MI Annuity Application Packet

The

Individual Annuity

Primary Owner

Individual Non Person Entity Male Female

Sex

Legal Name (First, Middle, Last, Suffix)

Social Security Number/

Driver’s License Number,

Residence

of

Date Marital Status

City State Zip Code

Mailing Address

different

City State Zip Code

Primary Phone

Yes No

the

Joint Owner

Email Address

be spouse of

Legal Name (First, Middle, Last, Suffix)

Owner. Available for

Male Sex Female

Social Security Number Date of Birth Marital Status

Driver’s License Number, State,

Residence

City State Zip Code

Primary Phone

Email Address

GBU FINANCIAL LIFE

Primary Annuitant

Legal Name (First, Middle, Last, Suffix)

Social Security Number

(Complete only if the Annuitant is not the Policy Owner. Must be completed if Annuitant is aged 0 to 17.)

Male Sex Female

Date of Birth

Driver’s License Number, State, and Expiration (If none, provide alternate ID type, issuer, number and expiration date.)

Relationship to the Owner

Residence Address or Legal Address

City State Zip Code

Primary Phone Email Address

Joint Annuitant

(Available for non qualified annuities only.)

Legal Name (First, Middle, Last, Suffix)

Social Security Number

Date of Birth

Male Sex Female

Driver's License Number, State and Expiration (If none, provide alternate ID type, issuer, number and expiration date.)

Relationship to the Annuitant

Residence Address or Legal Address

City State Zip Code

Primary Phone Email Address

Beneficiaries

Primary Beneficiaries

Full Legal Name and Address

(Total shares between beneficiaries of each class must equal 100%. If percentage shares are not listed, they will be divided equally among beneficiaries.)

Social Security # Relationship to the Owner

Date of Birth Share % (Must equal 100%)

Contingent

Product Information

Plan

Flexible

Flex

Flex

Flex

Flex

Period

Life

Life

Joint

Joint

Joint

Joint

Joint

Joint

Asset

Payment

of Funds

Existing Insurance

Do you have any existing life insurance policies or annuity contracts?

(If Yes, please fill out the table below for all existing life/annuity coverage. Complete state required forms, if applicable.)

Yes No (Producer)

Yes No (Applicant)

Is the contract intended to replace or change any part of, or all of, an existing life insurance policy or annuity contract?

(If Yes, please note the coverage to be replaced in the table below and complete the state required forms, if applicable.)

Company

Yes No (Producer)

Yes No (Applicant)

Type of Coverage Policy Number Face Amount Replacement (Y/N)

If any replacement is intended as a

Exchange,

policy

be exchanged.

Agreements and Signatures

The signatories of this application represent that all statements and information contained herein are true and complete to the best of their belief and knowledge. The insurance producer declares that all answers and information in this application have been truly and accurately recorded as provided by the applicant. The insurance producer declares that the identity of the applicant(s) has been verified by reviewing government-issued photo identification. The insurance producer also declares that with respect to the suitability of this sales recommendation, the applicable state requirements have been met. The signatories of this application also declare that this application was signed by the applicant(s) after all answers and information were recorded herein. Additionally, the signatories of this application declare and certify the following: the insurance producer has delivered and the applicant has received The Buyer's Guide to Deferred Annuities

Insurance Producer: Yes No Applicant: Yes No

The signatories to this application have read through the applicable product disclosure. The insurance producer has explained and the applicant(s) understand the various product features. For deferred annuities this includes, but is not limited to: (a) surrenders and withdrawals; (b) surrender charges; (c) surrender charge period; (d) early withdrawal tax penalty; and (e) annuitization. For immediate annuities this includes, but is not limited to: (a) modal payments; (b) death benefit payments; and (c) commutation, if available under the contract. A signed product disclosure is enclosed with this application. For immediate annuities, the signed copy of the contract illustration is also enclosed.

Insurance Producer: Yes No Applicant: Yes No

The applicant(s) is purchasing an annuity that includes a market value adjustment feature. If yes, the insurance producer has explained and the applicant(s) understands that during the market value adjustment period: (a) any amount surrendered may be subject to a market value adjustment; and (b) the adjustment may increase or decrease amounts payable under the contract. The insurance producer has explained and the applicant(s) understands that: (a) if interest rates rise after the contract effective date, the market value adjustment will generally decrease the surrender value; and (b) if interest rates fall after the contract effective date, the market value adjustment will generally increase the surrender value.

Insurance Producer: Yes No Applicant: Yes No

The insurance producer has explained and the applicant(s) understands that GBU Financial Life does not offer legal, financial, tax, investment or estate planning advice. The applicant(s) has had the opportunity to seek such advice from the proper sources before applying for this annuity.

Insurance Producer: Yes No Applicant: Yes No

The insurance producer has explained and the applicant(s) understands that GBU Financial Life is licensed to do business as a not for profit organization. Fraternal benefit societies are not included in any state’s guaranty association. That means that fraternal benefit societies cannot be assessed for the insolvency of other life insurers or other fraternal benefit societies. By law, a fraternal society is responsible for its own solvency. If there is an impairment of reserves, a contract or certificate holder may be assessed a proportionate share of the impairment.

Insurance Producer: Yes No Applicant: Yes No

The insurance producer and the applicant(s) agree that the purchase of this annuity is appropriate to the applicant’s particular legal, financial, tax investment, estate planning goals and other circumstances. The insurance producer and the applicant(s) have reviewed and completed the suitability form, as applicable. The completed and signed original of that form is enclosed with this application, a copy has been retained by the applicant(s), and a copy has been retained and is on file with the insurance producer.

Insurance Producer: Yes No Applicant: Yes No

Agreements

IRS Certification

Signatures

Under penalties of perjury, I certify that: (1)The Social Security Number or Taxpayer Identification Number on this form is correct (or I am waiting for a number to be issued to me), and (2) I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and (3) I am a U.S. citizen or other U.S. person (as defined in the General Instructions of IRS Form W 9)

Certification Instructions: You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. The Internal Revenue Service does not require your consent to any provisions of this document other than the certifications required to avoid backup withholding.

ANY PERSON WHO KNOWINGLY PRESENTS A FALSE STATEMENT IN AN APPLICATION FOR INSURANCE MAY BE GUILTY OF A CRIMINAL OFFENSE AND SUBJECT TO PENALTIES UNDER STATE LAW.

I, the undersigned, have read the application including all supplements and all statements and answers, and affirm that these statements and answers are true, complete, and correctly recorded to the best of my knowledge and belief. I hereby adopt all statements made in the application and agree to be bound by them.

City and State where the application is being signed by the Primary Owner

Signature of Primary Owner (If actual age is under 16, signature of parent/guardian.) Date

Printed Legal Name of Primary Owner

Signature of Joint Owner Date

Printed Legal Name of Joint Owner

Signature of Primary Annuitant Date

Printed Legal Name of Primary Annuitant

Signature of Joint Annuitant (Required, if applicable) Date

Printed Legal Name of Joint Annuitant (Required, if applicable)

Signature of Insurance Producer Date

Printed Legal Name of Insurance Producer

GBU Producer Number State License Number (If required)

Suitability

General Information

Name of Owner/Applicant (custodian/trust/business)

Name of Joint Owner/Applicant (custodian/trustee/authorized person)

Employment status/occupation for primary owner/applicant

Risk Tolerance and Investment Objective

Select

Additional Account Information Aggregated

Net Worth (Not Including Primary Residence)

Under $50,000

$50,000 $99,999 $100,000 $249,999 $250,000 $499,999 $500,000 $999,999 $1,000,000 $2,999,999 $3,000,000 +

Liquid Net Worth

Under $20,000 $20,000 $49,999 $50,000 $99,999 $250,000 $499,999 $500,000 $999,999 $1,000,000 $2,999,999

Annual Income

Under $20,000 $20,000 $49,999 $50,000 $99,999 $160,000 $299,999 $300,000 $499,999 $500,000 +

Source of Income

$100,000 $249,999 $3,000,000 +

$100,000 $159,999

Select all prior investment experience and provide approximate current value of assets (exclude this purchase).

Bank Savings, CDs, Money Market Funds

Stocks

Bonds Mutual Funds

Yes No Yes No

Yes No

Yes No

Variable Annuities

Fixed Annuities

Other

Life Insurance (Cash Value) Yes No Yes No Yes No Yes No

Does your current income cover your expected day to day living expenses?

Do you have cash and/or other liquid assets available to you that may be used in the event of a financial emergency?

Individual Product Information

Purpose (select all that apply)

Yes No Yes No

Death Benefit Guarantee Future Needs and Purchases Income (current or future) Bequeath Assets to Heirs Other

Time Horizon

0 3 years* 4 7 years* More than 7 years

*Time Horizon explanation:

Source of Funding (select all that apply)

Income/Savings/Checking

In-service distribution

Employer sponsored retirement plan Gift/Inheritance/Death proceeds Investment Home equity credit/reverse mortgage Life insurance cash value

Required Supporting Rationale

Use the following considerations to support your recommendation in the space below (include additional pages if necessary).

• Why the current strategy no longer meets the client's needs

• Provide rationale for recommended strategy

• What options were considered and why were they ruled out

• Explain why it's more advantageous to the client

Disclosure Information

I understand and acknowledge that:

I have received and reviewed the product disclosure guide for this purchase and understand the features, risks, expenses, and costs associated with this product (for immediate and deferred annuities only).

The company and/or its subsidiaries and representatives will benefit financially from this sale and that my representative, in most cases, will receive commissions and other incentives for serving as my agent for the sale of this product.

There may be a 10% federal tax penalty on the taxable portion if a withdrawal is taken or the contract is surrendered if you are under the age of 59 1/2.

There was someone else involved during the sales presentation or decision making process to purchase/elect this product/agreement.

Provide Relationship of the Individual(s) to the Purchaser

Agreements and Signatures Signatures

ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.

I, the undersigned, have read the Application including all supplements and all statements and answers, and affirm that these statements and answers are true, complete, and correctly recorded to the best of my knowledge and belief. I hereby adopt all statements made in the Application and agree to be bound by them.

City and State where the application is being signed by the Owner:

Signature of Owner Date

Signature of Joint Owner Date

Signature of Writing Producer Date

Name of Writing Producer

Insurance Agent (Producer) Disclosure for Annuities

Do Not Sign Unless You Have Read and Understand the Information in this Form Insurance Agent (Producer) Information (“Me,” “I,” “My”)

First Name: Last Name: Business/Agency Name: Website: Business Telephone Number: Business Mailing Address: Email Address: National Producer Number in [state ]:

Customer Information (“You,” “Your”)

First Name: Last Name:

What Types of Products Can I Sell You?

I am licensed to sell annuities to You in accordance with state law. If I recommend that You buy an annuity, it means I believe that it effectively meets Your financial situation, insurance needs and financial objectives. Other financial products, such as life insurance or stocks, bonds and mutual funds, also may meet Your needs.

I need a separate license to provide advice about or to sell non insurance financial products. I have checked below any non-insurance financial products that I am licensed and authorized to provide advice about or to sell.

Whose Annuities Can I Sell You?

I am authorized to sell: Annuities from only one (1) insurer Annuities from two (2) or more insurers Annuities from two (2) or more insurers although I primarily sell annuities from:

How I’m Paid for My Work

It’s important for You to understand how I’m paid for my work. Depending on the particular annuity You purchase, I may be paid a commission or a fee. Commissions are generally paid to Me by the insurance company while fees are generally paid to Me by the consumer. If You have questions about how I’m paid, please ask Me.

Depending on the particular annuity You buy, I will or may be paid cash compensation as follows: Commission, which is usually paid by the insurance company or other sources. If other sources, describe:

Fees (such as a fixed amount, an hourly rate or a percentage of your payment), which are usually paid directly by the customer.

Other (describe):

Charges

Your annuity contract includes certain charges imposed by the Insurance Company as the issuer of the contract. These may include surrender charges, bonus recapture provisions, market value adjustments, or fees for optional annuity contract features available through a rider to the contract. The specific charges, fees and provisions applicable to Your specific annuity contract(s) is/are described in detail in the Annuity Disclosure Statement that has been provided to and signed by You in connection with Your annuity application. It is important that You understand the charges that may be imposed under the annuity contract You are purchasing, so if You have any questions, please ask the Agent for more information.

GBU FINANCIAL LIFE

Conflicts of Interest

The Agent may be affected by potential conflicts of interest in connection with the purchase of, additional payments to, or distributions from the annuity contract. A conflict of interest exists when a reasonable person would conclude that a financial interest affects the Agent’s best judgment when recommending the purchase of an annuity contract.

The Agent will receive a commission from the Insurance Company when You purchase or make subsequent payments to the annuity contract. The amount of Agent’s commission(s) will vary depending on the type of annuity that You purchase and the amount of premium payment(s) You allocate to the annuity contract. In addition, Agent is only able to offer a limited universe of products to You, either because Agent is limited by the scope of his or her licensure or because Agent is contracted with a limited number of issuing insurance companies. If You have any questions about the products and services the Agent can offer, You should ask the Agent for more information.

The Insurance Company, any applicable insurance agency of Agent, and Agent may receive services from third parties related to the marketing, training, administration, wholesaling, supervision, issuance and servicing of the annuity contract. For those services, such third parties may also receive commissions from the Insurance Company and may allocate a portion of its commissions to the Agent.

If You have questions about the above compensation that I will be paid for this transaction, please ask me. By signing below, You acknowledge that You have read and understand the information provided to You in this document.

Customer Signature Date Agent (Producer) Signature Date

The Insurer identified above

Automatic Payment Authorization

Full

Account Type

Checking Savings Routing Number

Name of Account Owner

Account Owner

State

Company

Payment Authorization

Policy Number

Account Number

Withdrawal Date

Code

For new business initial payments, I authorize the Company to make an immediate withdrawal from the bank account listed upon receipt of this form. I authorize the Company to 1) make electronic deposits, withdrawals, and corrections to my bank account that comply with U.S. law; 2) act on this authorization until I revoke it by contacting the Company; 3) apply this authorization to any future bank accounts I may designate; 4) make administrative changes to this authorization which I request such as date and amount changes, or adding or removing contracts for automatic payment; 5) release any and all information related to this authorization to the bank account owner or third party account owner; and 6) act upon electronic deposit, withdrawal, and administrative instructions I provide to my representative.

If this form is received less than 10 days prior to the withdrawal date you entered, your authorization shall take effect on the second occurrence of the mode you have selected. You further acknowledge that if you have selected a deduction to occur on day 29, 30, or 31, the Company will make the withdrawal on day 28.

Signature of Bank Account Owner Date

GBU FINANCIAL LIFE

645949,

PA 15264-5257

Make a Difference: One Member at a Time

GBU believes strongly in the concept of making a difference in the lives of others by recognizing all new members who join the GBU family with a $25 donation to a nationally recognized charity. GBU encourages all new members to participate in this worthwhile program by asking you to select one of the charities listed. By doing this, GBU and you will be joining hands in making a difference for others.

American Cancer Society (Health) www.cancer.org

Mission Statement: To eliminate cancer as a major health problem by preventing cancer, saving lives, and diminishing suffering from cancer, through research, education, advocacy, and service.

American Liver Foundation (Health) www.liverfoundation.org

Mission Statement: To facilitate, advocate and promote education, support and research for the prevention, treatment and cure of liver disease.

American Red Cross (Human Services/Disaster Relief) www.redcross.org

Mission Statement: Prevents and alleviates human suffering in the face of emergencies by mobilizing the power of volunteers and the generosity of donors.

Feeding America (Human Services/Disaster Relief) www.feedingamerica.org

Mission Statement: To feed America’s hungry through a nationwide network of member food banks and engage our country in the fight to end hunger.

Guiding Eyes for the Blind (Human Services) www.guidingeyes.org

Mission Statement: Guiding Eyes for the Blind is dedicated to enriching the lives of blind and visually impaired men and women by providing them with the freedom to travel safely, thereby assuring greater independence, dignity and new horizons of opportunity.

Marine Toys for Tots Foundation (Children/Family Services) www.toysfortots.org

Mission Statement: To collect new, unwrapped toys during October, November and December each year and distribute those toys as Christmas gifts to less fortunate children in the community in which the campaign is conducted.

National Center for Learning Disabilities (Education) www.ncld.org

Mission Statement: To improve the lives of the one in five children and adults nationwide with learning and attention issues by empowering parents and young adults, transforming schools and advocating for equal rights and opportunities.

National Parks Conservation Association (Environment) www.npca.org

Mission Statement: To protect and enhance America’s National Parks for present and future generations.

Operation Troop Appreciation (Military/Veterans) www.operationtroopappreciation.org

Mission Statement: To build and sustain the morale and well being of the military community, past and present, with the assurance that the American public supports and appreciates their selfless service and daily sacrifices.

Humane Society of the United States (Animal Rights and Care)

www.humanesociety.org

Mission Statement: Together with millions of supporters, we take on puppy mills, factory farms, the fur trade, trophy hunting, animal cosmetics testing and other cruel industries. We rescue and care for thousands of animals every year through our Animal Rescue Team’s work and other hands on animal care services. We fight all forms of animal cruelty to achieve the vision behind our name: A humane society.

Optional

Consumer Decision to Purchase an Annuity NOT Based on a Recommendation

Do Not Sign This Form Unless You Have Read and Understand It.

Why Are You Being Given This Form? You’re buying a financial product—an annuity.

To recommend a product that effectively meets Your needs, objectives and situation, the agent, broker or company needs information about You, Your financial situation, insurance needs and financial objectives.

If You sign this form, it means You know that you're buying an annuity that was not recommended

Statement of Purchaser:

I understand that I am buying an annuity, but the agent, broker or company did not recommend that I buy it. If I buy it without a recommendation, I understand I may lose protections under the Insurance Code of (select Customer's state) ______

Customer Signature Date

Agent/Producer Signature Date

GBU FINANCIAL LIFE newbusiness@gbu.org

Box 645949, Pittsburgh, PA 15264 5257 412 884 5100 800 765 4428

Consumer Refusal To Provide Information

Do Not Sign Unless You Have Read and Understand the Information in this Form.

Why Are You Being Given This Form?

You’re buying a financial product an annuity.

To recommend a product that effectively meets Your needs, objectives and situation, the agent, broker or company needs information about You, Your financial situation, insurance needs and financial objectives.

If You sign this form, it means You have not given the agent, broker or company some or all the information needed to decide if the annuity effectively meets Your needs, objectives and situation. You may lose protections under the Insurance Code of (select Customer’s state) if You sign this form or provide inaccurate information.

Statement of Purchaser:

I REFUSE to provide this information at this time.

I have chosen to provide LIMITED information at this time.

Customer Signature Date

GBU FINANCIAL LIFE newbusiness@gbu.org

PO Box 645949, Pittsburgh, PA 15264 5257 412 884 5100 800 765 4428

Trust Information

Trust Type

GBU FINANCIAL LIFE

Trust Signatures and Indemnification

1. The undersigned Trustee(s) hereby certifies to the Company that the Trust has been properly executed, is now in full force and effect, and is allowed by its term and by law to purchase and/or own the Contract.

2. The undersigned Trustee(s) agrees:

a. that the Company may rely solely upon instructions from the Trustee(s) for the exercise of any and all rights of ownership provided by the Contract and for the payment of any benefits thereunder; and,

b. to promptly provide to the Company at its Administrative/Home Office with evidence of the appointment of any successor Trustee(s), notice of the termination of the Trust, and notice of any changes or modifications of the Trust that in any way affect the agreements set forth herein.

3. The Trustee(s) warrants to the Company:

• that the Trustee(s) may, under the terms of the Trust and applicable law, exercise all rights of ownership provided by the Contract, including but not limited to, any rights to surrender or transfer, make loans or withdrawals, control dividends, designate beneficiaries and select pay-ment options, and

• that neither the Company nor its representatives are responsible for inquiring into the terms of the Trust and shall not be charged with knowledge of its terms or provisions.

The Company is relying on the representations made in this Certification and is not responsible for the validity or effectiveness of the Trust. The Company makes no representations directly or through its agents as to the suitability of this Trust as owner of this policy.

Taxpayer Identification

By signing, I also understand that no account/contract will be accepted without a valid TIN. Under penalties of perjury, I certify that:

1. the number shown on this form is the trust's correct TIN (or I am waiting for a number to be issued to the trust);

2. the trust is not subject to backup withholding because either the trust is exempt from backup withholding, has not been notified by the IRS that it is subject to backup withholding as a result of a failure to report all interest or dividends, or the trust has been notified by the IRS that it is no longer subject to backup withholding; and

3. the trust is a U.S. trust.

Signature of Trustee Date Signed

Signature of Trustee Date Signed

Signature of Trustee

Signature of Trustee

Date Signed

Date Signed

1035 Exchange

This form can be used to accomplish a FULL or PARTIAL Exchange of policies pursuant to Internal Revenue Code (IRC) Section 1035.

Complete the requested information concerning the existing policy and contract, check the appropriate boxes, and date and sign this form. Refer to the application, and if applicable, prospectus and any state required forms for additional important disclosures and information. Check with both the receiving and surrendering company for form requirements specific to the transaction that is being initiated.

The receiving company may not accept the exchange if the funds do not meet its minimum premium requirements. The receiving company may not accept the rollover/transfer if the funds do not meet its minimum premium requirements.

Receiving Company Information

Name

Street Address

City State Zip Code

Phone Number Fax Number

Surrendering Company Information

Name

Street Address

Complete one form for each surrendering company

City State Zip Code

Phone Number

Fax Number

Owner Information

Name

Joint Owner Information

Social Security/Tax ID #

Social Security/Tax ID #Name

Insured/Annuitant Information—if other than owner

Name

Social Security/Tax ID #

GBU FINANCIAL LIFE

newbusiness@gbu.org

PO Box 645949, Pittsburgh, PA 15264-5257 412-884-5100 800-765-4428

Complete one form for each surrendering policy / contract

1035 Exchange Details

Please confirm the availability of these options with both the surrendering and receiving company. Not all receiving companies provide life insurance products.

Full Exchange

Estimated Transfer Amount: $

If purchasing a Life Insurance policy, select any of the following that apply:

Loan Carry Forward

Loan Amount: $

Modified Endowment Contract

Partial Exchange (applicable to Annuity Contracts Only)

Type of Partial Exchange:

Specified Amount: $

Specified Percentage: %

Penalty Free Amount

This amount is subject to change base on the product provisions. Please check with the surrendering company to verify the amount.

Special Instructions for Liquidating Existing Contract

By executing this form, I authorize the full or partial liquidation of my existing contract or account in accordance with the sections completed above. I understand that fees and charges may apply if the transfer is processed before the maturity date. I hereby instruct the parties to process that liquidation:

Immediately—Waive any conservation period that may apply and process transfer request

At Maturity Date:

On a Specific Date:

Disclosures/Acknowledgements

I fully assign and transfer all claims, options, privileges, rights, title and interest to either all of the life insurance policy, all of the annuity contact or part of the annuity contract value identified in the Surrendered Policy / Contract Information section on Page 1 to the receiving company. The sole purpose of this assignment is to effect a tax-free exchange under Section 1035(a) of the Internal Revenue Code. All of the powers, elections, appointments, options and rights I have as owner of the contact, including the right to surrender, are now exercisable by the receiving company. Simultaneous with a full assignment, I also revoke all existing beneficiary designations under the Assigned Policy. Other than the above mentioned owner, no person, firm, or corporation other than myself and the insurer that issued the above numbered policy, has an interest in said policy. No proceedings in insolvency or bankruptcy have been instituted by or against me. I understand that the receiving company intends to surrender the contract for the cash value; or if this is a partial exchange, the portion assigned, subject to its terms and conditions, and to use the proceeds as the purchase payment for the new contract to be issued by the receiving company. I authorize the surrendering company to send the proceeds directly to the receiving company and understand that fees and surrender charges may apply. This exchange is subject to acceptance by the receiving company. The receiving company is not liable for changes in market value that may occur before the proceeds are received by the receiving company in good order and allocated to the new contract. Prior to the date of receipt of the proceeds by the receiving company, no value will accrue or be earned on the receiving company contract.

If this is a partial exchange, I understand that is subject to Revenue Ruling 2003-76, which dictates how much of the original contract’s cost basis must be allocated to the new contract. The cost basis should be allocated ratably between the two contracts based on the percentage of the value retained in the original contract and the percentage of the value transferred to the new contract. For example, if the contract value is $100,000 and basis is $50,000, and I assign 30% for a partial exchange, then $15,000 (30% of $50,000) of the basis would be applied to the new contract. I understand that the IRS has raised concerns about annuity contract owners using partial exchanges to avoid income tax, and I certify that I am not entering into this transaction for the purpose of reducing or avoiding income tax or the 10% penalty tax for early withdrawals.

I expressly represent that the sole purpose is to affect a partial 1035 exchange of an annuity contract. However, I acknowledge that Revenue Procedure 2011-38 states that withdrawals from annuitization, taxable owner or annuitant changes, or surrenders, other than an amount received as an annuity for a period of 10 years or more or during one or more lives, of either the original contract or the new contract during the 180 day period following the partial exchange, may affect the tax free status of the partial exchange.

Note: Other exceptions may apply and a subsequent direct transfer of all or a portion of either contract involved in the exchange could have tax and tax reporting consequences. Please consult your tax advisor. Please confirm with the carrier if they will support partial 1035 exchanges.

I acknowledge that the receiving company has made no representations concerning any tax treatment of this transaction. I understand that the receiving company has neither responsibility nor liability for the validity of this transaction or for my treatment under Section 1035(a) of the Internal Revenue Code or otherwise. Therefore, I agree to release and hold harmless the receiving company and its agents from any and all liability arising from, relating to, or in connection with, the taxation of a partial exchange of the above listed contact. I authorize the receiving company and the surrendering institution to share information necessary to maintain accurate records of the annuity cost basis and to ensure proper withholding and tax reporting. I have been directed to consult my tax or legal advisor before proceeding.

I authorize the receiving company to rely upon the cost basis information provide by the surrendering company, but agree that the receiving company will assume no responsibility for determining or verifying cost basis. If cost basis is not provided, I acknowledge that more restrictive or less beneficial tax rules may apply to the amounts transferred. I acknowledge that the receiving company provides this form and participates in this transaction as an accommodation to me. The receiving company does not give tax or legal advice on the tax consequences for replacing one contract for another, and assumes no responsibility or liability for the validity of this assignment or for the tax treatment of this exchange under IRC Section 1035(a) or other laws or regulations.

I agree that if the receiving company, in its sole discretion, determines that it is unlikely to receive timely payment of the full contract cash surrender values, the receiving company my reassign ownership of the policy/contract back to me.

LOAN CARRY FORWARD IF THE BOX IN THE 1035 EXCHANGE DETAILS SECTION IS NOT CHECKED, THE RECEIVING COMPANY WILL ASSUME THAT THE LOAN(S) IS/ARE NOT TO BE CARRIED FORWARD. If this box is checked, I request that the policy to be issued by the receiving company be subject to indebtedness equal to the loan on the existing policy. I acknowledge that when issued, the provisions of the receiving company policy will apply to the indebtedness and that the benefits and values of that policy will be reduced accordingly for the amount loaned and interest. I understand that the receiving company may not process this request prior to issuing a policy under the following conditions: Surrender value is insufficient as determined by the receiving company policy’s specifications or the existing insurer does not provide confirmation of cost basis with acknowledgement of loan carried forward.

RETURN OF LIFE INSURANCE POLICY OR ANNUITY CONTRACT Does not apply to partial 1035 exchanges on annuity contracts. Unless the surrendering company’s policy or contract is attached, I affirm that the policy or contract has been destroyed or lost and that reasonable effort has been made to locate it. To the best of my knowledge no one else has any right, title or interest in the contract, nor has it been assigned, pledged or encumbered, unless this is a life insurance policy with a loan to carry forward.

MAXIMUM ISSUE AGE DISCLOSURE An annuity contract may not be issued should the funding requirements be received after reaching maximum issue age for the annuity contract applied for. If the funds are received after the maximum issue age, the contract may be rejected and the funds returned to their original source. The surrendering company may or may not take the funds back, which could result in a taxable event.

The IRS has provided limited guidance on the tax consequences of transferring a life insurance policy with values less than the investment in the contract to a new or existing annuity contract. If the owner surrenders the newly acquired annuity contract, it is not clear whether the annuity losses are fully deductible against ordinary income or deductible as a miscellaneous deduction subject to a limitation of 2% of adjusted gross income (AGI). If the IRS views the two transactions as a single integrated transaction, they could consider it a step transaction and successfully disallow the losses as a tax deduction.

Taxpayer Identification Number Certification

Under penalties of perjury, I certify that:

1. The number on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and

2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and

3. I am a U.S. person (including a U.S. resident alien).

Check this box if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return.

Signatures

This transfer request also authorizes the receiving company to request information on the status of this transfer or exchange by phone or in writing. By signing below, I represent that the responses here in are, to the best of my knowledge, accurate and I have read the DISCLOSURES / ACKNOWLEDGEMENTS on page 3 of this form.

The Internal Revenue Service does not require your consent to any provisions of this document other than the certifications required to avoid backup withholding.

Signature of Owner/Plan Administrator/Trustee/Custodian

Date

Date

Signature of Insured/Annuitant (if applicable)

Signature of Spouse (Required in AZ, CA, ID, LA, NV, NM, TX, WA, and WI only)

Date

Signature of Joint Owner Date

Non-Qualified Transfer of Funds Details

Existing Funds: Investment Description: Redemption Value:

Mutual Funds Shares

Certificate of Deposit

Brokerage Account

Money Market Account Other

Entire Value or Partial Value, in the amount of: $ or %I wish to liquidate and transfer:

of the above-referenced account directly to the receiving company.

Specify Funds to Liquidate: Fund/Account Number:

Qualified Transfer of Funds Details SEP-IRA

Transferred from:

Traditional IRA Beneficial IRA Pension Plan

457(b) Plan

Specify Type:

SIMPLE IRA Roth IRA**

401(a) TSA/403(b)* Other

401(k)

401(k) Designated Roth Account

** Roth IRA funds can be transferred only to another Roth IRA.

* All existing TSA loans must be reconciled with our current carrier prior to the transfer

I wish to liquidate and transfer from my present qualified account to the contract/policy I have established through the receiving company: Specified PercentageSpecified Amount $

Penalty Free Amount %

Please confirm that the receiving company will accept a transfer/exchange of funds into a TSA/403(b). If the receiving company will process a transfer/exchange of funds into a TSA/403(b), the TSA/403(b) owner/participant’s employer or employer’s third-party administrator must authorize and sign this transfer request in Signature section on page 4.

Authorization for a TSA/403(b) transfer/exchange to a TSA/403(b): This request is for the direct transfer/exchange of non-ERISA funds from the TSA/403(b) (annuity contact) or 403(b)(7) (custodial account) identified in the Surrendering Policy section above to a TSA/403(b) (annuity contract) established on my behalf by the receiving company. I hereby agree to surrender my interest as indicated above and authorize the receiving company to take whatever action necessary to effect this transfer/exchange. I acknowledge that the transferred/exchanged funds shall be subject to the more stringent restrictions on distributions found in either the predecessor annuity contract or the receiving annuity contract. I intend this transaction to be a 403(b) transfer/exchange of funds pursuant to IRC section 403(b) and the final regulations. The transfer/exchange is to be executed from financial institution to financial institution in such a manner that it will not place me in actual or constructive receipt of all or any part of the transferred/exchanged funds. Because this transaction constitutes a direct rollover/transfer/exchange of funds and not a distribution, withholding does not apply. (Providing the receiving company with any records or documents they may request to this transfer/exchange.)

Special Instructions for Liquidating Existing Contract or Account

By executing this form, I authorize the full or partial liquidation of my existing contract or account in accordance with the sections completed above. I understand that fees and charges may apply if the transfer is processed before the maturity date. I hereby instruct the parties to process that liquidation:

Immediately Waive any conservation period that may apply and process transfer request

At Maturity Date:

On a Specific Date:

Disclosures/Acknowledgements

I agree that if the receiving company, in its sole discretion, determines that it is unlikely to receive timely payment of the full contract cash surrender values, the receiving company my reassign ownership of the policy/contract back to me.

RETURN OF LIFE INSURANCE POLICY OR ANNUITY CONTRACT—Does not apply to partial 1035 exchanges on annuity contracts. Unless the surrendering company’s policy or contract is attached, I affirm that the policy or contract has been destroyed or lost and that reasonable effort has been made to locate it. To the best of my knowledge no one else has any right, title or interest in the contract, nor has it been assigned, pledged or encumbered, unless this is a life insurance policy with a loan to carry forward.

MAXIMUM ISSUE AGE DISCLOSURE—An annuity contract may not be issued should the funding requirements be received after reaching maximum issue age for the annuity contract applied for. If the funds are received after the maximum issue age, the contract may be rejected and the funds returned to their original source. The surrendering company may or may not take the funds back, which could result in a taxable event.

NON-QUALIFIED TRANSFER OF FUNDS (NON 1035 EXCHANGE) - The receiving company will apply all such funds received to an annuity contract issued to me. I understand that the receiving company assumes no responsibility for tax treatment of this matter and I shall be responsible for payment of all federal, state and local taxes incurred with respect to the liquidation f such account. I acknowledge that the earnings credited under the annuity contract will begin to accrue when the receiving company receives these proceeds and all other necessary paperwork in good order. For index annuities, fixed account interest under the annuity contract will begin to accrue on the next Issue Day.

The IRS has provided limited guidance on the tax consequences of transferring a life insurance policy with values less than the investment in the contract to a new or existing annuity contract. If the owner surrenders the newly acquired annuity contract, it is not clear whether the annuity losses are fully deductible against ordinary income or deductible as a miscellaneous deduction subject to a limitation of 2% of adjusted gross income (AGI). If the IRS views the two transactions as a single integrated transaction, they could consider it a step transaction and successfully disallow the losses as a tax deduction.

Taxpayer Identification Number Certification

Under penalties of perjury, I certify that:

1. The number on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and

2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and

3. I am a U.S. person (including a U.S. resident alien).

Check this box if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return.

Signatures

This transfer request also authorizes the receiving company to request information on the status of this transfer or exchange by phone or in writing. By signing below, I represent that the responses here in are, to the best of my knowledge, accurate and I have read the DISCLOSURES/ACKNOWLEDGEMENTS on page 3 of this form.

The Internal Revenue Service does not require your consent to any provisions of this document other than the certifications required to avoid backup withholding.

Signature of Owner/Plan Administrator/Trustee/Custodian

Date

Signature of Joint Owner

Date

Signature of Insured/Annuitant (if applicable)

Date

Signature of Spouse (Required in AZ, CA, ID, LA, NV, NM, TX, WA, and WI only)

Date