITHDRAWAL BENEFIT 
 This rider is issued as a part of
the policy to which it is attached. All provisions of the policy that do not conflict with this rider apply to this rider. In the event of any conflict between the provisions of this rider and the provisions of the policy, the provisions of this
rider shall prevail over the provisions of the policy. 
 The purpose of the guaranteed living benefit provided under this
rider is to provide security through a stream of income payments to the Owner. This rider will terminate upon assignment or change in ownership of the policy unless the new assignee or Owner meets the qualifications specified in the Termination
provision on page 5 of this rider. 
 You may cancel this rider before midnight of the thirtieth calendar day after You
receive it and no Rider Fees will be assessed. 
 Rider Data Specification 

 

			
	Policy Number:	  	 12345

	Rider Date:	  	 05/01/2013

	Growth Rate Percentage:	  	 5.00%

	Initial Rider Fee Percentage*:	  	 1.25%

	Annuitant:	  	 John Doe

		
	Annuitant’s Issue Age/Sex:	  	 35    /  Male

	Annuitant’s Spouse:	  	 Jane Doe

	Annuitant’s Spouse’s Issue Age/Sex:	  	 35    /  Female

 *The initial rider fee percentage is also the maximum rider fee percentage for the life of the policy,
provided there are no automatic step-ups. When an automatic step-up is utilized, the maximum rider fee percentage will be 0.75% greater than the initial rider fee percentage shown above. 

Designated Allocations: If You elect this rider, 100% of Your Policy Value must be in one or more of the Designated Investment
Options. 
 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. You will be notified if there are any changes to the Designated Allocations. 
 Guaranteed
Lifetime Withdrawal Benefit: The withdrawal percentage is determined by the attained age and is used to determine the Rider Withdrawal Amount as described in Article III of this rider. The withdrawal percentages are shown in the table below:

  

							
		 		  	Withdrawal	 	
		 	Attained Age	  	Percentage	 	
				
		 	0 - 58	  	0.0%	 	
		 	59 - 64	  	3.8%	 	
		 	65 - 79	  	4.8%	 	
		 	80 +	  	5.8%	 	

  

					
	 ICC12 RGMB410513(IJ)
	  	(1)	  	  
 (Income-Joint)

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

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

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

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

The amount which will be deducted from Your Policy Value as a result of each partial withdrawal. 
 Rider Anniversary 
 The anniversary of the rider date. 

Rider Fee 
 The fees charged for the
benefits under this rider. The fees will be charged on a rider quarterly basis by the Company. 
 Rider Monthiversary 

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

 Each three-month period beginning on the rider date. 
 Rider Withdrawal Amount 
 The maximum amount that can be withdrawn from the
policy each Rider Year without causing an Excess Withdrawal under the terms of this rider and thus reducing the Withdrawal Base. This amount will change if the Withdrawal Base changes. 
 Rider Year 
 Each twelve-month period following the rider date. 

Withdrawal Base 

The amount used to calculate the Rider Withdrawal Amount and the Rider Fee. This amount cannot be taken as a surrender and is
not payable as a death benefit. 
 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
and the maximum rider fee percentage are described 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. 

  

					
	 ICC12 RGMB410513(IJ)
	  	(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 Rider Year, regardless of the Policy Value, (first as withdrawals from Your Policy Value and, if necessary, as payments from us) until the Annuitant’s or the Annuitant’s
spouse’s death, whichever is later. 
 The withdrawal percentage is determined by the attained age (age at last birthday)
of the younger of the living spouses at the time of the first withdrawal of any amount from the Policy Value taken on or after the Rider Anniversary following the younger of the living spouse’s 59th birthday. Once the withdrawal percentage is
established, it may only be changed by an automatic step-up. Upon automatic step-up, the withdrawal percentage will be reset based on the attained age of the younger of the living spouses at the time of the automatic step-up. The withdrawal
percentages are shown in the table in the Rider Data Specification section. 
 If the younger of the Annuitant and the
Annuitant’s spouse is not yet 59 on the rider date, the withdrawal percentage will be zero until the Rider Anniversary following the younger of the living spouse’s 59th birthday. Withdrawals prior to age 59 1/2 will be subject to the IRS
10% early withdrawal penalty. 
 Withdrawals will reduce the Policy Value and death benefit of the policy to which this rider is
attached. If the Policy Value equals zero, You cannot make subsequent Premium Payments and all other policy features, benefits and guarantees are no longer available. Also, if the Policy Value equals zero, You will need to request payments by
selecting the amount and frequency in accordance with the policy provisions to which this rider attaches, equal to the Rider Withdrawal Amount. Once the payment amount and frequency are established, they cannot be changed and no additional
withdrawals will be allowed. 
 ISSUE AGE AND SURVIVAL 
 The benefits under this rider depend on the Annuitant or Annuitant’s spouse being alive at the time of withdrawal and the amount of the benefit depends on the issue age of the Annuitant and
Annuitant’s spouse. Proof of survival and the issue ages may be required by the Company. 
 If the younger of the
spouses’ ages has been misstated, this rider’s fees and benefits will be adjusted to the amounts which would have been calculated for the correct age. However, if this rider would not have been issued had the age not been misstated, the
rider is treated as if it never existed, and any fees charged for this rider would be returned. If withdrawals under the provisions of the rider have already commenced and the misstatement caused the Rider Withdrawal Amount to be overstated, any
withdrawal in excess of the correct Rider Withdrawal Amount will be considered an Excess Withdrawal and will impact the Withdrawal Base and Rider Withdrawal Amount. If overpayments occurred when the sum of the accumulated values in all the
Investment Options was zero, the amount of that overpayment will be deducted from one or more future payments until this amount is paid in full. 
 RIDER WITHDRAWAL AMOUNT 
 The Rider Withdrawal Amount will be equal to the greater of 1)
and 2), where: 
  

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

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

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

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

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

  

					
	 ICC12 RGMB410513(IJ)
	  	(3)	  	  
 (Income-Joint)

 ARTICLE III CONTINUED 

 

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

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

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

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

 If You withdraw less than the Rider Withdrawal Amount in a Rider Year, the unused portion cannot be carried over to the next
Rider Year. 
 Surrender charges may apply if Your Rider Withdrawal Amount exceeds Your surrender charge-free amount. 

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

	 	1)	 The current Withdrawal Base; 

	 	2)	 The Policy Value on the Rider Anniversary; 

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

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

Item 3) above will be zero if there have been any Excess Withdrawals in the current Rider Year. Item 4) above will be zero
after the 10th Rider Anniversary or if there have been any withdrawals in the current Rider Year. 
 AUTOMATIC STEP-UP FEATURE

 The rider receives an automatic step-up on the Rider Anniversary if the Withdrawal Base is set equal to the Policy Value
or the highest Policy Value on a Rider Monthiversary. This feature does not require the termination of the existing rider. This rider will continue with the same rider date and features. The Rider Fee and withdrawal percentages may be changed due to
an automatic step-up. Beginning with the first Rider Anniversary, the rider fee percentage may be increased if there is an automatic step-up, but will not exceed the maximum rider fee percentage described in the Rider Data Specification section.

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

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

 

	1)	 is the Excess Withdrawal amount; and 

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

 

	 	A)	 is the Excess Withdrawal; 

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

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

  

					
	 ICC12 RGMB410513(IJ)
	  	(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 rider continues with the same rider values. In the case of spousal joint Owners where one spouse is the Annuitant, if the spouse who is the
Annuitant dies and the surviving spouse is the sole beneficiary, the rider continues with the same rider values if the policy to which this rider is attached is continued 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. 
 TERMINATION 
 This rider will terminate upon the earliest of: 

 

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

	2)	 the date the policy to which this rider is attached is assigned or if the Owner is changed without our approval; 

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

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

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

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

Termination of the rider will result in the loss of all benefits provided by the rider. After termination, rider fees will no longer be
assessed. 
 REPORTS TO OWNER 
 We will give You a report at least once each Policy Year. Before You are eligible to receive the Rider Withdrawal Amount, the report will direct You to contact the Company for information regarding Your
Rider Withdrawal Amount. After You are eligible for Your Rider Withdrawal Amount, this amount will be included in the report. 

Signed for us at our home office. 
  

							
		 	 

 SECRETARY
	  	 

 PRESIDENT
	 	
		 	  	 	

  

					
	 ICC12 RGMB410513(IJ)
	  	(5)	  	  
 (Income-Joint)Exhibit 4(a)

 EXHIBIT 4(a) 
 FORM OF POLICY 

			
	

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

(319) 355-8511

www.transamericaannuities.com

 READ YOUR POLICY CAREFULLY 
 This policy is a legal contract between the Owner and Transamerica Life Insurance Company issued in consideration of the payment of an initial premium. 

Amounts withdrawn or Surrendered may be subject to an excess interest adjustment reflecting changes in interest rates. The excess interest adjustment
may result in both upward and downward adjustments in partial withdrawals, Surrender benefits or amounts available for annuitizations, as applicable. The value held in the Separate Account may increase or decrease in value. Policy Value and benefits
based on Separate Account assets are not guaranteed and will decrease and increase with investment experience. 
 We agree to provide
annuity payments, to pay withdrawal or Surrender benefits, or to pay death proceeds in accordance with this policy, as applicable. 
 This
policy may be applied for and issued to qualify as a tax-qualified annuity under applicable sections of the Internal Revenue Code. 
 RIGHT TO CANCEL 
 You may cancel this policy by delivering or mailing a written notice in
Good Order to us or Your registered representative. You must return the policy to us before close of business on the 10th day after the day You receive it. Notice given by mail and return of the policy by mail are effective on being postmarked,
properly addressed and postage prepaid. 
 We will pay You an amount equal to the sum of the Premium Payments paid less prior withdrawals, if
any, plus or minus the accumulated gains or losses, if any, in the Separate Account on the date of the cancellation, unless otherwise required by law. 
 If this policy is a replacement of another annuity or life insurance policy, the Right to Cancel period is extended to 30 days. 
 Any questions or complaints pertaining to this policy may be directed to our Administrative Office. You may contact the State Department of Insurance at XXX-XXX-XXXX. 

Signed for us at our home office. 
  

			
	

	  	

		
	SECRETARY	  	PRESIDENT

 Flexible Premium Deferred Variable Annuity 

With Excess Interest Adjustment 
 Income Payable At Annuity Commencement Date 
 Benefits Based On The
Performance Of The Separate Account Are Variable 
 And Are Not Guaranteed As To Dollar Amount (See Sections 7 and 10)

 Non-Participating 
 ICC12 VA(2)0513 

  
 Page 1

 TABLE OF CONTENTS 

 

					
	 Definitions
	  	 	3	  
	 Policy Data Pages
	  	 	5	  
	 General Provisions
	  	 	6	  
	 Premium Payments
	  	 	9	  
	 Cash Value and Withdrawals
	  	 	9	  
	 Policy Value
	  	 	12	  
	 Separate Account
	  	 	12	  
	 Transfers
	  	 	14	  
	 Death Proceeds
	  	 	16	  
	 Income Options
	  	 	18	  
	 Fixed Account
	  	 	21	  
	 Income Option Tables
	  	 	22	  

  
 ICC12 VA(2)0513 

Page 2 

 SECTION 1 – DEFINITIONS 
 Adjusted Policy Value – The Policy Value increased or decreased by any applicable excess interest adjustment. This value may be used to fund one of the income options. 

Annuitant – The person on whose life any annuity payments involving life contingencies will be based. 

Annuity Commencement Date – The date an income option has been selected, all necessary paperwork is in Good Order, and the Company has issued
a supplementary contract. In no event can this date be earlier than the third Policy Anniversary, or later than the last day of the month following the month in which the Annuitant attains age 99. You may elect an Annuity Commencement Date at any
time by giving the Company 30 days written notice. If You do not elect an Annuity Commencement Date prior to the last available Annuity Commencement Date, annuity payments will begin as outlined in Section 10. 

Cash Value –The amount as defined in Section 5 that is available for Surrender. 

Commissioner - The primary Insurance Regulator for the State in which this policy has been issued. 

DCA Source Account - The Money Market Subaccount and/or other Subaccount(s) as identified by the Company and the DCA Fixed Account Option, if
offered, which are permitted to be used in conjunction with Dollar Cost Averaging. 
 Decedent - The deceased Annuitant or Owner.

 Earnings – An amount equal to the Policy Value at the time a withdrawal or Surrender is made, minus the sum of all Premium
Payments, reduced by all prior withdrawals deemed to have been from premium, if any. 
 Fixed Account Guaranteed Minimum Effective Annual
Interest Rate – If the Fixed Account is offered, the minimum guaranteed credited rate used to determine the Fixed Account portion of Your Policy Value prior to the Annuity Commencement Date. This rate will apply for the life of the policy
and is shown in Section 2 - Policy Data. 
 Good Order – The receipt by the Company, at our Administrative Office, of all
information, documentation, instructions and/or Premium Payment deemed necessary by the Company, in its sole discretion, to issue the policy or execute any transaction pursuant to the terms of the policy. 

Guaranteed Period Option or GPO – An Investment Option offered within the Fixed Account which credits a guaranteed interest rate for a
specified period of time. 
 Investment Options – Any of the Subaccounts of the Separate Account and any of the options of the Fixed
Account, if offered. 
 IIPRC - The Interstate Insurance Product Regulation Commission. 

Market Day – Any day and for so long as the New York Stock Exchange is open for business. 

Minimum Nonforfeiture Interest Rate - The interest rate shown in Section 2 - Policy Data which is used to determine the Minimum Required Cash
Value as defined in the nonforfeiture law. This rate is not the credited rate used to determine Your policy’s Cash Value. 
 Minimum
Required Cash Value – The minimum amount we will pay You on Surrender, which is equal to the sum of (1) and (2), where: 
  

	 	(1)	Is the Fixed Account portion of the Minimum Required Cash Value, equal to 87.5% of premiums and transfers to the Fixed Account, less prior requested withdrawals and
transfers from the Fixed Account, less a $50 deduction at the beginning of each Policy Year, all accumulated at the Minimum Nonforfeiture Interest Rate shown in Section 2 - Policy Data; and 

 

	 	(2)	Is the Separate Account portion of the Policy Value. 

  
 ICC12 VA(2)0513 

Page 3 

 Owner – The person who may exercise all rights and privileges under the policy. 

Policy Anniversary – The anniversary of the Policy Date for each year the policy remains in force. If a certain date does not exist in a
given month, the first day of the following month will be used. 
 Policy Date – The date, shown in Section 2 - Policy Data, on
which this policy becomes effective. 
 Policy Value – The amount described in Section 6, which represents the value of Your
Investment Options. 
 Policy Year – The 12-month period following the Policy Date shown in Section 2 - Policy Data. The first
Policy Year starts on the Policy Date. Each subsequent Policy Year starts on the anniversary of the Policy Date. 
 Premium Payment –
An amount paid to us by or on behalf of an Owner, as consideration for the benefits provided under this policy. 
 Separate Account
– The separate investment account(s) established by us, under the Investment Company Act of 1940, as amended (the “1940 Act”), to which Premium Payments under the policy may be allocated. 

Subaccount – A division within the Separate Account, the assets of which are invested in a specified underlying fund portfolio. 

Surrender – A full withdrawal of Cash Value and termination of this policy. 
 Valuation Period - The period of time from one determination of the value of each Subaccount to the next. Such determinations are made when the values of the assets and liabilities of each
Subaccount are calculated. This is generally the close of business on each Market Day. 
 You, Your – The Owner of this policy.
Unless otherwise specified, the Annuitant and the Owner shall be the same person. If a joint Owner is named, reference to “You” or “Your” in this policy will apply to both the Owner and any joint Owner. 

  
 ICC12 VA(2)0513 

Page 4 

 SECTION 2 – POLICY DATA 

Policy Information 
  

			
	Policy Number:	  	12345
		
	Policy Date:	  	May 1, 2013
		
	Income Tax Status of the Policy:	  	Non-Qualified
		
	Initial Premium Payment:	  	$5,000.00
		
	Last Available Annuity Commencement Date:	  	May 31, 2077
		
	Death Benefit Option:	  	Policy Value

 Annuitant(s) Information 

 

			
	Annuitant(s):	  	John Doe
		
	Primary Annuitant’s Issue Age/Sex:	  	35 / Male

 Owner(s) Information 

 

			
	Owner(s):	  	John Doe
		
	Primary Owner’s Issue Age/Sex:	  	35 / Male

 Rate Information for Fixed Account, if offered 

 

			
	Fixed Account Guaranteed Minimum Effective Annual Interest Rate:*	  	0.25%
		
	Minimum Nonforfeiture Interest Rate:**	  	1.00%

  

	*	This rate applies for the life of the policy. 

	**	This rate applies for the life of the policy. This rate is used in the calculation of Your Minimum Required Cash Value. Your Minimum Required Cash Value reflects a
12.50% reduction in premiums and transfers to the Fixed Account and a $50 annual expense allowance. See the definition of Minimum Required Cash Value for the details of this calculation. 

Regarding the Excess Interest Adjustment (EIA) feature: 
  

	 	a.	The guaranteed elements used to determine any EIA are the minimum guaranteed and current declared interest rates applicable to the Fixed Account;

  

	 	b.	Declared interest rates used in computing any EIA may change from time to time (subject to Fixed Account Guaranteed Minimum Effective Annual Interest Rate), which may
affect the benefits available under Your policy; and 

  

	 	c.	The U.S. Treasury rate may be used as a substitute for the current declared interest rate in the EIA formula as specified in Your policy. 

ICC12 PD(2)0513 

  
 Page 5(a)

 SECTION 2 – POLICY DATA (continued) 

 

 Minimum Premium Payments 

 

			
	Minimum Initial Premium Payment:	  	Non-Qualified - $5,000
 Qualified -
$1,000

		
	Minimum Subsequent Premium Payment:	  	$50

 Maximum Premium Payments (without prior Company Approval) 

 

					
	 	  	Issue Age 0-80*	  	Issue Age 81+*
	Total during the 1st Policy Year:	  	$1,000,000	  	$500,000
			
	Total during each Policy Year After 1st Policy Anniversary:	  	Non-qualified - $25,000

Qualified - Lesser of $60,000 or IRS
Contribution limit
	  	Non-qualified - $25,000
Qualified - Lesser of $60,000 or IRS
Contribution limit
			
	Cumulative Maximum Premiums - Life of Policy:	  	$1,000,000	  	$500,000

  

	*	Issue Age is the greater of the Owner(s)’ or Annuitant(s)’ age. 

 Mortality and Expense Risk Fee and Administrative Charge 
  

			
	Before the Annuity Commencement Date:	  	0.45%
		
	After the Annuity Commencement Date:	  	0.45%

 The amount paid on Surrender will never be less than the greater of the following amounts: 

 

	 	a.	Cash Value described in Section 5; and 

  

	 	b.	Minimum Required Cash Value. 

  
 ICC12 PD(2)0513 

Page 5(b) 

 SECTION 2 – POLICY DATA (continued) 

 

 Service Charge 

 

			
	Service Charge at the Time of Issue:	  	$35
		
	Maximum Annual Service Charge:	  	$50

 The Company may waive some or all of Your service charge each year based on Your Policy Value, Premium Payments made or
active participation in specific online or e-delivery service programs at the time a service charge is assessed. 
  

	1.	If Your Policy Value or sum of Premium Payments minus all withdrawals equals or exceeds: 

$50,000 = up to a $35 fee waiver 
 $250,000 = up to a $50 fee waiver 
  

	2.	Enrollment in specific online or e-delivery service programs may result in up to a $15 fee waiver. 

Transfer Minimums and Charges Before the Annuity Commencement Date 

 

			
	Transfers Allowed Without Charges in any One Policy Year:	  	12
		
	Charges After Allowable Transfers in any One Policy Year:	  	$10
		
	Minimum Transfer Amount from a Subaccount:	  	$500 or the entire Subaccount Policy Value, if less
		
	Minimum Transfer Amount from a GPO:	  	$50

 Fixed Account Transfer Maximum Before the Annuity Commencement Date 

 

			
	Maximum Transfer from the GPO when EIA has no Impact or a Positive Impact:	  	100% of the GPO’s Value
		
	Maximum Transfer from the GPO when EIA has a Negative Impact:	  	25% of the GPO’s Value

 Dollar Cost Averaging (DCA) 

 

			
	DCA Source Account Minimum:	  	$3,000
		
	Minimum Amount of each Transfer:	  	$500
		
	Minimum Time DCA can be Scheduled:	  	6 months
		
	Maximum Time DCA can be Scheduled:	  	24 months

  
 ICC12 PD(2)0513 

Page 5(c) 

 SECTION 2 – POLICY DATA (continued) 

 

 Fund Facilitation Fee 
 A Fund Facilitation Fee may be charged in addition to any policy fees and charges, and will be used in the calculation of net investment factor as described in Section 7 of the policy. The Fund
Facilitation Fee will only be charged when money is allocated to one of the Subaccounts listed with a Fund Facilitation Fee. The Fund Facilitation Fee is an annualized percentage taken from the daily net asset values of a fund share held in that
Subaccount. 
 We may update Fund Facilitation Fee funds and charge up to the maximum of 0.30% for Subaccounts made available subsequent to the
Policy Date. The Subaccount(s) as of Your Policy Date which include this fee are listed below with the current fee noted after the Subaccount name. 
 Initial Investment Options: 

 

 Fixed Account(s) : 
 1 Year Fixed Guaranteed Period 
 3 Year Fixed Guaranteed Period 

5 Year Fixed Guaranteed Period 
 7 Year Fixed
Guaranteed Period 
 Subaccounts: 

TA AEGON Money Market 
 TA AEGON High Yield Bond

 TA AEGON Tactical Vanguard ETF - Balanced 
 TA AEGON Tactical Vanguard ETF - Conservative 
 TA AEGON Tactical Vanguard ETF - Growth 

TA AEGON U.S. Government Securities 
 TA
AllianceBernstein Dynamic Allocation 
 TA Asset Allocation - Conservative 
 TA Asset Allocation - Growth 
 TA Asset Allocation - Moderate 

TA Asset Allocation - Moderate Growth 
 TA Barrow
Hanley Dividend Focused 
 TA BlackRock Global Allocation 
 TA BlackRock Tactical Allocation 
 TA BNP Paribas Large Cap Growth 

TA Clarion Global Real Estate Securities 
 TA
Hanlon Income 
 TA International Moderate Growth 
 TA Janus Balanced

 TA Jennison Growth 
 TA JPMorgan Core Bond 
 TA JPMorgan Enhanced Index 

TA JPMorgan Mid Cap Value 
 TA JPMorgan Tactical
Allocation 
 TA Jennison Growth 
 TA
Legg Mason Dynamic Allocation - Balanced 
 TA Legg Mason Dynamic Allocation - Growth 
 TA Market Participation Strategy 
 TA MFS International Equity 

TA Morgan Stanley Mid-Cap Growth 
 TA
Multi-Managed Balanced 
 TA PIMCO Real Return TIPS 
 TA PIMCO Tactical - Balanced 
 TA PIMCO Tactical - Conservative 

TA PIMCO Tactical - Growth 
 TA PIMCO Total
Return 
 TA Systematic Small/Mid Cap Value 
 TA T. Rowe Price Small Cap 
 TA TS&W International Equity 

TA Vanguard ETF - Aggressive Growth 
 TA Vanguard
ETF - Balanced 
 TA Vanguard ETF - Conservative 
 TA Vanguard ETF - Growth 
 TA WMC Diversified Growth

 

  
 NIC12 PD(2)0513 

  
 Page 5(d)

 SECTION 3 – GENERAL PROVISIONS 

The Contract 
 The entire contract
consists of this policy and any applications, endorsements or riders. If any portion of this policy or rider attached hereto shall be found to be invalid, unenforceable or illegal, the remainder shall not in any way be affected or impaired thereby,
but shall have the same force and effect as if the invalid, unenforceable or illegal portion had not been inserted. 
 Modification of Policy

 No change in this policy is valid unless made in writing by us and approved by one of our authorized officers. We may pay You more than
Your then current Policy Value for Your voluntary participation in certain promotional offerings. We will notify You of the terms of any such programs. 
 Tax Qualification and Change of Law 
 This policy is intended to qualify as an annuity
contract for federal income tax purposes. The provisions of this policy are to be interpreted to maintain such qualification, notwithstanding any other provisions to the contrary. To maintain such tax qualification, we reserve the right to amend
this policy, retroactively or prospectively, to reflect any amendment or clarifications that may be needed or are appropriate to maintain such tax qualification or to conform this policy to any applicable changes in the tax qualification
requirements. We will send You a copy in the event of any such amendment. If You refuse such an amendment, You must provide written notice to us, and Your refusal may result in adverse tax consequences. We reserve the right to amend this policy or
riders attached to, as necessary to comply with specific direction provided by our state or federal regulators, through change of law, rule, regulation, bulletin, regulatory directives or agreements. 

Non-Participating 
 This policy will not
share in our profits. 
 Form Approval 
 This policy is approved under the authority of the IIPRC and issued under the IIPRC standards. Any provision of this policy that on the provision’s effective date is in conflict with IIPRC standards
for this product type is hereby amended to conform to the IIPRC standards for this product type as of the provision’s effective date. 

Age or Sex Corrections 
 We may require
proof of the Annuitant’s or Owner’s age and/or sex before any payments associated with the death benefit or any rider(s) attached to this policy are made. If the age and/or sex of the Annuitant or Owner is incorrectly stated, we will base
any such payment associated with the death benefit and/or rider benefit proceeds on the Annuitant’s or Owner’s correct age and/or sex. If required by law to ignore differences in the sex of the Annuitant, the annuity payments will be
determined using the unisex factors in Section 10. 
 We may require proof of the Annuitant’s age and/or sex before starting annuity
payments. If the age and/or sex (or both) of the Annuitant is incorrectly stated, we will correct the amount payable based upon the Annuitant’s correct age and/or sex, if applicable. Any underpayment made by us will be paid with the next
payment. Any overpayment by us will be deducted from future payments. Any underpayment or overpayment will include annual interest at a rate of 1% per year, from the date of the underpayment or overpayment to the date of the adjustment.

 Incontestability 
 This
policy shall be incontestable from the Policy Date, except in instances involving fraud. 
 Involuntary Cashout 

If, at anytime, Your Adjusted Policy Value is below $2,000, and there have been no Premium Payments made to the policy within the last two Policy Years,
we reserve the right to terminate the policy and pay the greater of: 
  

	 	a.	The Fixed Account portion of the Minimum Required Cash Value plus the Separate Account portion of the Policy Value; or 

 

	 	b.	The Adjusted Policy Value. 

  
 ICC12 VA(2)0513 

Page 6 

 Evidence of Survival 
 We have the right to require satisfactory evidence that a person was alive if a payment is based on that person being alive. 
 Rights of Owner 
 The Owner may, while the Annuitant is living: 

 

	 	a.	Assign this policy; 

  

	 	b.	Surrender the policy to us; 

  

	 	c.	Amend or modify the policy with our consent; 

  

	 	d.	Receive annuity payments or name a payee to receive the payments; and 

  

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

 The use of these rights may be subject to the consent of any assignee or irrevocable beneficiary, and of the spouse in a community or marital property state. Unless we have been notified of a community or
marital property interest in this policy, we will rely on our good faith belief that no such interest exists and will assume no responsibility for inquiry. 
 Change of Ownership 
 In the case of a non-tax-qualified annuity, You can change the Owner
of this policy from Yourself to a new Owner. You must send written notification, to our Administrative Office, which contains all necessary information to make the change. Any Owner change made, unless otherwise specified by the Owner, shall take
effect on the date the notification is signed by the Owner, when received in Good Order, subject to any payments made or actions taken by us prior to receipt of the notification. No change will apply to any payment we made before the written notice
was received. 
 We may require that the change be endorsed in the policy. Changing the Owner does not change the beneficiary or the Annuitant.
A change of Ownership may result in adverse tax consequences. A change in Ownership due to death is outlined further in Section 9. 

Assignment 
 In the case of a
non-tax-qualified annuity, this policy may be assigned. You must send written notification, to our Administrative Office, which contains all necessary information to make the change. Any assignment made, unless otherwise specified by the Owner,
shall take effect on the date the notification is signed by the Owner, when received in Good Order, subject to any payments made or actions taken by us prior to receipt of the notification. 
 We assume no responsibility for the validity of any assignment. Any claim made under an assignment shall be subject to proof of interest and the extent of the assignment. Assignment does not change the
benefit or amount of the policy. 
 This policy may be applied for and issued to qualify as a tax-qualified annuity under certain sections of
the Internal Revenue Code (IRC). Ownership of this policy is then restricted so it will comply with provisions of the IRC. 
 Assignment of this
policy may result in adverse tax consequences. 
 Beneficiary 
 Amounts payable upon death in accordance with Section 9, may be payable to the designated beneficiary or beneficiaries. Such beneficiary(ies) must be named and may be changed without beneficiary
consent (unless irrevocably designated or required by law) by notifying us in writing, on a form acceptable to us. Unless otherwise specified by You, the change will take effect upon the date You sign it, whether or not You are living when we
receive it, subject to any payments made or actions taken by the Company prior to receipt of this notice. The notice must have been postmarked (or show other evidence of delivery that is acceptable to us) on or before the Decedent’s date of
death. Your most recent beneficiary change notice will replace any prior beneficiary designations. No change will apply to any payment we made before the written notice was received by us. If an irrevocable beneficiary dies, You may designate a new
beneficiary. 
 You may elect the method of payment for each named beneficiary, subject to our then current rules, prior to the date of death of
the Decedent. When no such election is made as to a specific beneficiary, such beneficiary must elect the method of payment within 60 days of the date we receive all required documentation, in Good Order, to pay the amount payable to that
beneficiary. 
 If there is more than one beneficiary at any level (primary or contingent), and You failed to specify their interest, they will
share equally. 

  
 ICC12 VA(2)0513 

Page 7 

	 	a.	General Distribution Rules 

Unless You have provided other specific instructions to us, amounts payable upon death will be paid in accordance with Section 9 and
as outlined below: 
  

	 	1.	If a primary beneficiary is alive at the time of Decedent’s death, payment will be made to the primary beneficiary; 

 

	 	2.	If a primary beneficiary dies before the Decedent and there are additional living primary beneficiaries, the deceased primary beneficiary’s interest will be shared
proportionately with all living primary beneficiaries; 

  

	 	3.	When all primary beneficiaries die before the Decedent’s death, payment will be made to the living contingent beneficiary(ies), if any; 

 

	 	4.	If a contingent beneficiary dies before the Decedent and there are additional living contingent beneficiaries, the deceased contingent beneficiary’s interest will
be shared proportionately with all living contingent beneficiaries; 

  

	 	5.	In the event no primary or contingent beneficiaries have been named and/or all have died before the Decedent, the Owner’s estate will become the beneficiary;

  

	 	6.	If a primary or contingent beneficiary dies after the Decedent’s death, but prior to death proceeds being payable to the beneficiary, payment will be made to the
beneficiary’s estate. 

  

	 	b.	Other Specific Instructions 

 You may provide specific instructions to the Company which direct that upon the death of a beneficiary, that their interest pass to a specific contingent beneficiary(ies) or per stirpes. 

 

	 	1.	Per Stirpes: If You provide instructions that a specific primary or contingent beneficiary’s share be passed per stirpes, we will pay that beneficiary’s share
to their identifiable lineal descendants who are living at the time of Decedent’s death. 

  

	 	2.	Specific Contingent: If You provide instructions that a specific primary or contingent beneficiary’s share be passed to a specified contingent beneficiary(ies), we
will pay that specific beneficiary’s share to those identifiable specific contingent beneficiaries who are living (or in existence) at the time of Decedent’s death. 

A deceased beneficiary share will be distributed as outlined under General Distributions Rules above. 

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

 Deferment 
 Payment of any
amount due from the Separate Account for a Surrender, withdrawal or death proceeds will generally occur within seven days from the date we receive in Good Order all required information. We may defer payments or transfers from the Separate Account
if: 
  

	 	a.	The New York Stock Exchange is closed other than for usual weekends or holidays or trading on the Exchange is otherwise restricted; 

 

	 	b.	An emergency exists as defined by the Securities and Exchange Commission (SEC) or the SEC requires that trading be restricted; or 

 

	 	c.	The SEC permits a delay for the protection of Owners. 

 When permitted by law, we may defer (with prior authorization from the Commissioner) payment of any transfers, withdrawals or Surrender proceeds from the Fixed Account, if offered, for up to 6 months from
the date we receive Your request. If the Owner or Annuitant dies after the request is received, but before the request is processed, the request will be processed before the death proceeds are determined. Interest will be paid on any amount deferred
for 30 days or more. This interest rate will be the Fixed Account Guaranteed Minimum Effective Annual Interest Rate shown in Section 2 - Policy Data, unless otherwise required by law. 
 If we delay payment of any transactions as noted above, we will disclose to You the specified date on which the above transactions will be effective and the reason for the delay. 

  
 ICC12 VA(2)0513 

Page 8 

 Reports to Owner 
 We will give You a report at least once each Policy Year, and may provide it more often. This report will show the start date and end date for the current period and include the following information:

  

	 	a.	The amounts credited or debited to the Policy Value during the current report period; 

 

	 	b.	The Policy Value at start and end date of the current report period; 

  

	 	c.	The number and value of the accumulation units held in each Separate Account; 

 

	 	d.	The Cash Value, which is after the application of any Excess Interest Adjustment (EIA), at start and end date of the current report period; 

 

	 	e.	The death benefit at the end of the current report period; 

  

	 	f.	The dollar amount in the Fixed Account, if any; and 

  

	 	g.	The EIA formula used to determine the Cash Value. 

 A report as described above will be mailed to Your last known address as shown in our records. The information provided will be as of a date not more than four months prior to the date of the mailing. We
will provide copies of the report available to You upon request at no additional cost. 
 SECTION 4 – PREMIUM PAYMENTS

 Payment of Premiums 

Premium Payments may be made any time while this policy is in force and prior to the Annuity Commencement Date, subject to the minimums and maximums as
specified in Section 2 – Policy Data. 
 Premium Payment Date 
 The Premium Payment date is the date the Premium Payment is credited to the policy. The initial Premium Payment will be credited to the policy within two Market Days after the Market Day we receive it and
Your complete policy information in Good Order. Subsequent Premium Payments will be credited to the policy as of the Market Day the Premium Payment and required information are received in Good Order. 

Allocation of Premium Payments 
 Premium
Payments may be applied to various Investment Options, which we make available. For the initial Premium Payment, You must indicate what percentage to allocate to various Investment Options. For additional Premium Payments, allocations will be what
is currently indicated by You. Each percentage may be either zero or any whole number; however, the allocation among all Investment Options must total 100%. 
 Change of Allocation 
 You may change allocations for additional Premium Payments by
providing us instructions. The allocation change will apply to Premium Payments received on or after the date we receive the allocation change in Good Order. We will allocate subsequent Premium Payments the same way, unless You request a different
allocation. 
 Premium Taxes 

Your state may impose premium taxes on the Premium Payments You make. We currently do not deduct for these taxes at the time You make a Premium Payment
unless required by the applicable state law. Generally, we will deduct the total amount of premium taxes, if any, from the Policy Value when You begin receiving annuity payments, You Surrender the policy, or death proceeds are paid. 

SECTION 5 – CASH VALUE AND WITHDRAWALS 
 A. Cash Value 
 On or before the Annuity Commencement Date, You may make withdrawals or
Surrender the Cash Value. The Cash Value is equal to the Adjusted Policy Value. Information on the current amount of Your Cash Value is available upon request. We must receive Your withdrawal or Surrender request, in Good Order, before the Annuity
Commencement Date. 

  
 ICC12 VA(2)0513 

Page 9 

 There is no Cash Value once an income option has been selected, all necessary instructions are received in
Good Order, and the Company has issued a supplementary contract. 
 Excess Interest Adjustment 

The Excess Interest Adjustment (EIA) is only applied to transactions affecting the Guaranteed Period Options (GPO) of the Fixed Account, if offered, and
is based on any change in interest rates from the time the affected guaranteed period(s) started until the time the EIA occurs. The EIA may be positive or negative. 
 An EIA applies in the following situations: 
  

	 	1.	When You withdraw or Surrender Your Cash Value; 

  

	 	2.	When You exercise an income option; 

  

	 	3.	When You transfer out of a GPO; or 

  

	 	4.	When a death benefit is calculated. However, the death benefit will not be reduced if the EIA results in a decrease in the Cash Value available to You.

 The EIA is applied as follows: 
  

	 	1.	The EIA is only applied when the transactions occur prior to the end of the GPO; 

 

	 	2.	Transfers to the GPO of the Fixed Account are considered Premium Payments for purposes of determining the EIA; 

 

	 	3.	The EIA may affect the death benefit defined in Section 9; 

  

	 	4.	If interest rates have decreased from the time the affected GPO started until the time the transaction occurs, the EIA will result in additional funds available to You;

  

	 	5.	If interest rates have increased from the time the affected GPO started until the time the transaction occurs, the EIA will result in a decrease in the funds available
to You; 

  

	 	6.	Certain amounts are not subject to the EIA as provided in Sections 5, 8 and 11; and 

 

	 	7.	Upon Surrender, the cumulative interest credited to the GPO of the Fixed Account at the time of Surrender will not be subject to an EIA. 

The formula for determining the amount of the EIA is as follows: 
 EIA = S x (G-C) x (M/12) where: 
  

	 	“S”	Is the amount (before premium taxes and the application of any Guaranteed Minimum Death Benefits, if any) being Surrendered, withdrawn, transferred, paid upon death, or
applied to an income option that is subject to EIA; 

  

	 	“G”	Is the guaranteed interest rate for the guaranteed period applicable to “S”; 

 

	 	“C”	Is the current guaranteed interest rate then being offered on new Premium Payments for the next longer guaranteed period than “M”. If this policy form or such
a GPO is no longer offered, “C” will be the U.S. Treasury rate for the next longer maturity (in whole years) than “M” on the 25th day of the previous calendar month; and 

 

	 	“M”	Is the number of months remaining in the guaranteed period for “S”, rounded up to the next higher whole number of months. 

The EIA for each GPO will not reduce the Adjusted Policy Value for that GPO below the amount allocated, less any prior withdrawals and transfers from
that GPO, plus interest at the Fixed Account Guaranteed Minimum Effective Annual Interest Rate shown in Section 2 - Policy Data. 
 B.
Withdrawals and Surrenders 
 You may, on or before the Annuity Commencement Date, withdraw all (Surrender) or a portion (withdrawal) of the
amount available under this policy, provided we receive Your request, in Good Order, while this policy is in effect and before the Annuity Commencement Date. The minimum withdrawal is $500, with the exception of systematic payouts and required
minimum distributions. 
 You may specify that the withdrawal be taken from one or more specific Investment Options or pro rata from all
Investment Options. If You do not specify the Investment Option from which the withdrawal is to be made, the withdrawal will be taken pro rata from all Investment Options relative to the value in each Investment Option. 

  
 ICC12 VA(2)0513 

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 Withdrawals will reduce the amount of the death proceeds. Withdrawals and Surrenders will normally be
effective as of the end of the Market Day the request is received in Good Order. 
 The gross withdrawal is the total amount which will be
deducted from Your Policy Value as a result of each withdrawal. The gross withdrawal may be more than Your requested withdrawal amount, depending on whether EIA applies at the time of the withdrawal. 

The gross withdrawal = R - E, where: 
  

	 	“R”	Is the requested withdrawal; and 

  

	 	“E”	Is the EIA. 

 Withdrawals in the amount of the
cumulative interest in the GPO(s) of the Fixed Account, at the time of withdrawal, may be withdrawn from the GPO(s) of the Fixed Account free of any EIA. 
 Systematic Payout Option 
 A Systematic Payout Option (SPO) is a series of pre-scheduled
withdrawals. Beginning in the first Policy Year, a SPO is available on a monthly, quarterly, semi-annual or annual basis. At the time a SPO is made, each such payout must be at least $50. Monthly and quarterly SPO’s must be sent through
electronic funds transfer directly to a checking, savings or other similar financial account. You may stop SPO payouts at any time with a 30 day written notice sent to our Administrative Office. 

Required Minimum Distribution 
 For
tax-qualified plans and policies, withdrawals taken to satisfy required minimum distribution requirements under Section 401(a)(9) of the Internal Revenue Code (IRC) are available with no EIA. The amount available from this policy with respect
to the required minimum distribution is based solely on this policy. 
 Any amount requested in excess of the IRC required minimum distribution
will have the appropriate EIA applied. 
 Minimum Values 
 Benefits available under this policy, including any paid up annuity values, Cash Values, or death benefits, are not less than the minimum benefits required by section 7B and 7G of the Model Variable
Annuity Regulation, model # 250 or successor models. Minimum benefits will be increased to reflect any guaranteed additional amounts credited to the policy and will be decreased by prior withdrawals. 

Minimum Required Cash Value 
 The Minimum
Required Cash Value is the amount prescribed by the nonforfeiture law, and is the minimum amount required to be paid to You on Surrender. 
 The
minimum amount is determined differently than Your policy’s Cash Value, and is described in Section 2 - Policy Data. The minimum amount for the Fixed Account, if offered, is calculated according to a procedure specified in the law using a
prescribed Minimum Nonforfeiture Interest Rate, which will be fixed at issue and determined as follows: 
 On the Policy Date, the Minimum
Nonforfeiture Interest Rate is equal to an “average Five Year Constant Maturity Treasury rate”, less 1.25%, but such rate will not be less than 1% nor more than 3%. The averaged rate is determined by averaging the daily Treasury rates for
the first 10 Market Days of the month immediately preceding the calendar quarter in which Your policy is issued. The average of these ten Treasury rates is rounded to the nearest 0.05% before the deduction of 1.25%. For example, if Your policy was
issued on any Market Day during the third calendar quarter, Your Minimum Nonforfeiture Interest Rate would be determined by averaging the first ten Market Days’ Five Year Constant Maturity Treasury rates for the month of June during the same
calendar year, rounding that result to the nearest 0.05%, then deducting 1.25% (with the resulting rate not being less than 1% nor more than 3%). 

  
 ICC12 VA(2)0513 

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 SECTION 6 – POLICY VALUE 

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

	 	a.	Premium Payment(s); minus 

  

	 	b.	Gross withdrawals (withdrawals plus or minus any EIA); plus 

  

	 	c.	Interest credited to the Fixed Account (if any); plus 

  

	 	d.	Accumulated gains in the Separate Account; minus 

  

	 	e.	Accumulated losses in the Separate Account; minus 

  

	 	f.	Service charges, rider fees, premium taxes, and transfer fees if any. 

 Service Charge 
 On each Policy Anniversary prior to the Annuity Commencement Date and at
the time of Surrender, we may deduct an annual service charge as set forth in Section 2 - Policy Data. The service charge will be deducted from each Investment Option in proportion to the portion of Policy Value (prior to such charge) in each
Investment Option. In no event will the service charge exceed 2% of the Policy Value or the maximum, as shown in Section 2 - Policy Data, on the Policy Anniversary or at the time of Surrender. 

SECTION 7 – SEPARATE ACCOUNT 
 Separate Account 
 We have established and will maintain one or more Separate Account(s),
under the laws of the state of Iowa. Any realized or unrealized income, net gains and losses from the assets of the Separate Account are credited to or charged against it without regard to our other income, gains or losses. Assets are put in the
Separate Account for this policy, as well as for other variable annuity policies. Any Separate Account may invest assets in shares of one or more mutual fund portfolio(s), or in the case of a managed Separate Account, direct investments in stocks or
other securities as permitted by law. Fund shares refer to shares of underlying mutual funds or pro-rata ownership of the assets held in a Subaccount of a managed Separate Account. Fund shares are purchased, redeemed and valued on behalf of the
Separate Account. 
 The Separate Account is divided into Subaccounts. Each Subaccount invests exclusively in shares of one of the portfolios of
an underlying fund. We reserve the right to add or remove any Subaccount of the Separate Account. 
 The assets of the Separate Account are our
property. These assets will equal or exceed the reserves and other contract liabilities of the Separate Account. These assets will not be chargeable with liabilities arising out of any other business we conduct. We reserve the right, subject to
regulations governing the Separate Account, to transfer assets of a Subaccount, in excess of the reserves and other contract liabilities with respect to that Subaccount, to another Subaccount or to our General Account. 

We will determine the fair market value of the assets of the Separate Account in accordance with the Valuation Period, which we establish in good faith.

 We also reserve the right to transfer assets of the Separate Account, which we determine to be associated with the class of policies to which
this policy belongs, to another Separate Account. If this type of transfer is made, the term “Separate Account”, as used in the policy shall then mean the Separate Account to which the assets are transferred. 

  
 ICC12 VA(2)0513 

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 We also reserve the right, when permitted by law to: 

 

	 	a.	Deregister the Separate Account under the Investment Company Act of 1940; 

  

	 	b.	Manage the Separate Account under the direction of a committee at any time; 

 

	 	c.	Restrict or eliminate any voting rights of policy Owners or other persons who have voting rights as to the Separate Account; 

 

	 	d.	Combine the Separate Account with one or more Separate Accounts; 

  

	 	e.	Create new Separate Accounts; 

  

	 	f.	Add new Separate Accounts to or remove existing Subaccounts from the Separate Account, or combine Subaccounts; and 

 

	 	g.	Add new underlying mutual funds, remove existing mutual funds, or substitute a new fund for an existing mutual fund. 

The net asset value of a fund share is the per-share value calculated by the mutual fund or, in the case of a managed Separate Account, by the Company.
The net asset value is computed by adding the value of the Subaccount’s investments, cash and other assets, subtracting its liabilities, and then dividing by the number of shares outstanding. Net asset values of fund shares reflect investment
advisory fees and other expenses incurred in managing a mutual fund or a managed Separate Account. 
 Change in Investment Objective or
Policy of a Mutual Fund 
 If required by law or regulation, an investment policy of the Separate Account will only be changed if approved by
the appropriate insurance official of the state of Iowa or deemed approved in accordance with such law or regulation. If so required, the process for obtaining such approval is filed with the insurance official of the state or district in which this
policy is delivered. 
 Charges and Deductions 
 The mortality and expense risk fee and the administrative charge are each deducted, both before and after the Annuity Commencement Date, to compensate for changes in mortality and expenses not anticipated
by the mortality and administration charges guaranteed in the policy. Expenses and mortality results will not adversely affect the dollar amounts of variable benefits or other variable contractual payments or values. The mortality and expense risk
fee and the administrative charge is specified in Section 2 - Policy Data. 
 Accumulation Units 

The Policy Value in the Separate Account before the Annuity Commencement Date is represented by accumulation units. The dollar value of accumulation units
for each Subaccount will change from Market Day to Market Day reflecting the investment experience of the Subaccount. 
 Premium Payments
allocated to and any amounts transferred to the Subaccounts will be applied to provide accumulation units in those Subaccounts. The number of accumulation units purchased in a Subaccount will be determined by dividing the amount allocated to or
transferred to that Subaccount by the value of an accumulation unit for that Subaccount on the Premium Payment or transfer date. 
 The number
of accumulation units withdrawn or transferred from the Subaccounts will be determined by dividing the amount withdrawn or transferred by the value of an accumulation unit for that Subaccount on the withdrawal or transfer date. 

The value of an accumulation unit on any Market Day is determined by multiplying the value of that unit at the end of the immediately preceding Valuation
Period by the net investment factor for the Valuation Period. 

  
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 The net investment factor used to calculate the value of an accumulation unit in each Subaccount for the
Valuation Period is determined by dividing (a) by (b) and subtracting (c) from the result, where: 
  

	 	(a)	Is the result of: 

  

	 	1.	The net asset value of a fund share held in that Subaccount determined as of the end of the current Valuation Period; plus 

 

	 	2.	The per share amount of any dividend or capital gain distributions made by the fund for shares held in that Subaccount if the ex-dividend date occurs during the
Valuation Period; plus or minus 

  

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

  

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

 

	 	(c)	Is a factor representing the mortality and expense risk fee and administrative charge before the Annuity Commencement Date. This factor is less than or equal to, on an
annual basis, the percentage shown in Section 2 - Policy Data, of the daily net asset value of a fund share held in that Subaccount. 

 Since the net investment factor may be greater or less than one, the accumulation unit value may increase or decrease. 
 SECTION 8 – TRANSFERS 
 A. TRANSFERS BEFORE THE ANNUITY COMMENCEMENT DATE

 Prior to the Annuity Commencement Date, You may transfer the value of the accumulation units from one Investment Option to another within
certain limitations. 
 Transfers of Policy Value from the Guaranteed Period Options (GPO) of the Fixed Account, if offered, prior to the end of
that GPO are subject to an EIA. Such transfers are limited to the maximum Fixed Account transfer limits shown in Section 2 - Policy Data, less values previously transferred out of that GPO during the current Policy Year. Transfer minimums and
charges shown in Section 2 - Policy Data, may also apply to transfers out of the GPO. 
 Transfers of interest credited in the GPO’s
to other Investment Options are allowed on a “First-In, First-Out” basis. Such transfers may be made monthly, quarterly, semi-annually, or annually. Each such transfer is subject to transfer minimums and charges as set forth in
Section 2 - Policy Data and will not be subject to an EIA. 
 You may choose which GPO to transfer to or from; however, any GPO elected may
not extend beyond the last available Annuity Commencement Date shown in Section 2 - Policy Data. 
 Transfers of Policy Value from the
Separate Account are subject to a minimum and charges as set forth in Section 2 - Policy Data. If the remaining Subaccount Policy Value is less than the minimum transfer amount, as shown in Section 2 - Policy Data, we reserve the right to
include that amount as part of the transfer. Transfers among multiple Investment Options will be treated as one transfer in determining the number of transfers that have occurred. 
 If You want to transfer the value of the variable units You must provide written notification with the following information provided: 

 

	 	1.	The Investment Option from which the transfer is to be made; 

  

	 	2.	The amount of the transfer; and 

  

	 	3.	The Investment Option(s) to receive the transferred amount. 

 The policy was not designed for the use of market timers or frequent or disruptive traders. Such transfers may be harmful to the underlying fund portfolios and increase transaction costs. We have
developed policies and procedures with respect to market timing and disruptive trading (which vary for certain Subaccounts at the request of the corresponding underlying fund portfolios). 

  
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 We employ various means in an attempt to detect market timing and disruptive trading. However, despite our
monitoring, we may not be able to detect nor halt all harmful trading. If we determine You are engaged in market timing or disruptive trading, we may take one or more actions in an attempt to halt such trading. Your ability to make transfers is
subject to modification or restriction if we determine, in our sole discretion, that Your exercise of the transfer privilege may disadvantage or potentially harm the rights or interests of other Owners (or others having an interest in the variable
insurance products). Transfer restrictions may take the form of loss of expedited transfer privilege. We consider transfers by telephone, fax, overnight mail, or the Internet to be “expedited” transfers. This means that we would accept
only an original signature transmitted to us only by U.S. mail. We may also restrict the transfer privileges of others acting on Your behalf, including Your registered representative or an asset allocation or investment advisory service. 

We reserve the right to reject any Premium Payments or transfer requests from any person without prior notice, if, in our judgment: 

 

	 	1.	The payment or transfer, or series of transfers, would have a negative impact on an underlying fund portfolio’s operations; or 

 

	 	2.	If an underlying fund portfolio would reject or has rejected our purchase order or has instructed us not to allow that purchase or transfer; or

  

	 	3.	Because of a history of market timing or disruptive trading. 

 Dollar Cost Averaging 
 Prior to the Annuity Commencement Date, You may enroll in Dollar
Cost Averaging (DCA) by instructing us to automatically make periodic transfers of Policy Value from a DCA Source Account without waiting for further instructions from You. A DCA program will begin once we have received, in Good Order, all necessary
information and the minimum required amount. 
 You must provide us with the following information to initiate DCA: 

 

	 	1.	The date on which the transfers are to begin. Your request will normally be effective the day after the effective date of the policy. If a certain date does not exist
in a given month, the first day of the following month will be used; 

  

	 	2.	The DCA Source Account from which the transfers are to be made. To begin dollar cost averaging, the value of the DCA Source Account is subject to minimums as described
in Section 2 - Policy Data; 

  

	 	3.	The amount and frequency of the transfers. You may choose monthly or quarterly transfers. The amount of each transfer is subject to minimums as described in
Section 2 - Policy Data; and 

  

	 	4.	The Investment Option(s) to receive the transferred amounts. You may choose one or more Investment Options. If You select more than one Investment Option, Your request
must specify how the transferred amounts are to be allocated among these Investments Options and cannot include Your DCA Source Account. 

 Transfers must be scheduled for a minimum or maximum length of time as specified in Section 2 - Policy Data. DCA results in the purchase of more accumulation units when the value of the accumulation
unit is low, and fewer accumulation units when the value of the accumulation unit is high. However, there is no guarantee that the DCA program will result in higher Policy Values or will otherwise be successful. 

Asset Rebalancing 
 Prior to the Annuity
Commencement Date, You may instruct us to automatically transfer amounts among the Subaccounts of the Separate Account on a regular basis to maintain a desired allocation of the Policy Value among the various Subaccounts offered. Rebalancing will
occur on a monthly, quarterly, semi-annual, or annual basis, beginning on a date selected by You. You must select the percentage of the Policy Value desired in each of the various Subaccounts offered. Any amounts in the DCA Source Account or Fixed
Account, if offered, are ignored for the purposes of Asset Rebalancing. Rebalancing can be started, stopped or changed at any time. Rebalancing will cease as soon as we receive a request for any transfer. 

B. TRANSFERS AFTER THE ANNUITY COMMENCEMENT DATE 
 After the Annuity Commencement Date, You may transfer the value of the variable annuity units from one Subaccount to another within the Separate Account or to the Fixed Account, if offered. If You want to
transfer the value of the variable units You must provide written notification with the following information provided: 
  

	 	1.	The Investment Option from which the transfer is to be made; 

  

	 	2.	The amount of the transfer; and 

  

	 	3.	The Investment Option(s) to receive the transferred amount. 

  
 ICC12 VA(2)0513 

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 The minimum amount which may be transferred is the lesser of $10 monthly income or the entire monthly income
of the variable annuity units in the Subaccount from which the transfer is being made. If the monthly income of the remaining units in a Subaccount is less than $10, we have the right to include the value of those variable annuity units as part of
the transfer. We reserve the right to limit transfers between the Subaccounts or to the Fixed Accounts to once per Policy Year. 
 After the
Annuity Commencement Date, no transfers may be made from the Fixed Account, if offered, to any other Investment Option. 

SECTION 9 - DEATH PROCEEDS 
 A. DEATH PRIOR TO THE ANNUITY COMMENCEMENT DATE 
 The amount payable upon death will be
determined and made payable upon receipt, in Good Order, of satisfactory proof of death, written directions from each eligible recipient regarding how they wish to receive the amount payable, and any other documents, forms and information that we
need (collectively referred to as “due proof of death”). Not withstanding the foregoing, we may confer with a variety of resources and/or other affiliates in order to ascertain or verify whether the Annuitant or any other relevant life in
being is or may have become deceased during the term of this policy. Any such activities or efforts by us in no manner abrogate, waive or otherwise diminish Your continued obligation to provide us with timely notice in writing of due proof of death
in Good Order. 
 The amount of the death benefit payable will be the greatest of: 

 

	 	1.	The Policy Value on the date we receive due proof of death and an election of method of settlement; 

 

	 	2.	The Cash Value on the date we receive due proof of death and an election of method of settlement; 

 

	 	3.	The Fixed Account portion of the Minimum Required Cash Value plus the Separate Account portion of the Policy Value, on the date we receive due proof and an election of
method of settlement; or 

  

	 	4.	The Guaranteed Minimum Death Benefit (GMDB), if any, on the date of death, plus any additional Premium Payments received, less any gross withdrawals from the date of
death to the date of payment of death proceeds. 

 The Owner(s) may elect the method of payment of death proceeds for each named
beneficiary, subject to our then current rules, prior to the date of the applicable Decedent’s death. When no such election is made as to a specific beneficiary, such beneficiary must elect the method of payment within 60 days of the date we
receive all required documentation, in Good Order, to pay the death proceeds to that beneficiary. 
 Guaranteed Minimum Death Benefit

 If elected, the GMDB will establish a minimum death benefit payable under the policy. Your election, if any, is shown in Section 2 -
Policy Data. You may not change Your election after the policy is issued. 
 Death of Annuitant Prior To The Annuity Commencement Date

 A death benefit will be payable if the Annuitant dies prior to the Annuity Commencement Date. 

 

	 	1.	Non-Natural Owner(s) 

 For
purposes of determining who receives the death benefit for a policy owned by a non-natural Owner, we will apply the rules for Individual Owner(s) as provided below in 2(a) or (b). 

 

	 	2.	Individual Owner(s) 

  

	 	(a)	Surviving Owner 

 If there is a
surviving Owner(s) when the Annuitant dies, the surviving Owner(s) will receive the death benefit (i.e., the surviving Owner(s) takes the place of any beneficiary designation). 

 

	 	(b)	No surviving Owner 

 If there is
no surviving Owner, the death benefit is payable to the named beneficiary(ies). If no beneficiary(ies) are named, the death benefit will be payable to the Owner’s estate. 

  
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 Death of Owner Prior To The Annuity Commencement Date 

If the Owner is not the Annuitant and the Owner dies before the Annuitant, under certain circumstances, an amount equal to the Cash Value, as of the date
we receive due proof of death, will be paid. 
 If You are not also the Annuitant and in the event of simultaneous deaths of both You and the
Annuitant, the death proceeds will be calculated under the Death of Annuitant provisions. 
  

	 	1.	Non-Natural Owner(s) 

  

	 	  	If the policy is owned by a trust using the grantor’s social security number as its taxpayer identification number, the death of the grantor will be treated as the
death of the Owner. 

  

	 	  	If there is a change in the Annuitant, such change will be treated as the death of the non-natural Owner and we will pay an amount equal to the Cash Value as of the day
we receive, in Good Order, the request to change the Annuitant. 

  

	 	2.	Individual Owner(s) 

  

	 	  	If You die while the Annuitant is living, the Cash Value will be paid to the first among the following who is living or in existence: 

 

	 	a.	The surviving Owner(s); 

  

	 	b.	Primary beneficiary(ies); 

  

	 	c.	Contingent beneficiary(ies); or 

  

	 	d.	Deceased Owner’s estate. 

  

	 	3.	Joint Owner(s) 

  

	 	  	If there is a joint Owner, the Cash Value will be payable upon the death of the first Owner, unless the surviving joint Owner is the spouse. 

Non-Spouse Individual Beneficiary: 
 If
the beneficiary is an individual who is not eligible to continue the contract as noted below, the amount payable must be distributed by the end of 5 years after the date of Decedent’s death, or payments must begin no later than one year after
the date of Decedent’s death and must be made for a period certain or for the beneficiary’s lifetime, so long as the period certain does not exceed the beneficiary’s life expectancy. 

If the beneficiary is not a natural person, the death proceeds must be distributed by the end of 5 years after the date of Decedent’s death.

 Spousal Beneficiary 
 A
spousal beneficiary, who is the sole beneficiary, may elect to continue this policy as Owner rather than receiving the amount payable when they are the deceased Owner’s surviving spouse. 
 If the surviving spouse does not elect to continue the contract, the amount payable must be distributed by the end of 5 years after the date of the Decedent’s death, or payments must begin no later
than one year after the Decedent’s death and must be made for a period certain or for the beneficiary’s lifetime, so long as the period certain does not exceed the beneficiary’s life expectancy. 

If a death benefit is payable and the policy is continued, an amount equal to the excess, if any, of the Guaranteed Minimum Death Benefit over the Policy
Value will then be added to the Policy Value. This is a one-time only Policy Value adjustment applied at the time the policy is continued. The spousal continuation election is only available once per policy. 

  
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 B. DEATH ON OR AFTER THE ANNUITY COMMENCEMENT DATE 

In the event of a death after the Annuity Commencement Date, the amount payable will depend on the income option selected. If any Owner dies on or after
the Annuity Commencement Date, but before the entire interest in the policy is distributed, the remaining portion of such interest in the policy will be distributed to the beneficiary(ies) at least as rapidly as under the method of distribution
being used as of the date of that death. 
 C. ADDITIONAL TAX INFORMATION 
 In any event, the death proceeds will be paid in accordance with Section 72(s) of the IRC. For purposes of applying the non-natural Owner death rules of Section 72(s)(6), we will apply the
Annuitant death rules set forth earlier in this section. 
 These distribution rules do not apply to an annuity provided under a plan described
in Section 401(a), 403(a), 403(b), 408 or 408A of the IRC or to an annuity that is a qualified funding asset as defined in Code Section 130(d) of the IRC. 
 SECTION 10 – INCOME OPTIONS 
 A. GENERAL PAYMENT PROVISIONS 

Payment 
 You may use the Adjusted Policy
Value or the Fixed Account portion of the Minimum Required Cash Value plus the Separate Account portion of the Policy Value, if greater, on the Annuity Commencement Date. If the policy is in force on the last available Annuity Commencement Date, we
will make annuity payments to the payee under Option 2(b), with 10 years certain, or if elected, under one or more of the other options described in this section, or any other method of payment if we agree. However, the option(s) elected must
provide for lifetime income or income for a period of at least 120 months. Payments will be made at 1, 3, 6 or 12 month intervals. We reserve the right to avoid making payments of less than $20.00. 

Before the Annuity Commencement Date, if the death proceeds become payable or if You Surrender this policy, we will pay any proceeds in one sum, or if
elected, all or part of these proceeds may be placed under one or more of the options described in this section. 
 Adjusted Age

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

			
	Annuity	  	 
	 Commencement Date
	  	Adjusted Age
	Before 2025	  	Actual Age
	2025 - 2032	  	Actual Age minus 1
	2033 - 2040	  	Actual Age minus 2
	2041 - 2048	  	Actual Age minus 3
	2049 - 2055	  	Actual Age minus 4
	After 2055	  	Determined by us

 Election of Optional Method of Payment 
 You may elect, in a manner acceptable to us, income options that may be either variable, fixed, or a combination of both. If You elect a combination, You must also tell us what part of the policy proceeds
on the Annuity Commencement Date is to be applied to provide each type of payment. You must also specify which Subaccounts to allocate policy proceeds. The amount of a combined payment will be the sum of the variable and fixed payments. Payments
under a variable income option will reflect the investment performance of the selected Subaccount of the Separate Account. 
 Qualified Plans
and Policies 
 Certain income options may not be available or may be limited for qualified plans and qualified policies in order to ensure
compliance with the IRC. 

  
 ICC12 VA(2)0513 

Page 18 

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

Minimum Proceeds 
 If the proceeds are
less than $2,000, we reserve the right to pay them out as a lump sum instead of applying them to an income option. 
 Supplementary Contract

 Once proceeds become payable and an income option has been selected, we will issue a supplementary contract to reflect the terms of the
selected option. The contract will name the payee(s) and will describe the payment schedule. 
 B. FIXED INCOME OPTIONS 

Guaranteed Income Options 
 The fixed
income option is determined by multiplying each $1,000 of policy proceeds allocated to a fixed income option by the amounts shown in Section 12 for the option You select. Options 1 and 3 are based on a guaranteed interest rate of 0.25%. Options
2 and 4 are based on a guaranteed interest rate of 0.25% and the “Annuity 2000” (male, female and unisex if required by law) mortality table projected for improvement using projection scale G. The rates were projected dynamically using an
assumed Annuity Commencement Date of 2020. The “Annuity 2000” mortality rates are adjusted based on improvements in mortality to more appropriately reflect increased longevity. 
 Option 1 – Income for a Specified Period 
 We will make level payments only for the
fixed period You choose. Payments should not exceed the Annuitant’s life expectancy. In the event of the death of the person receiving payments prior to the end of the fixed period elected, payments will be continued to that person’s
beneficiary. No funds will remain at the end of the specified period. 
 Option 2 – Life Income 

You may choose between: 
  

	 	a.	Life Only – We will make level payments only during the Annuitant’s lifetime;* or 

 

	 	b.	Life 10 Years Period Certain – We will make level payments for the longer of: 

 

	 	1.	The Annuitant’s lifetime; or 

  

	 	2.	10 years, whichever is longer; or 

  

	 	c.	Guaranteed Return of policy proceeds – We will make level payments for the longer of: 

 

	 	1.	The Annuitant’s lifetime; or 

  

	 	2.	Until the total dollar amount of payments made to You equals the amount applied to this option. 

 

	*	Option 2(a) is not available for adjusted ages greater than 85. 

 Option 3 – Income of a Specified Amount 
 Payments are made for any specified amount
until the amount applied to this option, with interest, is exhausted. Payments should not exceed the Annuitant’s life expectancy. This will be a series of level payments followed by a smaller final payment. In the event of the death of the
person receiving payments prior to the time policy proceeds with interest are exhausted, payments will be continued to that person’s beneficiary. 
 Option 4 – Joint and Survivor Annuity 
 You may choose between: 

 

	 	a.	Life Only – We will make level payments only during the Annuitants’ lifetimes;** or 

 

	 	b.	Life and 10 Years Period Certain – We will make level payments for the longer of: 

 

	 	1.	The Annuitant’s lifetime and a joint Annuitant of Your selection; or 

  

	 	2.	10 years, whichever is longer. 

  

	**	Option 4(a) is not available for adjusted ages greater than 85. 

  
 ICC12 VA(2)0513 

Page 19 

 Current Income Options 
 The amounts shown in the tables in Section 12 are the guaranteed amounts. Payments at the time of their commencement will not be less than those that would be provided by the application of the
policy proceeds to purchase a single premium immediate annuity policy at purchase rates offered by the Company at the time to the same class of Annuitants. 
 C. VARIABLE INCOME OPTIONS 
 Variable Annuity Units 

The policy proceeds You tell us to apply to a variable income option will be used to purchase variable annuity units in Your chosen Subaccounts. The
dollar value of variable annuity units in Your chosen Subaccounts will increase or decrease reflecting the investment experience of Your chosen Subaccounts. The value of a variable annuity unit in a particular Subaccount on any Market Day is equal
to “a” x “b” x “c”, where: 
  

	 	“a”	Is the variable annuity unit value for that Subaccount on the immediately preceding Market Day; 

 

	 	“b”	Is the net investment factor for that Subaccount for the Valuation Period; and 

 

	 	“c”	Is the Assumed Investment Return adjustment factor for the Valuation Period. 

 The net investment factor used to calculate the value of an accumulation unit in each Subaccount for the Valuation Period is determined by dividing “a” by “b” and subtracting
“c” from the result, where: 
  

	 	“a”	Is the result of: 

  

	 	1.	The net asset value of a fund share held in that Subaccount determined as of the end of the current Valuation Period; plus 

 

	 	2.	The per share amount of any dividend or capital gain distributions made by the fund for shares held in that Subaccount if the ex-dividend date occurs during the
Valuation Period; plus or minus 

  

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

  

	 	“b”	Is the net asset value of a fund share held in that Subaccount determined as of the end of the immediately preceding Valuation Period. 

 

	 	“c”	Is a factor representing the mortality and expense risk fee and administrative charge after the Annuity Commencement Date. This factor is less than or equal to, on an
annual basis, the percentage shown in Section 2 - Policy Data, of the daily net asset value of a fund share held in that Subaccount. 

 Determination of the First Variable Payment 
 The amount of the first variable payment is
determined by multiplying $1,000 of policy proceeds allocated to a variable income option by the amounts shown in Section 13 for the variable option You select. The tables are based on a 3% Effective Annual Assumed Investment Return and the
“Annuity 2000” (male, female and unisex if required by law) mortality table projected for improvement using projection scale G. The rates were projected dynamically using an assumed Annuity Commencement Date of 2020. The “Annuity
2000” mortality rates are adjusted based on improvements in mortality to more appropriately reflect increased longevity. 
 Option 2-V
– Life Income 
 You may choose between: 
  

	 	a.	Life Only – Payments will be made during the lifetime of the Annuitant;* or 

 

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

 

	*	Option 2-V(a) is not available for adjusted age(s) greater than 85. 

 Option 4-V – Joint and Survivor Annuity 
 Life Only - Payments are made
during the joint lifetime of the Annuitant and a joint Annuitant of Your selection. Payments will be made as long as either person is living. Option 4-V is not available for adjusted ages greater than 85. 

  
 ICC12 VA(2)0513 

Page 20 

 Determination of Subsequent Variable Payments 

The amount of each variable annuity payment after the first will increase or decrease according to the value of the variable annuity units which reflect
the investment experience of the selected Subaccounts. Each variable annuity payment after the first will be equal to the number of variable annuity units in the selected Subaccounts multiplied by the variable annuity unit value on the date the
payment is made. The number of variable annuity units in each selected Subaccount is determined by dividing the first variable annuity payment allocated to the Subaccount by the variable annuity unit value of such Subaccount on the Annuity
Commencement Date. 
 The smallest annual rate of investment return that would have to be earned on the assets of the Separate Account so that
the dollar amount of variable income payments will not decrease is 5.50%. 
 SECTION 11 – FIXED ACCOUNT 

We may make available a Fixed Account as an Investment Option. The Fixed Account, if offered, may be comprised of one or more options shown below.
Premium Payments applied to and any amount transferred to the Fixed Account will be credited interest based on a fixed rate. The interest rates we set will be credited for increments of at least one year measured from each Premium Payment or
transfer date. If the Fixed Account is available, these rates will never be less than the Fixed Account Guaranteed Minimum Effective Annual Interest Rate shown in Section 2 – Policy Data. We reserve the right at our sole discretion, to
limit or refuse Premium Payments and/or transfers allocated to any of the Fixed Account options, if we are crediting an interest rate equal to or less than the Minimum Nonforfeiture Annual Interest Rate. 

Guaranteed Period Options 
 We may offer
optional Guaranteed Period Options, into which Premium Payments may be paid or amounts transferred. The current interest rate we set for Policy Value allocated to each Guaranteed Period Option (GPO) is guaranteed until the end of that guaranteed
period. 
 We will notify You before the end of the GPO. You may elect to have the Policy Value in the GPO transferred to any Investment Option,
including any GPO we then make available. However, any GPO elected may not extend beyond the last available Annuity Commencement Date. If we do not receive instructions from You in Good Order before the end of the GPO regarding how the Policy Value
in that GPO is to be allocated, we will allocate the Policy Value in that GPO to the Money Market Subaccount available in Your policy. No Excess Interest Adjustment (EIA) applies at the end of a GPO. 

When funds are withdrawn or transferred from a GPO, the Policy Value associated with the oldest Premium Payment is considered to be withdrawn or
transferred first. If the amount withdrawn or transferred exceeds the Policy Value associated with the oldest premium, the Policy Value associated with the next oldest Premium Payment is considered to be withdrawn or transferred next, and so on
until the Policy Value associated with the most recent premium is considered to be withdrawn or transferred (this is a First-In, First-Out, or FIFO, basis). 
 Withdrawals, Surrenders, transfers and amounts applied to an income option from the GPO(s) may be subject to an EIA. Amounts received during the right to cancel period are not subject to an EIA.

 Dollar Cost Averaging Fixed Account Option 
 We may offer a Dollar Cost Averaging (DCA) Fixed Account Option (a “DCA Source Account”) separate from the Guaranteed Period Options. This option will have a one-year interest rate guarantee.
The current interest rate we credit may vary on different portions of the DCA Fixed Account. The credited interest rate will never be less than the Fixed Account Guaranteed Minimum Effective Annual Interest Rate shown in Section 2 - Policy
Data. The DCA Fixed Account Option will only be available under a Dollar Cost Averaging program as described in Section 8. 

  
 ICC12 VA(2)0513 

Page 21 

 APPENDIX 
 SECTION 12 - GUARANTEED FIXED INCOME OPTION TABLES 
 The amounts shown in
these tables are the guaranteed amounts for each $1,000 of the policy proceeds. 
 Higher current amounts may be available at the
time of settlement. 
  

																																													
	 Option 1
	 	  	 	 	  	Option 2(a)	 	  	Option 2(b)	 	  	Option 2(c)	 
	Number	  	Amount of	 	  	 	 	  	 	 	  	 	 	  	Monthly Installment For	 
	of Years	  	Monthly	 	  	 	 	  	Monthly Installment For	 	  	Monthly Installment For	 	  	Life Guaranteed Return of	 
	 Payable
	  	Installment	 	  	 	 	  	Life No Period Certain	 	  	Life 10 Years Certain	 	  	Policy Proceeds	 
	 	  	 	 	  	Age*	 	  	Male	 	  	Female	 	  	Unisex	 	  	Male	 	  	Female	 	  	Unisex	 	  	Male	 	  	Female	 	  	Unisex	 
		  				  	 	50	  	  	$	2.22	  	  	$	2.00	  	  	$	2.07	  	  	$	2.21	  	  	$	2.00	  	  	$	2.06	  	  	$	1.85	  	  	$	1.74	  	  	$	1.78	  
		  				  	 	51	  	  	 	2.27	  	  	 	2.05	  	  	 	2.12	  	  	 	2.26	  	  	 	2.05	  	  	 	2.11	  	  	 	1.89	  	  	 	1.78	  	  	 	1.80	  
		  				  	 	52	  	  	 	2.33	  	  	 	2.10	  	  	 	2.17	  	  	 	2.32	  	  	 	2.10	  	  	 	2.17	  	  	 	1.91	  	  	 	1.80	  	  	 	1.84	  
		  				  	 	53	  	  	 	2.40	  	  	 	2.15	  	  	 	2.23	  	  	 	2.39	  	  	 	2.15	  	  	 	2.22	  	  	 	1.95	  	  	 	1.84	  	  	 	1.88	  
		  				  	 	54	  	  	 	2.46	  	  	 	2.21	  	  	 	2.29	  	  	 	2.45	  	  	 	2.21	  	  	 	2.28	  	  	 	1.99	  	  	 	1.88	  	  	 	1.91	  
		  				  	 	55	  	  	 	2.54	  	  	 	2.27	  	  	 	2.35	  	  	 	2.52	  	  	 	2.26	  	  	 	2.34	  	  	 	2.03	  	  	 	1.91	  	  	 	1.95	  
		  				  	 	56	  	  	 	2.61	  	  	 	2.33	  	  	 	2.42	  	  	 	2.59	  	  	 	2.33	  	  	 	2.41	  	  	 	2.07	  	  	 	1.95	  	  	 	1.99	  
		  				  	 	57	  	  	 	2.69	  	  	 	2.40	  	  	 	2.49	  	  	 	2.67	  	  	 	2.39	  	  	 	2.48	  	  	 	2.13	  	  	 	1.99	  	  	 	2.03	  
		  				  	 	58	  	  	 	2.77	  	  	 	2.47	  	  	 	2.56	  	  	 	2.75	  	  	 	2.46	  	  	 	2.55	  	  	 	2.17	  	  	 	2.03	  	  	 	2.07	  
	 10
	  	 	8.44	  	  	 	59	  	  	 	2.86	  	  	 	2.54	  	  	 	2.64	  	  	 	2.83	  	  	 	2.53	  	  	 	2.62	  	  	 	2.21	  	  	 	2.07	  	  	 	2.13	  
	 11
	  	 	7.68	  	  	 	60	  	  	 	2.95	  	  	 	2.62	  	  	 	2.72	  	  	 	2.92	  	  	 	2.61	  	  	 	2.70	  	  	 	2.26	  	  	 	2.13	  	  	 	2.17	  
	 12
	  	 	7.05	  	  	 	61	  	  	 	3.05	  	  	 	2.70	  	  	 	2.81	  	  	 	3.02	  	  	 	2.69	  	  	 	2.79	  	  	 	2.32	  	  	 	2.17	  	  	 	2.21	  
	 13
	  	 	6.51	  	  	 	62	  	  	 	3.16	  	  	 	2.79	  	  	 	2.90	  	  	 	3.11	  	  	 	2.77	  	  	 	2.88	  	  	 	2.38	  	  	 	2.22	  	  	 	2.26	  
	 14
	  	 	6.06	  	  	 	63	  	  	 	3.27	  	  	 	2.88	  	  	 	3.00	  	  	 	3.22	  	  	 	2.86	  	  	 	2.97	  	  	 	2.44	  	  	 	2.28	  	  	 	2.33	  
	 15
	  	 	5.66	  	  	 	64	  	  	 	3.39	  	  	 	2.98	  	  	 	3.10	  	  	 	3.33	  	  	 	2.95	  	  	 	3.07	  	  	 	2.49	  	  	 	2.34	  	  	 	2.39	  
	 16
	  	 	5.31	  	  	 	65	  	  	 	3.51	  	  	 	3.09	  	  	 	3.21	  	  	 	3.45	  	  	 	3.05	  	  	 	3.17	  	  	 	2.55	  	  	 	2.39	  	  	 	2.43	  
	 17
	  	 	5.01	  	  	 	66	  	  	 	3.65	  	  	 	3.20	  	  	 	3.33	  	  	 	3.57	  	  	 	3.16	  	  	 	3.28	  	  	 	2.61	  	  	 	2.44	  	  	 	2.49	  
	 18
	  	 	4.73	  	  	 	67	  	  	 	3.79	  	  	 	3.32	  	  	 	3.46	  	  	 	3.70	  	  	 	3.27	  	  	 	3.40	  	  	 	2.69	  	  	 	2.50	  	  	 	2.55	  
	 19
	  	 	4.49	  	  	 	68	  	  	 	3.95	  	  	 	3.44	  	  	 	3.59	  	  	 	3.83	  	  	 	3.39	  	  	 	3.53	  	  	 	2.75	  	  	 	2.57	  	  	 	2.64	  
	 20
	  	 	4.27	  	  	 	69	  	  	 	4.11	  	  	 	3.58	  	  	 	3.74	  	  	 	3.97	  	  	 	3.52	  	  	 	3.66	  	  	 	2.82	  	  	 	2.64	  	  	 	2.69	  
		  				  	 	70	  	  	 	4.29	  	  	 	3.73	  	  	 	3.89	  	  	 	4.12	  	  	 	3.65	  	  	 	3.79	  	  	 	2.90	  	  	 	2.72	  	  	 	2.77	  
		  				  	 	71	  	  	 	4.47	  	  	 	3.89	  	  	 	4.06	  	  	 	4.27	  	  	 	3.80	  	  	 	3.94	  	  	 	3.00	  	  	 	2.79	  	  	 	2.84	  
		  				  	 	72	  	  	 	4.67	  	  	 	4.06	  	  	 	4.24	  	  	 	4.43	  	  	 	3.95	  	  	 	4.09	  	  	 	3.08	  	  	 	2.86	  	  	 	2.93	  
		  				  	 	73	  	  	 	4.88	  	  	 	4.24	  	  	 	4.43	  	  	 	4.59	  	  	 	4.11	  	  	 	4.25	  	  	 	3.15	  	  	 	2.94	  	  	 	3.02	  
		  				  	 	74	  	  	 	5.10	  	  	 	4.44	  	  	 	4.64	  	  	 	4.76	  	  	 	4.27	  	  	 	4.42	  	  	 	3.25	  	  	 	3.06	  	  	 	3.12	  
		  				  	 	75	  	  	 	5.34	  	  	 	4.65	  	  	 	4.86	  	  	 	4.94	  	  	 	4.45	  	  	 	4.60	  	  	 	3.35	  	  	 	3.13	  	  	 	3.20	  
		  				  	 	76	  	  	 	5.60	  	  	 	4.88	  	  	 	5.09	  	  	 	5.12	  	  	 	4.63	  	  	 	4.78	  	  	 	3.46	  	  	 	3.21	  	  	 	3.30	  
		  				  	 	77	  	  	 	5.88	  	  	 	5.13	  	  	 	5.35	  	  	 	5.31	  	  	 	4.82	  	  	 	4.97	  	  	 	3.60	  	  	 	3.35	  	  	 	3.41	  
		  				  	 	78	  	  	 	6.17	  	  	 	5.40	  	  	 	5.63	  	  	 	5.50	  	  	 	5.02	  	  	 	5.17	  	  	 	3.66	  	  	 	3.44	  	  	 	3.51	  
		  				  	 	79	  	  	 	6.49	  	  	 	5.69	  	  	 	5.92	  	  	 	5.69	  	  	 	5.22	  	  	 	5.37	  	  	 	3.81	  	  	 	3.53	  	  	 	3.62	  
		  				  	 	80	  	  	 	6.82	  	  	 	6.00	  	  	 	6.24	  	  	 	5.88	  	  	 	5.43	  	  	 	5.57	  	  	 	3.89	  	  	 	3.68	  	  	 	3.74	  
		  				  	 	81	  	  	 	7.19	  	  	 	6.34	  	  	 	6.59	  	  	 	6.08	  	  	 	5.65	  	  	 	5.78	  	  	 	4.06	  	  	 	3.81	  	  	 	3.87	  
		  				  	 	82	  	  	 	7.58	  	  	 	6.70	  	  	 	6.96	  	  	 	6.27	  	  	 	5.86	  	  	 	5.99	  	  	 	4.20	  	  	 	3.89	  	  	 	4.00	  
		  				  	 	83	  	  	 	7.99	  	  	 	7.10	  	  	 	7.36	  	  	 	6.46	  	  	 	6.08	  	  	 	6.20	  	  	 	4.34	  	  	 	4.09	  	  	 	4.16	  
		  				  	 	84	  	  	 	8.44	  	  	 	7.53	  	  	 	7.80	  	  	 	6.65	  	  	 	6.29	  	  	 	6.40	  	  	 	4.50	  	  	 	4.23	  	  	 	4.32	  
		  				  	 	85	  	  	 	8.92	  	  	 	7.99	  	  	 	8.27	  	  	 	6.83	  	  	 	6.49	  	  	 	6.60	  	  	 	4.70	  	  	 	4.40	  	  	 	4.49	  
		  				  	 	86	  	  				  				  				  	 	7.00	  	  	 	6.69	  	  	 	6.79	  	  	 	4.89	  	  	 	4.54	  	  	 	4.74	  
		  				  	 	87	  	  				  				  				  	 	7.17	  	  	 	6.88	  	  	 	6.97	  	  	 	5.11	  	  	 	4.71	  	  	 	4.84	  
		  				  	 	88	  	  				  				  				  	 	7.32	  	  	 	7.06	  	  	 	7.14	  	  	 	5.28	  	  	 	4.90	  	  	 	5.08	  
		  				  	 	89	  	  				  				  				  	 	7.47	  	  	 	7.23	  	  	 	7.31	  	  	 	5.53	  	  	 	5.19	  	  	 	5.27	  
		  				  	 	90	  	  				  				  				  	 	7.60	  	  	 	7.39	  	  	 	7.46	  	  	 	5.73	  	  	 	5.39	  	  	 	5.48	  
		  				  	 	91	  	  				  				  				  	 	7.73	  	  	 	7.53	  	  	 	7.59	  	  	 	5.88	  	  	 	5.63	  	  	 	5.79	  
		  				  	 	92	  	  				  				  				  	 	7.84	  	  	 	7.66	  	  	 	7.72	  	  	 	6.17	  	  	 	5.78	  	  	 	5.97	  
		  				  	 	93	  	  				  				  				  	 	7.95	  	  	 	7.79	  	  	 	7.84	  	  	 	6.44	  	  	 	6.02	  	  	 	6.17	  
		  				  	 	94	  	  				  				  				  	 	8.04	  	  	 	7.90	  	  	 	7.94	  	  	 	6.79	  	  	 	6.46	  	  	 	6.52	  
		  				  	 	95	  	  				  				  				  	 	8.12	  	  	 	8.00	  	  	 	8.04	  	  	 	7.13	  	  	 	6.73	  	  	 	6.83	  
		  				  	 	96	  	  				  				  				  	 	8.20	  	  	 	8.09	  	  	 	8.13	  	  	 	7.40	  	  	 	6.89	  	  	 	7.17	  
		  				  	 	97	  	  				  				  				  	 	8.26	  	  	 	8.17	  	  	 	8.20	  	  	 	7.91	  	  	 	7.53	  	  	 	7.66	  
		  				  	 	98	  	  				  				  				  	 	8.31	  	  	 	8.24	  	  	 	8.27	  	  	 	8.19	  	  	 	7.84	  	  	 	7.75	  
		  				  	 	99	  	  				  				  				  	 	8.35	  	  	 	8.30	  	  	 	8.32	  	  	 	8.82	  	  	 	8.18	  	  	 	8.57	  

  

	*	Adjusted Age as defined in Section 10.A. 

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

ICC12 AP(2)0513 

  
 Page 22(a)

 APPENDIX (continued) 
  

 Option 4(a) 

Monthly Installment For Joint and Survivor 
  

																													
	Adjusted Age	  	Adjusted Age of Female Annuitant*	 
	 of
 Male

Annuitant*
	  	15 Years
Less Than
Male	 	  	12 Years
Less Than
Male	 	  	9 Years
Less Than
Male	 	  	6 Years
Less Than
Male	 	  	3 Years
Less Than
Male	 	  	Same As
Male	 	  	3 Years
More Than
Male	 
	 50
	  	$	1.45	  	  	$	1.51	  	  	$	1.58	  	  	$	1.66	  	  	$	1.73	  	  	$	1.80	  	  	$	1.87	  
	 55
	  	 	1.58	  	  	 	1.66	  	  	 	1.75	  	  	 	1.84	  	  	 	1.93	  	  	 	2.02	  	  	 	2.10	  
	 60
	  	 	1.75	  	  	 	1.85	  	  	 	1.95	  	  	 	2.07	  	  	 	2.18	  	  	 	2.29	  	  	 	2.41	  
	 65
	  	 	1.95	  	  	 	2.08	  	  	 	2.21	  	  	 	2.36	  	  	 	2.51	  	  	 	2.66	  	  	 	2.81	  
	 70
	  	 	2.21	  	  	 	2.37	  	  	 	2.55	  	  	 	2.74	  	  	 	2.94	  	  	 	3.15	  	  	 	3.35	  
	 75
	  	 	2.54	  	  	 	2.76	  	  	 	3.00	  	  	 	3.26	  	  	 	3.54	  	  	 	3.83	  	  	 	4.11	  
	 80
	  	 	2.99	  	  	 	3.29	  	  	 	3.62	  	  	 	3.99	  	  	 	4.39	  	  	 	4.79	  	  	 	5.18	  
	 85
	  	 	3.60	  	  	 	4.02	  	  	 	4.50	  	  	 	5.03	  	  	 	5.59	  	  	 	6.17	  	  	 	6.71	  

 Monthly Installment For Unisex Joint and Survivor 

 

																													
	Adjusted Age	  	Adjusted Age of Joint Annuitant*	 
	 of
 First

Annuitant*
	  	15 Years
Less Than
First	 	  	12 Years
Less Than
First	 	  	9 Years
Less Than
First	 	  	6 Years
Less Than
First	 	  	3 Years
Less Than
First	 	  	Same As
First	 	  	3 Years
More Than
First	 
	 50
	  	$	1.47	  	  	$	1.53	  	  	$	1.60	  	  	$	1.66	  	  	$	1.72	  	  	$	1.78	  	  	$	1.84	  
	 55
	  	 	1.61	  	  	 	1.68	  	  	 	1.76	  	  	 	1.84	  	  	 	1.92	  	  	 	2.00	  	  	 	2.06	  
	 60
	  	 	1.78	  	  	 	1.87	  	  	 	1.97	  	  	 	2.07	  	  	 	2.17	  	  	 	2.27	  	  	 	2.36	  
	 65
	  	 	1.99	  	  	 	2.11	  	  	 	2.24	  	  	 	2.37	  	  	 	2.50	  	  	 	2.62	  	  	 	2.74	  
	 70
	  	 	2.26	  	  	 	2.41	  	  	 	2.58	  	  	 	2.76	  	  	 	2.93	  	  	 	3.11	  	  	 	3.27	  
	 75
	  	 	2.60	  	  	 	2.81	  	  	 	3.04	  	  	 	3.28	  	  	 	3.53	  	  	 	3.77	  	  	 	4.00	  
	 80
	  	 	3.07	  	  	 	3.36	  	  	 	3.68	  	  	 	4.02	  	  	 	4.37	  	  	 	4.71	  	  	 	5.04	  
	 85
	  	 	3.71	  	  	 	4.12	  	  	 	4.58	  	  	 	5.07	  	  	 	5.57	  	  	 	6.07	  	  	 	6.54	  

 Option 4(b) 
 Monthly Installment For Joint and Survivor (Life with 10 year Certain) 
  

																													
	Adjusted Age	  	Adjusted Age of Female Annuitant*	 
	 of
 Male

Annuitant*
	  	15 Years
Less Than
Male	 	  	12 Years
Less Than
Male	 	  	9 Years
Less Than
Male	 	  	6 Years
Less Than
Male	 	  	3 Years
Less Than
Male	 	  	Same As
Male	 	  	3 Years
More Than
Male	 
	 50
	  	$	1.45	  	  	$	1.51	  	  	$	1.58	  	  	$	1.66	  	  	$	1.73	  	  	$	1.80	  	  	$	1.87	  
	 55
	  	 	1.58	  	  	 	1.66	  	  	 	1.75	  	  	 	1.84	  	  	 	1.93	  	  	 	2.02	  	  	 	2.10	  
	 60
	  	 	1.75	  	  	 	1.85	  	  	 	1.95	  	  	 	2.07	  	  	 	2.18	  	  	 	2.29	  	  	 	2.41	  
	 65
	  	 	1.95	  	  	 	2.08	  	  	 	2.21	  	  	 	2.36	  	  	 	2.51	  	  	 	2.66	  	  	 	2.80	  
	 70
	  	 	2.21	  	  	 	2.37	  	  	 	2.55	  	  	 	2.74	  	  	 	2.94	  	  	 	3.14	  	  	 	3.34	  
	 75
	  	 	2.54	  	  	 	2.76	  	  	 	3.00	  	  	 	3.25	  	  	 	3.53	  	  	 	3.80	  	  	 	4.07	  
	 80
	  	 	2.98	  	  	 	3.27	  	  	 	3.60	  	  	 	3.95	  	  	 	4.32	  	  	 	4.68	  	  	 	5.02	  
	 85
	  	 	3.58	  	  	 	3.97	  	  	 	4.41	  	  	 	4.88	  	  	 	5.34	  	  	 	5.76	  	  	 	6.11	  

 Monthly Installment For Unisex Joint and Survivor (Life with 10 year Certain) 

 

																													
	Adjusted Age	  	Adjusted Age of Joint Annuitant*	 
	 of
 First

Annuitant*
	  	15 Years
Less Than
First	 	  	12 Years
Less Than
First	 	  	9 Years
Less Than
First	 	  	6 Years
Less Than
First	 	  	3 Years
Less Than
First	 	  	Same As
First	 	  	3 Years
More Than
First	 
	 50
	  	$	1.47	  	  	$	1.53	  	  	$	1.60	  	  	$	1.66	  	  	$	1.72	  	  	$	1.78	  	  	$	1.84	  
	 55
	  	 	1.61	  	  	 	1.68	  	  	 	1.76	  	  	 	1.84	  	  	 	1.92	  	  	 	2.00	  	  	 	2.06	  
	 60
	  	 	1.78	  	  	 	1.87	  	  	 	1.97	  	  	 	2.07	  	  	 	2.17	  	  	 	2.27	  	  	 	2.36	  
	 65
	  	 	1.99	  	  	 	2.11	  	  	 	2.24	  	  	 	2.37	  	  	 	2.50	  	  	 	2.62	  	  	 	2.74	  
	 70
	  	 	2.25	  	  	 	2.41	  	  	 	2.58	  	  	 	2.75	  	  	 	2.93	  	  	 	3.10	  	  	 	3.26	  
	 75
	  	 	2.60	  	  	 	2.81	  	  	 	3.04	  	  	 	3.27	  	  	 	3.52	  	  	 	3.75	  	  	 	3.96	  
	 80
	  	 	3.06	  	  	 	3.35	  	  	 	3.66	  	  	 	3.98	  	  	 	4.31	  	  	 	4.62	  	  	 	4.90	  
	 85
	  	 	3.68	  	  	 	4.06	  	  	 	4.48	  	  	 	4.91	  	  	 	5.33	  	  	 	5.70	  	  	 	6.00	  

  

	*	Adjusted Age as defined in Section 10.A. 

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

  
 ICC12 AP(2)0513 

Page 22(b) 

 APPENDIX (continued) 
  

 SECTION 13 - VARIABLE INCOME OPTION TABLES 

BASED ON ASSUMED INVESTMENT RETURN 
 The amounts shown in these tables are the initial payment amounts based on a 3.0% Assumed Investment Return for each $1,000 of the policy proceeds. 

 

																									
	 	  	Option 2-V(a)	 	  	Option 2-V(b)	 
	 	  	Monthly Installment For	 	  	Monthly Installment For	 
	 	  	Life No Period Certain	 	  	Life 10 Years Certain	 
	 Age*
	  	Male	 	  	Female	 	  	Unisex	 	  	Male	 	  	Female	 	  	Unisex	 
	 50
	  	$	3.70	  	  	$	3.47	  	  	$	3.54	  	  	$	3.68	  	  	$	3.47	  	  	$	3.53	  
	 51
	  	 	3.76	  	  	 	3.52	  	  	 	3.59	  	  	 	3.74	  	  	 	3.51	  	  	 	3.58	  
	 52
	  	 	3.82	  	  	 	3.57	  	  	 	3.65	  	  	 	3.80	  	  	 	3.56	  	  	 	3.63	  
	 53
	  	 	3.88	  	  	 	3.62	  	  	 	3.70	  	  	 	3.86	  	  	 	3.61	  	  	 	3.69	  
	 54
	  	 	3.95	  	  	 	3.68	  	  	 	3.76	  	  	 	3.92	  	  	 	3.66	  	  	 	3.74	  
	 55
	  	 	4.02	  	  	 	3.73	  	  	 	3.82	  	  	 	3.99	  	  	 	3.72	  	  	 	3.80	  
	 56
	  	 	4.09	  	  	 	3.80	  	  	 	3.89	  	  	 	4.06	  	  	 	3.78	  	  	 	3.87	  
	 57
	  	 	4.17	  	  	 	3.86	  	  	 	3.96	  	  	 	4.13	  	  	 	3.84	  	  	 	3.93	  
	 58
	  	 	4.25	  	  	 	3.93	  	  	 	4.03	  	  	 	4.21	  	  	 	3.91	  	  	 	4.00	  
	 59
	  	 	4.34	  	  	 	4.00	  	  	 	4.11	  	  	 	4.30	  	  	 	3.98	  	  	 	4.08	  
	 60
	  	 	4.44	  	  	 	4.08	  	  	 	4.19	  	  	 	4.38	  	  	 	4.05	  	  	 	4.15	  
	 61
	  	 	4.54	  	  	 	4.16	  	  	 	4.28	  	  	 	4.48	  	  	 	4.13	  	  	 	4.24	  
	 62
	  	 	4.65	  	  	 	4.25	  	  	 	4.37	  	  	 	4.57	  	  	 	4.21	  	  	 	4.32	  
	 63
	  	 	4.76	  	  	 	4.34	  	  	 	4.47	  	  	 	4.68	  	  	 	4.30	  	  	 	4.42	  
	 64
	  	 	4.89	  	  	 	4.44	  	  	 	4.58	  	  	 	4.79	  	  	 	4.39	  	  	 	4.51	  
	 65
	  	 	5.02	  	  	 	4.55	  	  	 	4.69	  	  	 	4.90	  	  	 	4.49	  	  	 	4.62	  
	 66
	  	 	5.16	  	  	 	4.66	  	  	 	4.81	  	  	 	5.02	  	  	 	4.60	  	  	 	4.73	  
	 67
	  	 	5.31	  	  	 	4.78	  	  	 	4.94	  	  	 	5.15	  	  	 	4.71	  	  	 	4.84	  
	 68
	  	 	5.47	  	  	 	4.91	  	  	 	5.08	  	  	 	5.28	  	  	 	4.83	  	  	 	4.97	  
	 69
	  	 	5.64	  	  	 	5.05	  	  	 	5.23	  	  	 	5.42	  	  	 	4.95	  	  	 	5.10	  
	 70
	  	 	5.82	  	  	 	5.21	  	  	 	5.39	  	  	 	5.56	  	  	 	5.09	  	  	 	5.23	  
	 71
	  	 	6.01	  	  	 	5.37	  	  	 	5.56	  	  	 	5.71	  	  	 	5.23	  	  	 	5.38	  
	 72
	  	 	6.22	  	  	 	5.55	  	  	 	5.75	  	  	 	5.86	  	  	 	5.37	  	  	 	5.53	  
	 73
	  	 	6.44	  	  	 	5.74	  	  	 	5.95	  	  	 	6.02	  	  	 	5.53	  	  	 	5.68	  
	 74
	  	 	6.67	  	  	 	5.94	  	  	 	6.16	  	  	 	6.19	  	  	 	5.70	  	  	 	5.85	  
	 75
	  	 	6.92	  	  	 	6.17	  	  	 	6.39	  	  	 	6.36	  	  	 	5.87	  	  	 	6.02	  
	 76
	  	 	7.18	  	  	 	6.40	  	  	 	6.64	  	  	 	6.53	  	  	 	6.05	  	  	 	6.20	  
	 77
	  	 	7.47	  	  	 	6.66	  	  	 	6.90	  	  	 	6.71	  	  	 	6.23	  	  	 	6.38	  
	 78
	  	 	7.77	  	  	 	6.94	  	  	 	7.19	  	  	 	6.89	  	  	 	6.42	  	  	 	6.57	  
	 79
	  	 	8.10	  	  	 	7.24	  	  	 	7.49	  	  	 	7.07	  	  	 	6.62	  	  	 	6.76	  
	 80
	  	 	8.45	  	  	 	7.56	  	  	 	7.83	  	  	 	7.25	  	  	 	6.82	  	  	 	6.96	  
	 81
	  	 	8.82	  	  	 	7.92	  	  	 	8.19	  	  	 	7.44	  	  	 	7.02	  	  	 	7.15	  
	 82
	  	 	9.23	  	  	 	8.30	  	  	 	8.57	  	  	 	7.62	  	  	 	7.23	  	  	 	7.35	  
	 83
	  	 	9.66	  	  	 	8.71	  	  	 	8.99	  	  	 	7.79	  	  	 	7.43	  	  	 	7.54	  
	 84
	  	 	10.12	  	  	 	9.16	  	  	 	9.44	  	  	 	7.96	  	  	 	7.63	  	  	 	7.73	  
	 85
	  	 	10.61	  	  	 	9.64	  	  	 	9.93	  	  	 	8.13	  	  	 	7.82	  	  	 	7.92	  
	 86
	  				  				  				  	 	8.29	  	  	 	8.00	  	  	 	8.09	  
	 87
	  				  				  				  	 	8.44	  	  	 	8.18	  	  	 	8.26	  
	 88
	  				  				  				  	 	8.58	  	  	 	8.34	  	  	 	8.42	  
	 89
	  				  				  				  	 	8.71	  	  	 	8.50	  	  	 	8.57	  
	 90
	  				  				  				  	 	8.84	  	  	 	8.64	  	  	 	8.70	  
	 91
	  				  				  				  	 	8.95	  	  	 	8.77	  	  	 	8.83	  
	 92
	  				  				  				  	 	9.06	  	  	 	8.89	  	  	 	8.95	  
	 93
	  				  				  				  	 	9.15	  	  	 	9.01	  	  	 	9.06	  
	 94
	  				  				  				  	 	9.24	  	  	 	9.11	  	  	 	9.15	  
	 95
	  				  				  				  	 	9.32	  	  	 	9.20	  	  	 	9.24	  
	 96
	  				  				  				  	 	9.39	  	  	 	9.29	  	  	 	9.32	  
	 97
	  				  				  				  	 	9.45	  	  	 	9.36	  	  	 	9.39	  
	 98
	  				  				  				  	 	9.49	  	  	 	9.43	  	  	 	9.45	  
	 99
	  				  				  				  	 	9.53	  	  	 	9.48	  	  	 	9.50	  

  

	*	Adjusted Age as defined in Section 10.A. 

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

  
 ICC12 AP(2)0513 

Page 22(c) 

 APPENDIX (continued) 
  

 Option 4-V 

Monthly Installment For Joint and Survivor 
  

																													
	Adjusted Age	  	Adjusted Age of Female Annuitant*	 
	 of
 Male

Annuitant*
	  	15 Years
Less Than
Male	 	  	12 Years
Less Than
Male	 	  	9 Years
Less Than
Male	 	  	6 Years
Less Than
Male	 	  	3 Years
Less Than
Male	 	  	Same As
Male	 	  	3 Years
More Than
Male	 
	 50
	  	$	2.96	  	  	$	3.01	  	  	$	3.06	  	  	$	3.12	  	  	$	3.18	  	  	$	3.24	  	  	$	3.31	  
	 55
	  	 	3.07	  	  	 	3.14	  	  	 	3.21	  	  	 	3.28	  	  	 	3.36	  	  	 	3.44	  	  	 	3.52	  
	 60
	  	 	3.21	  	  	 	3.30	  	  	 	3.39	  	  	 	3.49	  	  	 	3.59	  	  	 	3.70	  	  	 	3.81	  
	 65
	  	 	3.40	  	  	 	3.51	  	  	 	3.64	  	  	 	3.77	  	  	 	3.91	  	  	 	4.05	  	  	 	4.20	  
	 70
	  	 	3.64	  	  	 	3.79	  	  	 	3.96	  	  	 	4.14	  	  	 	4.34	  	  	 	4.54	  	  	 	4.74	  
	 75
	  	 	3.97	  	  	 	4.17	  	  	 	4.41	  	  	 	4.66	  	  	 	4.93	  	  	 	5.22	  	  	 	5.50	  
	 80
	  	 	4.41	  	  	 	4.70	  	  	 	5.03	  	  	 	5.39	  	  	 	5.79	  	  	 	6.19	  	  	 	6.60	  
	 85
	  	 	5.03	  	  	 	5.45	  	  	 	5.92	  	  	 	6.45	  	  	 	7.02	  	  	 	7.59	  	  	 	8.15	  

 Monthly Installment For Unisex Joint and Survivor 

 

																													
	Adjusted Age	  	Adjusted Age of Joint Annuitant*	 
	 of
 First

Annuitant*
	  	15 Years
Less Than
First	 	  	12 Years
Less Than
First	 	  	9 Years
Less Than
First	 	  	6 Years
Less Than
First	 	  	3 Years
Less Than
First	 	  	Same As
First	 	  	3 Years
More Than
First	 
	 50
	  	$	2.97	  	  	$	3.02	  	  	$	3.07	  	  	$	3.12	  	  	$	3.18	  	  	$	3.23	  	  	$	3.28	  
	 55
	  	 	3.09	  	  	 	3.15	  	  	 	3.22	  	  	 	3.29	  	  	 	3.35	  	  	 	3.42	  	  	 	3.48	  
	 60
	  	 	3.24	  	  	 	3.32	  	  	 	3.41	  	  	 	3.49	  	  	 	3.58	  	  	 	3.67	  	  	 	3.76	  
	 65
	  	 	3.43	  	  	 	3.54	  	  	 	3.65	  	  	 	3.77	  	  	 	3.89	  	  	 	4.02	  	  	 	4.13	  
	 70
	  	 	3.68	  	  	 	3.83	  	  	 	3.98	  	  	 	4.15	  	  	 	4.32	  	  	 	4.49	  	  	 	4.65	  
	 75
	  	 	4.02	  	  	 	4.22	  	  	 	4.44	  	  	 	4.67	  	  	 	4.92	  	  	 	5.16	  	  	 	5.39	  
	 80
	  	 	4.49	  	  	 	4.77	  	  	 	5.08	  	  	 	5.42	  	  	 	5.76	  	  	 	6.11	  	  	 	6.45	  
	 85
	  	 	5.14	  	  	 	5.54	  	  	 	6.00	  	  	 	6.48	  	  	 	6.99	  	  	 	7.50	  	  	 	7.97	  

  

	*	Adjusted Age as defined in Section 10.A. 

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

  
 ICC12 AP(2)0513 

Page 22(d) 

 This page left intentionally blank 

			
	

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

(319) 355-8511

www.transamericaannuities.com

  
 ICC12 VA(2)0513 

Page 23

Source: [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00215-of-00352.parquet"}, [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00215-of-00352.parquet"}]]