SAMPLE GROUP RETIREMENT POLICY G-* PACIFIC LIFE INSURANCE COMPANY, a Nebraska corporation (Pacific Life), agrees to purchase single premium Annuities in such amounts, and for such persons, as are designated in writing by * (policyholder) This policy is issued in consideration of the application of the policyholder, a copy of which is attached to and made a part of this policy, and the payment to Pacific Life of a single premium necessary to purchase the first Annuity under this policy. This policy is delivered in and subject to the laws of the State of *. This policy is executed at Pacific Life s office in Newport Beach, California, on * to take effect as of *. MASTER ANNUITY CONTRACT Pacific Life - Chairman and Chief Executive Officer Pacific Life - Secretary s Signature GR-8135 1-06
TABLE OF CONTENTS Page No. ARTICLE I - DEFINITIONS... 1 ARTICLE II - PROVISIONS RELATING TO ANNUITIES 2.01 Annuity Benefits... 2 2.02 Annuity Premiums... 2 2.03 Premium Payments... 2 2.04 Adjustment by Pacific Life of Annuity or Premium After Purchase... 3 2.05 Assignment of Benefits... 3 2.06 Certificates... 3 ARTICLE III - AVAILABLE FORMS OF ANNUITY 3.01 Annuity Forms... 4 3.02 Deferred Annuities... 5 ARTICLE IV - GENERAL PROVISIONS 4.01 The Contract... 6 4.02 Assignment of Policy... 6 4.03 Notice Required... 6 4.04 Amendment of Policy... 6 4.05 Information to be Furnished to Pacific Life... 6 4.06 Nonparticipation... 7 4.07 Discontinuance of Policy... 7 4.08 Termination of Policy... 7 4.09 Non-Waiver of Policy Provisions... 7 POLICY APPLICATION SAMPLE GR-8135 1-06
ARTICLE I - DEFINITIONS 1.01 As used in this policy, the following terms, when initial capital letters are used, shall have the meaning set forth below, unless a different meaning is clearly required by the context: (a) "Plan" means a pension, profit-sharing or thrift plan which meets the requirements for qualification under Section 401 of the United States Internal Revenue Code as now or hereafter amended. (b) "Annuity" means a benefit purchased under this policy that consists of a series of equal, or substantially equal payments made at regular intervals to a designated person or persons and that is guaranteed by Pacific Life as to both dollar amount and duration. (c) "Gross Premium" means the amount paid to Pacific Life to purchase an Annuity under this policy. (d) "Net Premium" means the Gross Premium reduced by the sum of (i) an amount equal to Pacific Life's then current "per-life" charge, and (ii) the amount of premium tax and commission or other payment to agents or brokers arising from the receipt of the Gross Premium. (e) "Annuity Commencement Date" means the first day of the month as of which payment of an Annuity purchased under this policy is to commence. (f) Annuity Confirmation Letter means each letter from Pacific Life to the policyholder specifying the terms and conditions of the Annuity purchase under this policy for a person or a group and which is to be reviewed and signed by the policyholder. SAMPLE Page 1
ARTICLE II - PROVISIONS RELATING TO ANNUITIES 2.01 Annuity Benefits Subject to Pacific Life's consent, Pacific Life shall, from time to time, upon the written direction of the policyholder and receipt of the Gross Premium, purchase an Annuity for such person or persons, in such manner and amounts, and upon such terms and conditions as are specified in the written direction of the policyholder. All Annuity payments shall be made as of the first day of the month. In no event, shall Pacific Life purchase an Annuity under this policy if the monthly Annuity payment to the annuitant is less than fifty dollars ($50.00) or if such Annuity is to be provided other than from monies arising under a Plan. 2.02 Annuity Premiums On the date an Annuity is purchased under this policy, Pacific Life will apply the current nonparticipating Annuity premium rates to determine a) in the case of a defined benefit plan, the amount of premium necessary to provide such Annuity, or b) in the case of a defined contribution plan, the amount of monthly payment under such Annuity. However, the premium for each Annuity with an immediate income commencement date shall not exceed the premium based on the mortality table described below, with a no age setback for males and females, assuming an interest rate of 2% per annum. The mortality table is based on mortality rates in accordance with the 1994 Group Annuity Reserving Table (1994 GAR) for Males. 2.03 Premium Payments Premium payment(s) shall be made as shown in the respective Annuity Confirmation Letter. SAMPLE Page 2
ARTICLE II - PROVISIONS RELATING TO ANNUITIES - CONTINUED 2.04 Adjustment by Pacific Life of Annuity or Premium After Purchase If Pacific Life determines that the date of birth of an annuitant or contingent annuitant has been incorrectly stated, Pacific Life will calculate the adjustment as follows: In the case of a Defined Benefit Plan benefit, the cost generated by the change in date of birth of the annuitant or contingent annuitant shall be a charge to the policyholder/plan for any increase in liability or a refund to the policyholder/plan for any decrease in liability. The calculation of the adjustment shall be based on current market rates of interest in effect at the time of the discovery of the misstatement of the date of birth of the annuitant or contingent annuitant, and may include an administrative expense for processing such calculation. In the case of a Defined Contribution Plan benefit, the amount of the monthly Annuity payment to such annuitant or contingent annuitant shall be such as the Gross Premium paid to Pacific Life for such Annuity would have purchased had the date of birth of the annuitant or contingent annuitant been correctly stated. Any overpayment or underpayment by Pacific Life on account of any misstatement of a date of birth of an annuitant or contingent annuitant shall, with interest at the rate of five percent (5%) per annum, be charged against the current or next succeeding payment or payments or added to the current or next succeeding payment to be made by Pacific Life to the annuitant or contingent annuitant. 2.05 Assignment of Benefits The benefits, or any part thereof payable under this policy, shall not be subject to alienation, anticipation, assignment or encumbrance by any annuitant or beneficiary entitled thereto, and, to the extent permitted by law, shall not be subject to any debts, contracts or engagements of any annuitant or beneficiary, or to any judicial process to levy upon or to attach the same. The preceding sentence shall also apply to the creation, assignment, or recognition of a right to any benefit payable with respect to an annuitant pursuant to a domestic relations order, unless such order is determined to be a qualified domestic relations order, as defined in Section 414(p) of the United States Internal Revenue Code. 2.06 Certificates Pacific Life shall issue to the policyholder for delivery to each person for whom an Annuity is provided pursuant to this policy, a certificate summarizing the principal provisions of such Annuity. The certificate is not a contract between Pacific Life and the annuitant; it is merely a summary of the benefits payable to the annuitant under this policy. In the event that the certificate does not accurately state the benefits to which the annuitant is entitled and the provisions applicable thereto, the provisions of this policy shall govern such benefits. SAMPLE Page 3
ARTICLE III - AVAILABLE FORMS OF ANNUITY 3.01 Annuity Forms An Annuity may be purchased under this policy in any of the forms described below. These are the only Annuity forms available under this policy without the consent of Pacific Life. (a) Life Annuity A Life Annuity provides for monthly payments to be made to an annuitant, commencing on the Annuity Commencement Date, if the annuitant is then living, and ceasing with the last payment due immediately prior to the death of the annuitant. (b) Certain Period Only Annuity A Certain Period Only Annuity provides for a designated number of monthly payments to be made to an annuitant, commencing on the Annuity Commencement Date, if the annuitant is then living. The number of monthly payments must be designated at the time the Annuity is purchased and may not exceed two hundred forty (240) or extend beyond age ninety (90). If the annuitant dies after the Annuity Commencement Date but before the designated number of payments has been made to him, the payments shall continue to his beneficiary until the total designated number of payments has been made. (c) Life Annuity With Payments For A Period Certain A Life Annuity With Payments For A Period Certain provides for monthly payments to be made to an annuitant, commencing on the Annuity Commencement Date, if the annuitant is then living, and ceasing with the last payment due immediately prior to the death of the annuitant. If the annuitant dies after the Annuity Commencement Date but before the expiration of the period certain term, the payments shall continue to his beneficiary until the total designated number of payments in the period certain term has been made. The period certain term must be designated at the time the Annuity is purchased and may not exceed twenty (20) years or extend beyond age ninety (90). (d) Cash Refund Annuity A Cash Refund Annuity provides for monthly payments to be made to an annuitant, commencing on the Annuity Commencement Date, if the annuitant is then living, and ceasing with the last payment due immediately prior to the death of the annuitant. However, if at the annuitant's death the sum of the monthly payments made under the Annuity is less than the Gross Premium for the Annuity, the difference will be paid in a single sum to the annuitant's beneficiary. SAMPLE Page 4
ARTICLE III - AVAILABLE FORMS OF ANNUITY - CONTINUED (e) Contingent Annuitant Annuity A Contingent Annuitant Annuity provides for monthly payments to be made to an annuitant, commencing on the Annuity Commencement Date and ceasing with the last payment due immediately prior to the death of the annuitant. However, if the annuitant predeceases the designated contingent annuitant, the contingent annuitant shall be entitled to monthly payments until the last payment due immediately prior to the death of the contingent annuitant. The amount of each monthly payment to the contingent annuitant shall be fifty percent (50%), sixty-six and two-thirds percent (66 2/3%), seventy-five percent (75%), or one hundred percent (100%) of the amount of each monthly payment to the annuitant, as specified at the time the Annuity is purchased. 3.02 Deferred Annuities If an annuitant for whom a deferred Annuity has been purchased dies prior to the Annuity Commencement Date, Pacific Life's sole liability with respect to the Annuity will be to pay a death benefit to the annuitant's beneficiary. For purposes of the preceding sentence, beneficiary means the annuitant's spouse if the annuitant is married on the date of his death and no qualified election waiving the qualified pre-retirement survivor annuity has been made. The amount of the death benefit will be an amount equal to the Net Premium for the Annuity accumulated with interest at the interest rate used in the premium to purchase such Annuity from the date such Annuity is purchased to the first of the month next following the date Pacific Life receives due notice and proof of the annuitant's death. Deferred Annuities without death benefits or with death benefits which differ from the above will be allowed only if needed to conform with the provisions of the Plan. Further, Deferred Annuities that involve other ancillary benefits such as Early Retirement will be allowed only if needed to conform to the provisions of the Plan, subject to Pacific Life s consent. A Contingent Annuitant Annuity shall be paid, in lieu of any other annuity form, to each deferred annuitant who is married as of the Annuity Commencement Date, unless the Annuitant and his/her spouse make a qualified election waiving such annuity form. The amount of each monthly payment shall be the actuarial equivalent of the monthly payment the Annuitant would otherwise have received under the form of deferred Annuity originally purchased. If the primary Annuitant pre-deceases his/her spouse, monthly payments shall be continued to the spouse in an amount equal to fifty-percent (50%) of the amount of each monthly payment to the primary Annuitant. SAMPLE Page 5
ARTICLE IV - GENERAL PROVISIONS 4.01 The Contract The policy and application constitute the entire contract. Statements made in the application shall, in the absence of fraud, be deemed representations and not warranties. No statement shall void this policy unless it is contained in the application, signed by the policyholder, a copy of which is attached to this policy when issued. 4.02 Assignment of Policy No assignment of this policy shall be made by either the policyholder or Pacific Life. 4.03 Notice Required Any notice, directive, certificate, or other writing required by the provisions of this policy to be delivered to Pacific Life shall be delivered in writing to its office at P.O. Box 9000, Newport Beach, California 92658-9030. Any notice, certificate or other writing required by the provisions of this policy to be delivered to the policyholder shall be delivered in writing to the policyholder at its principal place of business. 4.04 Amendment of Policy This policy may be amended or modified, with respect to any provision, at any time, and from time to time, by written agreement between the policyholder and Pacific Life without the consent of any other person. No agent has authority to change this policy or to waive any of its provisions. Pacific Life may, at any time upon ninety (90) days' advance written notice to the policyholder, change the Annuity premium rates in effect under this policy and/or change the allowance for expenses and other charges of Pacific Life without the concurrence of the policyholder. No such change will affect any Annuities purchased prior to the effective date of such change. 4.05 Information to be Furnished to Pacific Life The policyholder and each person entitled to receive benefits under this policy shall furnish any information Pacific Life may reasonably require. The information shall be submitted in the form and at the time specified by Pacific Life. Notwithstanding any provisions of this policy to the contrary, Pacific Life shall not be obligated or required to provide any Annuity until it has received the information in the form required. Pacific Life may rely upon the information so received and shall not be liable with respect to any omission or inaccuracy contained therein. Pacific Life may require proof that any person to whom a payment is to be made is living at the time specified for payment, and if so requested, proof shall be submitted before payment shall be made. SAMPLE Page 6
ARTICLE IV - GENERAL PROVISIONS - CONTINUED 4.06 Nonparticipation This policy shall not participate in any divisible surplus of Pacific Life. 4.07 Discontinuance of Policy This policy may be discontinued by either the policyholder or Pacific Life upon written notice to the other party. The effective date of such discontinuance shall be the later of (i) ninety (90) days after the receipt of such notice by the other party, or (ii) the date specified in such written notice. Discontinuance of this policy by either the policyholder or Pacific Life shall in no way affect any Annuity purchased under this policy prior to the date of discontinuance. 4.08 Termination of Policy This policy shall terminate and cease to be of any further force or effect at the close of the first day upon which Pacific Life has completed all of the duties and obligations which have arisen under this policy. 4.09 Non-Waiver of Policy Provisions Failure by Pacific Life to enforce any provision of this policy shall not affect Pacific Life's right thereafter to enforce such provision, nor shall such failure estop it from exercising its right to enforce any provision of this policy. SAMPLE Page 7
APPLICATION G-* Application is hereby made to Pacific Life Insurance Company by *, whose Main Office Address is *, for Group Retirement Policy No. G-*, which is attached to this Application. The terms of the attached Policy are approved and its terms accepted. This Application is executed in duplicate, one counterpart being retained by applicant and the other returned to Pacific Life Insurance Company. It is agreed that this Application supersedes any previous application for the Policy. Dated this day of 20, at * By: (Full or Corporate Name of Applicant) Signature and Title SAMPLE GR-8276