AMERICAN FIDELITY ASSURANCE COMPANY (A Stock Company) 2000 N. Classen Boulevard Oklahoma City, Oklahoma American Fidelity Assurance
Company (the Company) certifies that it has issued and delivered to the Employer the Contract shown below. This Certificate is evidence that the person named below is a Participant under the Contract. This Certificate is issued in consideration of:
1) the application, which is attached; and 2) the payment by the Employer of any contribution which the Employer may elect to make to the Company. Name of Participant_____ Date of Birth of Participant Beneficiary _____ Relationship
______________________________________________________________________________________ Name of Employer _______________________________’ _______ •‘ Certificate No. Group Deferred Variable Annuity Contract
No._________________________ The benefits and terms of the Contract are described in this Certificate. It takes the place of and cancels any other Certificate issued to the Participant under the Contract. President Secretary GROUP DEFERRED VARIABLE
ANNUITY Certificate Individual Allocation Separate Account Non-Participating ALL PAYMENTS AND VALUES PROVIDED IN THIS CERTIFICATE ARE BASED ON INVESTMENT EXPERIENCE OF A SEPARATE ACCOUNT. THE VALUES ARE
VARIABLE AND ARE NOT GUARANTEED AS TO FIXED DOLLAR AMOUNT. GVA-1985-CX Page 1
Part 1 Definitions Accumulated Value The total value of all Units to the credit of the Participant. Annuitant A person receiving annuity
payments. Annuity A contract promising a periodic series of payments. Annuity Commencement The first day of any month after the Participant’s retirement, but no later than the distribution Date date required by federal law for the Contract
Owner’s tax-qualified Plan. Annuity Unit Value Value of units for purpose of calculating amount of annuity payments. Company American Fidelity Assurance Company, Oklahoma City, Oklahoma. Contract
Anniversary The anniversary of the Date of Issue of the Contract. Contract Owner The Owner of the Contract named in the application. Contract Year Any period of one year that begins with the date of issue or the Contract anniversary. Deferred
Annuity An annuity to commence at a future date. Effective Date The date as shown on the application. Fixed Annuity An annuity providing paymentamount after the first payment is made. Immediate Annuity An annuity Inactive Participant A participant
whose account is no longer accumulating units, but still has a unit balance. Payment Date The Valuation Date on which a premium payment is received at our Company unless it is received after the close of the New York Stock Exchange, in which case it
will be the next Valuation Date. Participant An employee who participates in the Plan. Participant’s Account The sum of the units credited to a plan participant. Separate Account An account of American Fidelity’s assets which are kept
apart from other assets. This account is invested separately and is called “The American Fidelity Fund A Account.” Tax-Qualified Plans Retirement plans qualified under Section 401(a), 401(k),
403(b) or 408 of the Internal Revenue Code, and governmental plans and eligible State deferred compensation plans under Section 414(d) and 457 of the Internal Revenue Code. A tax-qualified payroll
deduction plan is a tax-qualified plan which allows plan participants to make contributions through the employer’s payroll system. Unit A standard of measurement used to measure the value of each
account. Unit Value Value assigned to each accumulation Unit on every Valuation Date. Valuation Date The Valuation Date is a day on which the value of the fund is determined. Valuation Period The Valuation Period is the period between successive
Valuation Dates. GVA-1985-CX Page 2
Part 2 General Provisions Participation To become a Participant, an Employee must complete an application supplied by the Company. The
application must be sent to the Company. The Company will send a Certificate to each Participant. It will summarize the terms of the Contract. Changes by the Contract Owner If a change in the Contract or a waiver of its terms is requested by the
Contract Owner, the request must be in writing and will take effect only if signed by an authorized officer of the Company. Changes by the Company The Company may change the Contract at any time if required by State or Federal laws. After the
Contract has been in force for three years, the Company may change any term of the Contract except that benefits already earned by Participants cannot be decreased and the monthly life incomes guaranteed in Part 8 cannot be decreased. The Company
will notify the Contract Holder of any change at least 90 days before the change will take effect. Non-participating The Contract is non-participating. It does not share
in the profits or earnings of the Company. Proof of Age No lifetime annuity will be paid under the Contract unlass roof of age is submitted to the Company by the person who will receive the benefit. The based on the correct age regardless of any
prior record to the contrary. Assignment The Contract cannot be assigned except when agreed to by the Company. All benefits are exempt from the claims of creditors to the maximum extent allowed by law. Loans The Contract does not permit loans by the
Participant from the Cash Value. If the Company, at some future date, permits such loans, they will be authorized by issuing a rider to the Certificate held by the Participant after written application is made by the Participant. In any period when
loans are available, they will be available to all participants holding a Certificate under this Contract series. The loan provision may be discontinued without notice. Voting Rights The Contract Owner will have the right to vote at the Contract
Owner’s meetings. The number of votes that may be cast will conform to the Rules and Regulations of the Separate Account. Participant Reports Twice each year, January 1 and June 30, each Participant will receive a fund statement.
This statement will include the unit value on the reporting date, the account’s unit balance, and the value of those units on that date GVA-1985-CX Page 3
Part 3 Premiums and Unit Accumulation Contributions by Contract Owner The Contract Owner will send all premium amounts required for the
Plan to the Company. The Company will apply the premiums sent by the Contract Owner to the Participant’s Account in order to purchase accumulation Units. Premium Amounts The minimum initial premium for each Participant is $20. The minimum
amount of each subsequent premium is $10. The Company makes the following deductions from each premium: (1) 4% from each premium for: sales (3%); administrative expense (1/4°/o); and minimum death payment (3/4%); (2) $.50 administrative charge
per payment; (3) $15.00 one-time certificate issue fee; (4) premium taxes, if any; and (5) charges by an Employer or other agency for payroll reductions or other handling costs. The balance of each
premium after these deductions is called the net premium. Application of Net Premium On the Payment Date, the Company will apply the net premium to purchase units for the Participant’s Account. The number of units credited will be determined
by dividing the net prernjwn by the current Unit Value. Discontinued Premiums If premium payments for a Participant are stoppeclaario Commencement Date, the Participant will then become an Inactive Participant. The in his or her account will remain
constant until one of the following events occurs: (1) premium payments resume; (2) a withdrawal of units occurs; or (3) an annuity is purchased. Part 4 Withdrawals Withdrawals A Participant who wants to make a withdrawal should apply
to the Company using a form the Company provides. A partial or complete withdrawal may be made at any time prior to the Annuity Commencement Date. The value of the amount withdrawn will depend on the number of Units withdrawn and the Unit Value on
that Valuation Date. Termination of Account In accordance with the above provisions regarding withdrawals, this policy may be surrendered for its full Accumulated Value on the date of withdrawal. If the Accumulated Value of any Participant’s
Account falls below $1,000 as the immediate result of a transfer or withdrawal, that Participant’s Account may be terminated at the Company’s sole option. Unless the Participant otherwise directs in writing, the remaining units in the
Participant’s Account will be released and surrendered and the resultant Accumulated Value.paid to the participant in cash. Written notice of such termination will be mailed to the Contract Owner at least 31 days in advance. GVA-1985-CX Page 4
Part 4 Withdrawals (Continued) Delay Due to Impossibility If a withdrawal is to be made during any period when regular banking
activities have been suspended; or when there is restricted trading on any stock exchange, the securities of which are held by any sub-account; or for any period when an emergency or other circumstances beyond
the Company’s control exists and as a result of which the disposal of securities or other assets, including sale, delivery or receipt of payment by the Company is not reasonably practicable or as a result of which it is not reasonably
practicable to determine the value of any account; such withdrawal or transfer shall be deferred to the earliest succeeding Valuation Date as of which the above described circumstances no longer exist. Rules and regulations of the Securities and
Exchange Commission, if any are applicable, will govern determinations as to suspended or restricted trading on a stock exchange or emergencies limiting disposal of securities. Part 5 Death Benefits A death benefit will be paid if the Company
receives proof of the Participant’s death at its Home Office. If the Participant’s spouse is the beneficiary, he or she may choose to receive the account value in any form that the Participant could have chosen while living. If the
Participant dies before receiving annuity income payments, the Accumulated Value of the Participant’s Account will be paid to the Participant’s beneficiary. The value will be’ based on the Valuation Date on which both the proof of
death and the beneficiary’s written instructions are received. . If the Participant’s death occurs prior to receiving annuity income payments arid prior to age 65, the beneficiary will receive the greater of: (1) 100% of all premium
payments made by the Participant less any withdrawals; or (2) the value of the Participant’s Account. If the Participant’s beneficiary is not the Participant’s spouse, such person must: (1) receive all of the value within
five years of the Participant’s death; or (2) start to receive annuity payments within one year of the Participant’s death for a period not to exceed the beneficiary’s expected lifetime. If the Participant dies while receiving
income payments, the Company will pay any remaining guaranteed payments to: (a) the Participant’s beneficiary; or (b) the Participant’s estate, if no such beneficiary survives. Any payments made to a beneficiary must be on a
payment schedule at least as rapid as that made to the Participant. GVA-1985-CX Page 5
Part 6 Retirement Benefits The Participant elects when retirement annuity payments will begin. This is done by using a form the Company
provides. Total distribution must begin by the age required by federal law for the Contract Owner’s tax-qualified plan. Total distribution is either: (1) withdrawal of all the Accumulated Cash
Value; or (2) the first periodic annuity payment under any option described below. If no annuity option is elected by the required distribution date, option 2, the life variable annuity with 120 monthly payments certain, may be effected. The
Company has the right to change the frequency of payments. Should payments become less than $20, the Company may change the payment intervals to result in payments of at least $20. Variable Annuity Options (1) Life Variable Annuity—A
variable annuity paid each month while the Annuitant is living and ending with the last payment due preceding the date of the Annuitant’s death. (2) Life Variable Annuity with Payments Certain—A variable annuity payable monthly and
ending with the last payment due preceding the later of: (a) the date of the Annuitant’s death; or (b) the end of the certain period elected by the AnnuitaOhe period certain may be 10, 15, or 20 years. If the Annuitant’s
beneficiary dies before the payments cease, the present value of the current dollar amount of the remaining certain paid to the estate of the beneficiary. This payment will be commuted on the basis of 31/2 pounded annually. (3) Unit Refund Life
Variable Annuity—A unit Refund Life Variable Annuity is a variable annuity payable monthly during the lifetime of the Annuitant. Upon death, an additional payment will be made of the value at date of death of the number of variable annuity
units equal to the excess, if any, of (a) the total amount applied under this option, divided by the variable annuity unit value on the date variable annuity installments commence over (b) the variable annuity units represented by each
installment, multiplied by the number of installments paid prior to death. (4) Joint and Last Survivor Variable Annuity—A Joint and Last Survivor Variable Annuity is a variable annuity providing a monthly benefit payable during the joint
lifetime of the annuitant and a designated second person, and thereafter two-thirds of such monthly benefit payable during the remaining lifetime of the survivor. There is no predetermined number of annuity
payments. Because of certain Internal Revenue Code Requirements, this option may not be elected if, as of the date the variable annuity is effected, the present value of the payment to which the designated second person may become entitled exceeds
49% of the present value of all payments provided for the Annuitant and the designated second person; however, such limitations shall not apply if the designated second person is the spouse of the Annuitant. Variable Annuities A variable annuity is
an annuity with payments which vary in amount with the net investment result of the Separate Account. The number of annuity units remains fixed during the annuity payment period. The number of annuity units is set by dividing the first monthly
payment by the annuity unit value at the Annuity Commencement Date. The subsequent annuity payments may change with the value of a variable annuity unit. GVA-1985-CX
Page 7
Part 6 Retirement Benefits (Continued) Determining the First Payment Table A of the Contract is used to determine the first monthly
payment. It shows the dollar amount of the first monthly payment which can be purchased with each $1,000 of value in the Participant’s Account after deducting any premium taxes not previously deducted. Table A assumes a net investment rate of
41/2°/o and mortality is based on the 1983 Table a, modified. The value of the Participant’s Account is found by multiplying the Participant’s accumulated units by the unit value on the fourteenth day before the first annuity payment
is due. The first monthly payment varies according to the option selected, and the age nearest birthday of the Annuitant. Amount of Subsequent Monthly Variable Annuity Payments The amount of the first monthly annuity payment, determined as above, is
divided by the value of a Variable Annuity Unit for the Valuation Date on which the first payment is due to determine the number of Variable Annuity Units represented by the first payment. This number of Variable Annuity Units remains fixed during
the annuity period, and in each subsequent month, the dollar amount of the annuity payment is determined on the fourteenth calendar day preceding the payment date by multiplying this fixed number of Variable Annuity Units by the value of a Variable
Annuity Unit. All subsequent monthly payments become the same day of the month as the date of the first payment Fixed Annuity Options A Participant also has the option to fixed annuities with essentially the same characteristics as Annuity Options
(1) through (4) described part. Table B of the Contract applies to Fixed Annuity Options and is based on the 1983 Table a, modified, with interest at the rate of 4% per year. Part 7 Individual Retirement Annuities If the Contract is issued as
an Individual Retirement Annuity under Internal Revenue Code Section 408(b), the following provisions will apply: Premiums Premiums may be paid in any amount up to the lesser of: $2,000; 100% of compensation; or any subsequent limitations set
by Congress. Compensation means income as defined in Section 219(f)(1) of the Internal Revenue Code. The two exceptions to the contribution rule are: (1) a rollover contribution (as allowed under Sections 402(a)(5), 402(a)(7), 403(a)(4),
403(b)(8), 405(d)(3), 408(d)(3), or 409(b)(3)(C) of the Internal Revenue Code; or (2) a contribution made as part of a Simplified Employee Pension (SEP) as described in Section 408(k) of the Internal Revenue Code. No part of the premiums
paid will be used to purchase life insurance contracts. GVA-1985-CX Page 8
Part 7 Individual Retirement Annuities (Continued) Death Benefit A death benefit will be paid if the Company receives proof of the
Participant’s death at its Home Office. If the Participant dies before receiving any income payments, the Company will pay the account value to: (a) the beneficiary named by the Participant; or (b) the Participant’s estate if
no beneficiary survives. If the beneficiary is the Participant’s spouse, such person may choose to receive payment of the Cash Value in any form that the Participant could have chosen while living. The spouse must begin receiving payment by
the date the Participant would have reached age 701/2. If the beneficiary is not the Participant’s spouse, such person must: (1) receive all of the Cash Value within five years of the Participant’s death; or (2) start to
receive annuity payments within one year of the Participant’s death for a period not to exceed the beneficiary’s expected lifetime. If the Participant dies while receiving income payments, the Company will pay any remaining guaranteed
payments to: (a) the Participant’s beneficiary; or (b) the Participant’s estate if no such beneficiary survives. Payment made to a beneficiary must Retirement Benefits The Participant decides when retirement payments will
begin. done by using a form the Company provides. Total distribution must begin before age 70. upon: (1) withdrawal of all the Cash Value; (2) receipt of the first periodic payment described in Part 6 of the Contract, provided that no
option selected exceeds the life expectancy of the Participant. be on a payment schedule at least as rapid as that made to the Participant. Payment made to an estate will be the commuted value of the remaining guaranteed payments. If a beneficiary
is named, the periodic payments cannot exceed the expected lifetime of the Participant and his or her beneficiary. Life expectancy and joint and last survivor life expectancy are computed using section 1.72-9
of the Income Tax Regulations. Cash Withdrawal Benefit A Participant who wants to withdraw all or some of the Cash Value should apply to the Company using a form the Company provides. The Participant must notify the Company of the intent of the
withdrawal. This will allow the Company to report correctly for state or federal income tax purposes. The Cash Value will be reduced by the amount of the withdrawal. Assignment No assignment of the Contract or any of its benefits or privileges will
be recognized. All benefits are exempt from claims of creditors to the maximum extent permitted by law. The Contract is not transferable by the Participant. The entire interest of the Contract is not forfeitable by the Participant. Premium Refunds
Any refund of premiums other than excess contributions must be applied toward future premiums. They must be applied before the close of the calendar year following the year of the refund. Page 9 GVA-1985-CX