Registration Statement for a Separate Account (Unit Investment Trust) — Form N-4
Filing Table of Contents
Document/Exhibit Description Pages Size
1: N-4 Registration Statement for a Separate Account 110± 459K
(Unit Investment Trust)
2: EX-99 Miscellaneous Exhibit 22 82K
3: EX-99 Miscellaneous Exhibit 5 23K
4: EX-99 Miscellaneous Exhibit 3 14K
5: EX-99 Miscellaneous Exhibit 2± 7K
6: EX-99 Miscellaneous Exhibit 2 8K
7: EX-99 Miscellaneous Exhibit 7± 37K
8: EX-99 Miscellaneous Exhibit 1 8K
EX-99 — Miscellaneous Exhibit
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EX-4.i
JACKSON NATIONAL LIFE
INSURANCE COMPANY [Graphic Omitted]
2900 Westchester Avenue OF NEW YORK
Purchase, New York 10577 A STOCK COMPANY
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GUARANTEED MINIMUM INCOME BENEFIT ENDORSEMENT
THIS ENDORSEMENT IS MADE A PART OF THE CONTRACT TO WHICH IT IS ATTACHED AND IS
EFFECTIVE ON THE ISSUE DATE. TO THE EXTENT ANY PROVISIONS CONTAINED IN THIS
ENDORSEMENT ARE CONTRARY TO OR INCONSISTENT WITH THOSE OF THE CONTRACT TO WHICH
IT IS ATTACHED, THE PROVISIONS OF THIS ENDORSEMENT WILL CONTROL. THIS GUARANTEED
MINIMUM INCOME BENEFIT (ALSO REFERRED TO AS THE GMIB) MAY ONLY BE ELECTED PRIOR
TO THE ISSUE DATE, AND ONLY IF THE ANNUITANT IS NOT OLDER THAN AGE 75 ON THE
ISSUE DATE.
THE GMIB BENEFIT BASE IS ESTABLISHED FOR THE SOLE PURPOSE OF DETERMINING THE
MINIMUM INCOME BENEFIT. THE GMIB BENEFIT BASE IS NOT AVAILABLE AS A CASH
SURRENDER OR DEATH BENEFIT NOR USED IN THE CALCULATION OF THE CASH SURRENDER OR
DEATH BENEFIT.
ONCE ELECTED, THE GMIB CANNOT BE TERMINATED EXCEPT AS PROVIDED IN THE
TERMINATION OF THE GMIB PROVISION BELOW.
THE CONTRACT IS AMENDED AS FOLLOWS:
1. The following are added to the DEFINITIONS section:
"EXERCISE DATE. The Business Day that You elect Your annuity payments to begin
under this endorsement. This date can only be on or during the 30-calendar day
period following the 10th Contract Anniversary or on or during the 30-calendar
day period following each subsequent Contract Anniversary thereafter, but in no
event later than the 30-calendar day period following the Contract Anniversary
immediately following the Annuitant's 85th birthday.
GMIB BENEFIT BASE. The GMIB Benefit Base will be determined at the end of any
Business Day, and is equal to the greater of a. or b. where:
a. is the Roll-Up Component and is equal to:
1. all Premium paid into the Contract (net of any applicable premium
taxes),
2. plus any Contract Enhancements credited on or before such Business
Day,
3. less any withdrawal adjustments,
compounded at an annual interest rate of 5% from the Issue Date until the
earlier of the Annuitant's 80th birthday or the Exercise Date. All adjustments
for Premium and any Contract Enhancements are made on the date of the Premium
payment. All withdrawal adjustments are made at the end of the Contract Year and
on the Exercise Date. For withdrawals that total up to 5% of the Roll-Up
Component as of the previous Contract Anniversary, the withdrawal adjustment is
the dollar amount of the withdrawals (including any applicable charges and
adjustments for such withdrawals). The withdrawal adjustment for additional
withdrawals in a Contract Year in excess of 5% of the Roll-Up Component as of
the previous Contract Anniversary is the Roll-Up Component immediately prior to
the withdrawal multiplied by the percentage reduction in the Contract Value
attributable to the additional withdrawal (including any applicable charges and
adjustments for such withdrawals).
7485NY
b. is the Greatest Contract Anniversary Value Component and is equal to the:
1. greatest Contract Value on any Contract Anniversary prior to the
Annuitant's 81st birthday,
2. less any withdrawal adjustments subsequent to that Contract
Anniversary,
3. plus any Premium paid (net of any applicable premium taxes and Sales
Charges) subsequent to that Contract Anniversary,
4. less any applicable charges due under the Contract and any applicable
charges due under any optional endorsement to the Contract deducted
subsequent to that Contract Anniversary, and
5. less any taxes deducted subsequent to that Contract Anniversary.
All adjustments are made on the date of the transaction. The withdrawal
adjustment is the Greatest Contract Anniversary Value Component immediately
prior to the withdrawal multiplied by the percentage reduction in the Contract
Value attributable to the withdrawal (including any applicable charges and
adjustments for such withdrawals).
Neither component of the GMIB Benefit Base shall ever be permitted to exceed
200% of Premiums paid into the Contract (net of any applicable premium taxes and
excluding Premium paid in the 12 months prior to the Exercise Date), less any
withdrawals (including any applicable charges and adjustments for such
withdrawals) taken since the issuance of the Contract. The applicability of this
limitation will be determined after the calculation of each component of the
GMIB Benefit Base.
The GMIB Benefit Base is established for the sole purpose of determining the
minimum income benefit. The GMIB Benefit Base is used only in connection with
the determination of the GMIB, does not affect other Contract endorsements, and
is not reflective of the Contract Value.
The minimum values for annuity, cash surrender or death benefits attributable to
the Fixed Account Option(s) of the Contract are based on the Fixed Account
Contract Value in the Fixed Account Option(s) and not the GMIB Benefit Base. The
GMIB Benefit Base is not available as a cash surrender or death benefit nor used
in the calculation of the cash surrender or death benefit."
2. The following provision is added to the INCOME PROVISIONS.
"GUARANTEED MINIMUM INCOME BENEFIT (GMIB). You have the option of taking the
GMIB instead of the other income options described in the INCOME PROVISIONS of
the Contract. Your monthly income payments will be the GMIB Benefit Base on the
Exercise Date applied to the annuity rates based upon the Table of Guaranteed
Annuity Purchase Rates attached to this endorsement. The Guaranteed Annuity
Purchase Rates under the GMIB endorsement will be lower than those attached to
the Contract.
If you elect to exercise the GMIB, you may choose any life contingent fixed
annuity payment income option described in the Contract. Such fixed annuity
payment income options include:
1. Life Income,
2. Joint and Survivor,
3. Life Annuity with 120 Monthly Periods Guaranteed, and 4. Joint and Survivor
Life Annuity with 120 Monthly Periods Guaranteed.
NO OTHER INCOME OPTIONS WILL BE AVAILABLE.
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BASIS OF COMPUTATION. The actuarial basis for the Table of Guaranteed Annuity
Purchase Rates shall be a 10-year setback of the Annuity 2000 Mortality Table,
with an interest rate of 2.5%, and a 2% expense load. This table does not
include any applicable tax.
ASSESSMENT OF GMIB CHARGE. The GMIB Charge is as specified on the Contract Data
Page. This charge will be deducted at the end of each calendar quarter after the
Issue Date on a pro rata basis from the Separate Account Contract Value and the
Fixed Account Contract Value. The first GMIB Charge will be assessed on a pro
rata basis from the Issue Date to the end of the first calendar quarter after
the Issue Date. GMIB Charges are applied to the Separate Account Contract Value
resulting in a redemption of Accumulation Units. The GMIB Charge will not affect
the value of the Accumulation Units. All or a portion of the GMIB Charge
allocated to the Fixed Account Option(s) will be waived in any time period if
full assessment would result in net interest being credited at less than the
Minimum Guaranteed Interest Rate shown on the Contract Data Page.
Upon termination of the GMIB, a pro rata GMIB Charge will be assessed against
Your Contract Value for the period since the last quarterly GMIB Charge.
DEATH OF THE OWNER OR ANNUITANT. If You are also the Annuitant, and You die and
Your spouse continues the Contract, Your spouse will become the Annuitant and
will continue to be eligible for the GMIB; as long as Your spouse would have
been eligible as an Annuitant on the Issue Date under the terms of this GMIB
endorsement and is not age 85 or older. If Your spouse would not have been
eligible as an Annuitant on the Issue Date under the terms of this endorsement
or is age 85 or older, the GMIB Charge will be discontinued, and the GMIB
endorsement shall immediately terminate, and Your spouse will not receive the
GMIB hereunder.
If the Owner (assuming the Owner is a natural person) and the Annuitant are not
the same person and the Annuitant dies, You may select a new Annuitant; as long
as the new Annuitant would have been eligible as an Annuitant on the Issue Date
under the terms of this endorsement and is not age 85 or older. If the new
Annuitant would not have been eligible as an Annuitant on the Issue Date under
the terms of this endorsement or is age 85 or older, the GMIB Charge will be
discontinued, and the GMIB endorsement shall immediately terminate, and You will
not receive the GMIB hereunder.
The Contract to which this endorsement is attached is hereby amended under this
endorsement to limit the Owner's right to change/or select a new Annuitant as
provided for in the immediately preceding paragraph.
TERMINATION OF THE GMIB. Prior to the exercise of the GMIB, the GMIB will
terminate and not be payable under this endorsement on the earlier of:
1. the date You elect to receive income payments under the Contract;
2. the 31st calendar day following the Contract Anniversary immediately after
the Annuitant's 85th birthday;
3. the date You make a total withdrawal from the Contract; and,
4. upon Your death (unless Your spouse is the Beneficiary and elects to
continue the Contract and is eligible for this benefit); or, upon the death
of the Annuitant if the Owner is not a natural person.
Once income payments under the GMIB have been elected, payments will continue as
defined by the income option selected.
7485NY 3
LIMITATIONS AND RESTRICTIONS --- PLEASE READ CAREFULLY
1. The GMIB may only be elected prior to the Issue Date.
2. If the GMIB endorsement is elected, the Annuitant must not be older than
age 75 on the Issue Date.
3. If the GMIB endorsement is elected, the GMIB endorsement is irrevocable and
will remain in place as long as the Contract remains in force or until
otherwise terminated hereunder.
4. The GMIB will only be payable as one of the following life contingent fixed
annuity payments:
a. Life Income,
b. Joint and Survivor,
c. Life Annuity with 120 Monthly Periods Guaranteed, and
d. Joint and Survivor Life Annuity with 120 Monthly Periods Guaranteed.
5. The GMIB may only be exercised on or during the 30-calendar day period
following Your 10th Contract Anniversary and on or during the 30-calendar
day period following each subsequent Contract Anniversary thereafter, but
in no event later than the 30-calendar day period following the Contract
Anniversary immediately following the Annuitant's 85th birthday.
6. In the event of Joint Annuitants, the age of the youngest Annuitant will be
used to determine all limits dependent on age in this endorsement."
SIGNED FOR THE JACKSON NATIONAL LIFE
INSURANCE COMPANY OF NEW YORK
/s/ Clark P. Manning
PRESIDENT AND CHIEF EXECUTIVE OFFICER
7485NY 4
[Enlarge/Download Table]
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TABLE OF GUARANTEED ANNUITY PURCHASE RATES
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The following table is for a GMIB Benefit Base of $1,000 and will apply pro
rata to the actual GMIB Benefit Base calculated under this endorsement.
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Monthly Monthly Monthly Monthly
Installments Installments Installments Installments
----------------- ----------------- ----------------- -----------------
Age of Life w/ Age of Life w/ Age of Life w/ Age of Life w/
Annuitant Life 120 mos. Annuitant Life 120 mos. Annuitant Life 120 mos. Annuitant Life 120 mos.
MALE Only Certain MALE Only Certain FEMALE Only Certain FEMALE Only Certain
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40 2.85 2.84 64 4.03 3.99 40 2.74 2.74 64 3.74 3.72
41 2.88 2.87 65 4.11 4.07 41 2.76 2.76 65 3.81 3.79
42 2.90 2.90 66 4.20 4.15 42 2.79 2.79 66 3.89 3.86
43 2.93 2.93 67 4.30 4.24 43 2.81 2.81 67 3.97 3.94
44 2.97 2.96 68 4.40 4.33 44 2.84 2.84 68 4.05 4.02
45 3.00 2.99 69 4.51 4.43 45 2.87 2.87 69 4.15 4.10
46 3.03 3.03 70 4.62 4.53 46 2.90 2.90 70 4.24 4.19
47 3.07 3.06 71 4.74 4.64 47 2.93 2.93 71 4.34 4.29
48 3.11 3.10 72 4.87 4.76 48 2.96 2.96 72 4.45 4.39
49 3.15 3.14 73 5.01 4.88 49 2.99 2.99 73 4.57 4.50
50 3.19 3.18 74 5.16 5.00 50 3.03 3.03 74 4.69 4.61
51 3.23 3.22 75 5.32 5.13 51 3.07 3.06 75 4.83 4.73
52 3.28 3.27 76 5.49 5.27 52 3.10 3.10 76 4.97 4.85
53 3.33 3.32 77 5.67 5.41 53 3.14 3.14 77 5.12 4.99
54 3.38 3.36 78 5.87 5.56 54 3.19 3.18 78 5.28 5.13
55 3.43 3.41 79 6.07 5.72 55 3.23 3.22 79 5.46 5.27
56 3.48 3.47 80 6.29 5.87 56 3.28 3.27 80 5.65 5.43
57 3.54 3.52 81 6.53 6.04 57 3.32 3.31 81 5.85 5.59
58 3.60 3.58 82 6.78 6.20 58 3.37 3.36 82 6.07 5.76
59 3.66 3.64 83 7.04 6.37 59 3.43 3.42 83 6.31 5.94
60 3.73 3.70 84 7.33 6.55 60 3.48 3.47 84 6.57 6.12
61 3.80 3.77 85 7.63 6.72 61 3.54 3.53 85 6.85 6.31
62 3.87 3.84 86 7.96 6.90 62 3.60 3.59 86 7.15 6.51
63 3.95 3.91 63 3.67 3.65
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NOTE: Due to the length of the information, the Tables for the Joint and
Survivor income option and the Joint and Survivor Life Annuity with 120
Monthly Periods Guaranteed income option are available from the Service
Center upon Your request.
7485NY 5
8 Subsequent Filings that Reference this Filing
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