Form of Supplemental Contract Data Pages (7780-S), attached hereto

7780-S SUPPLEMENTAL CONTRACT DATA PAGES Please refer to the attached Crediting Method endorsements for further explanation of values shown on these Supplemental Contract Data Pages. Contract Number: [1234567890] Issue Date: [October 1, 2020] Index Account Options. Subject to availability. Index choices of: [S&P 500®] [Russell 2000®] [MSCI Emerging Markets] [MSCI KLD 400 Social] [MSCI EAFE] Crediting Method and term choices of: Term Buffer Selection* Floor Selection* Crediting Method 1-Year 10%, 20% 10%, 20% Cap 3-Year 10%, 20%, 30% 10%, 20% Cap 6-Year 10%, 20%, 30% 10%, 20% Cap 1-Year 10% 10% Performance Trigger 1-Year 10% N/A Performance Trigger Plus *Buffer and Floor selections cannot be chosen together with the same Index Account Option.

 

7780-S 2 Guaranteed Index Adjustment Factors: The Index Adjustment Factors are determined and guaranteed for each Index Account Option term. These guaranteed Index Adjustment Factors apply for the life of the Contract. • [Cap Rate (CR): The CR will never be less than [1.00% for the 1-year], [1.50% for the 3-year], and [2.00% for the 6-year].] • [Performance Trigger Rate (PTR): The PTR will never be less than [1.00%].] • [Performance Trigger Plus Rate (PTPR): The PTPR will never be less than [1.00%].] • [Buffer: The Buffer will never be less than [5%].] • [Floor: The Floor will never be more than [50%].] • [Interim Value Proration Factor and Interim Value Proration Factor Term: The Interim Value Proration Factor is guaranteed to equal [100%] for the first [6] Contract Years, and to never be less than [50%] thereafter.] Discontinuation of or Substantial Change to an Index. If an Index is discontinued or if the calculation is changed substantially, the Company may substitute a comparable Index. The Company will obtain approval from Your state insurance department and will notify You and any assignee before using a substitute Index.

 

7780-S 3 Current Index Account Options: These are the Index Account Options You elected, as of the Issue Date of Your Contract. Term Index Crediting Method Buffer / Floor Rate 1-year S&P 500 Cap with Buffer 10% 1.00% 1-year S&P 500 Cap with Buffer 20% 1.00% 1-year S&P 500 Cap with Floor 10% 1.00% 1-year S&P 500 Cap with Floor 20% 1.00% 3-year S&P 500 Cap with Buffer 10% 1.50% 3-year S&P 500 Cap with Buffer 20% 1.50% 3-year S&P 500 Cap with Buffer 30% 1.50% 3-year S&P 500 Cap with Floor 10% 1.50% 3-year S&P 500 Cap with Floor 20% 1.50% 6-year S&P 500 Cap with Buffer 10% 2.00% 6-year S&P 500 Cap with Buffer 20% 2.00% 6-year S&P 500 Cap with Buffer 30% 2.00% 6-year S&P 500 Cap with Floor 10% 2.00% 6-year S&P 500 Cap with Floor 20% 2.00% 1-year Russell 2000 Cap with Buffer 10% 1.00% 1-year Russell 2000 Cap with Buffer 20% 1.00% 1-year Russell 2000 Cap with Floor 10% 1.00% 1-year Russell 2000 Cap with Floor 20% 1.00% 3-year Russell 2000 Cap with Buffer 10% 1.50% 3-year Russell 2000 Cap with Buffer 20% 1.50% 3-year Russell 2000 Cap with Buffer 30% 1.50% 3-year Russell 2000 Cap with Floor 10% 1.50% 3-year Russell 2000 Cap with Floor 20% 1.50% 6-year Russell 2000 Cap with Buffer 10% 2.00% 6-year Russell 2000 Cap with Buffer 20% 2.00% 6-year Russell 2000 Cap with Buffer 30% 2.00% 6-year Russell 2000 Cap with Floor 10% 2.00% 6-year Russell 2000 Cap with Floor 20% 2.00% 1-year MSCI Emerging Markets Cap with Buffer 10% 1.00% 1-year MSCI Emerging Markets Cap with Buffer 20% 1.00% 1-year MSCI Emerging Markets Cap with Floor 10% 1.00% 1-year MSCI Emerging Markets Cap with Floor 20% 1.00% 3-year MSCI Emerging Markets Cap with Buffer 10% 1.50% 3-year MSCI Emerging Markets Cap with Buffer 20% 1.50% 3-year MSCI Emerging Markets Cap with Buffer 30% 1.50% 3-year MSCI Emerging Markets Cap with Floor 10% 1.50% 3-year MSCI Emerging Markets Cap with Floor 20% 1.50% 6-year MSCI Emerging Markets Cap with Buffer 10% 2.00% 6-year MSCI Emerging Markets Cap with Buffer 20% 2.00% 6-year MSCI Emerging Markets Cap with Buffer 30% 2.00% 6-year MSCI Emerging Markets Cap with Floor 10% 2.00% 6-year MSCI Emerging Markets Cap with Floor 20% 2.00% 1-year MSCI KLD 400 Social Cap with Buffer 10% 1.00% 1-year MSCI KLD 400 Social Cap with Buffer 20% 1.00% 1-year MSCI KLD 400 Social Cap with Floor 10% 1.00% 1-year MSCI KLD 400 Social Cap with Floor 20% 1.00% 3-year MSCI KLD 400 Social Cap with Buffer 10% 1.50% 3-year MSCI KLD 400 Social Cap with Buffer 20% 1.50%

 

7780-S 4 Term Index Crediting Method Buffer / Floor Rate 3-year MSCI KLD 400 Social Cap with Buffer 30% 1.50% 3-year MSCI KLD 400 Social Cap with Floor 10% 1.50% 3-year MSCI KLD 400 Social Cap with Floor 20% 1.50% 6-year MSCI KLD 400 Social Cap with Buffer 10% 2.00% 6-year MSCI KLD 400 Social Cap with Buffer 20% 2.00% 6-year MSCI KLD 400 Social Cap with Buffer 30% 2.00% 6-year MSCI KLD 400 Social Cap with Floor 10% 2.00% 6-year MSCI KLD 400 Social Cap with Floor 20% 2.00% 1-year MSCI EAFE Cap with Buffer 10% 1.00% 1-year MSCI EAFE Cap with Buffer 20% 1.00% 1-year MSCI EAFE Cap with Floor 10% 1.00% 1-year MSCI EAFE Cap with Floor 20% 1.00% 3-year MSCI EAFE Cap with Buffer 10% 1.50% 3-year MSCI EAFE Cap with Buffer 20% 1.50% 3-year MSCI EAFE Cap with Buffer 30% 1.50% 3-year MSCI EAFE Cap with Floor 10% 1.50% 3-year MSCI EAFE Cap with Floor 20% 1.50% 6-year MSCI EAFE Cap with Floor 10% 2.00% 6-year MSCI EAFE Cap with Buffer 10% 2.00% 6-year MSCI EAFE Cap with Buffer 20% 2.00% 6-year MSCI EAFE Cap with Buffer 30% 2.00% 6-year MSCI EAFE Cap with Floor 20% 2.00% 1-year S&P 500 Performance Trigger with Buffer 10% 1.00% 1-year S&P 500 Performance Trigger with Floor 10% 1.00% 1-year Russell 2000 Performance Trigger with Buffer 10% 1.00% 1-year Russell 2000 Performance Trigger with Floor 10% 1.00% 1-year MSCI Emerging Markets Performance Trigger with Buffer 10% 1.00% 1-year MSCI Emerging Markets Performance Trigger with Floor 10% 1.00% 1-year MSCI KLD 400 Social Performance Trigger with Buffer 10% 1.00% 1-year MSCI KLD 400 Social Performance Trigger with Floor 10% 1.00% 1-year MSCI EAFE Performance Trigger with Buffer 10% 1.00% 1-year MSCI EAFE Performance Trigger with Floor 10% 1.00% 1-year S&P 500 Performance Trigger Plus with Buffer 10% 1.00% 1-year Russell 2000 Performance Trigger Plus with Buffer 10% 1.00% 1-year MSCI Emerging Markets Performance Trigger Plus with Buffer 10% 1.00% 1-year MSCI KLD 400 Social Performance Trigger Plus with Buffer 10% 1.00% 1-year MSCI EAFE Performance Trigger Plus with Buffer 10% 1.00%