Document:

Amended & Restated Covidien Change in Control Severance Plan

 Exhibit 10.7 
 COVIDIEN CHANGE IN CONTROL SEVERANCE PLAN 
 FOR CERTAIN U.S. OFFICERS AND EXECUTIVES 

As Amended and Restated Effective January 1, 2009 

 TABLE OF CONTENTS 
  

					
	 	  	 	 	Page
	ARTICLE I	  	BACKGROUND, PURPOSE AND TERM OF PLAN	 	1
			
	 Section 1.01
	  	 Purpose and Intent of the Plan
	 	1
			
	 Section 1.02
	  	 Term of the Plan
	 	1
			
	 Section 1.03
	  	 Adoption of the Plan
	 	1
			
	ARTICLE II	  	DEFINITIONS	 	2
			
	 Section 2.01
	  	 “Annual Bonus”
	 	2
			
	 Section 2.02
	  	 “Base Salary”
	 	2
			
	 Section 2.03
	  	 “Board”
	 	2
			
	 Section 2.04
	  	 “Cause”
	 	2
			
	 Section 2.05
	  	 “Change in Control”
	 	2
			
	 Section 2.06
	  	 “Change in Control Benefits”
	 	3
			
	 Section 2.07
	  	 “Change in Control Termination”
	 	3
			
	 Section 2.08
	  	 “COBRA”
	 	3
			
	 Section 2.09
	  	 “Code”
	 	3
			
	 Section 2.10
	  	 “Committee”
	 	3
			
	 Section 2.11
	  	 “Company”
	 	3
			
	 Section 2.12
	  	 “Effective Date”
	 	3
			
	 Section 2.13
	  	 “Eligible Employee”
	 	3
			
	 Section 2.14
	  	 “Employee”
	 	4
			
	 Section 2.15
	  	 “Employer”
	 	4
			
	 Section 2.16
	  	 “ERISA”
	 	4
			
	 Section 2.17
	  	 “Exchange Act”
	 	4
			
	 Section 2.18
	  	 “Executive Severance Plan”
	 	4
			
	 Section 2.19
	  	 “Good Reason Resignation”
	 	4
			
	 Section 2.20
	  	 “Involuntary Termination”
	 	5
			
	 Section 2.21
	  	 “Key Employee”
	 	5
			
	 Section 2.22
	  	 “Notice Pay”
	 	5
			
	 Section 2.23
	  	 “Officer”
	 	5
			
	 Section 2.24
	  	 “Participant”
	 	5
			
	 Section 2.25
	  	 “Permanent Disability”
	 	5

  

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 TABLE OF CONTENTS 
 (continued) 
  

					
	 	  	 	 	Page
	 Section 2.26
	  	 “Plan”
	 	5
			
	 Section 2.27
	  	 “Plan Administrator”
	 	5
			
	 Section 2.28
	  	 “Postponement Period”
	 	6
			
	 Section 2.29
	  	 “Release”
	 	6
			
	 Section 2.30
	  	 “Separation from Service”
	 	6
			
	 Section 2.31
	  	 “Separation from Service Date”
	 	6
			
	 Section 2.32
	  	 “Severance Benefits”
	 	6
			
	 Section 2.33
	  	 “Severance Period”
	 	6
			
	 Section 2.34
	  	 “Subsidiary”
	 	6
			
	 Section 2.35
	  	 “Successor”
	 	6
			
	 Section 2.36
	  	 “Voluntary Resignation”
	 	6
			
	 ARTICLE III
	  	PARTICIPATION AND ELIGIBILITY FOR BENEFITS	 	7
			
	 Section 3.01
	  	 Participation
	 	7
			
	 Section 3.02
	  	 Conditions
	 	7
			
	 ARTICLE IV
	  	DETERMINATION OF SEVERANCE BENEFITS	 	9
			
	 Section 4.01
	  	 Amount of Severance Benefits Upon Involuntary Termination and Good Reason Resignation
	 	9
			
	 Section 4.02
	  	 Voluntary Resignation; Termination for Death or Permanent Disability
	 	11
			
	 Section 4.03
	  	 Termination for Cause
	 	11
			
	 Section 4.04
	  	 Reduction of Severance Benefits
	 	11
			
	 ARTICLE V
	  	METHOD, DURATION AND LIMITATION OF SEVERANCE BENEFIT PAYMENTS	 	12
			
	 Section 5.01
	  	 Method of Payment
	 	12
			
	 Section 5.02
	  	 Other Arrangements
	 	12
			
	 Section 5.03
	  	 Code Section 409A
	 	12
			
	 Section 5.04
	  	 Termination of Eligibility for Benefits
	 	13
			
	 Section 5.05
	  	 Limitation on Benefits
	 	13
			
	 ARTICLE VI
	  	CONFIDENTIALITY, COVENANT NOT TO COMPETE AND NOT TO SOLICIT	 	15
			
	 Section 6.01
	  	 Confidential Information
	 	15

  

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 TABLE OF CONTENTS 
 (continued) 
  

					
	 	  	 	 	Page
	 Section 6.02
	  	 Non-Competition
	 	15
			
	 Section 6.03
	  	 Non-Solicitation
	 	15
			
	 Section 6.04
	  	 Non-Disparagement
	 	16
			
	 Section 6.05
	  	 Reasonableness
	 	16
			
	 Section 6.06
	  	 Equitable Relief
	 	16
			
	 Section 6.07
	  	 Survival of Provisions
	 	17
			
	 ARTICLE VII
	  	THE PLAN ADMINISTRATOR	 	18
			
	 Section 7.01
	  	 Authority and Duties
	 	18
			
	 Section 7.02
	  	 Compensation of the Plan Administrator
	 	18
			
	 Section 7.03
	  	 Records, Reporting and Disclosure
	 	18
			
	 ARTICLE VIII
	  	AMENDMENT, TERMINATION AND DURATION	 	19
			
	 Section 8.01
	  	 Amendment, Suspension and Termination
	 	19
			
	 Section 8.02
	  	 Duration
	 	19
			
	 ARTICLE IX
	  	DUTIES OF THE COMPANY AND THE COMMITTEE	 	20
			
	 Section 9.01
	  	 Records
	 	20
			
	 Section 9.02
	  	 Payment
	 	20
			
	 Section 9.03
	  	 Discretion
	 	20
			
	 ARTICLE X
	  	CLAIMS PROCEDURES	 	21
			
	 Section 10.01
	  	 Claim
	 	21
			
	 Section 10.02
	  	 Initial Claim
	 	21
			
	 Section 10.03
	  	 Appeals of Denied Administrative Claims
	 	21
			
	 Section 10.04
	  	 Appointment of the Named Appeals Fiduciary
	 	22
			
	 Section 10.05
	  	 Arbitration; Expenses
	 	22
			
	 ARTICLE XI
	  	MISCELLANEOUS	 	24
			
	 Section 11.01
	  	 Nonalienation of Benefits
	 	24
			
	 Section 11.02
	  	 Notices
	 	24
			
	 Section 11.03
	  	 Successors
	 	24
			
	 Section 11.04
	  	 Other Payments
	 	24
			
	 Section 11.05
	  	 No Mitigation
	 	24
			
	 Section 11.06
	  	 No Contract of Employment
	 	24

  

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 TABLE OF CONTENTS 
 (continued) 
  

					
	 	  	 	 	Page
	 Section 11.07
	  	 Severability of Provisions
	 	24
			
	 Section 11.08
	  	 Heirs, Assigns, and Personal Representatives
	 	25
			
	 Section 11.09
	  	 Headings and Captions
	 	25
			
	 Section 11.10
	  	 Gender and Number
	 	25
			
	 Section 11.11
	  	 Unfunded Plan
	 	25
			
	 Section 11.12
	  	 Payments to Incompetent Persons
	 	25
			
	 Section 11.13
	  	 Lost Payees
	 	25
			
	 Section 11.14
	  	 Controlling Law
	 	25
			
	APPENDIX	  	 Salary Continuation Schedule
	 	A-1

  

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 ARTICLE I 
 BACKGROUND, PURPOSE AND TERM OF PLAN 
 Section 1.01 Purpose and Intent of the
Plan. The purpose of the Plan is to provide Eligible Employees with certain compensation and benefits in the event that such Employee’s employment with the Company or a Subsidiary is terminated due to a Change in Control Termination.
The Plan is not intended to be an “employee pension benefit plan” or “pension plan” within the meaning of Section 3(2) of ERISA. Rather, the Plan is intended to be a “welfare benefit plan” within the meaning of
Section 3(1) of ERISA and to meet the descriptive requirements of a plan constituting a “severance pay plan” within the meaning of regulations published by the Secretary of Labor at Title 29, Code of Federal Regulations,
Section 2510.3-2(b). Accordingly, no employee shall have a vested right to benefits paid by the Plan. The terms of the Plan are intended to, and shall be interpreted so as to, comply in all respects with the provisions of Code Section 409A
and the regulations and rulings promulgated thereunder and, if necessary, any provision shall be held null and void to the extent such provision (or any part thereof) fails to comply with Code Section 409A or the regulations or rulings
promulgated thereunder. 
 Section 1.02 Term of the Plan. The Plan, as amended and restated, shall generally be effective
as of the Effective Date. The Plan is intended to supersede, and not to duplicate, the provisions of the Covidien Severance Plan for U.S. Officers and Executives (“Executive Severance Plan”) in any case in which an Eligible Employee would
otherwise be entitled to severance or related benefits under both this Plan and the Executive Severance Plan arising out of the Eligible Employee’s Change in Control Termination. Moreover, this Plan is intended to supersede any other plan,
program, arrangement or agreement providing an Eligible Employee with severance or related benefits in the case of an Eligible Employee’s Change in Control Termination. The Plan shall continue until terminated pursuant to Article VIII of the
Plan. 
 Section 1.03 Adoption of the Plan. The Plan was adopted by the Board of Directors of Covidien Ltd. on
June 30, 2007. The Board of Directors of Covidien Ltd., by action of its Compensation and Human Resources Committee on November 20, 2008, amended and restated the Plan and provided for the transfer of sponsorship of the Plan to Tyco
Healthcare Group LP, and Tyco Healthcare Group LP agreed to accept such transfer of sponsorship. 

 ARTICLE II 
 DEFINITIONS 
 Section 2.01 “Annual Bonus” means the average of
the actual bonuses paid to the respective Participant pursuant to The Covidien Annual Incentive Plan that are attributable to the three Company fiscal years that immediately precede the fiscal year in which the Participant’s Separation from
Service Date occurs. 
 Section 2.02 “Base Salary” means the Participant’s annual base salary in effect as
of the Participant’s Separation from Service Date. 
 Section 2.03 “Board” means the Board of Directors of
the Covidien Ltd. 
 Section 2.04 “Cause” means an Employee’s (i) substantial failure or refusal to
perform duties and responsibilities of his or her job as required by the Company, (ii) violation of any fiduciary duty owed to the Company, (iii) conviction of a felony or misdemeanor, (iv) dishonesty, (v) theft,
(vi) violation of Company rules or policy, or (vii) other egregious conduct, that has or could have a serious and detrimental impact on the Company and its employees. The Committee, in its sole and absolute discretion, shall determine
Cause. Examples of “Cause” may include, but are not limited to, excessive absenteeism, misconduct, insubordination, violation of Company policy, dishonesty, and deliberate unsatisfactory performance (e.g., Employee refuses to improve
deficient performance). 
 Section 2.05 “Change in Control” means the first to occur of any of the following
events: 
 (i) any “person” (as defined in Section 13(d) and 14(d) of the Exchange Act, excluding for this purpose,
(i) the Company or any Subsidiary or (ii) any employee benefit plan of the Company or any Subsidiary (or any person or entity organized, appointed or established by the Company for or pursuant to the terms of any such plan that acquires
beneficial ownership of voting securities of the Company), is or becomes the “beneficial owner” (as defined in Rule 13d-3 under the Exchange Act) directly or indirectly of securities of the Company representing more than 30 percent of the
combined voting power of the Company’s then outstanding securities; provided, however, that no Change in Control will be deemed to have occurred as a result of a change in ownership percentage resulting solely from an acquisition of securities
by the Company; 
 (ii) persons who, as of the Effective Date, constitute the Board (the “Incumbent Directors”) cease for any
reason (including without limitation, as a result of a tender offer, proxy contest, merger or similar transaction) to constitute at least a majority thereof, provided that any person becoming a Director of the Company subsequent to the Effective
Date shall be considered an Incumbent Director if such person’s election or nomination for election was approved by a vote of at least 50 percent of the Incumbent Directors; but provided further, that any such person whose initial assumption of
office is in connection with an actual or threatened proxy contest relating to the election of members of the Board or other actual or threatened solicitation of proxies or consents by or on behalf of a “person” (as defined in Section

  

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13(d) and 14(d) of the Exchange Act) other than the Board, including by reason of agreement intended to avoid or settle any such actual or threatened contest
or solicitation, shall not be considered an Incumbent Director 
 (iii) consummation of a reorganization, merger or consolidation or
sale or other disposition of at least 80 percent of the assets of the Company (a “Business Combination”), in each case, unless, following such Business Combination, all or substantially all of the individuals and entities who were the
beneficial owners of outstanding voting securities of the Company immediately prior to such Business Combination beneficially own directly or indirectly more than 50 percent of the combined voting power of the then outstanding voting securities
entitled to vote generally in the election of directors of the company resulting from such Business Combination (including, without limitation, a company which, as a result of such transaction, owns the Company or all or substantially all of the
Company’s assets either directly or through one or more Subsidiaries) in substantially the same proportions as their ownership, immediately prior to such Business Combination, of the outstanding voting securities of the Company; or 

(iv) approval by the stockholders of the Company of a complete liquidation or dissolution of the Company. 
 Section 2.06 “Change in Control Benefits” means the payments described in Section 4.01(b) and Section 4.01(c)(ii).

 Section 2.07 “Change in Control Termination” means a Participant’s Involuntary Termination or Good
Reason Resignation that occurs during the period beginning 60 days prior to the date of a Change in Control and ending two years after the date of such Change in Control. 
 Section 2.08 “COBRA” means the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended, and the regulations promulgated thereunder. 
 Section 2.09 “Code” means the Internal Revenue Code of 1986, as amended, and the regulations promulgated thereunder.

 Section 2.10 “Committee” means the Compensation and Human Resources Committee of the Board or any successor
committee or other committee to which the Compensation and Human Resources Committee delegates its authority under this Plan. The Committee may delegate its authority under the Plan to an individual or another committee. 
 Section 2.11 “Company” means Covidien Ltd., a Bermuda company, or any successor thereto. Unless it is otherwise clear from
the context, Company shall generally include participating Subsidiaries. 
 Section 2.12 “Effective Date” means
January 1, 2009. 
 Section 2.13 “Eligible Employee” means an Employee who is an Officer, or in career band
one, and who is not covered under any other severance plan or program sponsored by the Company or a Subsidiary (other than the Executive Severance Plan). If there is any question as to whether an Employee is an Eligible Employee under the Plan, the
Senior Vice President – Human Resources of Covidien Ltd. shall make the determination. 
  

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 Section 2.14 “Employee” means any individual who is a common law employee on
the payroll of any United States Subsidiary of Covidien Ltd., and shall not include any person providing services to the Company or any Subsidiary through a temporary service or on a leased basis or who is hired by the Company or any Subsidiary as
an independent contractor, consultant, or otherwise as a person who is not an employee for purposes of withholding United States federal income or employment taxes, as evidenced by payroll records or a written agreement with the individual,
regardless of any contrary governmental agency determination or judicial holding relating to such status or tax withholding. Notwithstanding the above, in the event that Section 409A applies to any payments made hereunder, subsection
(iv) of the definition of “Subsidiary” shall apply. 
 Section 2.15 “Employer” means the Company
or any Subsidiary. 
 Section 2.16 “ERISA” means the Employee Retirement Income Security Act of 1974, as
amended, and the regulations promulgated thereunder. 
 Section 2.17 “Exchange Act” means the United States
Securities Exchange Act of 1934, as amended, and the regulations promulgated thereunder. 
 Section 2.18 “Executive
Severance Plan” means the Covidien Severance Plan for U.S. Officers and Executives, which plan is superseded by this Plan in the event of any Participant’s Change in Control Termination. 
 Section 2.19 “Good Reason Resignation” means any retirement or termination of employment by a Participant that is not
initiated by the Employer and that is caused by any one or more of the following events which occurs during the period beginning 60 days prior to the date of a Change in Control and ending two years after the date of such Change in Control:

 (1) Without the Participant’s written consent, assignment to the Participant of any duties inconsistent in any material respect
with the Participant’s authority, duties or responsibilities as in effect immediately prior to the Change in Control; 
 (2) Without the
Participant’s written consent, a material diminution in the authority, duties or responsibilities of the supervisor to whom the Participant is required to report as in effect immediately prior to the Change in Control; 
 (3) Without the Participant’s written consent, a material change in the geographic location at which the Participant must perform services to a
location which is more than 50 miles from the Participant’s principal place of business immediately preceding the Change in Control; 
 (4) Without the Participant’s written consent, a material reduction in the Participant’s compensation and benefits, taken as a whole, as in effect immediately prior to the Change in Control; 
 (5) The Company’s failure to obtain a satisfactory agreement from any Successor to assume and agree to perform the Company’s obligations
to the Participant under this Plan, as contemplated in Section 11.03 herein; or 
  

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 (6) Without the Participant’s written consent, a material diminution in the budget over which the
Participant retains authority; 
 Notwithstanding the foregoing, the Participant shall be considered to have a Good Reason Resignation only
if (x) the Participant provides written notice to the Employer specifying in reasonable detail the event upon which the Participant is basing such Good Reason Resignation within ninety (90) days after the occurrence of such event,
(y) the Employer fails to cure such event within thirty (30) days after its receipt of such notice, and (z) the Participant terminates employment within sixty (60) days after the expiration of such cure period. 
 Section 2.20 “Involuntary Termination” means the date that a Participant experiences a Company-initiated Separation from
Service from the Employer for any reason other than Cause, Permanent Disability or death, as provided under and subject to the conditions of Article III. 
 Section 2.21 “Key Employee” means an Eligible Employee who is a “specified employee” under Code Section 409A, as determined by the Committee or its delegate. The
determination of Key Employees, including the number and identity of persons considered specified employees and the identification date, shall be made by the Committee or its delegate in accordance with the provisions of Code Section 409A and
the regulations promulgated thereunder. 
 Section 2.22 “Notice Pay” means the amounts that a Participant is
eligible to receive pursuant to Article IV of the Plan. 
 Section 2.23 “Officer” means any individual who is an
officer, as such term is defined pursuant to Rule 16a-1(f) as promulgated under the Exchange Act, of the Company. 
 Section 2.24
“Participant” means any Eligible Employee who meets the requirements of Article III and thereby becomes eligible for Severance Benefits. 
 Section 2.25 “Permanent Disability” means that an Employee has a permanent and total incapacity from engaging in any employment for the Employer for physical or mental reasons. A
“Permanent Disability” shall be deemed to exist if the Employee meets the requirements for disability benefits under the Employer’s long-term disability plan or under the requirements for disability benefits under the Social Security
law then in effect, or if the Employee is designated with an inactive employment status at the end of a disability or medical leave. 
 Section 2.26 “Plan” means the Covidien Change in Control Severance Plan for Certain U.S. Officers and Executives as set forth herein, and as the same may from time to time be amended. 
 Section 2.27 “Plan Administrator” means the individual(s) appointed by the Committee to administer the terms of the Plan as
set forth herein and if no individual is appointed by the Committee to serve as the Plan Administrator for the Plan, the Plan Administrator shall be the Senior Vice President – Human Resources of Covidien Ltd. Notwithstanding the preceding
sentence, in the event the Plan Administrator is entitled to Severance Benefits under the Plan, the 

  

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Committee or its delegate shall act as the Plan Administrator for purposes of administering the terms of the Plan with respect to the Plan Administrator. The
Plan Administrator may delegate all or any portion of its authority under the Plan to any other person(s). 
 Section 2.28
“Postponement Period” means, for a Key Employee, the period of six (6) months after such Key Employee’s Separation from Service Date (or such other period as may be required by Code Section 409A). 
 Section 2.29 “Release” means the “Separation of Employment Agreement and General Release,” as provided by the
Company or such other agreement between the Company and Participant under which the Participant releases potential claims against the Company in exchange for Severance Benefits. 
 Section 2.30 “Separation from Service” means “separation from service” within the meaning of Code
Section 409A(a)(2)(A)(i) and the applicable regulations and rulings promulgated thereunder. 
 Section 2.31
“Separation from Service Date” means, with respect to a Participant, the date on which such Participant experiences a Separation from Service. 
 Section 2.32 “Severance Benefits” means the salary replacement amounts and other benefits that a Participant is eligible to receive pursuant to Article IV of the Plan. 
 Section 2.33 “Severance Period” means the period for which a Participant is entitled to receive Severance Benefits under
this Plan, as set forth in the Appendix. 
 Section 2.34 “Subsidiary” means (i) a subsidiary company
(wherever incorporated) as defined by Section 86 of the Companies Act 1981 of Bermuda (as amended), (ii) any separately organized business unit, whether or not incorporated, of the Company, (iii) any employer that is required to be
aggregated with the Company pursuant to Code Section 414 and regulations promulgated thereunder, and (iv) any service recipient or employer that is within a controlled group of corporations as defined in Code Sections 1563(a)(1),
(2) and (3) where the phrase “at least 50%” is substituted in each place “at least 80%” appears and any service recipient or employer within trades or businesses under common control as defined in Code
Section 414(c) and Treas. Reg. Section 1.414(c)-2 where the phrase “at least 50%” is substituted in each place “at least 80%” appears, provided, however, that when the relevant determination is to be based upon
legitimate business criteria (as described in Treas. Reg. Section 1.409A-1(b)(5)(iii)(E) and 1.409A-1(h)(3)), the phrase “at least 20%” shall be substituted in each place “at least 80%” appears as described above with
respect to both a controlled group of corporations and trades or business under common control. 
 Section 2.35
“Successor” means any other corporation or unincorporated entity or group of corporations or unincorporated entities which acquires ownership, directly or indirectly, through merger, consolidation, purchase or otherwise, of all
or substantially all of the assets of the Company. 
 Section 2.36 “Voluntary Resignation” means any Separation
from Service that is not initiated by the Employer other than a Good Reason Resignation. 
  

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 ARTICLE III 
 PARTICIPATION AND ELIGIBILITY FOR BENEFITS 
 Section 3.01 Participation.
Each Eligible Employee in the Plan who incurs a Change in Control Termination and who satisfies all of the conditions of Section 3.02 shall be eligible to receive the Severance Benefits described in the Plan. An Eligible Employee shall not be
eligible to receive any other severance benefits from the Company or Subsidiary on account of a Change in Control Termination, unless otherwise provided in the Plan. In addition, any Eligible Employee who is a party to an employment agreement with
the Company pursuant to which such Eligible Employee is entitled to severance benefits shall be ineligible to participate in the Plan. 
 Section 3.02 Conditions. 
 (a) Eligibility for any Severance Benefits is expressly conditioned on the
occurrence of the following within 60 days following the Participant’s Separation from Service Date: (i) execution by the Participant of a Release in the form provided by the Company; (ii) compliance by the Participant with all the
terms and conditions of such Release; (iii) the Participant’s written agreement to the confidentiality, non-solicitation, and non-disparagement provisions in Article VI during and after the Participant’s employment with the Company;
and (iv) to the extent permitted in Section 4.04 of the Plan, execution of a written agreement that authorizes the deduction of amounts owed to the Company prior to the payment of any Severance Benefits (or in accordance with any other
schedule as the Committee may, in its sole discretion, determine to be appropriate). If the Company determines, in its sole discretion, that the Participant has not fully complied with any of the terms of the Agreement and/or Release, the Company
may deny Severance Benefits not yet in pay status or discontinue the payment of the Participant’s Severance Benefits and may require the Participant, by providing written notice of such repayment obligation to the Participant, to repay any
portion of the Severance Benefits already received under the Plan. If the Company notifies a Participant that repayment of all or any portion of the Severance Benefits received under the Plan is required, such amounts shall be repaid within thirty
(30) calendar days after the date the written notice is sent. Any remedy under this Section 3.02(a) shall be in addition to, and not in place of, any other remedy, including injunctive relief, that the Company may have. 
 (b) An Eligible Employee will not be eligible to receive Severance Benefits under any of the following circumstances: 
 (i) The Eligible Employee’s Voluntary Resignation; 
 (ii) The Eligible Employee resigns employment (other than a Good Reason Resignation) before the job-end date specified by the Employer or while the Employer still desires the Eligible Employee’s services;

 (iii) The Eligible Employee’s employment is terminated for Cause; 
 (iv) The Eligible Employee voluntarily retires (other than a Good Reason Resignation); 
  

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 (v) The Eligible Employee’s employment is terminated due to the Eligible Employee’s death or
Permanent Disability; 
 (vi) The Eligible Employee does not return to work at the end of an approved leave of absence. 
 (vii) The Eligible Employee does not satisfy the Conditions for Severance in Section 3.02(a); 
 (viii) The Eligible Employee continues in employment with the Company or any Subsidiary for more than sixty (60) days following the expiration of
the cure period set forth in the last paragraph of Section 2.19 with respect to a Good Reason Resignation; or 
 (ix) The Eligible
Employee’s employment with the Employer terminates as a result of a Change in Control and the Eligible Employee accepts employment, or has the opportunity to continue employment, with a Successor (other than under terms and conditions which
would permit a Good Reason Resignation). The payment of Severance Benefits in the circumstances described in this subsection (ix) would result in a windfall to the Eligible Employee, which is not the intention of the Plan. 
 (c) The Plan Administrator has the sole discretion to determine an Eligible Employee’s eligibility to receive Severance Benefits. 
 (d) An Eligible Employee returning from approved military leave during the period beginning 60 days before a Change in Control and ending two years after
a Change in Control will be eligible for Severance Benefits if: (i) he/she is eligible for reemployment under the provisions of the Uniformed Services Employment and Reemployment Rights Act (USERRA); (ii) his/her pre-military leave job is
eliminated; and (iii) the Employer’s circumstances are changed so as to make reemployment in another position impossible or unreasonable, or re-employment would create an undue hardship for the Employer. If the Eligible Employee returning
from military leave qualifies for Severance Benefits, his/her severance benefits will be calculated as if he/she had remained continuously employed from the date he/she began his/her military leave. The Eligible Employee must also satisfy any other
relevant conditions for payment set forth in this Article III, including execution of a Release. 
  

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 ARTICLE IV 
 DETERMINATION OF SEVERANCE BENEFITS 
 Section 4.01 Amount of Severance Benefits
Upon Involuntary Termination and Good Reason Resignation. The Severance Benefits to be provided to a Participant shall be as follows: 
 (a) Notice Pay. Each Eligible Employee who is eligible for Severance Benefits shall receive at least thirty (30) calendar days notice as a Notice Period. In the event that the Company determines that an Eligible Employee’s
last day of work shall be prior to the end of his or her Notice Period, such Employee shall be entitled to pay in lieu of notice for the balance of such Notice Period. Notice Pay paid to an Eligible Employee shall be in addition to, and shall not be
offset against, the Severance Benefits the Participant may be entitled to receive under this Article IV. An Eligible Employee who does not sign, or who revokes his or her signature on, a Release shall only be eligible for Notice Pay. Unless
otherwise permitted by the applicable plan documents or laws, an Eligible Employee will not be eligible to apply for short-term disability, long-term disability and/or workers’ compensation during the Notice Period, or anytime thereafter.
Notice pay shall be paid in accordance with Article V. 
 (b) Salary Replacement. Salary replacement shall be provided for the
Severance Period applicable to the Participant as set forth in the Salary Replacement Schedule in the Appendix and shall be paid in accordance with Article V. 
 (c) Bonus. 
 (i) The Participant shall receive a cash payment equal to his or her pro rated annual
bonus for the fiscal year in which the Participant’s Separation from Service Date occurs, to the extent provided in the applicable plan; provided, however, that if the Participant’s Separation from Service Date occurs during the same
fiscal year as a Change in Control and the Participant has received an annual bonus attributable to such fiscal year solely because of the Change in Control, then the Participant shall not receive a pro rated annual bonus pursuant to this
Section 4.01(c)(i). 
 (ii) The Participant shall also receive a cash payment equal to his or her Annual Bonus for the Severance Period
applicable to the Participant as set forth in the Bonus Payment Schedule in the Appendix, which shall be paid in accordance with Article V. 
 (d) Medical, Dental and Health Care Reimbursement Account Benefits. The Participant (and his/her spouse, domestic partner or child(ren), as applicable) shall be eligible for continued coverage under the Company’s medical and
dental plans as required by and pursuant to COBRA. The Company shall provide COBRA coverage only if such coverage is timely elected by the Participant or other qualified beneficiary (as defined by COBRA). If the Participant timely elects COBRA
coverage, subject to the other provisions in this Section 4.01(d), during the Severance Period, the Participant will be responsible for paying the employee portion of the applicable premium under the respective plan(s) at the same rate and at
the same time as such employee contributions are paid by similarly-situated active Company employees. 

  

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If the Severance Period is less than the applicable COBRA coverage period then, effective for the first premium payment due after the Severance Period
expires, the Participant will be required to pay the entire premium for COBRA coverage and shall be responsible for paying such premium during the remainder of the applicable COBRA coverage period. If the Severance Period exceeds eighteen
(18) months after the Participant’s Separation from Service Date, then (a) effective for any premium payments for COBRA coverage that are due after eighteen (18) months after the Participant’s Separation from Service Date,
the Participant will be required to pay the entire premium for such COBRA coverage and shall be responsible for paying such premium during the remainder of the applicable COBRA period and (b) the Company shall pay to the Participant, within
sixty (60) days after such eighteen (18) month period expires, a single lump-sum cash payment in an amount equal to the employer portion of the applicable premium in effect for the Participant, based on the type of coverage provided to the
Participant at such time, for the last month of such eighteen (18) month period times the number of full months that the Severance Period exceeds such eighteen (18) month period. COBRA coverage will cease upon the expiration of the maximum
period required under COBRA or at such earlier time if the Participant does not pay the required premium within the applicable time period, if the Participant terminates COBRA coverage, or if an event occurs that, pursuant to COBRA, permits the
earlier termination of COBRA coverage. 
 (e) Stock Options. All stock options held by the Participant as of his or her Separation
from Service Date which are not already vested and exercisable as of such date shall become vested and exercisable on the Participant’s Separation from Service Date. All outstanding stock options held by the Participant that are vested and
exercisable as of the Participant’s Separation from Service Date and all stock options held by the Participant that become vested and exercisable under the preceding sentence shall be exercisable for the greater of (i) the period set forth
in Participant’s option agreement covering such options, or (ii) twelve (12) months from the Participant’s Separation from Service Date. In no event, however, shall an option be exercisable beyond its original expiration date. If
the Participant dies, the terms and conditions of the applicable option agreement shall govern. 
 (f) Restricted Stock, Restricted Stock
Units and Performance Share Units. All unvested restricted stock and restricted stock units held by the Participant as of his or her Separation from Service Date which are subject solely to time-vesting requirements shall accelerate and become
immediately vested as of the Participant’s Separation from Service Date. All unvested restricted stock and restricted stock units held by the Participant as of his or her Separation from Service Date which are subject in whole or part to
performance-based vesting provisions shall accelerate and become vested if and to the extent that the Committee determines in its sole discretion that the applicable performance vesting requirements have been or will be attained, or would have been
attained during the Severance Period in the ordinary course but for the Change in Control and the Participant’s Change in Control Termination. The treatment of any performance share units upon a Participant’s Change in Control Termination
shall be governed by the terms and conditions of the applicable award agreement. 
 (g) Outplacement Services. The Company may, in its
sole and absolute discretion, pay the cost of outplacement services for the Participant at the outplacement agency that the Company regularly uses for such purpose; provided, however, that the period of outplacement shall not exceed twelve
(12) months after the Participant’s Separation from Service Date or, if earlier, the date of the Participant’s death. 
  

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 Section 4.02 Voluntary Resignation; Termination for Death or Permanent Disability. If
the Eligible Employee’s employment terminates on account of (i) the Eligible Employee’s Voluntary Resignation, (ii) death, or (iii) Permanent Disability, then the Eligible Employee shall not be entitled to receive Severance
Benefits under this Plan and shall be entitled only to those benefits (if any) as may be available under the Company’s then-existing benefit plans and policies at the time of such termination. 
 Section 4.03 Termination for Cause. If any Eligible Employee’s employment terminates on account of termination by the Company for
Cause, the Eligible Employee shall not be entitled to receive Severance Benefits under this Plan and shall be entitled only to those benefits that are required to be provided to the Eligible Employee by applicable law. Notwithstanding any other
provision of the Plan to the contrary, if the Committee or the Plan Administrator determine, during the Severance Period, that a Participant engaged in conduct at any time that constitutes Cause, any Severance Benefits payable to the Participant
shall immediately cease and the Participant shall be required to return any Severance Benefits paid to the Participant prior to such determination to the Company. The Company may withhold paying Severance Benefits pending resolution of an inquiry
that could lead to a finding resulting in Cause and any such payment that was withheld and which is subsequently determined to be payable shall be paid to the Participant within ninety (90) days after the date of the final and binding
resolution of the related inquiry. 
 Section 4.04 Reduction of Severance Benefits. With respect to amounts paid under the
Plan that are not subject to Code Section 409A and the regulations promulgated thereunder, the Plan Administrator reserves the right to make deductions in accordance with applicable law for any monies owed to the Company by the Participant or
the value of Company property that the Participant has retained in his/her possession. With respect to amounts paid under the Plan that are subject to Code Section 409A and the regulations promulgated thereunder, the Plan Administrator reserves
the right to make deductions in accordance with applicable law for any monies owed to the Company by the Participant or the value of the Company property that the Participant has retained in his/her possession; provided, however, that such
deductions cannot exceed $5,000 in the aggregate in any Company fiscal year. 
  

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 ARTICLE V 
 METHOD, DURATION AND LIMITATION OF SEVERANCE BENEFIT PAYMENTS 
 Section 5.01 Method
of Payment. Subject to Section 5.03, the cash Severance Benefits to which a Participant is entitled, as determined pursuant to Section 4.01, shall be paid in a single lump sum payment within sixty five (65) days following the
Participant’s Severance from Service Date, subject to the fulfillment of all conditions for payment set forth in Section 3.02 and subject to the expiration of the Release revocation period specified in the Release; provided, however, that
the pro rated annual bonus payable to the Participant pursuant to Section 4.01(c)(i) shall be paid at such time and in such manner as set forth in The Covidien Annual Incentive Plan (or successor plan) and that COBRA coverage under
Section 4.01(d) shall be provided or paid in accordance with the provisions of that subsection. Notwithstanding the foregoing, if the Participant’s Change in Control Termination occurs based on a Change in Control that does not qualify as
a “change in control event” under Code Section 409A and the regulations promulgated thereunder, then any portion of the Severance Benefit payable under this Plan that (i) is subject to Code Section 409A and the regulations
and rulings promulgated thereunder and (ii) equals the amount of benefit the Participant could be eligible to receive under the Executive Severance Plan (if the Participant were to satisfy the eligibility requirements in order to receive a
benefit under that plan), shall be paid at the same time and in the same form as under the Executive Severance Plan. In no event will interest be credited on the unpaid balance for which a Participant may become eligible. Payment shall be made by
mailing to the last address provided by the Participant to the Company or such other reasonable method as determined by the Plan Administrator. All payments of Severance Benefits are subject to applicable federal, state and local taxes and
withholdings. In the event of a Participant’s death prior to the completion of all payments to which the Participant is entitled, the remaining payments shall be paid to the Participant’s estate in a single lump sum payment within sixty
(60) days following the Participant’s death. 
 Section 5.02 Other Arrangements. The Severance Benefits under
this Plan are not additive or cumulative to severance or termination benefits that a Participant might also be entitled to receive under the terms of a written employment agreement, a severance agreement or any other arrangement with the Employer,
including, without limitation, the Executive Severance Plan. As provided in Section 3.01, any Eligible Employee who is a party to an employment agreement with the Company or Subsidiary pursuant to which such Eligible Employee is entitled to
severance benefits shall be ineligible to participate in the Plan. Therefore, as a condition of participating in the Plan, the Eligible Employee must expressly agree that this Plan supersedes all prior plans or agreements, and sets forth the entire
benefit the Eligible Employee is entitled to under the Plan. 
 Section 5.03 Code Section 409A. 
 (a) Notwithstanding any other provision of the Plan to the contrary, if required by Code Section 409A, no Change in Control Benefits shall be paid to
a Participant who is a Key Employee during the Postponement Period. If the previous sentence applies, then the payment of Change in Control Benefits shall commence after expiration of the applicable Postponement Period and any amounts that would
have been paid during the Postponement 

  

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Period but for the previous sentence shall be paid in a single lump sum within 30 days after the end of such Postponement Period. If the Participant dies
during the Postponement Period, however, amounts withheld pursuant to this Section 5.03(a) shall be paid to the Participant’s estate no later than the earlier of 60 days after the Participant’s death or 30 days after the end of the
Postponement Period. 
 (b) This Plan is intended to provide certain benefits that meet the requirements of the “short-term
deferral” exception, the “separation pay” exception and other exceptions under Code Section 409A and the regulations promulgated thereunder. Notwithstanding any other provision of the Plan to the contrary, if required by Code
Section 409A, payments may only be made under this Plan upon an event and in a manner permitted by Code Section 409A. For purposes of Code Section 409A, each individual payment that constitutes part of the Change in Control Benefits
shall be treated as a separate payment from any other such payment. All reimbursements and in-kind benefits provided under the Plan shall be made or provided in accordance with the requirements of Code Section 409A including, where applicable,
the requirement that (i) any reimbursement is for expenses incurred during the period of time specified in the Plan, (ii) the amount of expenses eligible for reimbursement, or in-kind benefits provided, during a calendar year may not
affect the expenses eligible for reimbursement, or in-kind benefits to be provided, in any other calendar year, (iii) the reimbursement of an eligible expense will be made no later than the last day of the calendar year following the year in
which the expense is incurred, and (iv) the right to reimbursement, or in-kind benefits is not subject to liquidation or exchange for another benefit. In no event may a Participant designate the year of payment for any amounts payable under the
Plan. 
 Section 5.04 Termination of Eligibility for Benefits. 
 (a) All Eligible Employees shall cease to be eligible to participate in the Plan, and all Severance Benefit payments payable to a Participant shall cease
upon the occurrence of the earlier of: 
 (i) Subject to Article VIII, termination or modification of the Plan; or 
 (ii) Completion of the provision of Severance Benefits to the Participant. 
 (b) Notwithstanding any other provision of the Plan to the contrary, the Company shall have the right to cease all Severance Benefits (except as
otherwise required by law) and to recover any payments previously made to the Participant should the Participant at any time breach the Participant’s undertakings under the terms of the Plan, the Release the Participant executed to obtain the
Severance Benefits under the Plan or the confidentiality, non-competition, non-solicitation and non-disparagement provisions of Article VI. 
 Section 5.05 Limitation on Benefits. 
 (a) Notwithstanding anything in this Plan to the contrary, if it is
determined that the payments or distributions by the Company or its Subsidiaries to or for the benefit of a Participant (whether paid or provided pursuant to the terms of this Plan or otherwise) which are contingent on a change in control of the
Company (within the meaning of Code Section 

  

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280G(b)(2)(A)(i)) (“Payments”) would be nondeductible by the Company for Federal income tax purposes because of Code Section 280G and the
Payments exceed three times such Participant’s “base amount” (as defined in Code Section 280G(b)(3)) by no more than fifty thousand dollars ($50,000.00), then the aggregate present value of the benefits provided to the
Participant under this Plan (benefits provided under this Plan are hereinafter referred to individually as a “Plan Payment” and collectively as “Plan Payments”) shall be reduced to the Reduced Amount. The Reduced Amount shall be
an amount expressed in present value which maximizes the aggregate present value of Plan Payments without causing any Payments to be nondeductible by the Company because of Code Section 280G. For purposes of this Section 5.05, present
value shall be determined in accordance with Section 280G(d)(4) of the Code. Notwithstanding the provisions of this Section 5.05(a), if Payments to any Participant are determined to be nondeductible because of Code Section 280G and
the Payments would exceed three times such Participant’s base amount by more than fifty thousand dollars ($50,000.00), then at the time that each Plan Payment is made, the Company shall pay to the Participant the Plan Payment plus an additional
amount (“Additional Amount”) such that the net Additional Amount retained by the Participant after deduction of any federal, state and local income tax, payroll tax, and Code Section 4999 excise tax applicable to such Additional
Amount shall be equal to the Code Section 4999 excise tax applicable to the Plan Payment. 
 (b) All determinations required to be made
under this Section 5.05 shall be made by an accounting firm selected by the Company before the Change in Control (the “Accounting Firm”), which shall provide detailed supporting calculations both to the Company and the Participant
within fifteen (15) business days of the Separation from Service Date or such earlier time as requested by the Company. Any such determination by the Accounting Firm shall be binding upon the Company and the Participant. Within five
(5) business days of the determination by the Accounting Firm as to the Reduced Amount, the Company shall provide to the Participant such Severance Benefits as are then due to the Participant in accordance with the rights afforded under this
Plan. If Plan Payments are to be reduced, then such Plan Payments shall be reduced in a manner which maximizes the aggregate value of the Payments. If (i) any Payments would be treated as paid pursuant to a nonqualified deferred compensation
plan (within the meaning of Code Section 409A(d)(1)); (ii) Plan Payments are required to be reduced pursuant to Section 5.05(a); and (iii) Plan Payments are to be paid on separate payment dates, then any reduction shall be
applied to Plan Payments that are first payable to the Participant. The Reduced Payment shall be effected by reducing or eliminating a Participant’s Payment or Payments (or portion(s) thereof), until no portion of such Payments is rendered
non-deductible by application of Section 280G of the Code, in the following order: (i) the portion denominated and payable in cash (other than “24(c) Payments” as defined below), such as severance; (ii) the portion payable
in-kind, such as insurance coverage, or in cash as a reimbursement, such as for outplacement, legal fees, or moving expenses (other than 24(c) Payments); (iii) the portion of equity-based compensation, including stock options and stock
appreciation rights or similar rights, that are not 24(c) Payments, including such compensation subject to the achievement of performance-based objectives; and (iv) the portion of 24(c) Payments, such as equity-based compensation or any other
Payment. The Company has full discretionary authority to determine which Payments to reduce within each of the four categories described above in the preceding sentence. The Company cannot, however, reduce Payments in one category unless all
Payments in the preceding category have been eliminated. A “24(c) Payment” is any Payment permitted to be valued under Treas. Reg. Section 1.280G-1, Q&A 24(c), or any successor provision, promulgated under Code Section 280G.

  

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 ARTICLE VI 
 CONFIDENTIALITY, COVENANT NOT TO COMPETE AND NOT TO SOLICIT 
 Section 6.01
Confidential Information. The Participant agrees that he or she shall not, directly or indirectly, use, make available, sell, disclose or otherwise communicate to any person, other than in the course of the Participant’s assigned
duties and for the benefit of the Company, either during the period of the Participant’s employment or at any time thereafter, any nonpublic, proprietary or confidential information, knowledge or data relating to the Company, any of its
Subsidiaries, affiliated companies or businesses, which shall have been obtained by the Participant during the Participant’s employment by the Company or a Subsidiary. The foregoing shall not apply to information that (i) was known to the
public prior to its disclosure to the Participant; (ii) becomes known to the public subsequent to disclosure to the Participant through no wrongful act of the Participant or any representative of the Participant; or (iii) the Participant
is required to disclose by applicable law, regulation or legal process (provided that the Participant provides the Company with prior notice of the contemplated disclosure and reasonably cooperates with the Company at its expense in seeking a
protective order or other appropriate protection of such information). Notwithstanding clauses (i) and (ii) of the preceding sentence, the Participant’s obligation to maintain such disclosed information in confidence shall not
terminate where only portions of the information are in the public domain. 
 Section 6.02 Non-Competition. The
Participant acknowledges that he or she performs services of a unique nature for the Company that are irreplaceable, and that his or her performance of such services for a competing business will result in irreparable harm to the Company.
Accordingly, during the Participant’s employment with the Company or Subsidiary and for the one (1) year period thereafter, the Participant agrees that the Participant will not, directly or indirectly, own, manage, operate, control, be
employed by (whether as an employee, consultant, independent contractor or otherwise, and whether or not for compensation) or render services to any person, firm, corporation or other entity, in whatever form, engaged in any business of the same
type as any business in which the Company or any of its Subsidiaries or affiliates is engaged on the date of termination or in which they have proposed, on or prior to such date, to be engaged in on or after such date and in which the Participant
has been involved to any extent (other than de minimis) at any time during the one (1) year period ending with the date of termination, in any locale of any country in which the Company or any of its Subsidiaries conducts business. This
Section 6.02 shall not prevent the Participant from owning not more than one percent of the total shares of all classes of stock outstanding of any publicly held entity engaged in such business, nor will it restrict the Participant from
rendering services to charitable organizations, as such term is defined in Code Section 501(c). 
 Section 6.03
Non-Solicitation. During the Participant’s employment with the Company or a Subsidiary and for the two (2) year period thereafter, the Participant agrees that he or she will not, directly or indirectly, individually or on behalf
of any other person, firm, corporation or other entity, knowingly solicit, aid or induce (i) any employee of the Company or any Subsidiary, as defined by the Company, to leave such employment in order to accept employment with or render
services to or with any other person, firm, corporation or other entity unaffiliated with the Company or knowingly take any action to materially assist or aid any other person, firm, corporation or other entity in identifying or hiring any such
employee, or (ii) any 

  

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customer of the Company or any Subsidiary to purchase goods or services then sold by the Company or any Subsidiary from another person, firm, corporation or
other entity or assist or aid any other persons or entity in identifying or soliciting any such customer. 
 Section 6.04
Non-Disparagement. Each of the Participant and the Company (for purposes hereof, the Company shall mean only the executive officers and directors thereof and not any other employees) agrees not to make any statements that disparage the
other party, or in the case of the Company or its Subsidiaries, their respective affiliates, employees, officers, directors, products or services. Notwithstanding the foregoing, statements made in the course of sworn testimony in administrative,
judicial or arbitral proceedings (including, without limitation, depositions in connection with such proceedings) shall not be subject to this Section 6.04. 
 Section 6.05 Reasonableness. In the event the provisions of this Article VI shall ever be deemed to exceed the time, scope or geographic limitations permitted by applicable laws, then such
provisions shall be reformed to the maximum time, scope or geographic limitations, as the case may be, permitted by applicable laws. 
 Section 6.06 Equitable Relief. 
 (a) By participating in the Plan, the Participant acknowledges that the
restrictions contained in this Article VI are reasonable and necessary to protect the legitimate interests of the Company, its Subsidiaries and its affiliates, that the Company would not have established this Plan in the absence of such
restrictions, and that any violation of any provision of this Article will result in irreparable injury to the Company. By agreeing to participate in the Plan, the Participant represents that his or her experience and capabilities are such that the
restrictions contained in this Article VI will not prevent the Participant from obtaining employment or otherwise earning a living at the same general level of economic benefit as is currently the case. The Participant further represents and
acknowledges that (i) he or she has been advised by the Company to consult his or her own legal counsel in respect of this Plan, and (ii) that he or she has had full opportunity, prior to agreeing to participate in this Plan, to review
thoroughly this Plan with his or her counsel. 
 (b) The Eligible Employee agrees that the Company shall be entitled to preliminary and
permanent injunctive relief, without the necessity of proving actual damages, as well as an equitable accounting of all earnings, profits and other benefits arising from any violation of this Article VI, which rights shall be cumulative and in
addition to any other rights or remedies to which the Company may be entitled. In the event that any of the provisions of this Article VI should ever be adjudicated to exceed the time, geographic, service, or other limitations permitted by
applicable law in any jurisdiction, then such provisions shall be deemed reformed in such jurisdiction to the maximum time, geographic, service, or other limitations permitted by applicable law. 
 (c) The Eligible Employee irrevocably and unconditionally (i) agrees that any suit, action or other legal proceeding arising out of this Article VI,
including without limitation, any action commenced by the Company for preliminary and permanent injunctive relief or other equitable relief, may be brought in the United States District Court for the District of Massachusetts, or if such court does
not have jurisdiction or will not accept jurisdiction, in any court of general jurisdiction in Massachusetts, (ii) consents to the non-exclusive jurisdiction of 

  

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any such court in any such suit, action or proceeding, and (iii) waives any objection which Participant may have to the laying of venue of any such
suit, action or proceeding in any such court. Participant also irrevocably and unconditionally consents to the service of any process, pleadings, notices or other papers in a manner permitted by the notice provisions of Section 11.02.

 Section 6.07 Survival of Provisions. The obligations contained in this Article VI shall survive the termination of the
Participant’s employment with the Company or a Subsidiary and shall be fully enforceable thereafter. 
  

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 ARTICLE VII 
 THE PLAN ADMINISTRATOR 
 Section 7.01 Authority and Duties. It shall be the
duty of the Plan Administrator, on the basis of information supplied to it by the Company and the Committee, to properly administer the Plan. The Plan Administrator shall have the full power, authority and discretion to construe, interpret and
administer the Plan, to make factual determinations, to correct deficiencies therein, and to supply omissions. All decisions, actions and interpretations of the Plan Administrator shall be final, binding and conclusive upon the parties, subject only
to determinations by the Named Appeals Fiduciary (as defined in Section 10.04), with respect to denied claims for Severance Benefits. The Plan Administrator may adopt such rules and regulations and may make such decisions as it deems necessary
or desirable for the proper administration of the Plan. 
 Section 7.02 Compensation of the Plan Administrator. The Plan
Administrator shall receive no compensation for services as such. However, all reasonable expenses of the Plan Administrator shall be paid or reimbursed by the Company upon proper documentation. The Plan Administrator shall be indemnified by the
Company against personal liability for actions taken in good faith in the discharge of the Plan Administrator’s duties. 
 Section 7.03 Records, Reporting and Disclosure. The Plan Administrator shall keep a copy of all records relating to the payment of Severance Benefits to Participants and former Participants and all other records necessary
for the proper operation of the Plan. All Plan records shall be made available to the Committee, the Company and to each Participant for examination during business hours except that a Participant shall examine only such records as pertain
exclusively to the examining Participant and to the Plan. The Plan Administrator shall prepare and shall file as required by law or regulation all reports, forms, documents and other items required by ERISA, the Code, and every other relevant
statute, each as amended, and all regulations thereunder (except that the Company, as payor of the Severance Benefits, shall prepare and distribute to the proper recipients all forms relating to withholding of income or wage taxes, Social Security
taxes, and other amounts that may be similarly reportable). 
  

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 ARTICLE VIII 
 AMENDMENT, TERMINATION AND DURATION 
 Section 8.01 Amendment, Suspension and
Termination. Except as otherwise provided in this Section 8.01, the Board or its delegate shall have the right, at any time and from time to time, to amend, suspend or terminate the Plan in whole or in part, for any reason or without
reason, and without either the consent of or the prior notification to any Participant, by a formal written action. No such amendment shall give the Company the right to recover any amount paid to a Participant prior to the date of such amendment or
to cause the cessation of Severance Benefits already approved for a Participant who has executed a Release as required under Section 3.02. Notwithstanding the foregoing, this Plan may not be terminated, suspended or be amended in any material
respect during the period beginning 60 days prior to a Change in Control and ending two years after a Change in Control. Any amendment or termination of the Plan must comply with all applicable legal requirements including, without limitation,
compliance with Code Section 409A and the regulations and rulings promulgated thereunder, securities, tax, or other laws, rules, regulations or regulatory interpretation thereof, applicable to the Plan. 
 Section 8.02 Duration. Unless terminated sooner by the Board or its delegate, the Plan shall continue in full force and effect until
termination of the Plan pursuant to Section 8.01; provided, however, that after the termination of the Plan, if any Participants terminated employment on account of an Involuntary Termination prior to the termination of the Plan and are still
receiving Severance Benefits under the Plan, the Plan shall remain in effect until all of the obligations of the Company are satisfied with respect to such Participants. 
  

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 ARTICLE IX 
 DUTIES OF THE COMPANY AND THE COMMITTEE 
 Section 9.01 Records. The Company
or a Subsidiary thereof shall supply to the Committee all records and information necessary to the performance of the Committee’s duties. 
 Section 9.02 Payment. Payments of Severance Benefits to Participants shall be made in such amount as determined by the Committee under Article IV, from the Company’s general assets. 
 Section 9.03 Discretion. Any decisions, actions or interpretations to be made under the Plan by the Board, the Committee and the Plan
Administrator, acting on behalf of either, shall be made in each of their respective sole discretion, not in any fiduciary capacity and need not be uniformly applied to similarly situated individuals and such decisions, actions or interpretations
shall be final, binding and conclusive upon all parties. As a condition of participating in the Plan, the Eligible Employee acknowledges that all decisions and determinations of the Board, the Committee and the Plan Administrator shall be final and
binding on the Eligible Employee, his or her beneficiaries and any other person having or claiming an interest under the Plan on his or her behalf. 
  

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 ARTICLE X 
 CLAIMS PROCEDURES 
 Section 10.01 Claim. Each Participant under this Plan
may contest only the administration of the Severance Benefits awarded by completing and filing with the Plan Administrator a written request for review in the manner specified by the Plan Administrator. No appeal is permissible as to an Eligible
Employee’s eligibility for or a Participant’s amount of the Severance Benefit, which are decisions made solely within the discretion of the Company. No person may bring an action for any alleged wrongful denial of Plan benefits in a court
of law unless the claims procedures described in this Article X are exhausted and a final determination is made by the Plan Administrator and/or the Named Appeals Fiduciary. If an Eligible Employee or Participant or other interested person
challenges a decision by the Plan Administrator and/or Named Appeals Fiduciary, a review by the court of law will be limited to the facts, evidence and issues presented to the Plan Administrator during the claims procedure set forth in this Article
X. Facts and evidence that become known to the terminated Eligible Employee or Participant or other interested person after having exhausted the claims procedure must be brought to the attention of the Plan Administrator for reconsideration of the
claims administrator. Issues not raised with the Plan Administrator and/or Named Appeals Fiduciary will be deemed waived. 
 Section 10.02 Initial Claim. Before the date on which payment of a Severance Benefit commences, each such application must be supported by such information as the Plan Administrator deems relevant and appropriate. In the
event that any claim relating to the administration of Severance Benefits is denied in whole or in part, the terminated Participant or his or her beneficiary (“claimant”) whose claim has been so denied shall be notified of such denial in
writing by the Plan Administrator within ninety (90) days after the receipt of the claim for benefits. This period may be extended an additional ninety (90) days if the Plan Administrator determines such extension is necessary and the Plan
Administrator provides notice of extension to the claimant prior to the end of the initial ninety (90) day period. The notice advising of the denial shall specify the following: (i) the reason or reasons for denial, (ii) make specific
reference to the Plan provisions on which the determination was based, (iii) describe any additional material or information necessary for the claimant to perfect the claim (explaining why such material or information is needed), and
(iv) describe the Plan’s review procedures and the time limits applicable to such procedures, including a statement of the claimant’s right to bring a civil action under ERISA Section 502(a) following an adverse benefit
determination on review. If it is determined that payment is to be made, any such payment shall be made within ninety (90) days after the date by which notification is required. 
 Section 10.03 Appeals of Denied Administrative Claims. All appeals shall be made by the following procedure: 
 (a) A claimant whose claim has been denied shall file with the Plan Administrator a notice of appeal of the denial. Such notice shall be filed within
sixty (60) calendar days after notification by the Plan Administrator of the denial of a claim, shall be made in writing, and shall set forth all of the facts upon which the appeal is based. Appeals not timely filed shall be barred. 

 

 -21- 

 (b) The Named Appeals Fiduciary shall consider the merits of the claimant’s written presentations,
the merits of any facts or evidence in support of the denial of benefits, and such other facts and circumstances as the Named Appeals Fiduciary shall deem relevant. 
 (c) The Named Appeals Fiduciary shall render a determination upon the appealed claim which determination shall be accompanied by a written statement as to the reasons therefor. The determination shall be made to the
claimant within sixty (60) days after the claimant’s request for review, unless the Names Appeals Fiduciary determines that special circumstances requires an extension of time for processing the claim. In such case, the Named Appeals
Fiduciary shall notify the claimant of the need for an extension of time to render its decision prior to the end of the initial sixty (60) day period, and the Named Appeals Fiduciary shall have an additional sixty (60) day period to make
its determination. The determination so rendered shall be binding upon all parties. If the determination is adverse to the claimant, the notice shall provide (i) the reason or reasons for denial, (ii) make specific reference to the Plan
provisions on which the determination was based, (iii) a statement that the claimant is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records and other information relevant to a the
claimant’s claim for benefits, and (iv) state that the claimant has the right to bring an action under ERISA Section 502(a). If the final determination is that payment shall be made, then any such payment shall be made within ninety
(90) days after the date by which notification of the final determination is required. 
 Section 10.04 Appointment of the
Named Appeals Fiduciary. The Named Appeals Fiduciary shall be the person or persons named as such by the Board or Committee, or, if no such person or persons be named, then the person or persons named by the Plan Administrator as the Named
Appeals Fiduciary. Named Appeals Fiduciaries may at any time be removed by the Board or Committee, and any Named Appeals Fiduciary named by the Plan Administrator may be removed by the Plan Administrator. All such removals may be with or without
cause and shall be effective on the date stated in the notice of removal. The Named Appeals Fiduciary shall be a “Named Fiduciary” within the meaning of ERISA, and unless appointed to other fiduciary responsibilities, shall have no
authority, responsibility, or liability with respect to any matter other than the proper discharge of the functions of the Named Appeals Fiduciary as set forth herein. 
 Section 10.05 Arbitration; Expenses. In the event of any dispute under the provisions of this Plan, other than a dispute in which the primary relief sought is an equitable remedy such as an
injunction, the parties shall have the dispute, controversy or claim settled by arbitration in Boston, Massachusetts (or such other location as may be mutually agreed upon by the Employer and the Participant) in accordance with the National Rules
for the Resolution of Employment Disputes then in effect of the American Arbitration Association, before a panel of three arbitrators, two of whom shall be selected by the Company and the Participant, respectively, and the third of whom shall be
selected by the other two arbitrators. Any award entered by the arbitrators shall be final, binding and nonappealable and judgment may be entered thereon by either party in accordance with applicable law in any court of competent jurisdiction. This
arbitration provision shall be specifically enforceable. The arbitrators shall have no authority to modify any provision of this Plan or to award a remedy for a dispute involving this Plan other than a benefit specifically provided under or by
virtue of the Plan. If the Participant substantially prevails on any material issue, which is the subject of such arbitration or lawsuit, the Company shall be responsible for all of the fees of the American Arbitration Association and the
arbitrators 

  

 -22- 

 
and any expenses relating to the conduct of the arbitration (including the Company’s and Participant’s reasonable attorneys’ fees and
expenses); in this event, any such fees and expenses are limited to those typically incurred in the usual course of arbitration proceedings and shall not be negotiable or determinable by the Participant, and payment to the Participant of such
amounts shall occur within ninety (90) days after the date of entry of judgment (entered in accordance with applicable law in any court of competent jurisdiction) of the final, binding and non-appealable arbitration settlement. Otherwise, each
party shall be responsible for its own expenses relating to the conduct of the arbitration (including reasonable attorneys’ fees and expenses) and shall share the fees of the American Arbitration Association. 
  

 -23- 

 ARTICLE XI 
 MISCELLANEOUS 
 Section 11.01 Nonalienation of Benefits. None of the
payments, benefits or rights of any Participant shall be subject to any claim of any creditor of any Participant, and, in particular, to the fullest extent permitted by law, all such payments, benefits and rights shall be free from attachment,
garnishment (if permitted under applicable law), trustee’s process, or any other legal or equitable process available to any creditor of such Participant. No Participant shall have the right to alienate, anticipate, commute, plead, encumber or
assign any of the benefits or payments that he may expect to receive, continently or otherwise, under this Plan, except for the designation of a beneficiary as set forth in Section 5.01. 
 Section 11.02 Notices. All notices and other communications required hereunder shall be in writing and shall be delivered personally
or mailed by registered or certified mail, return receipt requested, or by overnight express courier service. In the case of the Participant, mailed notices shall be addressed to him or her at the home address which he or she most recently
communicated to the Company in writing. In the case of the Company, mailed notices shall be addressed to the Plan Administrator. 
 Section 11.03 Successors. Any Successor shall assume the obligations under this Plan and expressly agree to perform the obligations under this Plan. 
 Section 11.04 Other Payments. Except as otherwise provided in this Plan, no Participant shall be entitled to any cash payments or
other severance benefits under any of the Company’s then current severance pay policies for a termination that is covered by this Plan for the Participant, including, without limitation, the Executive Severance Plan. 
 Section 11.05 No Mitigation. Except as otherwise provided in Section 4.04, a Participant shall not be required to mitigate the
amount of any Severance Benefit provided for in this Plan by seeking other employment or otherwise, nor shall the amount of any Severance Benefit provided for herein be reduced by any compensation earned by other employment or otherwise, except if
the Participant is re-employed by the Company as an Employee, in which case Severance Benefits shall cease on the date of the Participant’s re-employment. 
 Section 11.06 No Contract of Employment. Neither the establishment of the Plan, nor any modification thereof, nor the creation of any fund, trust or account, nor the payment of any benefits shall be
construed as giving any Eligible Employee or any person whosoever, the right to be retained in the service of the Company, and all Eligible Employees shall remain subject to discharge to the same extent as if the Plan had never been adopted.

 Section 11.07 Severability of Provisions. If any provision of this Plan shall be held invalid or unenforceable by a
court of competent jurisdiction, such invalidity or unenforceability shall not affect any other provisions hereof, and this Plan shall be construed and enforced as if such provisions had not been included. 
  

 -24- 

 Section 11.08 Heirs, Assigns, and Personal Representatives. This Plan shall be binding
upon the heirs, executors, administrators, successors and assigns of the parties, including each Participant, present and future. 
 Section 11.09 Headings and Captions. The headings and captions herein are provided for reference and convenience only, shall not be considered part of the Plan, and shall not be employed in the construction of the Plan.

 Section 11.10 Gender and Number. Where the context admits: words in any gender shall include any other gender, and,
except where otherwise clearly indicated by context, the singular shall include the plural, and vice-versa. 
 Section 11.11
Unfunded Plan. The Plan shall not be funded. No Participant shall have any right to, or interest in, any assets of the Company that may be applied by the Company to the payment of Severance Benefits. 
 Section 11.12 Payments to Incompetent Persons. Any benefit payable to or for the benefit of a minor, an incompetent person or other
person incapable of receipting therefor shall be deemed paid when paid to such person’s guardian or to the party providing or reasonably appearing to provide for the care of such person, and such payment shall fully discharge the Company, the
Committee and all other parties with respect thereto. 
 Section 11.13 Lost Payees. A benefit shall be deemed forfeited if
the Committee is unable to locate a Participant to whom a Severance Benefit is due. Such Severance Benefit may be reinstated if application is made by the Participant for the forfeited Severance Benefit while this Plan is in operation. 

Section 11.14 Controlling Law. This Plan shall be construed and enforced according to the laws of the Commonwealth of Massachusetts
to the extent not superseded by federal laws. 
  

 -25- 

 Appendix 
 Salary Replacement Schedule 
  

			
	Chief Executive Officer	  	36 month Severance Period*
		
	Executive Vice President and Chief Financial Officer, Senior Vice Presidents and Presidents of business whose annual revenue is $1.5 billion or more	  	24 month Severance Period
		
	Any other Global Business Unit Presidents, any other Officer and any other Band 1 Eligible Employee	  	18 month Severance Period

 Bonus Payment Schedule 
  

			
	Chief Executive Officer	  	2.99x Annual Bonus
		
	Executive Vice President and Chief Financial Officer, Senior Vice Presidents and Presidents of business whose annual revenue is $1.5 billion or more	  	2.0x Annual Bonus
		
	Any other Global Business Unit Presidents, any other Officer and any other Band 1 Eligible Employee	  	1.5x Annual Bonus

  

	*	The total salary replacement benefits paid shall not exceed 2.99 times the President and Chief Executive Officer’s base salary. 

  

 A-1Exhibit 4(b)

 EXHIBIT (4)(b)
 Form of Policy 

 WESTERN RESERVE LIFE 
 ASSURANCE CO. OF OHIO 
 (A STOCK COMPANY) 
 Home Office: Columbus, Ohio 
 Administrative Office: Clearwater, Florida 
 IN THIS CONTRACT Western Reserve Life Assurance Co. Of Ohio will be referred to as WE, OUR or US. OFFICE refers to Our Administrative Office located in
Clearwater, Florida. 
 WE agree to pay the benefits of this Contract in accordance with its provisions. CONTRACT VALUES DURING THE ACCUMULATION PERIOD WILL
INCREASE OR DECREASE IN ACCORDANCE WITH THE CONTRACT VALUE PROVISIONS AND THE INVESTMENT EXPERIENCE OF THE APPLICABLE SUB-ACCOUNTS IN THE SEPARATE ACCOUNT. CONTRACT VALUES, WHEN BASED ON THE INVESTMENT EXPERIENCE OF A SUB-ACCOUNT OF THE SEPARATE
ACCOUNT, ARE VARIABLE AND ARE NOT GUARANTEED AS TO FIXED DOLLAR AMOUNT. 
 THE CONSIDERATION for this Contract is the application and the payment of the
Initial Payment. 
 THE ANNUITANT, OWNER, AND BENEFICIARY are as shown in the application unless changed in accordance with the provisions of this Contract.

 THE PROVISIONS on the following pages are part of this Contract. 
 IN WITNESS WHEREOF, We have signed this Contract at our Office in Clearwater, Florida as of the Contract Date. 
  

					
			
	

	 		 	

	Secretary	 		 	President

 RIGHT TO EXAMINE CONTRACT - The Owner may cancel this Contract at any time within ten days after receipt by
returning it to us at P.O. Box 5068, Clearwater, Florida 33758. If the Contract is returned within this period, We will pay to the Owner the sum of: 
  

	1.	The purchase payments received; plus (or minus) 

  

	2.	The accumulated gains (or losses), if any, in the Separate Account for this Contract as of the date we receive the returned Contract. 

 FLEXIBLE PAYMENT VARIABLE ACCUMULATION DEFERRED ANNUITY 
 Death Benefit Prior to Maturity 
 Monthly Annuity Commencing on Maturity Date 
 Non-Participating - No Dividends 

 CONTRACT GUIDE 
  

			
	 ENDORSEMENTS
	  	2
		
	 CONTRACT SCHEDULE
	  	3
		
	 DEATH BENEFIT PROVISIONS
	  	4
		
	 DEFINITIONS
	  	5
		
	 SEPARATE ACCOUNT PROVISIONS
	  	6
		
	 GENERAL PROVISIONS
	  	8
		
	 PURCHASE PAYMENT PROVISIONS
	  	9
		
	 CONTRACT VALUE PROVISIONS
	  	10
		
	 ANNUITY PROVISIONS
	  	12
		
	 FIXED ACCOUNT ANNUITY PAYMENTS
	  	13
		
	 VARIABLE ACCOUNT ANNUITY PAYMENTS
	  	14

 ENDORSEMENTS 
  

 Page 2 

 WESTERN RESERVE LIFE ASSURANCE CO. OF OHIO 
 CLEARWATER, FLORIDA 
 CONTRACT SCHEDULE 
  

			
	 OWNER:
	 	!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
	 !!!!!!!
	 	” ” ” ” ” ” ” ” ” ” ” ” ” ” ” ” ” ” ” ” ” ” ” ” ” ” ”
” ” ” ” ” ” ” ” ” ” ” ” ” ” ” ” ” ” ” ” ” ” ” ” ” ” ” ” ” ” ” ” ”
”

			
	 ANNUITANT:
	 	!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
	!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

  

							
	ANNUITY OPTION:	  	D - 10 YEAR CERTAIN  	  	CONTRACT NUMBER:	  	###############
				
	INITIAL PAYMENT:	  	###############	  	CONTRACT DATE:	  	#################
				
		  		  	MATURITY DATE:	  	#################

 ANTICIPATED PURCHASE PAYMENT PATTERN* 
  

					
	@@@@@@	  	@@@@	  	# # # # # # # # # # # # #
			
	# # # # # # # # # # # # # # #	  	# # # # # # # # # # # # # # #	  	@@@  @@@@@

  

	*	THE ANTICIPATED PURCHASE PAYMENT PATTERN IS BASED UPON SELECTION MADE IN THE APPLICATION. THE AMOUNT AND MODE MAY BE CHANGED IN ACCORDANCE WITH THE PURCHASE PAYMENT PROVISIONS ON
PAGE 9. 

  

			
	SEPARATE ACCOUNT PROVISIONS	 	
		
	 SEPARATE ACCOUNT:
	 	 WRL SERIES ANNUITY ACCOUNT

		
	 MORTALITY AND EXPENSE CHARGE:
	 	 .00003424

		
	 PURCHASE PAYMENT PROVISIONS
	 	
		
	 MAXIMUM ADDITIONAL PAYMENT:
	 	 $1,000,000

		
	 MINIMUM ADDITIONAL PAYMENT:
	 	 $50

		
	 CONTRACT VALUE PROVISIONS
	 	
		
	 MINIMUM ALLOCATION PERCENTAGE:
	 	 10%

		
	 ANNUAL CONTRACT CHARGE:
	 	 # # # # ##

		
	 MINIMUM BALANCE:
	 	 $10,000

		
	 WITHDRAWAL CHARGE PERIOD:
	 	60 MONTHS FROM THE DATE OF EACH PURCHASE PAYMENT

 WITHDRAWAL CHARGE PERCENTAGE (AS A PERCENTAGE OF EACH RESPECTIVE PURCHASE PAYMENT): 
  

				
	 MONTHS SINCE DATE OF PAYMENT
	  	PERCENTAGE	 
	 24    MONTHS    OR LESS
	  	6	%
	 25    MONTHS    THROUGH    36    MONTHS
	  	4	%
	 37    MONTHS    THROUGH    48    MONTHS
	  	3	%
	 49    MONTHS    THROUGH    60    MONTHS
	  	2	%
	 61    MONTHS    OR MORE
	  	0	%

  

 Page 3 

 DEATH BENEFIT PROVISIONS 
 DEATH OF ANNUITANT DURING THE ACCUMULATION PERIOD. If the Annuitant dies during the Accumulation Period and the Owner is a natural person other than the Annuitant, the Owner will automatically become the Annuitant and
the Contract will continue. 
 If the Annuitant dies during the Accumulation Period and the Owner is either (1) the same individual as the Annuitant, or
(2) other than a natural person: then the Death Benefit Proceeds as calculated below are payable to the Beneficiary. 
 DEATH BENEFIT PROCEEDS. If the
Annuitant dies during the Accumulation Period and prior to the sixth contract year, the Death Benefit Proceeds, if payable, will be the greater of: 
  

	1.	The Annuity Value as of the Death Report Day; or 

  

	2.	Total purchase payments (less partial withdrawals), increased by 5% on each contract anniversary prior to the Owner’s age 80 (Annuitant’s age 80 if the Owner is not a
natural person), up to an amount not to exceed 200% of the purchase payments less partial withdrawals. 

 If the Annuitant dies during the
Accumulation Period and after the fifth contract year, the Death Benefit Proceeds, if payable, will be the greatest of: 
  

	1.	The Annuity Value as of the Death Report Day; or 

  

	2.	Total purchase payments (less partial withdrawals), increased by 5% on each contract anniversary prior to the Owner’s age 80 (Annuitant’s age 80 if the Owner is not a
natural person), up to an amount not to exceed 200% of the purchase payments less partial withdrawals; or 

  

	3.	The Annuity Value as of the fifth contract anniversary, less any amounts withdrawn from the Contract after the fifth contract year to pay for partial withdrawals.

 ALTERNATIVE ELECTION. If the Beneficiary is entitled to receive the Death Benefit Proceeds, the Beneficiary may elect in lieu of a lump sum
payment, one of the following options that provide for complete distribution and termination of this Contract at the end of the distribution period: 
  

	1.	Within 5 years of the date of death of the Annuitant; or 

  

	2.	Over the lifetime of the Beneficiary; or 

  

	3.	Over a period that does not exceed the life expectancy (as defined by the Internal Revenue Code and Regulations adopted under the Code) of such Beneficiary.

 For subparagraphs (1) and (3), the Annuity Value as of the Death Report Day will be adjusted to equal the Death Benefit Proceeds and
this Contract will remain in force as a deferred annuity until the end of the elected distribution period. For subparagraph (2), the Maturity Date will be changed to the Death Report Day and the Death Benefit Proceeds will be used to purchase
annuity payments under the Annuity Provisions of this Contract. 
 Subparagraphs (2) and (3) may be elected only if the Beneficiary is a natural
person and payments start within one year of the date of death of the Annuitant. . 
 In addition, if the Beneficiary is entitled to receive the Death
Benefit Proceeds and is the spouse of the deceased Annuitant, then the Beneficiary may elect to become the new Annuitant and Owner and keep the Contract in force in lieu of receiving the Death Benefit Proceeds. 
  

 Page 4 

 THE BACK OF THIS PAGE INTENTIONALLY LEFT BLANK 

 DEFINITIONS 
 ACCOUNTS. Allocation options including the Fixed Account and the Sub-Accounts of the Separate Account. 
 ACCUMULATION PERIOD. The period between
the Contract Date and the Maturity Date while the Contract is in force. 
 ACCUMULATION UNIT VALUE. An accounting unit of measure used to calculate
Sub-Account values for the Contract during the Accumulation Period. 
 ANNUITANT. The person named on the application, or as subsequently changed, to receive
annuity payments. The Annuitant may be changed as provided in the Death Benefit Provisions and Annuity Provisions. 
 ANNUITY PROCEEDS. The amount applied to
purchase periodic annuity payments. Such amount is the Annuity Value on the Maturity Date, less any applicable Premium Tax. 
 ANNUITY UNIT VALUE. An
accounting unit of measure used to calculate annuity payments from a Sub-Account after the Maturity Date. 
 ANNUITY VALUE. The value as described in the
Annuity Value section of the Contract Value Provisions. 
 CASH VALUE. The value as described in the Cash Value section of the Contract Value Provisions.

 CONTINGENT BENEFICIARY. The new Beneficiary upon the current Beneficiary’s death. 
 CONTRACT DATE. The later of the date on which payments are first received and the date the properly .completed application is received by us at our Office. 
 DEATH BENEFIT PROCEEDS. The value as described in the Death Benefit Proceeds section of the Death Benefit Provisions. 
 DEATH REPORT DAY. The Valuation Date coincident with or next following the day on which we have received both: 1) due proof of death; and 2) a Written Notice for an
election of a) a single sum payment or b) an alternative election as described under the Death Benefit Provisions. 
 FIXED ACCOUNT. An allocation option
other than the Separate Account. 
 MATURITY DATE. The date on which the Accumulation Period ends and annuity payments are to commence. The date may be
changed as provided in the Annuity Provisions. 
 PREMIUM TAX. Premium Tax levied by a state or other government entity. The Premium Tax will be paid when
due and charged either against the purchase payment or the contract value. 
 SEC. The Securities and Exchange Commission. 
 SEPARATE ACCOUNT. A separate investment account composed of several Sub-Accounts established to receive and invest net payments under the Contract and under other
variable annuity contracts issued by the Company. 
 SERIES FUND. A designated mutual fund from which a Sub-Account of the Separate Account will buy shares.

  

 Page 5 

 SUB-ACCOUNT. A Separate Account allocation option that is made available under this Contract. 
 SURRENDER. The termination of the Contract at the option of the Owner. 
 VALUATION DATE. Each Monday through Friday except customary national business holidays on which the New York Stock Exchange is not open for business. 
 VALUATION PERIOD. The period commencing at the end of one Valuation Date and continuing to the end of the next succeeding Valuation Date. 
 WITHDRAWAL CHARGE PERIOD. The period of time during which a withdrawal charge may be imposed as shown on Page 3. For each purchase payment, the period begins on the date the payment is received by us. 
 WRITTEN NOTICE. Written Notice means a notice by the Owner to us requesting or exercising a right of the Owner as provided in the Contract provisions. In order for a
notice to be considered a Written Notice, it must: be in writing, signed by the Owner; be in a form acceptable to us; and contain the information and documentation, as determined in our sole discretion, necessary for us to take the action requested
or for the Owner to exercise the right specified. A Written Notice will not be considered complete until all necessary supporting documentation required or requested by us has been received by us at our Administrative Office. 
 SEPARATE ACCOUNT PROVISIONS 
 The variable benefits
under this Contract are provided through the Separate Account referenced on Page 3. The assets of the Separate Account are our property. Assets equal to the liabilities of the Separate Account will not be charged with liabilities arising out of any
other business we may conduct. If the assets of the Separate Account exceed the liabilities arising under the contracts supported by the Separate Account, then the excess may be used to cover the liabilities of our general account. The assets of the
Separate Account shall be valued as often as any contract benefits vary, but at least monthly. 
 SUB-ACCOUNTS. The Separate Account has various
Sub-Accounts. Each Sub-Account invests exclusively in shares of one of the portfolios of an underlying Series Fund. Assets invested after the Maturity Date may be invested in different Sub-Accounts than assets invested during the Accumulation
Period. We reserve the right to add or remove any Sub-Account of the Separate Account. Income and realized and unrealized gains and losses from assets in each Sub-Account are credited to, or charged against, that Sub-Account without regard to
income, gains, or losses in other Sub-Accounts. Any amount charged against the contract value for federal or state income taxes will be deducted from that Sub-Account. 
 TRANSFERS AMONG SUB-ACCOUNTS. During the Accumulation Period, the Owner may transfer all or a portion of this Contract’s value in its Sub-Accounts to other Sub-Accounts or the Fixed Account. We reserve the right
to charge a $10 fee for each transfer after the first twelve transfers during any one contract year. This charge will be deducted from the funds transferred. We must be notified in a manner satisfactory to us. The transfer ordinarily will take
effect on the first Valuation Date on or following the date notice is received at our Office. 
  

 Page 6 

 ADDITION, DELETION OR SUBSTITUTION OF INVESTMENTS. We reserve the right to transfer assets of the Separate Account, which
we determine to be associated with the class of contracts to which this Contract belongs, to another Separate Account. If this type of transfer is made, the term “Separate Account”, as used in this Contract, shall then mean the Separate
Account to which the assets were transferred. We also reserve the right to add, delete, or substitute investments held by any Sub-Account. 
 We reserve the
right, when permitted by law, to: 
  

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

  

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

  

	3.	Restrict or eliminate any voting privileges of contractowners or other persons who have voting privileges as to the Separate Account; and 

  

	4.	Combine the Separate Account or any Sub-Account(s) with one or more other separate accounts or sub-accounts. 

 CHANGE OF INVESTMENT OBJECTIVES. We reserve the right to change the investment objective of any Sub-Account. If required by law or regulation, an investment objective of
the Separate Account, or of a Series Fund portfolio designated for a Sub-Account, will not be materially changed unless a statement of the change is filed with and approved by the appropriate insurance official of the state of our domicile or deemed
approved in accordance with such law or regulation. If required, approval of or change of any investment objective will be filed with the Insurance Department of the state where this Contract is delivered. 
 ACCUMULATION UNIT VALUE. Some of the contract values fluctuate with the investment results of the Sub-Accounts. In order to determine how investment results affect the
contract values, an Accumulation Unit Value is determined for each Sub-Account. The Accumulation Unit Value may increase or decrease from one Valuation Period to the next. Accumulation Unit Values also will vary between Sub-Accounts. 
 The Accumulation Unit Value of any Sub-Account at the end of a Valuation Period is the result of: 
  

	1.	The total value of the assets held in the Sub-Account. This value is determined by multiplying the number of shares of the designated Series Fund portfolio owned by the Sub-Account
times the net asset value per share; minus 

  

	2.	The accrued charge for administration and adverse mortality and expense experience. The daily amount of this charge is equal to the net assets of the Sub-Account multiplied by the
Mortality and Expense Charge shown on Page 3; minus 

  

	3.	The accrued amount of reserve for any taxes that are determined by us to have resulted from the investment operations of the Sub-Account; and the result divided by

  

	4.	The number of outstanding units in the Sub-Account. 

 The use of the
Accumulation Unit Value in determining contract values is described in the Contract Value Provisions. 
  

 Page 7 

 GENERAL PROVISIONS 
 THE CONTRACT. This Contract and the attached application constitute the entire Contract. All statements in the application, in the absence of fraud, will be deemed representations and not warranties. No statement can
be used to void this Contract or be used in defense of a claim unless it is contained in the written application. No Contract provision can be waived or changed except by endorsement. Such endorsement must be signed by our President or Secretary. We
reserve the right to amend the Contract to meet the requirements of any applicable Federal or state laws or regulations. 
 OWNERSHIP. This Contract belongs
to the Owner. The Owner as shown on Page 3, or as subsequently changed, may exercise all rights under this Contract including the right to transfer ownership. These rights may be subject to the consent of any assignee or irrevocable beneficiary.

 SUCCESSOR OWNER. A Successor Owner can be named in the application or by Written Notice. If the Owner is not the Annuitant, the Successor Owner will
become the new Owner should the Owner die before the Annuitant. 
 CHANGE OF OWNERSHIP UPON REQUEST. We will not be bound by any requested change in the
ownership designation unless it is made by Written Notice. The change will be effective on the date the Written Notice is accepted by us. If we request, this Contract must be returned to our Office for endorsement. 
 Changing the Owner or naming a new Successor Owner cancels any prior designation of Successor Owner, but it does not change the Beneficiary or the Annuitant. 

CHANGE OF OWNERSHIP UPON DEATH OF OWNER. Should the Owner die during the Accumulation Period, we will be bound by the following: 
  

	1.	If the Owner is the Annuitant, then the Death Benefit Proceeds are payable as provided in the Death Benefit Provisions. 

  

	2.	If the Owner is not the Annuitant and dies before the Annuitant: 

  

	 	(a)	If no Successor Owner is named and alive, the Owner’s estate will become the new Owner. The Cash Value must be distributed within five years of the former Owner’s death;
or 

  

	 	(b)	If the Successor Owner is alive and is the Owner’s spouse, this Contract will continue with the spouse as the new Owner; or 

  

	 	(c)	If the Successor Owner is alive and is not the Owner’s spouse, the Successor Owner will become the new Owner. The Cash Value must be distributed either:

  

	 	(1)	within five years of the former Owner’s death; or 

  

	 	(2)	over the lifetime of the new Owner, if a natural person, with payments beginning within one year of the former Owner’s death; or 

  

	 	(3)	over a period that does not exceed the life expectancy (as defined by the Internal Revenue Code and Regulations adopted under the Code) of the new Owner, if a natural person, with
payments beginning within one year of the former Owner’s death. 

 ASSIGNMENT. This Contract may be assigned prior to the Maturity Date.
We will not be bound by any assignment unless made by Written Notice. The assignment will be effective on the date the Written Notice is received at our Office and accepted by us. We assume no responsibility for the validity of any assignment.

 INCONTESTABILITY. This Contract is incontestable from the Contract Date. 
  

 Page 8 

 BENEFICIARY. The Beneficiary, as named in the application or subsequently changed, is entitled to receive the Death
Benefit Proceeds, if any, as provided in the Death Benefit Provisions of this Contract. If no Beneficiary is alive, the benefits payable to the Beneficiary will be paid to the Owner, if surviving, otherwise to the Owner’s estate. 
 CHANGE OF BENEFICIARY. We will not be bound by any change in the Beneficiary designation unless it is made by Written Notice. The change will be effective on the date
the Written Notice was signed; however, no change will apply to any payment we made before the Written Notice is received. If we request, this Contract must be returned to our Office for endorsement. 
 AGE AND SEX. If a date of birth or sex has been misstated, any amount payable will be adjusted to conform to the correct date of birth and sex. 
 CONTRACT YEARS. Contract years and anniversaries are measured from the Contract Date. 
 REPORTS. During the Accumulation Period, we will send a report to the Owner at least once each year. It will show the activity that occurred during the year and the value of the Contract as of the date of the report.

 CONTRACT PAYMENT. All payments from the Fixed Account will be paid in one sum unless otherwise elected under the Annuity Provisions of this Contract. We
have the right to postpone payments and transfers from the Fixed Account for up to six months. All payments and transfers from the Sub-Accounts will be processed as provided in this Contract unless one of the following situations exist: 

 

	1.	The New York Stock Exchange is closed; or 

  

	2.	The SEC requires that trading be restricted or declares an emergency; or 

  

	3.	The SEC allows us to defer payments to protect our contractowners. 

 PROTECTION OF PROCEEDS. Unless the Owner directs by filing Written Notice, no Beneficiary may assign any payments under this Contract before the same are due. To the extent permitted by law, no payments under this Contract will be subject
to the claims of creditors of any Beneficiary. 
 PURCHASE PAYMENT PROVISIONS 
 PURCHASE PAYMENTS. Payments after the first are payable at our Office. The amount of payment which may be paid during any contract year may not exceed the Maximum
Additional Payment shown on Page 3 without our consent. Payments will not be accepted in an amount less than the Minimum Additional Payment shown on Page 3 without our consent. Our acceptance of any payment shall not constitute a waiver of these
limits with respect to subsequent payments. 
  

 Page 9 

 CONTRACT VALUE PROVISIONS 
 NET PAYMENT. The net payment will be the payment received less Premium Tax, if any. 
 ALLOCATION OF NET PAYMENTS. Net
payments will be allocated to the Accounts on the first Valuation Date on or following the date the payment is received at our Office. With respect to the Initial Payment, the allocation will take place on the Contract Date. 
 Any allocation to an Account must not be less than the Minimum Allocation Percentage shown on Page 3. No fractional percentages are permitted. The allocation of future
net payments may be changed by the Owner. We reserve the right to limit such change to once each year. The request for change of allocations must be in a manner satisfactory to us. The allocation change will be effective the date the request for
change is recorded by us. 
 SUB-ACCOUNT VALUE. At the end of any Valuation Period, the Sub-Account value is equal to the number of units that the Contract
has in the Sub-Account, multiplied by the Accumulation Unit Value of that Sub-Account. 
 The number of units that the Contract has in each Sub-Account is
equal to: 
  

	1.	The initial units purchased on the Contract Date; plus 

  

	2.	Units purchased at the time additional net payments are allocated to the Sub-Account; plus 

  

	3.	Units purchased through transfers from another Account; minus 

  

	4.	Any units that are redeemed to pay for partial withdrawals; minus 

  

	5.	Any units that are redeemed as part of a transfer to another Account; minus 

  

	6.	Any units that are redeemed to pay the Annual Contract Charge, Premium Tax and transfer fees, if any. 

 FIXED ACCOUNT. At the end of any Valuation Period, the value is equal to: 
  

	1.	The sum of all net payments allocated to the Fixed Account; plus 

  

	2.	Any amounts transferred from a Sub-Account to the Fixed Account; plus 

  

	3.	Total interest credited to the Fixed Account; minus 

  

	4.	Any amounts withdrawn from the Fixed Account to pay for partial withdrawals; minus 

  

	5.	Any amounts transferred to a Sub-Account from the Fixed Account; minus 

  

	6.	Any amounts charged to pay the Annual Contract Charge, Premium Tax and transfer fees, if any. 

 Interest on the Fixed Account will be compounded daily at a minimum guaranteed effective annual interest rate of 4% per year. We may declare from time to time higher current interest rates. The interest rates we
set will be credited for increments of at least one year measured from each purchase payment or transfer date. 
 On transfers from the Fixed Account to a
Sub-Account, unless we otherwise consent: 
  

	1.	Written Notice must be within 30 days after a contract anniversary. 

  

	2.	The transfer will ordinarily take place on the first Valuation Date on or following the date we receive such Written Notice. 

  

	3.	The amount that may be transferred is the greater of (a) 25% of the amount in the Fixed Account; or (b) the amount transferred in the prior policy year from the Fixed
Account. 

  

 Page 10 

 We reserve the right to defer payment of any amounts from the Fixed Account for no longer than six months after we
receive such Written Notice. 
 ANNUAL CONTRACT CHARGE. During the Accumulation Period, the Annual Contract Charge shown on Page 3 will be made once a year
on each contract anniversary from the Annuity Value. If the Contract is surrendered on other than an anniversary date, the charge will also be made on the date of surrender. 
 ANNUITY VALUE. At the end of any Valuation Period, the Annuity Value is equal to the sum of the Account values. 
 PARTIAL
WITHDRAWAL. Prior to the Maturity Date, a partial withdrawal may be made by the Owner without surrender of this Contract. Unless we otherwise consent: 
  

	1.	The request must be made by Written Notice. 

  

	2.	The partial withdrawal may not reduce the Cash Value to less than the Minimum Balance shown on Page 3. 

  

	3.	No partial withdrawal may be made during the first contract year. 

  

	4.	No more than one partial withdrawal may be made during any contract year. 

  

	5.	No amount from the Fixed Account may be withdrawn. 

 The amount payable
will be the partial withdrawal less any applicable withdrawal charge and Premium Tax. The Sub-Account(s) for the withdrawal may be specified. If not specified, withdrawals will be based on the current allocation election. 
 CASH VALUE. This Contract may be surrendered by the Owner for its Cash Value upon Written Notice at any time prior to the then current Maturity Date. The Cash Value at
any time equals the Annuity Value on the Valuation Date coincident with or next following the date we receive Written Notice of surrender less any applicable withdrawal charge and Premium Tax. Payment will usually be made within seven days of
Written Notice subject to the Contract Payment section of the General Provisions and the Fixed Account section of these provisions. 
 WITHDRAWAL CHARGE. On
the surrender or partial withdrawal of purchase payments paid beyond the Withdrawal Charge Period shown on Page 3, no withdrawal charge will be imposed. 
 On the partial withdrawal of purchase payments within the Withdrawal Charge Period, the withdrawal charge will equal the purchase payment paid within the Withdrawal Charge Period times the applicable Withdrawal Charge Percentage shown on
Page 3. However, for the first partial withdrawal during each contract year, any withdrawal charge will be waived on the first 10% of the Annuity Value being withdrawn. 
 On the surrender of purchase payments within the Withdrawal Charge Period, the withdrawal charge will equal the purchase payment paid within the Withdrawal Charge Period times the applicable Withdrawal Charge
Percentage shown on Page 3. No waiver of a withdrawal charge will be made for any portion of a surrender. 
 BASIS OF COMPUTATION. A detailed statement of
the method of computation of values has been filed with the insurance supervisory official of the jurisdiction in which this Contract is delivered. All values for this Contract are equal to or greater than the values required by statutes in such
jurisdiction. 
  

 Page 11 

 ANNUITY PROVISIONS 
 COMMENCEMENT OF ANNUITY PAYMENTS. Monthly annuity payments will begin as of the Maturity Date shown on Page 3, unless another Maturity Date has been elected as provided in these provisions. 
 MATURITY DATE. The Maturity Date shown on Page 3 may be changed to a different Maturity Date, subject to all of the following: 
  

	1.	Written Notice prior to the Maturity Date. 

  

	2.	The new Maturity Date is at least 5 years after the Contract Date. 

  

	3.	The attained age of the Annuitant as of the new Maturity Date is not greater than 90. 

 ANNUITY OPTION. The Annuity Option shown on Page 3 may be changed to any other option available upon Written Notice prior to the Maturity Date. If a variable account annuity payment option is chosen, the Owner must
include in the Written Notice the Sub-Account allocation of the Annuity Proceeds as of the Maturity Date. 
 CHANGE OF ANNUITANT. As of the Maturity Date and
upon agreement with us, the Owner may elect a different Annuitant or add a joint annuitant who will be a joint payee under either Option C or Option E. 
 PAYEE. The Annuitant(s) on the Maturity Date will become the payee(s) and receive the annuity payments. 
 AVAILABILITY. If the payee is not a
natural person, an Annuity Option is only available with our permission. No Annuity Option is available if: 
  

	1.	The payee is an assignee; or 

  

	2.	The periodic payment is less than $20. 

 AGE. Age, when required, means
age nearest birthday on the effective date of the option. We will furnish rates for ages or combination of ages not shown upon request. 
 PROOF OF AGE AND
SEX. Prior to making the first monthly annuity payment under this Contract, we reserve the right to require satisfactory evidence of the birthdate and the sex of any payee. If required by law to ignore differences in sex of any payee, annuity
payments will be determined using unisex rates. 
 PROOF OF SURVIVAL. Prior to making any payment under this Contract, we reserve the right to require
satisfactory evidence that the payee is: 
  

	1.	Alive on the due date of such payment; and 

  

	2.	Legally qualified to receive such payment. 

 DEATH BENEFIT AFTER THE
MATURITY DATE. The death benefit after the Maturity Date and after the commencement of annuity payments depend upon the annuity option selected. If a payee dies on or after the commencement of annuity payments, the remaining portion of any interest
in the Contract will be distributed at least as rapidly as under the method of distribution being used as of the date of the payee’s death. 
 RESTRICTIONS. After the Maturity Date, no additional purchase payments, partial withdrawals, transfers, full surrenders, change of Annuitants nor Annuity Options may be made under this Contract. 
  

 Page 12 

 FIXED ACCOUNT ANNUITY PAYMENTS 
 INTEREST AND MORTALITY. All Fixed Account annuity option payments are based on a guaranteed interest rate of 3%. Mortality is based on the “1983 Table a” mortality table with projection. Gender based
mortality tables will be used unless prohibited by law. 
 AMOUNT OF MONTHLY FIXED ACCOUNT ANNUITY PAYMENT. The amount of each monthly annuity payment will
be determined by multiplying: 
  

	1.	The appropriate rate based on the guaranteed interest rate and, for Options B and C, the mortality table for Fixed Account annuity payments; times 

  

	2.	The Annuity Proceeds as of the Maturity Date. 

 FIXED ACCOUNT ANNUITY
OPTIONS. The following options are available for payment of Fixed Account monthly annuity payments. The rates shown are the guaranteed rates for each $1,000 of Annuity Proceeds at selected ages. Any guaranteed rates not shown for the options below
will be available upon request. Higher current rates may be available at the Maturity Date. 
 Option A - Fixed Period. The Annuity Proceeds will be paid in
equal installments. The installments will be paid over a fixed period determined from the following table: 
  

			
	 Fixed Period
 (in Months)
	  	Rate
	 60
	  	17.91
	 120
	  	9.61
	 180
	  	6.87
	 240
	  	5.51

 Option B - Life Income. The Annuity Proceeds will be paid in equal installments determined from the following
table. Such installments are payable: 
  

	1.	during the payee’s lifetime only (Life Annuity); or 

  

	2.	during a 10 Year fixed period certain and for the payee’s remaining lifetime (Certain Period); or 

  

	3.	until the sum of installments paid equals the Annuity Proceeds applied and for the payee’s remaining lifetime (Installment Refund). 

  

																			
	  	  	Life Annuity	  	Certain Period	  	Installment Refund
	 Payee’s Age
	  	Male	  	Female	  	Unisex	  	Male	  	Female	  	Unisex	  	Male	  	Female	  	Unisex
	 55
	  	4.20	  	3.81	  	4.01	  	4.15	  	3.79	  	3.98	  	4.00	  	3.71	  	3.85
	 60
	  	4.67	  	4.17	  	4.43	  	4.59	  	4.14	  	4.37	  	4.37	  	4.02	  	4.19
	 65
	  	5.33	  	4.68	  	5.01	  	5.17	  	4.61	  	4.90	  	4.84	  	4.42	  	4.62
	 70
	  	6.26	  	5.39	  	5.82	  	5.89	  	5.24	  	5.58	  	5.45	  	4.94	  	5.18
	 75
	  	7.53	  	6.42	  	6.97	  	6.75	  	6.06	  	6.42	  	6.24	  	5.64	  	5.91
	 80
	  	9.33	  	7.95	  	8.63	  	7.66	  	7.04	  	7.37	  	7.25	  	6.57	  	6.88
	 85
	  	11.84	  	10.21	  	11.02	  	8.48	  	8.04	  	8.27	  	8.55	  	7.78	  	8.14
	 90
	  	15.31	  	13.49	  	14.40	  	9.08	  	8.81	  	8.96	  	10.21	  	9.30	  	9.74

 Option C - Joint and Survivor Life Income. The Annuity Proceeds will be paid in equal installments during the
joint lifetime of two payees and continuing upon the death of the first payee for the remaining lifetime of the survivor. 
  

 Page 13 

 VARIABLE ACCOUNT ANNUITY PAYMENTS 
 ANNUITY UNIT VALUE. The Annuity Proceeds will be used to purchase variable annuity units in the chosen Sub-Account(s). The Annuity Unit Value in any Sub-Account will increase or decrease reflecting the investment
experience of that Sub-Account. 
 The Annuity Unit Value of any Sub-Account at the end of a Valuation Period is equal to (a) multiplied by
(b) multiplied by (c), where: 
  

	(a)	is the Annuity Unit Value for that Sub-Account at the end of the immediately preceding Valuation Period; 

  

	(b)	is the net investment factor for the Sub-Account for the Valuation Period; and 

  

	(c)	is the Assumed Investment Return adjustment factor for the Valuation Period. 

 The Assumed Investment Return adjustment factor for the Valuation Period is the product of discount factors of .99986634 per day to recognize the 5.0% effective annual Assumed Investment Return. 
 The net investment factor used to calculate the value of the Annuity Unit Value in each Sub-Account for the Valuation Period is determined by dividing (d) by
(e) and subtracting (f) from the result, where: 
  

	(d)	is the net result of: 

  

	 	(1)	the net asset value of a Series Fund share held in that Sub-Account 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 Series Fund for shares held in that Sub-Account if the ex-dividend date occurs during the Valuation
Period; plus or minus 

  

	 	(3)	a per share charge or credit for any taxes reserved for, which we determine to have resulted from the investment operations of the Sub-Account. 

  

	(e)	is the net asset value of a Series Fund share held in the Sub-Account determined as of the end of the immediately preceding Valuation Period. 

  

	(f)	is a factor representing the mortality and expense risk fee, and administrative charge. This factor is equal, on an annual basis, to 1.40% of the daily net asset value of a Series
Fund share held in the Separate Account for that Sub-Account. 

 DETERMINATION OF THE FIRST VARIABLE PAYMENT. The amount of the first variable
payment is determined by multiplying the Annuity Proceeds times the appropriate rate from the variable option selected. The tables are based on the “1983 Table a” mortality table with projection with a 5% effective annual Assumed
Investment Return and assuming a Maturity Date in the year 2000. Gender based mortality tables will be used unless prohibited by law. 
 The amount of the
first payment depends upon the adjusted age of the Annuitant. The adjusted age is the Annuitant’s actual age nearest birthday at the Maturity Date, adjusted as follows: 
  

			
	 Maturity Date
	  	Adjusted Age
	 Before 2001
	  	Actual Age
	 2001 - 2010
	  	Actual Age minus 1
	 2011 -2020
	  	Actual Age minus 2
	 2021 - 2030
	  	Actual Age minus 3
	 2031 - 2040
	  	Actual Age minus 4

 After the year 2040 as determined by us. 
  

 Page 14 

 DETERMINATION OF SUBSEQUENT VARIABLE PAYMENTS. The amount of variable annuity payments after the first will increase or
decrease according to the Annuity Unit Value which reflects the investment experience of the selected Sub-Account(s). Each variable annuity payment after the first will be equal to the number of variable annuity units in each selected Sub-Account
multiplied by the Annuity Unit Value of that Sub-Account on the date the payment is processed. The number of variable annuity units in any selected Sub-Account is determined by dividing the first variable annuity payment allocated to that
Sub-Account by the variable Annuity Unit Value of that Sub-Account on the date the first annuity payment is processed. 
 VARIABLE ACCOUNT ANNUITY OPTIONS.
The following options are available for payment of Variable Account monthly annuity payments. The rates shown are the guaranteed rates for each $1,000 of Annuity Proceeds at selected ages. These rates are used to determine the first variable payment
under each option. Any guaranteed rates not shown for the options below will be available upon request. 
 Option D - Variable Life Income. The Annuity
Proceeds will be paid in installments determined from the following table. Such installments are payable: 
  

	1.	during the payee’s lifetime only (Variable Life Annuity); or 

  

	2.	during a 10 year fixed period certain and for the payee’s remaining lifetime (Variable Certain Period). 

  

													
	  	  	Variable Life Annuity	  	Variable Certain Period
	 Adjusted Payee’s Age
	  	Male	  	Female	  	Unisex	  	Male	  	Female	  	Unisex
	 55
	  	5.39	  	4.98	  	5.19	  	5.33	  	4.95	  	5.14
	 60
	  	5.88	  	5.36	  	5.63	  	5.77	  	5.31	  	5.55
	 65
	  	6.57	  	5.88	  	6.23	  	6.35	  	5.78	  	6.07
	 70
	  	7.53	  	6.61	  	7.08	  	7.05	  	6.41	  	6.75
	 75
	  	8.84	  	7.68	  	8.25	  	7.86	  	7.21	  	7.54
	 80
	  	10.69	  	9.26	  	9.97	  	8.71	  	8.15	  	8.44
	 85
	  	13.27	  	11.62	  	12.44	  	9.48	  	9.07	  	9.29
	 90
	  	16.82	  	15.02	  	15.89	  	10.03	  	9.79	  	9.93

 Option E - Variable Joint and Survivor Life Income. The Annuity Proceeds will be paid in installments during the
joint lifetime of two payees and continuing upon the death of the first payee for the remaining lifetime of the survivor. 
  

 Page 15 

 WESTERN RESERVE LIFE 
 ASSURANCE CO. OF OHIO 
 FLEXIBLE PAYMENT VARIABLE ACCUMULATION DEFERRED ANNUITY 
 Death Benefit Prior to Maturity 
 Monthly
Annuity Commencing on Maturity Date 
 Non-Participating - No Dividends

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