1987-0901_HARTFORD_Administrative Services AgreementADMINISTRATIVE SERVICES AGREEMENT
This Administrative Services Agreement (ASA) is made and entered into
by and between the City of San Juan Capistrano
and Hartford Variable Annuity Life Insurance Company, a Connecticut
corporation.
The intent of this agreement is to facilitate the administration of
the City of San Juan Capistrano Deferred Compensation
Plan as it pertains to accounting for deferrals, the disbursement of
funds, withholding of taxes and the proper reporting to participants,
annuitants, and governmental agencies.
Section 1 Definitions
Unless this agreement expressly provides otherwise, the following
definitions shall apply herein.
A. "Agent" means the Hartford Variable Annuity Life Insurance
Company.
B. "Contract Owner" means the City of San Juan Capistrano
in the State of California.
C. "participant" means an employee of the Contract Owner electing to
participate in the Deferred Compensation Plan.
0
D. "Annuity Contract" means the Master Group Annuity Contracts
between the Contract Owner and the Hartford Variable Annuity Life
Insurance Company.
E. "Plan" means the Contract Owner's Deferred Compensation Plan.
Section 2 Scope of Service
The Agent shall perform the administrative services described below.
Section 3. Term
This agreement shall become effective immediately upon execution by
both parties and shall remain in force until terminated by either party as
provided herein.
Section 4. _Relationship of the Parties
The Agent shall perform its obligations hereunder as an Agent for the
Contract owner.
The Contract Owner may administer this agreement and monitor the
Agent's compliance with its obligations hereunder. The Contract Owner
shall not supervise or direct the Agent other than as expressly provided
in this agreement.
Section 5. Services to be Performed
The Contract Owner shall notify the Agent in writing of the
participants entitled to receive disbursements under the terms of the Plan
and the Contract Owner shall indemnify the Agent for any damage suffered
by the Agent due to any incorrect information provided hereunder to the
Agent by the Contract Owner.
A. The Agent shall issue the disbursements to the participants in
accordance with the provisions of the Annuity Contract and the Plan.
B. Disbursements shall be made from the account maintained by the
Agent on behalf of the Contract Owner in accordance with the terms of the
Annuity Contract and the Plan provided. However, if the Contract Owner
terminates the Annuity Contract, the Agent shall be obligated to make
disbursements only to the extent that funds are still available in the
Account of the Contract Owner.
C. The Agent shall compute and deduct from the disbursements all
appropriate Federal, State and Local income taxes required by law to be
withheld from plan distributions by the Contract Owner in accordance with
the percentage rates illustrated in the attached Supplemental information
Addendum. A detailed report including such withheld taxes will be
forwarded by the Agent to the applicable taxing authority, with a copy to
the Contract Owner, within the time frame prescribed by law unless other
instructions are provided in the attached Supplemental Information
Addendum.
0 0
D. The Agent shall furnish annually to all annuitants/participants
receiving payment or benefits from the plan the tax reporting form(s)
required by the applicable taxing authority within the time frame
prescribed by law.
Section 6 Financial Management System
The Agent shall establish and maintain a financial management system
for the purposes of this agreement in accordance with generally accepted
accounting practices and procedures including:
1. For each disbursement:
a. A record of all notifications from the Contract owner
concerning participants who are to receive disbursements under this
agreement.
b. Statements of gross disbursements under the agreement.
C. Statements of all Federal, State and Local income taxes
withheld under this agreement.
2. Records of all income taxation reports filed with the Federal,
State and Local governments on behalf of the Contract Owner.
0 1 0
Section 7. Financial Reporting and Audits
A. The Agent shall furnish directly to the participants a statement of
the gross disbursement under the agreement which includes the amount of
Federal, State and Local taxes withheld and the net amount paid with each
disbursement to a participant.
B. The Agent shall furnish to the Contract Owner:
1. A report containing a statement of each and every disbursement
made under this agreement which includes the amount of Federal, State and
Local taxes withheld pursuant to Section 5, paragraph c above.
2. A payment/transaction confirmation for each participant
including pertinent financial data relating to the transaction uneless
otherwise instructed in the attached Supplemental Information Addendum.
3. A Statement of Account for each participant (in duplicate)
reflecting a summary of appropriate financial data will be prepared and
mailed as instructed in the attached Supplemental Information Addendum.
4. At the discretion of the Contract Owner, an annual and
semi --annual report for the Hartford Variable Annuity Life Insurance Separate
Account and/or Hartford Fund for distribution.
5. Such other reports as the Contract Owner may reasonably require
or as are required under the Annuity Contract.
0 0
Section 8. Records Management
A. Retention: Except as provided otherwise, the Agent shall retain
all financial records, supporting documents, statistical records, reports,
minutes, correspondence and other written materials kept or used by the
Agent during the course of its performance of obligations under this
agreement for three years following the date of termination. Agent may
retain such records and documents on microfilm.
B. Late Audits: If any audit by or on behalf of the Contract Owner
has begun but has not been completed at the end of the three-year period
or if audit findings have not been resolved at the end of the three-year
period, the Agent shall retain the records described in subsection A of
this section until audit findings are resolved.
C. Termination or Cessation Before Expiration of Retention Period:
If, for any reason, the Agent ceases operations prior to the expiration of
records retention period required by this section, all records as
described in subsection A of this section immediately shall be delivered
to the Contract Owner.
D. Emergency Custody of Records: If the Agent fails to adequately
protect records from fire, theft, damage, deterioration or any other type
of loss during the required period of retention, the Contract Owner hereby
reserves the right to take custody of all records in danger of being lost,
deslcoyed.or damaged.
9 9
E. Inspection of Records: Upon prior request and during normal
business hours, the Agent shall allow the Contract owner full and complete
access to all records required to be retained by the Agent. The Contract
Owner shall have the right upon reasonable notice, exercised directly or
through its independent auditors, to examine and audit the Agent's records
and accounts to determine the Agent's compliance with the terms and
conditions herein.
Section 9. Termination
A. This agreement may be terminated without any further liability of
either party for any obligation maturing subsequent to the date of such
termination.
1. By either party upon sixty (60) days' written notice to the
other party of the intent to terminate.
2. By the Contract Owner, upon learning of the Agent's violation
of any Federal, State or Local law, ordinance or regulation that governs
activities related to the Agent's performance of this agreement.
B. DuLloc Upon Termination
1. The Agent shall deliver to the Contract Owner all records and
reports required by this Agreement.
• 0
2. The Agent shall submit within thirty (30) days after the date
of termination of this agreement all financial, performance and any other
reports required by this agreement.
Section 10. Nondiscrimination
The Agent agrees to comply with all requirements of law, including
the nondiscrimination and affirmative action requirements applicable to
the Contract Owner.
Section 11. Nonwaiver
The failure of the Contract Owner or Agent at any time to enforce a
provision of this agreement shall in no way constitute a waiver of the
provision, nor in any way affect the validity of this agreement or any
part hereof, or the right of the Contract Owner or Agent thereafter to
enforce each and every provision hereof.
Section 12 Assignments
Any attempted assignment of this agreement or any part of it without
the written consent of the other party shall be void.
Section 13. Amendment
The parties may amend this agreement only by written agreement and
approved by the President or a Vice President of Hartford Variable Annuity
and an authorized person for the Contract Owner.
Section 14. Notices
Any notice provided for herein shall be in writing and shall be
deemed to have been given when received by personal delivery or United
States mail addressed as follows:
Contract Owner: City of San Juan Capistrano
32400 Paseo Adelanto
San Juan Capistrano, California 92675
Agent: Frank Lord
Vice President/Administration
Hartford Variable Annuity Life Insurance Company
P.O. Sox 2999
Hartford, CT 06104-2999
or to such other persons or addresses which the Contract Owner or Agent
may from time to time designate in writing.
Section 15. Jurisdiction: Choice of Law
The Law of the State of California shall govern
the rights and obligations of the parties under this agreement.
Section 16. Integration
This instrument and any written appendices and amendments hereto
embody the entire agreement of the parties. Thre are no promises, terms,
conditions, or obligations other than those contained herein, and this
agreement shall supersede all previous communications, representations or
agreements, either oral or written, between the parties hereto with .
respect to this agreement.
Section 17. No Cost to the Contractowner
The services rendered by the Agent pursuant to this agreement shall
be performed without cost to the Contract Owner.
IN WITNESS WHEREOF, the Parties hereto have caused this agreement to
be signed as of the date shown below:
ATTEST:
CITY OF SAN JUAN CAPISTRANO
i
V'72 / �/ % �'_+� Date 9/ /
Mary Ann over, City Clerk Bob Boone
Director of Administrative Services
ATTEST:
HARTFORD VARIABLE ANNUITY
LIFE INSURANCE CONPANY
Vice President/Administration
9 0
September 3, 1987
Douglas J. Naylor, Field Director
Hartford Variable Annuity
Life Insurance Company
3435 Wilshire Boulevard
Los Angeles, California 90010
MEMBERS OF THE CITY COUNCIL
ANTHONY L. BLAND
LAWRENCE F. BUCHHEIM
KENNETH E. FRIESS
GARY L. HAUSOORFER
PHILLIP R. SCHWARTZE
CITY MANAGER
STEPHEN B JULIAN
Re: Selection of Additional Deferred Compensation Program (Hartford Variable Annuitv)
Dear Mr. Naylor
The City Council of the City of San Juan Capistrano at its regular meeting held
September 1, 1987, adopted Resolution No. 87-9-1-1 establishing a Deferred
Compensation Plan with Hartford Variable Annuity Insurance Company.
A copy of Resolution No. 87-9-1-1 is enclosed for your records. Also enclosed are the
following:
1. Two copies of the Administrative Services Agreement
2. Supplemental Information
3. Master Application for Individually Allocated Group Variable Annuity Contract
Please execute both copies of the .Administrative Services Agreement and return the
"City Copy" to this office. The remaining documents are for your records.
Thank you for your cooperation. If we can be of further assistance, please call.
Very truly yours,
Mary Ann Hanover, CMC
City Clerk
MAH/mac
Enclosures
cc: City Manager
Director of Administrative Services
32400 PASEO ADELANTO, SAN JUAN CAPISTRANO. CALIFORNIA 92675 • (714) 493-1171
0
SUPPLEMENTAL INFORMATION
0
1. City of San Juan Capistrano Deferred Compensation Plan.
2. Effective Date: 5e yr.. /. /987 tt��
3. Contract Owner Contact: Roe Pao -r/E 7)/.f, 40MIV. JE.Q✓/CSS__
(Name) (Title)
32400 Paseo Adelanto; San Juan Capistrano, CA 92675 h1�1) !{93- 117/
(Address) (Phone Number)
4. Tax Withholding - Federal
Tax Withheld in accordance with IRS Rev. Ruling 82-46 utilizing Federal Employee
Withholding Form W-4.
5. Tax Depositing and Reporting - Federal
Utilizing The Harford's Tax ID Number, withheld taxes will be deposited directly
with the local IRS depository, with a report given to the Contract Owner.
6. Tax Withholding Percentage (Flat Rate - State and Local)
a) Benefit Payments State: 3 % Local: 0 %
b) Lump Sum Withdrawal Payment and State: 3 % Local: 0 %
Refund after Withdrawal: State: 3 % Local: 0 %
Note: All changes to State Withholding must be submitted in writing to Account
Services, Hartford Variable Annuity Life Insurance Co., P.O. Box 2999, Hartford
CT 06101-2999.
7. Tax Depositing and Reporting - State and Local
Utilizing The Hartford's Tax ID Number, withheld taxes will be remitted to the
appropriate state taxing authority and to the applicable local taxing authority,
with a report given to the Contract Owner.
8. Statement of Account
a) Prepare on the follwing basis:
Annual Semi -Annual X Quarterly
b) Mail to:
Contract Owner for distribution
X One to Contract Owner and one directly to participants
FOR CONTRACT OWNER:
1/87
•RESOLUTION NO.
A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF SAN
JUAN CAPISTRANO, CALIFORNIA, ESTABLISHING A DEFERRED
COMPENSATION PLAN WITH THE HARTFORD VARIABLE
ANNUITY INSURANCE COMPANY
WHEREAS, the City of San Juan Capistrano (herein referred to as "Employer")
has employees rendering valuable services; and,
WHEREAS, the establishing of a deferred compensation plan for such
employees will serve the interests of the Employer by enabling it to provide reasonable
retirement security for its employees, by providing increased flexibility in its personnel
management system, and by assisting in the attraction and retention of competent
personnel; and,
WHEREAS, the Employer has determined that the establishment of a deferred
compensation plan to be administered by the Hartford Variable Annuity Life Insurance
Company will serve the above objectives; and,
WHEREAS, the Employer desires that the investment of funds held under its
deferred compensation plan be administered by the Hartford Variable Annuity Life
Insurance Company, as Trustee.
NOW, THEREFORE, BE IT RESOLVED, that the Employer authorizes the
Director of Administrative Services to act on its behalf to make necessary application to
and sign administrative documents to enter into an agreement with Hartford Variable
Annuity Life Insurance Company. These documents include the Master Application,
Supplemental Information document and Administrative Services Agreement, Attached
hereto by reference as Appendices A, B, and C, respectively.
BE IT FURTHER RESOLVED, that the Director of Administrative Services
shall be the coordinator for this program and shall receive necessary reports, notices,
etc. from the Hartford Variable Annuity Life Insurance Retirement Corporation as
Administrator. Administrative duties to carry out the plan may be assigned to the
appropriate departments.
PASSED, APPROVED, AND ADOPTED this 1st day
of September ,1987.
ATTEST:
ITY CLERI
X� 641
ANTHONY AND, MAYOR
-1-
STATE OF CALIFORNIA )
COUNTY OF ORANGE ) ss
CITY OF SAN JUAN CAPISTRANO )
I, MARY ANN HANOVER, City Clerk of the City of San Juan Capistrano,
California, DO HEREBY CERTIFY that the foregoing is a true and correct copy of
Resolution No. 87-9-1-1 adopted by the City Council of the City of San Juan
Capistrano, California, at a regular meeting thereof held on the 1st day
of September , 1987, by the following vote:
AYES: Councilmen Friess, Buchheim, Hausdorfer, Schwartze,
and Mayor Bland
NOES: None
ABSENT: None
(SEAL)
MARY ANNPANOVER, CITY CLERK
WAS
Master Application for • •
Individually Allocated Group
Variable Annuity Contract qqk THE HARTFORD
Hartford Variable Annuity Life Insurance Company
Hartford Plaza
Hartford, Connecticut 06115
Application is hereby made for an Individually Allocated Group Variable Annuity Contract:
1. Applicant -Contract Owner:
City of San Juan Capistrano
32400 Paseo Adelanto
Street or r.v. t3ox
San Juan Capistrano, CA 92675
City State Zip Code
2. Nature of Applicants Business: Government
3. Requested Effective Date of Master Contract September 1, 1987
4. Special Requests:
It is understood that all payments and values provided by the Contract are the exclusive property of the Appli-
cant -Contract Owner and when based on the investment experience of a Separate Account, are variable and not
guaranteed as to fixed dollar amount.
Dated at San Juan Capistrano this day of September 1, 1987
Form MV -1145 (DC) Prnn d in U.6.A,
For City of San Juan Capistrano
(Contract Owner)
��//
By '$offoS one
Director of Administrative Services
r W
0
!I
CONTRACT SPECIFICATIONS
CONTRACT OWNER
EFFECTIVE DATE
PLACE OF DELIVERY
CONTRACT NUMBER
CITY OF SAN JUAN CAPISTRANO
SEPTEMBER 01, 1987
SAN JUAN CAPISTRANO, CALIFORNIA
109068
Group Annuity Contract -Individually Allocated
FORM NUMBERS
HV -
1425 -0, 1426, 1427-1
1469-1, 1662-0, 1430-0
1431-1, 1708-1
Guaranteed Interest Rates prior to and including the Annuity Commencement Date:
The interest rate applicable to the General Account values in the Active Life
Find for any date prior to and including the Annuity Commencement Date shall be at
least equivalent to 4%.
The Company reserves the right to pay Interest at Rates in excess of this amount with
respect to Participants' General Account values.
Underlying Investment for the accounts under this Contract:
ACCOUNT:
Fixed Account
Fixed Income Fund Account
Stock Fund Account
Money Market Fund Account
Advisers Find Account
U.S. Government Money Market Fund Account
Aggressive Growth Fund Account
GNMA/Mortgage Securities Fund Account
Index Fund Account
Page 3
Form HV -1426 (1)
BASED ON:
General Account of the Company
HVA Fixed Income Find, Inc.
HVA Stock Fund, Inc.
HVA Money Market, Inc.
HVA Advisers Find, Inc.
Hartford U. S. Government
Money Market Fund, Inc.
HVA Aggressive Growth Fund, Inc.
Hartford GNMA/Mortgage Securities
Fund, Inc.
Hartford Index Fund, Inc.
• CONTRACT SPECIFICATIONS •
Contingent Deferred Sales Charges:
Five percent (5%) of the surrendered gaunt from a Participant's Individual Account
during the first eight Participant's Contract years and three (3%) of the
surrendered amount during the next seven (7) years. After the fifteenth (15th)
Participant's Contract year, surrenders will no longer be subject to any deduction
for Contingent Deferred Sales Charges.
Death Benefits are never subject to any deduction for Contingent Deferred Sales
Charges.
No deductions for Contingent Deferred Sales Charges shall apply to a withdrawal
from a Participant's Individual Account which qualifies as a "Hardship Withdrawal"
under the Deferred Compensation Plan of the Contract Owner.
Amounts applied to effect an annuity payout involving life contingencies or
non -life contingencies for a period of three (3) years or more are not subject to
any deduction for Contingent Deferred Sales Charges.
Deduction for Annual Policy Fee SEE FU I (nlip SEMEN
An Annual Policy Fee deduction shall be made against the value of a Participant's
Individual Account under this Contract on the last day of a Participant's Contract Year
or during such year if the account is surrendered before the end of such year.
The Annual Policy Fee has been set at $25.00 until May 1, 1984. On and after that
date the Company may increase the Fee subject to an overall restriction that the Fee
will never exceed $50.00 per Participant's Individual Account under the Contract.
Deduction for Mortality, Expense and Administrative Undertakings
For assuming the mortality, expense ano administrative undertakings under this
contract the Company makes a deduction from the average daily net assets of the Separate
Account as follows:
The deduction for such risks has initially been set at 1.25% per year of the
average daily net assets of DC -1 and DC -11. The Company guarantees that this will be
the maximum rate charged until May 1, 1984. The rate or amount may be increased by the
Company, in its sole discretion thereafter, subject to a maximum charge of 2.00% per
year.. n(�(�[�(�(��(
Transfer Fee SEE C�a1U0G RSE 11EK
A fee of $5.00 will be charged on each exchange within this contract of values to
or among the available investment alternatives provided for in this contract, which
takes place within each Participant's Individual Account.
ENDORSEMENT
Page 4
Form HV -1426 (2)
0
ENDORSEMENTS
These endorsements are made a part of Contract HV -1425-0 as issued to City Of San Juan
Capistrano. The conditions and provisions of the contract apply except as amen e
herein.
1. The second paragraph of the
herein is amended and resta
follows:
gal Policy Fee provision as stated
y e��ec�ive September O1, 1987 as
"The Annual Policy Fee is $15.00. The Company may increase the Fee subject to the
-overall restriction that the fee will never exceed $50.00 per Participant's Individual
Account under the contract."
2. The Transfer Fee provision as stated herein is amended and restated in its entirety
effective e-p-t-e-mber 01, 1987 as follows:
"A fee of $0.00 will be charged on each exchange within this contract of values to or
among the available investment alternatives provided for in this contract, which takes
place within each Participants' Individual Account."
P4j74t�M-JA26.§3A. Page 4a
Accumulation Period — The period under this contract prior to the Annuity
Commencement Date.
Accumulation Unit — An accounting unit of measure used to calculate the
Separate Account values of a Participant's Individual Account during the
Accumulation Period.
Active Life Fund — A term used to describe the sum of the value of all
Participant's Individual Accounts under this contract during the Accumulation
Period.
Annual Policy Fee — The amount set forth on Page 4, if any, which is
deducted from the value of a Participant's Individual Account on the last
business day of a Participant's Contract Year or on the date of termination of
the Individual Account, if earlier.
Annuitant — The Participant on whose behalf annuity payments are to be made
under this contract.
Annuity Commencement Date — The date on which annuity payments are to
begin as described under Settlement Provisions in this contract.
Annuity Period — The period in the contracts, following the Accumulation
Period, during which actual annuity payments are made.
Annuity Unit — An accounting unit of measure in the Separate Account used to
calculate the amount of variable annuity payments.
Contract Year — A period of 12 months commencing with the effective date of
this contract or with any contract anniversary.
Date of Coverage — The date on which the initial Contribution made on behalf
of a Participant is received by the Company.
Due Proof of Death — A certified copy of the death certificate, an order of a
court of competent jurisdiction, a statement from a physician who attended the
deceased or any other proof acceptable to the Company.
General Account — All assets of the Company other than those in the Separate
Account, or in any other separate investment account established by the
Company.
Minimum Death Benefit — The minimum amount payable upon the death of a
Participant prior to age 65 and before annuity payments have commenced.
Participant — A term used to define, for recordkeeping purposes only, any
employee electing to participate in the deferred compensation plan of the
employer/Contract Owner.
Participant's Contract Year — A period of twelve (12) months commencing with
the Date of Coverage under this contract and each successive twelve (12) month
period thereafter.
Participant's Individual Account — An account to which the General Account
+alues and the Separate Account Accumulation Units held by the Contract
Owner on behalf of a Participant are allocated.
Premium Tax — The tax or amount of tax, if any, charged by a state or
municipality on premiums, purchase payments or contract values.
Separate Account — The Separate Accounts of HVA entitled HVA -DC -VA -I and
HVA -DC -VA -II under which income, gains and losses, whether or not realized,
from assets allocated to such account are, in accordance with the contracts
issued with respect thereto, credited to or charged against such Separate
Account without regard to the other income, gains, or losses of HVA.
Underlying Security — The Funds designated on Page 3
Fpm HV -1427-1 (DC)
Primed In U.S.A. Page 5
ANNUITY TABLE The attached Tables show the dollar amount of the first monthly
payments for each $1,000 applied under the first five Options.
Under the First, Second, or Third Options, the amount of each
payment will depend upon the age of the payee at the time the
first payment is due. Under the Fourth Option, the Amount of
each payment will depend upon the ages of both payees at the
time the first payment is due.
The Tables for the First, Second, Third and Fourth Options are
based on the 1983 Talbe A for Individual Annuity Mortality Table
set back one year and a net Investment rate of 4% per annum.
The Table for the Fifth Option is based on a net investment rate
of 48 per annum.
Page 14
Amount of First Monthly I ayrt
For Each $1,000 Applied
Second and subsequent monthly annuity payments, when teased on the investment experience of a Separate Account, are variable and are not
guaranteed as to fixed dollar amount.
FIRST, SECOND AND THIRD OPTIONS - SINGLE LIFE ANNUITIES WITH:
Payee's
Aga
UNISEX PAYEE
Monthly Paynend Ouarnise0
nehnd
45 50
None
120
180
240
45
35
W.94
$3.94
$3.93
$3.92
$3.91
40
4.11
4.10
4.09
4.07
4.07
45
4.33
4.31
4.29
4.25
4.25
50
4.61
4.58
4.54
4.48
4.50
51
4.68
4.64
4.59
4.53
4.54
52
4.75
4.70
4.65
4.58
4.60
53
4.82
4.77
4.71
4.63
4.66
54
4.89
4.84
4.78
4.69
4.73
55
4.98
4.92
4.85
4.74
4.79
56
5.06
5.00
4.92
4.80
4.86
57
5.15
5.08
4.99
4.86
4.94
58
5.25
5.17
5.07
4.92
5.02
59
5.35
5.26
5.14
4.98
5.09
60
5.46
5.36
5.23
5.05
5.20
61
5.58
5.46
5.31
5.11
5.27
62
5.70
5.57
5.40
5.18
5.38
63
5.84
5.68
5.49
5.24
5.48
64
5.98
5.80
5.59
5.30
5.60
65
6.13
5.93
5.69
5.37
5.73
66
6.30
6.06
5.78
5.43
5.86
67
6.48
6.20
5.88
5.49
5.97
68
6.66
6.35
5.99
5.55
6.13
69
6.87
6.50
6.09
5.60
819
70
7.08
6.66
6.19
5.65
6.47
71
7.32
6.82
6.29
5.70
8.63
72
7.57
6.99
6.39
5.75
6.85
73
7.84
7.16
6.49
5.79
7.02
74
8.13
7.34
6.58
5.82
7.27
75
8.44
7.52
6.67
5.85
7.49
76
8.78
7.70
6.75
5.88
7.62
77
9.14
7.89
6.83
5.91
7.96
76
9.53
8.07
6.91
5.93
8.32
79
9.95
8.25
6.97
5.94
8.83
80
10.41
8.43
7.03
5.96
8.96
FOURTH OPTION - JOINT AND LAST SURVIVOR ANNUITY
First
Payee's
Age
Amount
40
45 50
40
$3.73
4.39
$4.57
45
3.78
$3.86
Amount
50
3.83
3.93
$4.04
55
3.87
4.00
4.13
60
3.91
4.06
4.22
65
3.94
4.10
4.29
70
3.96
4.14
4.35
75
3.98
4.16
4.39
80
3.99
4.19
4.43
Age of Second Payee
55 1 60 1 65 1 70 1 75 1 80
$4.27
Amount
Amount
Amount
4.39
$4.57
Amount
Amount
4.51
4.74
$4.99
of
No
of
4.60
4.90
5.23
$5.57
No
of
4.67
5.02
5.44
5.90
$6.40
Monthly
4.73
5.12
5.60
6.20
6.87
$7.58
FIFTH OPTION - PAYMENTS FOR A DESIGNATED PERIOD
The monthly payment for any combination of ages not shown will be quoted upon request.
Form HV -1706-1
Amount
Amount
Amount
Amount
Amount
Amount
No
of
No
of
No
of
No
of
No
of
No
of
of
Monthly
of
Monthly
of
Monthly
of
Monthly
of
Monthly
of
Monthly
Years
Payments
Years
Payments
Years
Payments
Years
Payments
Years
Payments
Years
Payments
6
$15.56
11
$9.31
16
$7.00
21
$5.81
26
$5.10
7
13.59
12
8.69
17
6.71
22
5.64
27
5.00
3
$29.40
8
12.12
13
8.17
18
6.44
23
5.49
28
4.90
4
22.47
9
10.97
14
7.72
19
6.21
24
5.35
29
4.$0
5
18.32
10
10.06
15
7.34
20
6.00
25
5.22
30
4.72
The monthly payment for any combination of ages not shown will be quoted upon request.
Form HV -1706-1
Master Application for
Individually Allocated Group
Variable Annuity Contract 11fa
Hartford Variable Annuity Llfe Insurance Company
Hartford Plaza
Hartford, Connecticut 06115
THE HARTFORD
Application is hereby made for an Individually Allocated Group Variable Annuity Contract:
1. Applicant -Contract Owner:
City of San Juan Capistrano
32400 Paseo Adelanto
street or r.u. Cox
San Juan Capistrano, CA 92675
ity State Zip Code
2. Nature of Applicants Business: Government
3. Requested Effective Date of Master Contract September 1, 1987
4. Special
/ 0 5+01i? -
It Is understood that all payments and values provided by the Contract aro the exclusive property of the Appil-
cant-Contract Owner and when based on the investment experience of a Separate Account, aro variable and not
guaranteed as to fixed dollar amount.
Dated at San Juan Capistrano this day of September 1, 19$Z
Fon MV -1145 (DC) Aimed in US A.
For City of San Juan Ca"strano
(Contraq Own
By
Director of Administrative Service!
(Title)
THE HARTFORD
Hartford Variable Annuity Llfs Insurance Company
Hartford Plaza
Hartford, Connecticut 06116
(a stock life insurance company)
Group Annuity Contract
Individually Allocated
This contract makes provision for the accumulation of con-
tract values in the General Account of the Company to
provide fixed annuity accumulations and benefits and in
the Separate Accounts of the Company (DC -1 and II,
respectively) to provide Variable Annuity Accumulations
and benefits. Actual annuity payout commencing on the
Annuity Commencement Date may be on a variable basis
(Separate Account) and/or on a fixed basis (General
Account) as determined by the Contract Owner.
Individual Allocations
Nonparticipating
ALL PAYMENTS AND VALUES PROVIDED BY THIS CON-
TRACT, WHEN BASED ON INVESTMENT EXPERIENCE OF
A SEPARATE ACCOUNT, ARE VARIABLE AND ARE NOT
GUARANTEED AS TO FIXED DOLLAR AMOUNT.
Pone HV -142" toot
AIin USA