The insurer identified above will be referred to herein as the "Company"
Individual Annuity Application
Please print or type:
Primary Owner Individual
(For Trust Ownership, provide the completed Trust Certification form.)
Non-Person Entity
Male
Female
Sex Legal Name (First, Middle, Last, Suffix) Social Security Number/TIN
Date of Birth/Trust Date
Marital Status
Driver’s License Number, State and Expiration (If none, provide alternate ID type, issuer, number and expiration date.) Residence Address or Legal Address State
City
Zip Code
Mailing Address (If different from Residence Address.) City
State
Zip Code
Primary Phone
Email Address
No Yes Is the Proposed Owner a member of GBU Financial Life?
Joint Owner
(Must be spouse of the Primary Owner. Available for non-qualified annuities only.) Male
Legal Name (First, Middle, Last, Suffix) Social Security Number
Female
Sex Date of Birth
Marital Status
Driver’s License Number, State, and Expiration (If none, provide alternate ID type, issuer, number and expiration date.) Residence Address or Legal Address City
State
Zip Code
Primary Phone
Email Address
GBU FINANCIAL LIFE
www.gbu.org newbusiness@gbu.org PO Box 645949, Pittsburgh, PA 15264-5257 412-884-5100 800-765-4428 ICC21-ANA
1 of 6
Primary Annuitant
(Complete only if the Annuitant is not the Policy Owner. Must be completed if Annuitant is aged 0 to 17.) Male
Legal Name (First, Middle, Last, Suffix)
Female
Sex Date of Birth
Social Security Number
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 State
City Primary Phone
Joint Annuitant
Zip Code
Email Address
(Available for non-qualified annuities only.) Male Sex
Legal Name (First, Middle, Last, Suffix) Social Security Number
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 Annuitant Residence Address or Legal Address City
State
Primary Phone
Email Address
ICC21-ANA
Zip Code
2 of 6
Beneficiaries
(Total shares between beneficiaries of each class must equal 100%. If percentage shares are not listed, they will be divided equally among beneficiaries.)
Primary Beneficiaries Full Legal Name and Address of Full Legal Name and AddressDate ate of Birth irth
Social Social Security ## Security
Relationship to to the the Relationship Owner Owner
Share % (Must equal 100%)
Social Security #
Relationship to the Owner
Share % (Must equal 100%)
Contingent Beneficiaries Full Legal Name and Address
Date of Birth
(If additional room is needed, please use a separate page; include full legal name and address, date of birth, social security number, relationship to the Owner, share %, Owner signature and date.)
Product Information Product Details Plan Type Non-Qualified
Inherited IRA
Traditional IRA
Roth IRA
Coverdell
SEP
Non-Qualified Stretch
Product Multi-Year Growth Annuity (MYGA) Asset Guard 2 Asset Guard 3 Asset Guard 4 Asset Guard 5
ICC21-ANA
3 of 6
Payment Information Total Initial Premium
Initial Payment Method
Recurring Premium Amount (EFT only. For flexible premium annuities only.) Monthly
Quarterly
Semi-Annually
Recurring Premium Frequency
Payor Information
Recurring Premium Method
Annually
(Complete if the Payor is not the Owner of the policy.)
Legal Name (First, Middle, Last, Suffix)
Residence Address or Legal Address
Zip Code
State
City Primary Phone
Email Address
Source of Funds New Investment
Exchange Rollover
1035 Exchange
Transfer
Other
Identify the source(s) of funds used for this contract
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 Yes
No (Producer) 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.) No (Producer) Yes No (Applicant) Yes Company
Type of Coverage
Policy Number
Face Amount
Replacement (Y/N)
If any replacement is intended as a 1035 Exchange, complete a 1035 Supplement form for each policy to be exchanged. ICC21-ANA
4 of 6
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:
ICC21-ANA
Yes
No
Applicant:
Yes
No
5 of 6
Agreements and Signatures, Continued IRS Certification
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 Printed Legal Name of Insurance Producer
ICC21-ANA
Date GBU Producer Number
State License Number (If required)
6 of 6
GBU FINANCIAL LIFE
PO BOX 645949 PITTSBURGH, PENNSYLVANIA 15264-5257 412-884-5100 800-765-4428 WWW.GBU.ORG NEWBUSINESS@GBU.ORG
Asset Guard Annuity Disclosure Please check the appropriate box:
□ Qualified Annuity
□ Non-qualified Annuity
The Asset Guard Annuity is an individual fixed single-premium deferred annuity. You purchase the annuity with one premium payment, but premiums are accepted during the first 90 contract days to accommodate multiple roll-overs, transfers and exchanges. Interest is earned during the accumulation phase and annuity benefit payments are deferred until the Maturity Date or upon Annuitization. Under current tax law: (a) the principal and earnings are not subject to income taxes until funds are withdrawn or distributed; and (b) a 10% IRS early-withdrawal penalty may apply to withdrawals or distributions prior to age 59½. Tax law is subject to change. Please consult your financial or tax professional for any exceptions to the earlywithdrawal penalty. The main purposes of a deferred annuity are: (a) to save money for retirement; and (b) to receive retirement income for life. It is not meant for short-term financial goals. THE ANNUITY CONTRACT.
How will my annuity grow?
Annuity. An annuity allows you to pay a premium for the Contract and interest will be earned on a taxdeferred basis. The premium and interest earnings are not subject to income taxes until the funds are withdrawn or distributed. Issue Age. The Asset Guard Annuity will be issued to Owners age 18-95 and Annuitants age 0-95. Contract Effective Date. The contract effective date is the date premium is received in GBU’s home office. The effective date is shown on the contract cover. Premium. An Asset Guard Annuity may be established with an initial premium of $25,000 to $2,000,000 (or more with prior home-office approval). Interest Rates. The initial premium will receive the interest rate in effect as of the date the application and premium are received in the home office. Additional premium received during the first 90 days of the Contract will receive the interest rate in effect at the time it is received in the home office.
□
□
□
□
5 years, 4 years, 3 years or Premium payments are credited with a guaranteed interest rate for 2 years, depending on the plan design (please check the applicable number of years). Thereafter, the Accumulation Value will be credited with renewal interest rates based on the current economic and interest rate environment. Annuity Values. The Accumulation Value is the amount available to provide annuity benefit payments and death benefits. The Accumulation Value is: (a) premium plus credited interest; minus (b) amounts surrendered, including surrender charges and associated market value adjustments. The Surrender Value is the amount available to provide surrender benefits. The Surrender Value is: (a) the Accumulation Value; minus (b) surrender charges, including any associated market value adjustment. Safety and Guarantees. GBU guarantees that the Owner will never receive less than: (a) 87½% of the total premium payments, net of any withdrawals; accumulated at (b) an annual interest rate no less than1.00%. SURRENDER BENEFITS.
May I take money out of my annuity?
You may take money out of your annuity any time before annuity benefit payments begin. You may take out all of your annuity’s Surrender Value (full surrender) or part of it (partial surrender). Withdrawals must be $500 or more. At least $2,000 must remain in the annuity for the Contract to remain in force. A 10% IRS penalty may apply to withdrawals made before you reach age 59½.
DISC_SPDA_AG_(4-21)
Page 1 of 5
Initial Surrender Charge Period. A surrender charge will be assessed on amounts you withdraw during the Surrender Charge Period, as follows: Contract Year Asset Guard 5 Surrender Charge Asset Guard 4 Surrender Charge Asset Guard 3 Surrender Charge Asset Guard 2 Surrender Charge
1 8.0% 8.0% 8.0% 8.0%
2 8.0% 8.0% 7.0% 7.0%
3 7.0% 7.0% 6.0%
4 6.0% 6.0%
5 5.0%
Subsequent Surrender Charge Period(s). The surrender charges for each Contract Year of each subsequent Surrender Charge Period are the same as those for each Contract Year of the initial Surrender Charge Period. There are no surrender charges during the first 45 days of each subsequent Surrender Charge Period. During those 45 days, you may choose one of the following options: 1. Continue your Contract and apply the current Accumulation Value to the subsequent Surrender Charge Period. You may also pay additional premium at this time. 2. Begin payment of the Accumulation Value under a payment option without a surrender charge. 3. Make a partial surrender without a surrender charge and apply the remaining Accumulation Value to the subsequent Surrender Charge Period. 4. Surrender your Contract without a surrender charge. If you do not make a choice during that 45-day period, option 1 above automatically becomes effective. We will provide you with written notice of your options at least 30 days before each subsequent Surrender Charge Period. Market Value Adjustment. The Asset Guard Annuity includes a market value adjustment feature. During each Market Value Adjustment Period, any amount surrendered is subject to a market value adjustment (MVA). The MVA may increase or decrease the amounts payable. Generally, if interest rates rise after the beginning of the current Market Value Adjustment Period, the MVA will decrease the Surrender Value; and, if interest rates fall, the MVA will increase the Surrender Value. The MVA is waived for any surrender or benefit payment for which surrender charges are waived. Market Value Adjustment Period. The Market Value Adjustment Period begins on the date each Surrender Charge Period begins and runs concurrently with each Surrender Charge Period. Example. The following example shows the effective combination of surrender charges and the MVA upon an early surrender during the initial MVA Period when the MVA index rates increase or decrease. The example below assumes the index is 3.00% as of the Contract Effective Date, then either rises to 5.00% or drops to 1.00%. This is for example purposes only. Actual results may vary and depend upon a variety of factors, as described in the Market Value Adjustment rider. 5-Year MVA Period End of MVA Period Year 1 2 3 4 5 Unchanged at 3.00% 8.0% 8.0% 7.0% 6.0% 5.0% 13.8% 13.2% 10.5% 7.8% 5.0% Increased to 5.00% Decreased to 1.00% 2.2% 2.4% 3.3% 4.1% 5.0% 4-Year MVA Period End of MVA Period Year Unchanged at 3.00% Increased to 5.00% Decreased to 1.00% 3-Year MVA Period End of MVA Period Year Unchanged at 3.00% Increased to 5.00% Decreased to 1.00% 2-Year MVA Period End of MVA Period Year Unchanged at 3.00% Increased to 5.00% Decreased to 1.00% DISC_SPDA_AG_(4-21)
1 2 8.0% 8.0% 13.2% 11.5% 2.4% 4.3%
3 7.0% 8.8% 5.2%
1 8.0% 11.5% 4.3%
2 7.0% 8.8% 5.2%
3 6.0% 6.0% 6.0%
1 8.0% 9.8% 6.2%
2 7.0% 7.0% 7.0%
4 6.0% 6.0% 6.0%
Page 2 of 5
ANNUITY BENEFITS. What annuity benefit payment options are available? Maturity Date. The Maturity Date is: (a) the Contract Anniversary coinciding with or next following the date of the (older) annuitant’s 115th birthday; or (b) the 10th Contract Year; whichever is later. The Contract will automatically Annuitize and begin its payout phase, unless otherwise directed. The Contract may be Annuitized at any time. Payout Options. You may choose from the following payment options: Life Income – A guaranteed income for as long as the annuitant lives. Joint & Survivor Life Income – A guaranteed income for as long as one of the annuitants lives. Life Income with Installment Refund – A guaranteed income for as long as the annuitant lives. If the annuitant dies before the total of all payments equals the amount applied to this option, payments will continue to the Beneficiary until the total of all payments equals the amount applied to this option. Certain Period – A guaranteed income for your chosen time period, e.g. 5, 10, 15 or 20 years. Life Income with Certain Period – A guaranteed income for your minimum chosen time period. If the annuitant is still living at the end of that period, payments continue as long as the annuitant lives. Joint & Survivor Life Income with Certain Period – A guaranteed income for your minimum chosen time period. If an annuitant is still living at the end of that period, payments continue as long as any annuitant lives. Joint & Survivor Life Income with Installment Refund – A guaranteed income for as long as an annuitant lives. If the last annuitant dies before the total of all payments equals the amount applied to this option, payments will continue to the Beneficiary until the total of all payments equals the amount applied to this option. Lump Sum – One lump-sum payment of the annuity fund. If a payment option is not chosen, we will automatically pay under the 10-year certain and life payment option. Annuity Benefit Payments. The Contract may not be surrendered once annuity benefit payments have begun. ACCESSING FUNDS. Are there ways to access funds without incurring a surrender charge? Your annuity offers a number of ways to access funds without incurring a surrender charge. There are no surrender charges associated with the following options, but an IRS early-withdrawal penalty may apply to withdrawals before you reach age 59½. Terminal Condition. Nursing Home Confinement or Home Health Care. Critical Illness. Inability to perform two or more Activities of Daily Living or Severe Cognitive Impairment. Earned interest withdrawals. IRS Required Minimum Distributions. Out-of-surrender-charge-period withdrawals. DEATH BENEFITS. What happens if I die? The death benefit is paid to the Beneficiary if the Owner or the Annuitant dies before the Maturity Date, with a choice of payment options. The death benefit is equal to the Accumulation Value as of the date of death. Death benefits must begin within one year of the date of death and may not extend beyond the Beneficiary’s life expectancy. If the deceased Owner’s surviving Beneficiary is the deceased Owner’s spouse as recognized under federal law, that spouse does not need to have death benefits paid. Rather, that spouse may continue the Contract as though that spouse were the original owner. ADVANTAGES OF TAX DEFERRAL UNDER CURRENT TAX LAW. withdrawals from my annuity be taxed? DISC_SPDA_AG_(4-21)
How
will
payouts
and
Page 3 of 5
Your annuity grows tax deferred. Taxes will be due only when withdrawals or distributions are paid from the annuity. An IRS early-withdrawal penalty may also apply to payouts and withdrawals paid before you reach age 59½. There are no additional tax advantages to purchasing an annuity as part of a qualified plan other than those provided by the qualified plan itself. Please consult your broker or financial advisor. OTHER INFORMATION.
What else do I need to know about my annuity?
Free Look. You have 10 days to look over the Contract. You may return the Contract to the agent who sold it or to our home office within those 10 days. Any premium paid will be refunded, less any benefits paid. The Contract will be void and considered never in force. If the Contract is a replacement of a life insurance policy or other annuity contract, the free-look period is extended to 30 days. Commission. We pay a commission to the agent, broker or firm selling you the annuity. OWNER ACKNOWLEDGEMENT I understand the Asset Guard Annuity product features to the extent summarized in this disclosure. I understand that the Contract is intended as a long-term savings vehicle and, as such, may have substantial penalties for early surrenders. I understand and acknowledge that GBU does not offer legal, financial, tax, investment or estate planning advice. I affirm that I have sought such advice from the proper sources before purchasing the Contract. I acknowledge and represent that the purchase of this annuity meets the financial purpose for which it is purchased given my particular legal, financial, tax, investment, estate planning or other goals or circumstances. I further understand that annuities are not: (a) insured by the FDIC or any federal government agency; (b) deposits of or guaranteed by any bank or credit union; (c) provision or conditions of any bank or credit union activity. Some annuities are subject to investment risk and may lose value. I certify that: (a) I have read and understand the Asset Guard Annuity product brochure, the application and this disclosure statement; (b) I have retained a copy of all solicitation materials and this disclosure used during the course of the sale; and (c) I understand that this disclosure is not part of the Contract. __________________________________________________________________________________ (Owner Signature) (Date - mm/dd/yyyy) __________________________________________________________________________________ (Owner Printed/Typed Name) Signed at: ______________________________ (City, State)
Email Address: ________________________
__________________________________________________________________________________ (Joint Owner Signature, if any) (Date – mm/dd/yyyy) __________________________________________________________________________________ (Joint Owner Printed/Typed Name) Signed at: ______________________________ (City, State)
Email Address: ________________________
__________________________________________________________________________________ (Annuitant Signature, if other than Owner) (Date - mm/dd/yyyy) __________________________________________________________________________________ (Annuitant Printed/Typed Name) Signed at: ______________________________ (City, State)
Email Address: ________________________
__________________________________________________________________________________ (Joint Annuitant Signature, if any) (Date – mm/dd/yyyy) __________________________________________________________________________________ (Joint Annuitant Printed/Typed Name) Signed at: ______________________________ (City, State) DISC_SPDA_AG_(4-21)
Email Address: ________________________ Page 4 of 5
INSURANCE PRODUCER ACKNOWLEDGEMENT I have provided the applicant(s) with the consumer materials used during the course of the sales presentation, the application and the Asset Guard Annuity disclosure document. I have informed the applicant(s) of the various features of the Asset Guard Annuity. I certify that given the information provided to me by the applicant(s), I believe to the best of my knowledge and belief that the Asset Guard Annuity meets the applicant’s financial purpose for which it is purchased given the applicant’s particular legal, financial, tax, investment, estate planning or other goals or circumstances I further certify that I have made no statements, representations or promises about product features and future rate performance that are in any way inconsistent with those materials. __________________________________________________________________________________ (Insurance Producer Signature) (Date - mm/dd/yyyy) __________________________________________________________________________________ (Insurance Producer Printed/Typed Name) Signed at: ______________________________ (City, State)
DISC_SPDA_AG_(4-21)
Email Address: ________________________
Page 5 of 5
Suitability Information The Insurer identified above will be referred to herein as the “Company”
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
Employed
Retired
Unemployed
Risk Tolerance and Investment Objective Select the highest risk tolerance the owner/applicant is willing to accept. Aggressive
Moderately Aggressive
Moderate
Moderately Conservative
Conservative
Select the investment objective that matches registration’s investments. Aggressive
Growth
Balanced/Conservative Growth
Preservation of Principal
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 +
Under $20,000
$20,000 - $49,999
$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 +
Under $20,000
$20,000 - $49,999
$50,000 - $99,999
$100,000 - $159,999
$160,000 - $299,999
$300,000 - $499,999
$500,000 +
Earned/Spousal Income
IRA/SEP/SIMPLE/Roth
Qualified Plan/Pension
Investment/Rental
Reverse Mortgage
None
Liquid Net Worth
Annual Income
Source of Income
Social Security
Other -
Federal Tax Bracket 0 - 12%
13 - 31%
32% +
GBU FINANCIAL LIFE
ASQ-0421
www.gbu.org newbusiness@gbu.org PO Box 645949, Pittsburgh, PA 15264-5257 412-884-5100 800-765-4428
1 of 3
Select all prior investment experience and provide approximate current value of assets (exclude this purchase). Bank Savings, CDs, Money Market Funds
Yes
No
Stocks
Yes
No
Bonds
Yes
No
Mutual Funds
Yes
No
Life Insurance (Cash Value)
Yes
No
Variable Annuities
Yes
No
Fixed Annuities
Yes
No
Other
Yes
No
Does your current income cover your expected day to day living expenses?
Yes
No
Do you have cash and/or other liquid assets available to you that may be used in the event of a financial emergency?
Yes
No
Individual Product Information Purpose (select all that apply) 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
ASQ-0421
2 of 3
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
ASQ-0421
3 of 3
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”) Last Name: First 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 offer the following products:
Fixed or Fixed Indexed Annuities
Variable Annuities
Life Insurance
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. Mutual Funds Stocks/Bonds Certificates of Deposit Whose Annuities Can I Sell You? I am authorized to sell: Annuities from only one (1) Annuities from two (2) insurer 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
www.gbu.org newbusiness@gbu.org PO Box 645949 Pittsburgh, PA 15264-5257 412-884-5100 800-765-4428 GBU-AGTAN-DISC-0821_REV011922
1
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
GBU-AGTAN-DISC-0821_REV011922
2
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
GBU-CPNR Form-1121
Date
GBU FINANCIAL LIFE
www.gbu.org newbusiness@gbu.org PO Box 645949 Pittsburgh, PA 15264-5257 412-884-5100 800-765-4428
1
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
GBU-CRPI-Form-0821
Date
GBU FINANCIAL LIFE
www.gbu.org newbusiness@gbu.org PO Box 645949 Pittsburgh, PA 15264-5257 412-884-5100 800-765-4428
1
Payment Authorization The Insurer identified above will be referred to herein as the “Company”
Policy Number
Automatic Payment Authorization Full Name of Bank
Account Type Checking
Account Number
Routing Number
Withdrawal Date
Savings
Name of Account Owner Account Owner Address
City
State
Zip 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.
Date
Signature of Bank Account Owner
GBU FINANCIAL LIFE www.gbu.org newbusiness@gbu.org PO Box 645949, Pittsburgh, PA 15264-5257 412-884-51 00 800-765-4428
API-0522V2
1 of 1
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. www.cancer.org American Cancer Society (Health) 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. www.liverfoundation.org American Liver Foundation (Health) Mission Statement: To facilitate, advocate and promote education, support and research for the prevention, treatment and cure of liver disease. www.redcross.org American Red Cross (Human Services/Disaster Relief) 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.
www.toysfortots.org Marine Toys for Tots Foundation (Children/Family Services) 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. www.npca.org National Parks Conservation Association (Environment) Mission Statement: To protect and enhance America’s National Parks for present and future generations. www.operationtroopappreciation.org Operation Troop Appreciation (Military/Veterans) 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. www.humanesociety.org Humane Society of the United States (Animal Rights and Care) 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. Please visit GBU at www.gbu.org to learn more about GBU, member benefits and our desire to help others. Member’s Signature _________________________________________________________________________ Email (please print clearly): ____________________________________________________________________
GBU FINANCIAL LIFE
OMT 01.20
www.gbu.org newbusiness@gbu.org PO Box 645949, Pittsburgh, PA 15264-5257 412-884-5100 800-765-4428
1
Optional Documents Trust Certification 1035 Exchange Transfer/Rollover
Trust Certification The Insurer identified above will be referred to herein as the “Company”
Complete if there is a Trust Owner on the application for:
Trust Information Date of Trust
Name of Trust
Trust Tax ID Number
Trust Type Revocable
Irrevocable
Name of Grantor(s) Trust Address
State
City
Name of Trustee
Address
Phone Number
If there is more than one trustee, can trustees act independently? •
Zip Code
Yes
No
If No, how many trustee signatures are required to complete a transaction (Enter number or All)? _____
GBU FINANCIAL LIFE
TF-0522V2
www.gbu.org newbusiness@gbu.org PO Box 645949, Pittsburgh, PA 15264-5257 412-884-51 00 800-765-4428
1 of 2
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
Date Signed
Signature of Trustee
Date Signed
TF-0522V2
2 of 2
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 State
City Phone Number
Zip Code
Fax Number
Surrendering Company Information
Complete one form for each surrendering company
Name
Street Address City Phone Number
State
Zip Code
Fax Number
Owner Information Social Security/Tax ID #
Name
Joint Owner Information Name
Social Security/Tax ID #
Insured/Annuitant Information—if other than owner Social Security/Tax ID #
Name
GBU FINANCIAL LIFE
EXC-0522V2
www.gbu.org newbusiness@gbu.org PO Box 645949, Pittsburgh, PA 15264-5257 412-884-5100 800-765-4428
Page 1 of 4
Joint Insured/Annuitant Information Name
Social Security/Tax ID #
Surrendering Policy/Contract Information
Complete one form for each surrendering policy / contract Policy/Contract Type
Policy/Contract Number
Policy/Contract Status
Life
Lost or Destroyed
Annuity
Attached to Application
1035 Exchange Details Please confirm the availability of these options with both the surrendering and receiving company. Not all receiv-ing 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:
EXC-0522V2
Page 2 of 4
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. EXC-0522V2
Page 3 of 4
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 be-cause 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
EXC-0522V2
Page 4 of 4
Transfer/Rollover This form can be used to accomplish a Transfers of Funds and Direct Rollovers of policies. 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 rollover/transfer if the funds do not meet its minimum premium requirements.
Receiving Company Information Name Street Address State
City Phone Number
Zip Code
Fax Number
Surrendering Company Information Complete one form for each surrendering company Name Street Address State
City Phone Number
Zip Code
Fax Number
Owner Information Social Security/Tax ID #
Name
Joint Owner Information Name
Social Security/Tax ID #
Insured/Annuitant Information—if other than owner Name
Social Security/Tax ID #
Joint Insured/Annuitant Information Social Security/Tax ID #
Name
GBU FINANCIAL LIFE
TF-0522V2
www.gbu.org newbusiness@gbu.org PO Box 645949, Pittsburgh, PA 15264-5257 412-884-5100 800-765-4428
Page 1 of 4
Surrendering Policy/Contract Information
Complete one form for each surrendering policy / contract
Policy/Contract Number
Non-Qualified Transfer of Funds Details Existing Funds: Mutual Funds Shares
Brokerage Account
Certificate of Deposit
Money Market Account
Other
Investment Description: Redemption Value: I wish to liquidate and transfer:
Entire Value or
Partial Value, in the amount of: $
or
%
of the above-referenced account directly to the receiving company. Specify Funds to Liquidate: Fund/Account Number:
Qualified Transfer of Funds Details Transferred from: Traditional IRA
SEP-IRA
SIMPLE IRA
Roth IRA**
401(k) Designated Roth Account
Beneficial IRA
Specify Type:
Pension Plan
401(a)
401(k)
457(b) Plan
TSA/403(b)*
Other
** 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 Percentage Specified 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.) TF-0522V2
Page 2 of 4
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.
TF-0522V2
Page 3 of 4
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
TF-0522V2
Page 4 of 4