EX-99.4KK 14 file013.txt FORM OF DATA PAGES FOR NJ ACTS DATA ---- PART A -- THIS PART LISTS YOUR PERSONAL DATA ------ OWNER: [EMPLOYER/TRUSTEE] ANNUITANT: [JOHN DOE] Age: [35] Sex: [Male] CERTIFICATE NUMBER: [2003] ISSUE DATE: [August 1, 2003 ] PARTICIPATION DATE: [August 31, 2003 ] ANNUITY COMMENCEMENT DATE: [August 8, 2031 ] THE MAXIMUM MATURITY AGE IS AGE [85] - SEE SECTION 7.05 BENEFICIARY: [Jane Doe] PART B--THIS PART LISTS THE CONTRACT TERMS THAT AFFECT YOUR CERTIFICATE. ------ Initial Guaranteed Interest Rate: [3.10% To August 1,2004 ] Minimum Guaranteed Interest Rate: [3.00% To December 31, 2003] [1.5% / 3.00% After December 31, 2003 ] 2003NJ403(b) Data Page 1 ANNUITANT: [John Doe] OWNER: [John Doe] CONTRACT NUMBER: [123456789] ISSUE DATE: [August 1, 2003] CONTRACT DATE: [August 1, 2003] RETIREMENT DATE: INITIAL GUARANTEED INTEREST RATE: [3.10% To 07/31/04] MINIMUM GUARANTEED INTEREST RATE: [3.00% To 12/31/03] [1.50% After 12/31/03] ******************************************************************************** TABLE OF GUARANTEED VALUES
NUMBER OF CONTRACT, OR GUARANTEED PARTICIPATION YEARS, IF APPLICABLE CASH VALUE ---------------------------------- ---------- [1 $1,031 2 $2,061 3 $3,107 4 $4,169 5 $5,247 6 $6,340 7 $7,450 8 $8,577 9 $9,721 10 $10,882 11 $12,060 12 $13,256 13 $14,470 14 $15,702 15 $16,952 16 $18,221 17 $19,510 18 $20,817 19 $22,145 20 $23,492 21 $24,859 22 $26,247 23 $27,656 24 $29,086 25 $30,537 26 $32,010 27 $33,505 28 $35,023 29 $36,563 30 (Age 65) $38,126
The table illustrates minimum guaranteed values. It assumes a $1,000 Contribution made each year on the first month which follows the Contract Date. The table assumes that 100% of all Contributions and earnings are in the Guaranteed Interest Option. Your actual values may differ from those shown above based on the level and frequency of your Contributions and election of any optional benefits. Based on the above assumptions, the Guaranteed Paid-Up Monthly Annuity at age 65 is 158.22. This amount assumes a fixed benefit life and 10-year certain annuity (Unisex table). It will be reduced by any charge we make for any taxes (see Section 7.03). Other forms of Annuity Benefits may be available.] 2003NJ403(b) Data Page 2 ANNUITANT: [John Doe] OWNER: [John Doe] CONTRACT NUMBER: [123456789] ISSUE DATE: [August 1, 2003] CONTRACT DATE: [August 1, 2003] RETIREMENT DATE: INITIAL GUARANTEED INTEREST RATE: [3.10% To 07/31/04] MINIMUM GUARANTEED INTEREST RATE: [3.00% To 12/31/03] [3.00% After 12/31/03] ******************************************************************************** TABLE OF GUARANTEED VALUES
NUMBER OF CONTRACT, OR GUARANTEED PARTICIPATION YEARS, IF APPLICABLE CASH VALUE ---------------------------------- ---------- [1 $1,031 2 $2,092 3 $3,185 4 $4,310 5 $5,470 6 $6,664 7 $7,894 8 $9,160 9 $10,465 10 $11,809 11 $13,193 12 $14,619 13 $16,088 14 $17,600 15 $19,158 16 $20,763 17 $22,416 18 $24,119 19 $25,872 20 $27,678 21 $29,539 22 $31,455 23 $33,428 24 $35,461 25 $37,555 26 $39,712 27 $41,933 28 $44,221 29 $46,578 30 (Age 65) $49,005
The table illustrates minimum guaranteed values. It assumes a $1,000 Contribution made each year on the first month which follows the Contract Date. The table assumes that 100% of all Contributions and earnings are in the Guaranteed Interest Option. Your actual values may differ from those shown above based on the level and frequency of your Contributions and election of any optional benefits. Based on the above assumptions, the Guaranteed Paid-Up Monthly Annuity at age 65 is 203.37. This amount assumes a fixed benefit life and 10-year certain annuity (Unisex table). It will be reduced by any charge we make for any taxes (see Section 7.03). Other forms of Annuity Benefits may be available.] 2003NJ403(b) Data Page 2a PART B (CONTINUED) ------ INVESTMENT OPTIONS AVAILABLE (SEE PART II); YOUR ALLOCATION PERCENTAGE (UNTIL CHANGED) IS ALSO SHOWN: [INVESTMENT OPTION* ALLOCATION PERCENTAGE** ------------------ ------------------------ o Guaranteed Interest Option o Fixed Maturity Option o EQ/JP Morgan Core Bond o EQ/Money Market o EQ/Janus Large Cap Growth o EQ/Bernstein Diversified Value o EQ/Calvert Socially Responsible o EQ/FI Mid Cap o EQ/Putnam International Equity o EQ Equity 500 Index o EQ/Small Company Index o EQ/Balanced ------------------------- TOTAL: 100%] ***[FIXED MATURITY OPTION: EXPIRATION DATE AND GUARANTEED RATE] *INVESTMENT OPTIONS SHOWN ARE INVESTMENT OPTIONS OF OUR SEPARATE ACCOUNT [A], EXCEPT THE FIXED MATURITY OPTIONS WHICH ARE OUR SEPARATE ACCOUNT NO.[48.] **SEE SECTION 3.01 ***FIXED MATURITY OPTIONS ARE OFFERED WITH VARYING EXPIRATION DATES SPANNING AN APPROXIMATE 10 YEAR PERIOD. 2003NJ403(b) Data Page 3 CONTRIBUTION LIMITS (SEE SECTION 3.01): Initial Contribution minimum is [$20]. Additional Contribution minimum is [$20]. We reserve the right to limit Contributions to the Guaranteed Interest Option to [25%] of each Contribution we accept. GUARANTEED INTEREST OPTION - Conditions, Contributions and Transfer Rules (Certificate Sections 2.03(c), 3.01 and 4.02). The percentage referred to in Sections 2.03(c), 3.01 and 4.02 of the Certificate is [25%]. MINIMUM TRANSFER AMOUNT (SEE SECTION 4.01): [$300] or the Annuity Account Value in an Investment Option if less. MINIMUM WITHDRAWAL AMOUNT (SEE SECTION 5.01A): [$300] or the Annuity Account Value if less. MINIMUM AMOUNT OF ANNUITY ACCOUNT VALUE AFTER A WITHDRAWAL (SEE SECTION 5.01A): [$500]. DEATH BENEFIT AMOUNT (SEE SECTIONS 5.02 ): [The death benefit is equal to the greater of : 1.) the Annuity Account Value less any outstanding loan; or 2.) the minimum death benefit. The minimum death benefit is the sum of all Contributions less any withdrawals and any outstanding loan balance. Any withdrawal will reduce the minimum death benefit (as adjusted by any previous withdrawal) by an amount that is in the same proportion to such minimum death benefit as the amount that is withdrawn is to the Annuity Account Value.] NORMAL FORM OF ANNUITY (SEE SECTION 7.02): [Ten Year Period Certain Annuity Form] MINIMUM AMOUNT TO BE APPLIED FOR AN ANNUITY (SEE SECTION 7.06): [$5,000], as well as a minimum of [$20] for the initial monthly annuity payment. INTEREST RATE TO BE APPLIED OR MISSTATEMENT OF AGE OR SEX (SEE SECTION 7.06): [6%] per year. WITHDRAWAL CHARGE (SEE SECTION 9.01): [None] 2003NJ403(b) Data Page 4 THIRD PARTY TRANSFERS (SEE SECTION 9.02) For a direct transfer to a third party of amounts under your Certificate or an exchange for another contract of another carrier, we will deduct a [$25] charge per occurrence up to a maximum of $65. CHARGES DEDUCTED FROM THE ANNUITY ACCOUNT VALUE (SEE SECTION 9.03): [Not Applicable] TRANSFER CHARGES BETWEEN INVESTMENT OPTIONS (SEE SECTION 9.04) [Not Applicable] DAILY SEPARATE ACCOUNT CHARGE (SEE SECTION 9.05): [.70%] this is subject to change as described in Sections 9.05 and 9.09. The maximum annual charge will not exceed [2.00%]. 2003NJ403(b) Data Page 5