Single Purchase Payment

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1 CONTRACT SUMMARY Pacific Life Insurance Company P.O. Box 2378 Omaha, NE (800) Contract Owners (800) Registered Representatives Pacific Income Provider Individual Single Premium Immediate Fixed Annuity Disclosure Contract Form Series: For use in all states except NJ, NY, & OR Pacific Income Provider is an individual single premium immediate fixed annuity contract, which means you buy it with one payment. It is an immediate annuity, which means your annuity payments start within 12 months of the contract issue date. You can use an immediate annuity to receive income for life or a specified period. It is not meant to be used to meet short-term financial goals. If there are multiple sources of premium used to fund this individual single premium immediate fixed annuity contract, the contract issuance will be the earlier of: 1) 60 calendar days from the illustration date (or application received date if there is no illustration date or the application is received more than 14 days after the illustration date), or 2) upon Pacific Life s receipt of the last expected premium. All expected premium should be indicated on the application. Purchase payments received and held by Pacific Life Insurance Company prior to contract issue will NOT earn interest. Single Purchase Payment You can establish this contract with a purchase payment of at least $25,000. At the time of application, you choose the annuity option, annuity payment amount, payment start date and payment frequency. These elections cannot be changed after the contract is issued. Payments are required to begin within one year of the contract issue date. Annuity Options The annuity options and their corresponding descriptions available under the contract are: Option 1 Life Only. Annuity payments are made during the annuitant s lifetime. Payments stop when the annuitant dies. Option 2 Life with Period Certain. Annuity payments are made for a guaranteed period, usually 5-30 years (in whole years only) as chosen by you, and thereafter as long as the annuitant lives. Once all the payments under the specified period have been made, payments stop when the annuitant dies. Option 3 Life with Cash Refund. Annuity payments are made during the annuitant s lifetime. If the annuitant dies before the total of all annuity payments made equal the amount you paid for the annuity, an amount equal to the purchase payment, less total annuity payments made under the contract, will be made in a single sum. Option 4 - Life with Installment Refund. Annuity payments are made during the Annuitant s lifetime. If the Annuitant dies after the Annuity Date but before the total of all Annuity Payments made equals or exceeds the Purchase Payment, Annuity Payments will continue to be made until the total amount of Annuity Payments made equals the Purchase Payment; the final Annuity Payment may be less than the Annuity Payment shown in the Contract Specifications. In lieu of receiving the remaining guaranteed Annuity Payments, an election can be made to receive the present value of the remaining guaranteed Annuity Payments in a single sum. If the Annuitant dies and the total amount of Annuity Payments made is equal to or exceeds the Purchase Payment, then no additional Annuity Payments will be made. Option 5 Joint Life Only. Annuity payments are made as long as either the annuitant or joint annuitant lives. After the death of the first annuitant, a percentage of the annuity payment, either 100%, 75%, 67%, or 50% as chosen by you at the time of application, will be made during the lifetime of the surviving annuitant. Payments stop when both annuitants have died. Option 6 Joint Life with Period Certain. Annuity payments are made for a guaranteed period, usually 5-30 years (in whole years only) as chosen by you, and thereafter for as long as either annuitant lives. Upon the later of the first annuitant s death or the end of the specified period, a percentage of the annuity payment, either 100%, 75%, 67%, or 50% as chosen by you at the time of application, will be made during the lifetime of the surviving annuitant. Once all the payments under the specified period have been made, payments stop when the last surviving annuitant dies. CS Page 1 of 5 10/ A

2 Option 7 Joint Life with Cash Refund. Annuity payments are made as long as either annuitant lives. After the death of the first annuitant, a percentage of the annuity payment, either 100%, 75%, 67%, or 50% as chosen by you at the time of application, will be made during the lifetime of the surviving annuitant. If both annuitants die before the total of all annuity payments made under the contract equal the amount you paid for the annuity, an amount equal to the purchase payment, less total annuity payments made under the contract, will be made in a single sum. Option 8 - Joint Life with Installment Refund. Annuity Payments are made as long as both Annuitants are alive or while the total of all Annuity Payments is less than the Purchase Payment. After the death of the first Annuitant and the total of all Annuity Payments equals or exceeds the Purchase Payment, a percentage of the Annuity Payment, designated as the Survivor Annuity Percentage shown in the Contract Specifications, will be made during the lifetime of the surviving Annuitant. If both Annuitants die before the total of all Annuity Payments made equals or exceeds the Purchase Payment, Annuity Payments will continue to be made until the total amount of Annuity Payments made equals the Purchase Payment; the final Annuity Payment may be less than the Annuity Payment shown in the Contract Specifications. In lieu of receiving the remaining guaranteed Annuity Payments, an election can be made to receive the present value of the remaining guaranteed Annuity Payments in a single sum. If both Annuitants die and the total amount of Annuity Payments made under the contract is equal to or exceeds the Purchase Payment, then no additional Annuity Payments will be paid. Option 9 Joint and Survivor Life Only. Annuity payments are made during the lifetime of the primary annuitant. If the primary annuitant dies before the joint annuitant, a percentage of the annuity payment, either 100%, 75%, 67%, or 50% as chosen by you at the time of application, will be made as long as the joint annuitant lives. Payments stop when both annuitants have died. Option 10 Joint and Survivor Life with Period Certain. Annuity payments are made for a guaranteed period, usually 5-30 years (in whole years only) as chosen by you, and thereafter for as long as the primary annuitant lives. Upon the later of the primary annuitant s death or the end of the specified period, a percentage of the annuity payment, either 100%, 75%, 67%, or 50% as chosen by you at the time of application, will be made during the lifetime of the joint annuitant, provided the joint annuitant survives the primary annuitant. Once all the payments under the specified period have been made, payments stop when the last surviving annuitant dies. Option 11 Joint and Survivor Life with Cash Refund. Annuity payments are made during the lifetime of the primary annuitant. If the primary annuitant dies before the joint annuitant, a percentage of the annuity payment, either 100%, 75%, 67%, or 50% as chosen by you at the time of application, will be made as long as the joint annuitant lives. If both annuitants die before the total of all annuity payments made equal the amount you paid for the annuity, an amount equal to the purchase payment, less total annuity payments made under the contract, will be made in a single sum. Option 12 - Joint and Survivor Life with Installment Refund. Annuity Payments are made during the lifetime of the Primary Annuitant or while the total of all Annuity Payments is less than the Purchase Payment. If the Primary Annuitant dies before the Joint Annuitant, after the total of all Annuity Payments equals or exceeds the Purchase Payment, a percentage of the Annuity Payment, designated as the Survivor Annuity Percentage shown in the Contract Specifications, will be made during the lifetime of the Joint Annuitant. If both Annuitants die before the total of all Annuity Payments made equals or exceeds the Purchase Payment, Annuity Payments will continue to be made until the total amount of Annuity Payments made equals the Purchase Payment; the final Annuity Payment may be less than the Annuity Payment shown in the Contract Specifications. In lieu of receiving the remaining guaranteed Annuity Payments, an election can be made to receive the present value of the remaining guaranteed Annuity Payments in a single sum. If both Annuitants die and the total amount of Annuity Payments made under the Contract is equal to or exceeds the Purchase Payment, then no additional Annuity Payments will be paid. Option 13 Period Certain. Annuity payments are made for a guaranteed period, usually 5-30 years (in whole years only) as chosen by you. CS Page 2 of 5 10/ A

3 Inflation Protection Option You can choose, at the time of application, an annual increase of 2%, 3% or 4% of your annuity payments. The increase will occur every year on the annuity payment start date anniversary. The election and increase amount cannot be changed after issue. If you elect this feature, you may receive a lower annuity payment initially than you would have if you did not elect this feature, but you could potentially receive more income over time. You may select either the Inflation Protection Option or the Future Adjustment Option described below, but not both. Future Adjustment Option You can choose, at the time of election, a future increase or decrease of your annuity payments. You choose the effective date that the annuity payment change will take effect. Once effective, the new payment amount will remain in effect for the remainder of the contract. You can elect to increase your annuity payment by 50%, 100%, 150%, 200%, 250%, or 300%, or you can elect to decrease your annuity payment by 10%, 20%, 30%, 40% or 50%. The effective date of the payment change can be any annuity payment start date anniversary that is prior to your or the annuitant s age 95 (whichever is earlier). This option is not available if you choose a joint life annuity option with a reduction in benefits. The election and adjustment amount cannot be changed after issue. Note: If you have a qualified contract, payment increases are not allowed. Annuity Payment Acceleration Option After annuity payments begin, you may request a lump sum payment equal to three (3) or six (6) months of monthly annuity payments. The lump sum payment will be equal to the scheduled monthly annuity payment and the next two monthly annuity payments (if a three-month acceleration is chosen), or five monthly annuity payments (if a six month acceleration is chosen). The Annuity Payment Acceleration Option is subject to the following conditions: You may exercise this option after the first contract anniversary; Your annuity frequency must be monthly; If you have a qualified contract, payment accelerations may not cross over tax years; for a three month acceleration no acceleration permitted if the next payment date is 11/1 or later and for a six month acceleration no acceleration permitted if the next payment date is 8/1 or later; You may exercise this option twice during the life of your contract; All owner(s) must be at least age 59 ½; For period certain only annuity options, the number of the accelerated payments cannot exceed the number of annuity payments remaining during the guaranteed period; If period certain or installment refund payments are being made after the death of the annuitant(s), you cannot receive more than the remaining guaranteed payments; No additional annuity payments will be made until the scheduled monthly annuity payments resume. Scheduled monthly annuity payments will resume in the fourth (if the three month acceleration is chosen) or seventh (if the six-month acceleration is chosen) month; If you exercise the Annuity Payment Acceleration Option, you cannot exercise it again until scheduled annuity payments have resumed and at least one monthly payment has been made; You must wait six (6) months from the payment acceleration transaction date to request a full or partial withdrawal of the commuted value, if available with your contract; You must wait six (6) months from the date you request a full or partial withdrawal of the commuted value, if available with your contract, to request the Annuity Payment Acceleration option; and Pacific Life is entitled to recover any overpayment of annuity payments made and/or adjust future annuity Payments because of delay or failure to notify the company of death of an owner and/or annuitant. The owner, owner s estate, successor owner or beneficiary entitled to receive any death benefit or remaining annuity benefits is liable to the company for any overpayment made, which includes payments to a payee other than the owner. Pacific Life is not responsible for any mispayments that result from delay or failure to notify the company immediately of such death. Commutation For all annuity options other than life only options, you can make a partial or full withdrawal of the commuted value any time after the first contract anniversary, provided you are age 59½ or older. The withdrawal amount will equal a percentage, as selected by you, of the present value of the remaining guaranteed annuity payments and will be paid to you in a single sum. The amount available for withdrawal will be the present value of the remaining guaranteed annuity CS Page 3 of 5 10/ A

4 payments. The interest rate used to determine the present value of remaining guaranteed annuity payments is Moody s Long-Term Corporate Bond Yield Averages, updated monthly, or a similar corporate bond index, less 0.75% plus a rate adjustment. If the Annuitant is still living once all remaining guaranteed payments have been made, the originally scheduled Annuity Payment amount will be paid during the lifetime of the Annuitant, if allowed under the elected annuity option. The minimum withdrawal amount is $5,000 and for a partial withdrawal, we may require a minimum of $250 for remaining annuity payments. NOTE: Commutation is not available for qualified contracts (including IRA and Roth IRA contracts). Additionally, you must wait six (6) months from any payment acceleration transaction date (if elected) to request a full or partial withdrawal of the commuted value. Death Benefit Before the annuity payment start date, if you or the annuitant dies, or is diagnosed with a medical condition which results in a life expectancy of 12 months or less, we will pay a death benefit. The death benefit will equal the purchase payment less any prior payments made by us. Taxes Qualified contracts, including traditional IRA, SEP-IRA, Roth IRA, inherited IRA, and inherited Roth IRA are eligible for favorable tax treatment under the Internal Revenue Code (IRC). Certain payout options and certain product features may not comply with various requirements for qualified contracts, which include required minimum distributions and substantially equal periodic payments under IRC Section 72(t). Therefore, certain product features, including the ability to exercise withdrawal features, may not be available or may have additional restrictions. The payment acceleration feature is available but will be considered a modification to the 72(t) program and may subject the series of 72(t) withdrawals to a 10% additional tax. In addition, certain payout options may not be available for qualified contracts. For Roth IRAs, upon the Roth IRA Owner's death, distributions to the designated beneficiaries may be subject to IRS required minimum distribution rules. Where the designated beneficiary is not the spouse, the beneficiary may be required to take a lump sum payment of the present value of the guaranteed payments if a death benefit becomes available. For the purpose of qualified distributions from Roth IRA, since the 5-year waiting period is tracked by the Roth IRA holder, the designated beneficiary and/or spouse who elects to treat the Roth IRA as his or her will also need to take on this responsibility going forward when claiming qualified distributions. Income from annuity payments received from Pacific Income Provider cannot be aggregated or combined with income from other IRA contracts/assets for purposes of satisfying IRS required minimum distributions. Nonqualified contracts may not be subject to the various requirements for qualified contracts, but are still subject to an additional 10% federal tax for annuity payments, withdrawals, and other distributions prior to age 59 1/2. While there are exceptions to this additional federal tax under Section 72(q), certain payment options may not comply. For nonqualified contracts, an additional 3.8% federal tax may apply on net investment income. Clients should consult their tax advisors and attorneys regarding their specific situations. Taxation of annuity payments is the responsibility of the primary owner regardless of the recipient of the annuity payments. Buying an annuity within an IRA or other qualified plan does not give you any extra tax benefits. Choose your annuity based on its other features and benefits as well as its risks and costs, not its tax benefits. You may also be subject to premium tax, depending on your state of residence. The amount of any premium tax imposed on us relating to the contract will be deducted in accordance with our then current practice and any applicable jurisdictional law regarding premium taxes. If premium tax rates change under laws of the jurisdiction in which you reside, the applicable premium tax may also change. If you change the jurisdiction in which you reside, the premium tax may or may not apply. Other Information We may change your annuity contract from time to time to follow federal or state laws and regulations. If we do, we will tell you about the changes in writing. We are entitled to recover any overpayment of annuity payments made and/or adjust future annuity income payments because of delay or failure to notify us of death of an owner and/or annuitant. Many states have laws that give you a set number of days to look at an annuity contract after you buy it. If you decide during that time that you do not want it, you can return the contract and receive your purchase payment back. Read your contract s Right to Cancel provision on the cover page to learn more about your free look period. We pay the independent producer or the independent producer s third party selling firm for selling the contract to you. CS Page 4 of 5 10/ A

5 This summary is not a contract and is not part of your contract with us. For questions regarding this summary, contact your producer or registered representative. If no producer or registered representative is involved, write to us at Pacific Life Insurance Company, P.O. Box 2378, Omaha, NE or call Pacific Life customer service at (800) CS Page 5 of 5 10/ A

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