Form of Individual Single Premium Deferred Index-Linked Annuity Contract Data Page

EX-4.II 4 ex4iicontractdatapage.htm EX-4.II Document

CONTRACT DATA PAGE

Product Name

Product Type
[Symetra Trek Plus
[Non-Qualified Annuity
Contract Date[12/01/2020]
Allocation Date[12/07/2020]
Contract Number[000000000]
Purchase Payment[$25,000]
Separate Account[Symetra Separate Account RI
Owner:[John Doe
[Date of Birth: [12/12/195Age at issue: [Sex: [Male]
[Joint Owner[Jane Doe
Date of Birth: [11/12/195Age at issue: [
Sex: [Female]]
Annuitant:[John Doe
Date of Birth: [12/12/195Age at issue: [Sex: [Male
[Joint Annuitant[Jane Doe
Date of Birth: [11/12/195
Age at issue: [
Sex: [Female]]

Maximum Issue Age: [80]. The Contract Date must be prior to the Owner's and Annuitant's [81st]
birthday(s).

Maximum Annuitization Age: [95]. Annuity Payments must begin prior to the Annuitant's [96]th birthday(s).

This is not later than [12/13/2084].

Delivered in the State of: [Any State] and governed by its laws.
Surrender Charge Schedule: Contract Year Charge
[1 9% of amount withdrawn
2 8% of amount withdrawn
3 7% of amount withdrawn
4 6% of amount withdrawn
5 5% of amount withdrawn
6 4% of amount withdrawn
After 6 0% of amount withdrawn]

Please see the "Charges and Taxes" section for a complete explanation of charges.



Free Withdrawal Percentage: [15%]

Minimum Withdrawal Amount: [$500]

Transfer Notice Deadline: [2 business days]

Annuity Payments Table: [Annuity Reserve 2012 mortality table with mortality improvement scale G2,
with age setback of five years], and an interest rate of [1%].

[Premium Taxes: [0.00%]

ANNUITY SERVICE OFFICE:
Home Office:

Symetra Life Insurance Company [777 108th Ave. NE, Suite 1200
Bellevue, Washington 98004]

Telephone: [1 ###-###-####]


Mailing Address:

Symetra Life Insurance Company [PO Box 674420
Houston, Texas ###-###-####]

Fax: [1 ###-###-####]