EX-1.A.5.A 2 d771604dex1a5a.htm EXHIBIT 1.A(5)(A) Exhibit 1.A(5)(a)

Exhibit 1.A (5) (a)

Specimen Flexible Premium Variable Life Insurance Policy


LOGO

 

WESTERN RESERVE LIFE

ASSURANCE CO. OF OHIO

(A STOCK COMPANY)

Home Office: Columbus, Ohio

Administrative Office: Clearwater, Florida

IN THIS POLICY the Primary Insured is named on Page 3. The Primary Insured will be referred to as YOU or YOUR. Western Reserve Life Assurance Co. Of Ohio will be referred to as WE, OUR or US.

IF YOU DIE before the Maturity Date and while this Policy is in force, WE WILL PAY the Death Benefit Proceeds to the Beneficiary upon receipt of due proof of your death. THE AMOUNT OF THE DEATH BENEFIT PROCEEDS WILL INCREASE OR DECREASE DEPENDING ON THE INVESTMENT EXPERIENCE OF THE SUBACCOUNTS IN THE SEPARATE ACCOUNT AND ON THE DEATH BENEFIT OPTION SELECTED AS DESCRIBED IN THE DEATH BENEFIT PROVISIONS.

IF YOU ARE ALIVE on the Maturity Date and this Policy is in force, WE WILL PAY the Net Surrender Value as of the Maturity Date. CASH VALUES WILL INCREASE OR DECREASE IN ACCORDANCE WITH THE POLICY VALUE PROVISIONS AND THE INVESTMENT EXPERIENCE OF THE SUBACCOUNTS IN THE SEPARATE ACCOUNT. CASH VALUES ARE NOT GUARANTEED AS TO DOLLAR AMOUNT.

THE PROVISIONS on the following pages are part of this contract.

IN WITNESS WHEREOF, we have signed this Policy at our Office in Clearwater, Florida as of the Policy Date.

 

Signature Appears Here    Signature Appears Here
Secretary    President

RIGHT TO EXAMINE POLICY—The Owner may cancel this Policy by returning it to us at P.O. Box 5068, Clearwater, Florida 34618 or to the representative through whom it was purchased within the later of: (a) 45 days after the application was signed; (b) 10 days after receipt of this Policy; or (c) 10 days after we mail or deliver the Notice of Withdrawal Right. If the Policy is returned within this period, it will be void from the beginning and a refund will be made to the Owner. The refund will equal the sum of:

 

1.

The difference between the premiums paid and the amounts allocated to any accounts under the Policy; plus

 

2.

The total amount of monthly deductions made and any other charges imposed on amounts allocated to the accounts; plus

 

3.

The value of amounts allocated to the accounts on the date we or our agent receive the returned Policy.

If state law prohibits the calculation above, the refund will be the total of all premiums paid for this Policy.

Flexible Premium Variable Life Insurance Policy

Death Benefit Proceeds Payable at Death of Primary Insured

Prior to Maturity Date

Net Surrender Value Payable at Maturity Date

Initial Premium Payable at Issue with Restricted Additional Premiums

Payable During Lifetime of Primary Insured Until the Maturity Date

Non-Participating—No Dividends

Some Benefits Reflect Investment Results

 

FORM VLS.03.02.90     


LOGO

 

POLICY GUIDE

 

POLICY SCHEDULE      3   
RIDER INFORMATION      4   
TABLE OF GUARANTEED RATES      5   
DEFINITIONS      8   
GENERAL PROVISIONS      9   
DEATH BENEFIT PROVISIONS      10   
PREMIUM PROVISIONS      12   
SEPARATE ACCOUNT PROVISIONS      13   
POLICY VALUE PROVISIONS      14   
SETTLEMENT OPTIONS      17   

ENDORSEMENTS

 

FORM VLS.03.02.90

  Page 2   


LOGO

 

WESTERN RESERVE LIFE ASSURANCE CO. OF OHIO

CLEARWATER, FLORIDA

POLICY SCHEDULE

 

PRIMARY INSURED:    JOHN DOE    POLICY NUMBER:    01–12345678
ISSUE AGE AND SEX:    35 – MALE    POLICY DATE:    JANUARY 1, 1990
SPECIFIED AMOUNT:    $100,000    RECORD DATE:    JANUARY 1, 1990
OPTION TYPE:    A    MATURITY DATE:    JANUARY 1, 2050
      INITIAL PREMIUM:    $10,000.00
RATE CLASS    SELECT      
MINIMUM SPECIFIED AMOUNT    $10,000   
SEPARATE ACCOUNT PROVISIONS      

SEPARATE ACCOUNT

   WRL SERIES LIFE ACCOUNT

MORTALITY AND EXPENSE RISK CHARGE

   .00002455   
POLICY VALUE PROVISIONS      

MONTHLY POLICY CHARGE

   $5.00   

 

     END OF     PERCENTAGE OF THE  

SURRENDER CHARGE

     POLICY YEAR      INITIAL PREMIUM   
     AT ISSUE        9%   

* THE SURRENDER CHARGE ON

     1        9%   

ANY DATE OTHER THAN AN

     2        8%   

ANNIVERSARY WILL BE

     3        8%   

INTERPOLATED BETWEEN THE

     4        7%   

TWO END OF YEAR CHARGES *

     5        7%   
     6        5%   
     7        4%   
     8        3%   
     9        2%   
     10+            0%   

THE MATURITY DATE IS THE ANNIVERSARY NEAREST YOUR 95TH BIRTHDAY. IT IS POSSIBLE THAT COVERAGE WILL EXPIRE PRIOR TO THE MATURITY DATE SHOWN IF EITHER: PREMIUMS PAID FOLLOWING PAYMENT OF THE INITIAL PREMIUM, OR INVESTMENT RESULTS ON THE DESIGNATED SUBACCOUNTS, ARE INSUFFICIENT TO CONTINUE COVERAGE TO SUCH DATE.

 

FORM VLS.03.02.90

  Page 3   


LOGO

 

WESTERN RESERVE LIFE ASSURANCE CO. OF OHIO

CLEARWATER, FLORIDA

POLICY NUMBER: 01-12345678

RIDER INFORMATION

NONE

 

FORM VLS.03.02.90

  Page 4   


LOGO

 

WESTERN RESERVE LIFE ASSURANCE CO. OF OHIO

CLEARWATER, FLORIDA

POLICY NUMBER: 01-12345678

TABLE OF GUARANTEED

MAXIMUM LIFE INSURANCE RATES

GUARANTEED RATE BASIS FOR INITIAL SPECIFIED AMOUNT ON PRIMARY INSURED

COMMISSIONERS 1980 STANDARD ORDINARY MORTALITY TABLE

MALE LIVES

NON-SMOKERS CLASSIFICATION

ANNUAL COST OF INSURANCE RATES PER $1,000

MONTHLY COST OF INSURANCE CALCULATIONS WILL USE ONE-TWELFTH OF THESE RATES

 

ATTAINED    ANNUAL    ATTAINED    ANNUAL

AGE

   RATE    AGE    RATE

35

   1.69    36    1.77

37

   1.88    38    2.00

39

   2.14    40    2.29

41

   2.47    42    2.65

43

   2.86    44    3.07

45

   3.32    46    3.59

47

   3.88    48    4.19

49

   4.54    50    4.91

51

   5.35    52    5.86

53

   6.43    54    7.09

55

   7.82    56    8.63

57

   9.49    58    10.42

59

   11.47    60    12.64

61

   13.94    62    15.42

63

   17.11    64    19.02

65

   21.13    66    23.40

67

   25.86    68    28.50

69

   31.38    70    34.63

71

   38.91    72    42.56

73

   47.44    74    52.92

75

   58.80    76    65.00

77

   71.64    78    78.47

79

   85.72    80    93.67

81

   102.52    82    112.52

83

   123.79    84    136.11

85

   149.20    86    162.80

87

   176.79    88    190.89

89

   205.29    90    220.19

91

   235.84    92    252.75

93

   271.63    94    295.65

 

FORM VLS.03.02.90

  Page 5   


LOGO

 

WESTERN RESERVE LIFE ASSURANCE CO. OF OHIO

CLEARWATER, FLORIDA

POLICY SCHEDULE

 

PRIMARY INSURED:    JOHN DOE    POLICY NUMBER:    01-12345678
ISSUE AGE AND SEX:    35 – MALE    POLICY DATE:    JANUARY 1, 1990
SPECIFIED AMOUNT:    $100,000    RECORD DATE:    JANUARY 1, 1990
OPTION TYPE:    A    MATURITY DATE:    JANUARY 1, 2050
      INITIAL PREMIUM:    $10,000.00
RATE CLASS    SELECT      
MINIMUM SPECIFIED AMOUNT    $10,000   
SEPARATE ACCOUNT PROVISIONS      
        SEPARATE ACCOUNT    WRL SERIES LIFE ACCOUNT
        MORTALITY AND EXPENSE RISK CHARGE    .00002455   
POLICY VALUE PROVISIONS      
        MONTHLY POLICY CHARGE    $5.00   

 

     END OF    PERCENTAGE OF THE
SURRENDER CHARGE    POLICY YEAR *    INITIAL PREMIUM
   AT ISSUE    9%

* THE SURRENDER CHARGE ON

   1    9%

ANY DATE OTHER THAN AN

   2    8%

ANNIVERSARY WILL BE

   3    8%

INTERPOLATED BETWEEN THE

   4    7%

TWO END OF YEAR CHARGES *

   5    7%
   6    5%
   7    4%
   8    3%
   9    2%
   10+        0%

THE MATURITY DATE IS THE ANNIVERSARY NEAREST YOUR 95TH BIRTHDAY. IT IS POSSIBLE THAT COVERAGE WILL EXPIRE PRIOR TO THE MATURITY DATE SHOWN IF EITHER: PREMIUMS PAID FOLLOWING PAYMENT OF THE INITIAL PREMIUM, OR INVESTMENT RESULTS ON THE DESIGNATED SUBACCOUNTS, ARE INSUFFICIENT TO CONTINUE COVERAGE TO SUCH DATE.

IT IS POSSIBLE THAT COVERAGE WILL EXPIRE PRIOR TO THE MATURITY DATE SHOWN, WHERE EITHER NO PREMIUMS ARE PAID FOLLOWING PAYMENT OF THE INITIAL PREMIUM, OR SUBSEQUENT PREMIUMS ARE INSUFFICIENT TO CONTINUE COVERAGE TO SUCH DATE.

 

FORM VLS.03.02.90

  Page 6   


LOGO

 

WESTERN RESERVE LIFE ASSURANCE CO. OF OHIO

CLEARWATER, FLORIDA

POLICY SCHEDULE

 

PRIMARY INSURED:   JOHN DOE    POLICY NUMBER:    01-12345678
ISSUE AGE AND SEX:   35 - MALE    POLICY DATE:    JANUARY 1, 1990
SPECIFIED AMOUNT:   $100,000    RECORD DATE:    JANUARY 1, 1990
OPTION TYPE:   A    MATURITY DATE:    JANUARY 1, 2050
     INITIAL PREMIUM:    $10,000.00
RATE CLASS   SELECT      
MINIMUM SPECIFIED AMOUNT    $10,000   
SEPARATE ACCOUNT PROVISIONS      
        SEPARATE ACCOUNT    WRL SERIES LIFE ACCOUNT
        MORTALITY AND EXPENSE RISK CHARGE    .00002455   
POLICY VALUE PROVISIONS      
        MONTHLY POLICY CHARGE    $5.00   

 

     END OF    PERCENTAGE OF THE

SURRENDER CHARGE

   POLICY YEAR *    INITIAL PREMIUM
   AT ISSUE    9%

* THE SURRENDER CHARGE ON

   1    9%

ANY DATE OTHER THAN AN

   2    8%

ANNIVERSARY WILL BE

   3    8%

INTERPOLATED BETWEEN THE

   4    7%

TWO END OF YEAR CHARGES *

   5    7%
   6    5%
   7    4%
   8    3%
   9    2%
   10+        0%

THE MATURITY DATE IS THE ANNIVERSARY NEAREST YOUR 95TH BIRTHDAY. IT IS POSSIBLE THAT COVERAGE WILL EXPIRE PRIOR TO THE MATURITY DATE SHOWN IF EITHER: PREMIUMS PAID FOLLOWING PAYMENT OF THE INITIAL PREMIUM, OR INVESTMENT RESULTS ON THE DESIGNATED SUBACCOUNTS, ARE INSUFFICIENT TO CONTINUE COVERAGE TO SUCH DATE.

IT IS POSSIBLE THAT COVERAGE WILL EXPIRE PRIOR TO THE MATURITY DATE SHOWN, WHERE EITHER NO PREMIUMS ARE PAID FOLLOWING PAYMENT OF THE FIRST YEAR PREMIUM, OR SUBSEQUENT PREMIUMS ARE INSUFFICIENT TO CONTINUE COVERAGE TO SUCH DATE.

 

FORM VLS.03.02.90

  Page 7   


LOGO

 

DEFINITIONS

ACCOUNTS. Allocation options including the fixed account and the subaccounts of the Separate Account.

AGE. Issue Age refers to the age on the insured’s birthday nearest the Policy Date. Attained Age refers to the Issue Age plus the number of completed policy years.

ANNIVERSARY. The same day and month as the Policy Date for each succeeding year the Policy remains in force.

FIXED ACCOUNT. An allocation option other than the Separate Account.

IN FORCE. Condition under which the coverage is active and the insured’s life remains insured.

INITIAL PREMIUM. The amount which must be paid before coverage begins. The amount is shown on Page 3.

LOAN RESERVE. Portion of the fixed account used as collateral for any policy loan.

MATURITY DATE. The date when coverage under the Policy will terminate if the Primary Insured is living and the Policy is in force.

MONTHIVERSARY. The day of each month coinciding with the Policy Date. If there is no day in a calendar month which coincides with the Policy Date, the Monthiversary will be the first day of the next month.

NET PREMIUM. The portion of the premium available for allocation as set forth in the Policy Value Provisions.

OFFICE. Refers to our Administrative Office located in Clearwater, Florida.

POLICY DATE. The date coverage is effective and monthly deductions commence under the Policy. Policy months, years and anniversaries are measured from the Policy Date, as shown on Page 3.

RECORD DATE. The date the Policy is recorded on our books as an in force Policy. The Record Date is shown on Page 3.

RIDER. Any attachment to this Policy which provides additional coverages or benefits.

SEC. The Securities and Exchange Commission.

SEPARATE ACCOUNT. A separate investment account shown on Page 3 which is composed of several subaccounts established to receive and invest net premiums under the Policy.

SERIES FUND. A designated mutual fund from which each subaccount of the Separate Account will buy shares.

TERMINATION. Condition when the insured’s life is no longer insured under the coverage provided.

VALUATION DATE. Any day we are required by law to value the assets of the Separate Account.

VALUATION PERIOD. The period commencing at the end of one valuation date and continuing to the end of the next succeeding valuation date.

 

FORM VLS.03.02.90

  Page 8   


LOGO

 

GENERAL PROVISIONS

THE CONTRACT. This Policy is issued in consideration of the attached application and payment of the initial premium. This Policy, the attached application and any additional applications at the time of reinstatement or increase in Specified Amount constitute the entire contract. All statements in these applications, in the absence of fraud, will be deemed representations and not warranties. No statement can be used to void this Policy or be used in defense of a claim unless it is contained in the written application. No policy provision can be waived or changed except by endorsement. Such endorsement must be signed by our President or Secretary.

OWNERSHIP. This Policy belongs to the Owner. The Owner, as named in the application or subsequently changed, may exercise all rights under this Policy during your lifetime including the right to transfer ownership. If the Owner should die during your lifetime, ownership of this Policy will pass to the Owner’s estate if no Contingent Owner is named.

We will not be bound by any change in the Ownership designation unless it is made in writing and received at our Office. The change will be effective on the date it was signed; however, no change will apply to any payment we made before the change is received. If we request, this Policy must be returned to our Office for endorsement.

BENEFICIARY. The Beneficiary, as named in the application or subsequently changed, will receive the benefits payable at your death. If the Beneficiary dies before you, the Contingent Beneficiary, if named, becomes the Beneficiary. If no Beneficiary survives you, the benefits payable at your death will be paid to the Owner or the Owner’s estate.

We will not be bound by any change in the Beneficiary designation unless it is made in writing and received at our Office. The change will be effective on the date it was signed; however, no change will apply to any payment we made before the change is received. If we request, this Policy must be returned to our Office for endorsement.

ASSIGNMENT. This Policy may be assigned. We will not be bound by any assignment unless made in writing and received at our Office; however, no assignment will apply to any payment made before the assignment is received. We assume no responsibility for the validity of any assignment.

INCONTESTABILITY. This Policy shall be incontestable as to the initial Specified Amount after it has been in force, while you are still alive, for two years from the Policy Date.

A new two year contestability period shall apply to each increase in insurance amount beginning on the effective date of each increase and will apply only to statements made in the application for the increase.

If this Policy is reinstated, a new two year contestability period (apart from any remaining contestability period) shall apply from the date of the application for reinstatement and will apply only to statements made in the application for reinstatement.

SUICIDE. If you die by suicide, while sane or insane, within two years from the Policy Date, the death benefit proceeds will be limited to the total premiums paid less any loan and any prior withdrawals.

If you die by suicide, while sane or insane, within two years from the effective date of any increase in insurance or any reinstatement, our total liability with respect to such increase or reinstatement will be its cost of insurance.

 

FORM VLS.03.02.90

  Page 9   


LOGO

 

ISSUE AGE AND SEX. If your date of birth or sex is not correctly stated, the death benefit will be adjusted. The death benefit will be adjusted based on what the cost of insurance charge for the most recent monthly deduction would have purchased based on your correct date of birth and sex.

ANNUAL REPORT. We will send a report to the Owner at least once each year. It will show for the Policy:

 

1.     The current cash value;

   4.     Any current policy loans;

2.     The current net surrender value;

   5.     Activity since the last report;

3.     The current death benefit;

   6.     Projected values.

Additional activity within each subaccount showing investment experience will also be provided.

TERMINATION. This Policy will terminate on the earliest of:

 

1.     The Maturity Date;

   3.     The end of the grace period;

2.     The date of your death;

   4.     The date of surrender.

POLICY PAYMENT. All proceeds to be paid upon termination will be paid in one sum unless otherwise elected under the Settlement Options of this Policy.

All payments and transfers from the subaccounts will be processed as provided in this Policy unless one of the following situations exists:

 

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 policyowners.

We reserve the right to defer the payment of any fixed account values for the period permitted by law, but not for more than 6 months.

CONVERSION RIGHTS. At any time upon written request within the first 2 policy years, the Owner may elect to transfer all subaccount values to the fixed account without a transfer charge.

DEATH BENEFIT PROVISIONS

SPECIFIED AMOUNT. The Specified Amount is as shown on Page 3, unless changed in accordance with the Changes section of this provision or reduced by a cash withdrawal as provided in the Withdrawals section of the Policy Value Provisons.

OPTION TYPE. The Option Type is as shown on Page 3, unless changed in accordance with the Changes section of this provision.

LIMITATION PERCENTAGE. The Limitation Percentage is a percentage based on your attained age at the beginning of the policy year equal to:

 

Attained Age

   Limitation Percentage

40 and under

   250%

41 through 45

   250% minus 7% for each attained age over age 40

46 through 50

   215% minus 6% for each attained age over age 45

51 through 55

   185% minus 7% for each attained age over age 50

56 through 60

   150% minus 4% for each attained age over age 55

61 through 65

   130% minus 2% for each attained age over age 60

66 through 70

   120% minus 1% for each attained age over age 65

71 through 75

   115% minus 2% for each attained age over age 70

76 through 90

   105%

91 through 95

   105% minus 1% for each attained age over age 90

 

FORM VLS.03.02.90

  Page 10   


LOGO

 

DEATH BENEFIT. The death benefit is based upon the Specified Amount, Option Type and the Limitation Percentage applicable on the date of your death.

If Option Type A is in effect, the death benefit is the greater of:

 

1.

The Specified Amount; or

 

2.

The Limitation Percentage times the cash value of this Policy on the date of your death.

If Option Type B is in effect, the death benefit is the greater of:

 

1.

The Specified Amount plus the cash value of this Policy on the date of your death; or

 

2.

The Limitation Percentage times the cash value of this Policy on the date of your death.

CHANGES. The Owner may change the Option Type after the first policy year by written request. No more than one change may be allowed within each policy year. The change will be effective on the first Monthiversary on or next following the day we receive the request. No change in the type of death benefit will be allowed if the resulting Specified Amount would be less than the Minimum Specified Amount shown on Page 3. The Specified Amount will be changed as follows:

 

1.

If the change is from Type A to Type B, the Specified Amount after such change will be equal to:

 

  (a)

The Specified Amount prior to such change; minus

 

  (b)

The cash value on the date of change.

 

2.

If the change is from Type B to Type A, the Specified Amount after such change will be equal to:

 

  (a)

The Specified Amount prior to such change; plus

 

  (b)

The cash value on the date of change.

The Specified Amount may be increased at any time after the first policy year or decreased at any time after the second policy year. No more than one change may be allowed within each policy year. The request for change must be from the Owner in a form satisfactory to us. The change is subject to the following:

 

1.

Any decrease will become effective on the first Monthiversary on or next following the day we receive the request.

 

2.

The Specified Amount after any requested decrease may not be less than the Minimum Specified Amount shown on Page 3.

 

3.

The Specified Amount may not be decreased to a level where the total premiums already paid to date exceed the limits as defined by the Internal Revenue Code and applicable regulations.

 

4.

Any request for an increase must be applied for on a supplemental application. Such increase shall be subject to evidence of your insurability satisfactory to us. An increase shall also be subject to the sufficiency of the net surrender value to cover the next monthly deduction. Any increase will become effective on the effective date shown on an endorsement to this Policy.

 

FORM VLS.03.02.90

  Page 11   


LOGO

 

DEATH BENEFIT PROCEEDS. The death benefit proceeds is the amount payable by us under this Policy provided this Policy has not terminated prior to your death.

The death benefit proceeds will be equal to:

 

1.

The death benefit; minus

 

2.

Any monthly deductions due during the grace period; minus

 

3.

Any outstanding policy loan; plus

 

4. Any unearned loan interest.

PREMIUM PROVISIONS

PAYMENT. The initial premium shown on Page 3 must be paid on or before the Policy Date. All premiums after the initial premium are payable at our Office.

ADDITIONAL PREMIUMS. While this Policy is in force, additional premiums after the initial premium may be paid after the first policy year and prior to the Maturity Date. We reserve the right to limit additional premium payments to one each policy year and to limit or refund any premium if:

 

1.

The amount is below our current premium amount requirement; or

 

2.

The premium would increase the death benefit by more than the amount of the premium; or

 

3.

The premium would disqualify this Policy as a life insurance contract as defined by the Internal Revenue Code and applicable regulations.

GRACE PERIOD. If the net surrender value on any Monthiversary is not sufficient to cover the monthly deductions on such day, we will mail a notice to the last known address of the Owner and any assignee of record. A grace period of 61 days after the mailing date of the notice will be allowed for the payment of premiums. The payment must be sufficient to provide a net premium to cover the sum of the monthly deductions due within the grace period. The notice will specify the minimum payment and the final date on which such payment must be received by us to keep the Policy in force. The Policy will remain in force during the grace period.

If the amount due is not received by us within the grace period, all coverage under the Policy and any riders will terminate without value at the end of the grace period.

REINSTATEMENT. If this Policy terminates, as provided in the Grace Period section, it may be reinstated. The reinstatement is subject to:

 

1.

Receipt at our Office of a written request from the Owner. Such request must be within 5 years after the date of termination and prior to the Maturity Date; and

 

2.

Receipt of evidence of insurability satisfactory to us; and

 

3.

Payment of a minimum premium to meet the current premium amount requirement and be sufficient to provide a net premium to cover (a) 1 monthly deduction at the time of termination, plus (b) the next 2 monthly deductions which will become due after the time of reinstatement.

The effective date of a reinstatement shall be the first Monthiversary on or next following the day we approve the application for reinstatement. Any policy loan as of the date of termination will not be reinstated. The cash value on the date of reinstatement will be equal to the net premium applied as of the date of reinstatement less the amount deducted for item 3(a) above. All future surrender charges will be waived.

 

FORM VLS.03.02.90

  Page 12   


LOGO

 

SEPARATE ACCOUNT PROVISIONS

The variable benefits under this Policy 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 policies 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 policy benefits vary, but at least monthly.

SUBACCOUNTS. The Separate Account has various subaccounts with different investment objectives. Income and realized and unrealized gains and losses from assets in each subaccount are credited to, or charged against, that subaccount without regard to income, gains, or losses in other subaccounts. Any amount charged against the investment base for federal or state income taxes will be deducted from that subaccount. The assets of the subaccounts are invested in shares of a corresponding investment portfolio of the Series Fund. The value of such shares is based on the value of the investment portfolio determined at the end of each valuation period in accordance with applicable law.

TRANSFERS. The Owner may transfer all or a portion of this Policy’s value in its subaccounts to other subaccounts or the fixed account. We reserve the right to charge a $10 fee for each transfer after the first twelve transfers during any one policy year. This charge will be deducted from the funds transferred. We must be notified in a form satisfactory to us. The transfer will ordinarily take effect on the first valuation date on or following the date notice is received at our Office.

CHANGES. We reserve the right to make certain changes if, in our judgement, they would best serve the interests of owners of these policies or would be appropriate in carrying out the purposes of the policies. Any changes will be made only to the extent and in the manner permitted by applicable laws. Also, when required by law, we will obtain the owners’ approval of the changes and approval from any appropriate regulatory authority.

UNIT VALUE. Some of the policy values fluctuate with the investment results of the subaccounts. In order to determine how investment results affect the policy values, a unit value is determined for each subaccount. The unit value of each subaccount was originally established at $10 per unit. The unit value may increase or decrease from one valuation period to the next. Unit values also will vary between subaccounts. The unit value of any subaccount at the end of a valuation period is the result of:

 

1.

The total value of the assets held in the subaccount. This value is determined by multiplying the number of shares of the designated mutual fund owned by the subaccount times the net asset value per share; minus

 

2.

The accrued risk charge for adverse mortality and expense experience. The current daily amount of this charge is equal to the net assets of the subaccount multiplied by the Mortality and Expense Risk 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 subaccount; and the result divided by

 

4.

The number of outstanding units in the subaccount.

The use of the unit value in determining contract values is described in the Policy Value Provisions.

 

FORM VLS.03.02.90

  Page 13   


LOGO

 

POLICY VALUE PROVISIONS

NET PREMIUM. For the initial premium payment, the net premium is equal to such payment. For any additional premium payments, the net premium is equal to 91.5% of such additional payments.

ALLOCATION OF NET PREMIUMS. Net premiums will be allocated to the subaccounts of the Separate Account and the fixed account on the first valuation date on or following the date the premium is received at our Office; except any net premium received prior to the Policy Date will be allocated on the first valuation date on or following the Policy Date. All net premiums allocated prior to the Record Date will be allocated to the money market subaccount. On the first valuation date on or following the Record Date, the values in the money market subaccount will be transferred in accordance with the Owner’s allocation as shown in the application.

Any allocation to any account must not be less than 10%. No fractional percentages are permitted. The allocation 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 form satisfactory to us. The allocation change will be effective on the date the request for change is recorded by us.

MONTHLY DEDUCTIONS. On each Monthiversary, a monthly deduction for this Policy will be made equal to the sum of the following:

 

1.

The Monthly Policy Charge as shown on Page 3:

 

2.

The Monthly Cost of Insurance for this Policy;

 

3.

The charge for benefits provided by riders attached to this Policy;

 

4.

For any month in which the Specified Amount is increased, a charge of $3.60 per thousand dollars of such increase.

Deductions will be withdrawn from each subaccount and the fixed account in accordance with the Owner’s current allocation. If the value of any account is insufficient to pay its part of the monthly deduction, the monthly deduction will be taken on a pro rata basis from all accounts.

MONTHLY COST OF INSURANCE. The monthly cost of insurance on each Monthiversary is determined as follows:

 

1.

Divide the death benefit on the Monthiversary by 1.0032737; and

 

2.

Reduce the result by the cash value on the Monthiversary; and

 

3.

Multiply (2) by the appropriate monthly cost of insurance rates.

MONTHLY COST OF INSURANCE RATES. The monthly cost of insurance rates are based on the sex, attained age, plan of insurance and rating class of the person(s) insured. Monthly cost of insurance rates may be changed by us from time to time. A change in the cost of insurance rates will apply to all persons of the same attained age, sex, plan of insurance and rating class and whose policies have been in effect for the same length of time. The rates will not exceed those shown in the Table of Guaranteed Maximum Life Insurance Rates.

 

FORM VLS.03.02.90

  Page 14   


LOGO

 

SUBACCOUNT VALUE. At the end of any valuation period, the subaccount value is equal to the number of units that the Policy has in the subaccount, multiplied by the unit value of that subaccount.

The number of units that the Policy has in each subaccount is equal to:

 

1.

The initial units purchased on the Policy Date; plus

 

2.

Units purchased at the time additional net premiums are allocated to the subaccount; plus

 

3.

Units purchased through transfers from another account; minus

 

4.

Those units that are redeemed to pay for monthly deductions as they are due; minus

 

5.

Any units that are redeemed to pay for cash withdrawals; minus

 

6.

Any units that are redeemed as part of a transfer to another account.

FIXED ACCOUNT VALUE. At the end of any valuation period, the fixed account value is equal to:

 

1.

The sum of all net payments allocated to the fixed account; plus

 

2.

Any amounts transferred from a subaccount to the fixed account; plus

 

3.

Total interest credited to the fixed account; minus

 

4.

Any amounts charged to pay for monthly deductions as they are due; minus

 

5.

Any amounts withdrawn from the fixed account to pay for cash withdrawals; minus

 

6.

Any amounts transferred from the fixed account to a subaccount.

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 various higher current interest rates. We may also apply a different current interest rate to that part of the cash value that equals the loan reserve.

On transfers from the fixed account to a subaccount, we reserve the right to impose the following limitations:

 

1.

Written request be received at our Office from the Owner within 30 days of an anniversary.

 

2.

The transfer will be effective on the later of the anniversary or the date we receive such written request.

We further reserve the right to defer payment of any amounts from the fixed account for no longer than six months after we receive such written request.

CASH VALUE. At the end of any valuation period, the cash value of the Policy is equal to the sum of the subaccount values plus the fixed account value.

NET SURRENDER VALUE. The net surrender value is the amount payable upon surrender of this Policy.

The net surrender value as of any date is equal to:

 

1.

The cash value as of such date; minus

 

2.

Any outstanding policy loan; plus

 

3.

Any unearned loan interest; minus

 

4.

Any surrender charge as of such date.

SURRENDER. The Owner may surrender this Policy for the net surrender value at any time during your lifetime. Payment will usually be made within seven days of the date we receive proper written request at our Office, subject to the Policy Payment section of the General Provisions.

 

FORM VLS.03.02.90

  Page 15   


LOGO

 

WITHDRAWALS. Cash withdrawals may be made at any time after the first policy year and during your lifetime. We reserve the right to limit cash withdrawals to once each year. The amount of a withdrawal may be limited to no more than 10% of the net surrender value. The request for a withdrawal must be from the Owner and in writing. A $25 fee will be deducted from each withdrawal amount and the balance paid to the Owner. Payment will usually be made within seven days of the date we receive the written request at our Office, subject to the Policy Payment section of the General Provisions.

When a withdrawal is made, the cash value shall be reduced by the amount of the withdrawal. If the death benefit is Type A, the Specified Amount shall also be reduced by the amount of the withdrawal. These reductions will result in a reduction in the death benefit, which may be determined from the Death Benefit Provisions. No withdrawal will be allowed if the resulting Specified Amount would be less than the Minimum Specified Amount shown on Page 3 or the resulting net surrender value would be less than $5,000.

The accounts from which the withdrawal will be made may be specified. If no account is specified, the withdrawal amount will be withdrawn from each account in accordance with the Owner’s current allocation. Payment will usually be made within seven days of the date we receive proper withdrawal request, subject to the Policy Payment section of the General Provisions of this Policy.

CONTINUATION OF INSURANCE. Insurance coverage under this Policy and any benefits provided by rider will be continued in force until the net surrender value is insufficient to cover the monthly deductions. This provision shall not continue this Policy beyond the Maturity Date nor continue any rider beyond the date for its termination, as provided in the rider.

INSUFFICIENT VALUE. If the net surrender value on any Monthiversary is not sufficient to cover the monthly deductions then due, this Policy shall terminate subject to the Grace Period section of the Premium Provisions.

BASIS OF COMPUTATIONS. Policy values and reserves are at least equal to those required by law. A detailed statement of the method of computation of values and reserves has been filed with the insurance department of the state in which this Policy was delivered.

POLICY LOANS. After the first policy year and during the continuance of this Policy, the Owner can borrow against the Policy an amount which is not greater than 90% of the cash value, less any surrender charge and any outstanding policy loan. The amount of any policy loan may be limited to no less than $500, except as noted below.

When a loan is made, an amount equal to the loan plus interest in advance until the next anniversary will be withdrawn from the accounts and transferred to the loan reserve. The Owner may specify the account or accounts from which the withdrawal will be made. If no account is specified, the withdrawal will be made from each account in accordance with the Owner’s current allocation.

The loan date is the date we process a loan request. Payment will usually be made within seven days of the date we receive proper loan request, subject to the Policy Payment section of the General Provisions of this Policy. This Policy will be the sole security for the loan.

While this Policy is in force, any loan may be repaid. Any amounts received on this Policy will be considered premiums unless clearly marked as loan repayments.

Interest on any loan will be at the policy loan rate of 7.4%, payable annually in advance. Interest is due at each anniversary. Interest not paid when due will be added to the loan and will bear interest at the same rate.

 

FORM VLS.03.02.90

  Page 16   


LOGO

 

At each anniversary, we will compare the amount of the outstanding loan (including interest in advance until the next anniversary, if not paid) to the amount in the loan reserve. We will also make this comparsion anytime the Owner repays all or part of the loan. At each such time, if the amount of the outstanding loan exceeds the amount in the loan reserve, we will withdraw the difference from the accounts and transfer it to the loan reserve, in the same fashion as when a loan is made. If the amount in the loan reserve exceeds the amount of the outstanding loan, we will withdraw the difference from the loan reserve and transfer it to the accounts in accordance with the Owner’s current allocation. However, we reserve the right to require the transfer to the fixed account.

SETTLEMENT OPTIONS

EFFECTIVE DATE AND FIRST PAYMENT DUE. The effective date of a settlement provision will be either the date of surrender or the date of death. The first payment due will be on the effective date of the settlement provision.

BETTERMENT OF MONTHLY ANNUITY. The payee will receive the greater of:

 

1. The income rate guaranteed in this Policy; or

 

2. The income rates in effect for us at the time income payments are made.

AVAILABILITY. If the payee is not a natural person, an Optional Method of Settlement is only available with our permission. No Optional Method of Settlement 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 other ages and for two males or two females upon request.

PROOF OF AGE. Prior to making the first payment under this Policy we reserve the right to require satisfactory evidence of the birthdate and sex of any payee.

PROOF OF SURVIVAL. Prior to making any payment under this Policy we reserve the right to require satisfactory evidence that any payee is alive on the due date of such payment.

INTEREST. All settlement options are based on the 1983 Individual Annuity Mortality Table, if applicable, and a guaranteed annual interest rate of 4%.

TABLE OF OPTIONAL METHODS OF SETTLEMENT

DESCRIPTION AND TABLES OF MONTHLY INSTALLMENT

PER $1,000 OF PROCEEDS.

Option A - Fixed Period. The proceeds will be paid in equal installments. The installments will be paid over a fixed period determined from the following table:

 

Fixed Period    Factor
(in Months)     

60

   18.32

120

   10.05

180

   7.33

240

   6.00

300

   5.22

360

   4.71

 

FORM VLS.03.02.90

  Page 17   


LOGO

 

Option B – Life Income. The 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 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).

 

     MALE    FEMALE

Payee’s

Age

  

Life

Annuity

  

Certain

5 yrs

  

Period

10 yrs

  

Installment

Refund

  

Life

Annuity

  

Certain

5 yrs

  

Period

10 yrs

  

Installment

Refund

65

     6.68      6.60    6.35      6.09      5.92      5.89    5.77    5.59

66

     6.88      6.78    6.50      6.23      6.08      6.03    5.90    5.71

67

     7.09      6.98    6.65      6.38      6.24      6.19    6.04    5.83

68

     7.31      7.18    6.81      6.53      6.42      6.36    6.19    5.97

69

     7.56      7.40    6.97      6.69      6.61      6.54    6.34    6.11

70

     7.82      7.64    7.14      6.86      6.81      6.74    6.50    6.26

71

     8.09      7.88    7.31      7.04      7.04      6.95    6.67    6.42

72

     8.39      8.14    7.48      7.23      7.28      7.17    6.84    6.59

73

     8.71      8.41    7.65      7.43      7.54      7.41    7.02    6.77

74

     9.05      8.70    7.83      7.64      7.83      7.67    7.21    6.97

75

     9.41      9.00    8.00      7.86      8.14      7.95    7.40    7.17

76

     9.81      9.32    8.17      8.10      8.47      8.24    7.60    7.39

77

   10.23      9.65    8.34      8.34      8.83      8.56    7.80    7.62

78

   10.68      9.99    8.50      8.60      9.23      8.89    7.99    7.86

79

   11.16    10.35    8.66      8.87      9.65      9.24    8.19    8.13

80

   11.68    10.72    8.81      9.16    10.12      9.61    8.38    8.40

81

   12.23    11.09    8.95      9.45    10.62    10.01    8.57    8.69

82

   12.81    11.47    9.09      9.76    11.16    10.41    8.74    9.01

83

   13.44    11.86    9.21    10.09    11.76    10.84    8.91    9.34

84

   14.09    12.25    9.32    10.44    12.39    11.28    9.06    9.68

Option C – Joint and Survivor Life Income. The proceeds will be paid in equal installments during the joint lifetime of two payees:

 

1.    continuing upon the death of the first payee for the remaining life- time of the survivor; or      2.    reduced by one-third upon the death of the first payee and continuing for the remaining lifetime of the survivor.
  

Joint Life Income with

Full Amount to Survivor

       

Joint Life Income with

2/3 to Survivor

 

Age Nearest
Birthday
  

Age Nearest Birthday

Male

Female

   55    60    65    70    75      55    60    65    70    75

55

   4.45    4.55    4.64    4.71    4.76      4.83    5.03    5.24    5.48    5.73

60

   4.62    4.79    4.94    5.06    5.14      5.05    5.28    5.54    5.83    6.13

65

   4.79    5.03    5.27    5.47    5.63      5.29    5.58    5.90    6.26    6.63

70

   4.94    5.27    5.61    5.94    6.22      5.57    5.91    6.32    6.77    7.25

75

   5.06    5.46    5.93    6.43    6.90      5.89    6.30    6.80    7.38    8.02

 

FORM VLS.03.02.90

  Page 18   


LOGO

 

WESTERN RESERVE LIFE

ASSURANCE CO. OF OHIO

Flexible Premium Variable Life Insurance Policy

Death Benefit Proceeds Payable at Death of Primary Insured

Prior to Maturity Date

Net Cash Value Payable at Maturity Date

Initial Premium Payable at Issue with Restricted Additional Premiums

Payable During Lifetime of Primary Insured Until the Maturity Date

Non-Participating – No Dividends

Some Benefits Reflect Investment Results

 

FORM VLS.03.02.90