THE PENN MUTUAL LIFE INSURANCE COMPANY

Transcription

1 THE PENN MUTUAL LIFE INSURANCE COMPANY TEXAS Instructions for the Fixed Deferred and Single Premium Immediate Annuity Applications This application package is broken down into 3 components: PM1151 PM1152 PM1154 Annuity Application - Gathers all the required information on product, owner and suit ability information. Agent(s) Certification and Signatures All agents receiving compensation must sign this document. Supplemental Application for the Single Premium Immediate Annuity Gathers information for income payment mode, selection of plan type and federal income tax withholding. Only PM1151 and PM1152 are required for the Flexible or Single Premium Fixed Deferred Annuity sales. All of the sections require signatures and must be submitted together as a package. Missing information will result in processing delays. Please have the client initial above crossed out application changes. Use of white out is not acceptable. We are unable to accept starter checks, money orders and cashier checks. To assist you with the sale of this annuity, we have included key state required forms and additional Penn Mutual forms. See next page for product information. Please go to Producer s Place on the Penn Mutual Website for state approvals and detailed product information. Mailing Address: Penn Mutual Life Insurance Company Annuity New Business C2L 600 Dresher Road Horsham, PA (800) PM1160(TX) Version 04/06

2 Fixed Deferred and Immediate Annuity Product Sheet Single Premium Fixed Deferred Annuity 7 year surrender schedule based on age of contract Enhanced interest rate on first year purchase payments $5,000 Minimum Maximum issue age is 85 (based on age nearest birthday) Accepts deposits in 1st contract year only Flexible Premium Fixed Deferred Annuity 7 year surrender schedule based on age of contract Enhanced interest rate on first year purchase payments $5,000 Minimum Maximum issue age is 85 (based on age nearest birthday) Accepts ongoing deposits Single Premium Immediate Annuity $2,500 Minimum Maximum issue age is 85 (based on age nearest birthday) Flexible Pay-Out Options COLA benefit available on non-qualified contracts PM1160(TX) Version 04/06

3 The Penn Mutual Life Insurance Company Philadelphia, PA Annuity Application GENERIC 1. PRODUCT / MARKET TYPE Product Type: FIXED DEFERRED VARIABLE DEFERRED SINGLE PREMIUM IMMEDIATE Must Also Complete: PM1152 PM1152 and PM1153 PM1152 and PM1154 Product Name: INSERT PRODUCT NAME FROM PRODUCT SHEET Type of Annuity to be Established Non Qualified Individual (includes Trusts and Corporations) 1035(a) Tax Free Exchange Charitable Remainder Trust (Check Product Availability) Qualified Traditional IRA (Roth IRA not available) SEP IRA* Simple IRA* Inherited IRA/Stretch Custodial IRA 403(b) 412(i) Qualified Plan* Type of Qualified Payment Regular Contribution Tax Year Transfer - Institution to Institution Rollover * Retirement Planner Only: Group Name or # Future Amount to be Billed $ 2. BENEFITS AND OPTIONS LIVING BENEFITS Not available with Enhanced Death Benefit Available on Selected Variable Deferred Products Only Guaranteed Minimum Accumulation Benefit Guaranteed Minimum Withdrawal, Accumulation and Death Benefit ENHANCED DEATH BENEFITS OTHER Available on Selected Variable Deferred Products Only Optional Step-Up Plus Optional Rising Floor Plus* (Not Available on Enhanced Credit) Estate Enhancement* (Not Available with IRA) *Not available in NY and WA 10% Cumulative Free Option - Check Product Availability If any rider or benefit I have selected in this Section cannot be added to the contract due to age restriction or state availability, I understand that the contract will be issued without the benefit or rider(s). PM1151 Page 1 of 7 Version 01/06

4 3. PURCHASE PAYMENT: Check Product Minimums Purchase Payment: Estimated Amount of Exchange/Transfer/Rollover: 4. ANNUITANT PRIMARY ANNUITANT: NAME Male Female RESIDENCE: STREET CITY STATE ZIP CODE DATE OF BIRTH: (mm/dd/yyyy) SOCIAL SECURITY # DAYTIME PHONE 5. OWNER: PRIMARY OWNER: NAME / / ( ) JOINT/SECONDARY ANNUITANT: NAME DATE OF BIRTH: (mm/dd/yyyy) SOCIAL SECURITY # DAYTIME PHONE / / ( ) If Annuitant and Owner are the same, it is not necessary to complete this section. Joint Owners must be spouses. List both as beneficiaries in Section 7 if contract is to continue to surviving spouse. RESIDENCE: STREET CITY STATE ZIP CODE Male Male Female Female Entity DATE OF BIRTH: (mm/dd/yyyy) SOCIAL SECURITY / TAX ID # DAYTIME PHONE / / ( ) JOINT OWNER: NAME Male Female DATE OF BIRTH: (mm/dd/yyyy) SOCIAL SECURITY # DAYTIME PHONE / / ( ) 6. OWNER SUITABILITY: To be completed for all annuity business unless otherwise noted below. For HTK Producers: Complete this section for Fixed Annuities ONLY. For Variable Annuities, complete the HTK Account Agreement in lieu of this section. For Non-HTK Producers: This section must be completed for both Fixed and Variable Annuities. HOUSEHOLD INCOME LIQUID NET WORTH (Exclude Value of Residence) TAX BRACKET % U.S. CITIZEN $ $ % Yes No A. Prior Investment Experience None - No investment experience. Previous holdings were generally limited to bank savings accounts and CDs. Average - Invests in securities on an infrequent basis. Has 1-2 years experience investing in securities. Has a general knowledge of the risks and rewards of investing in securities. Above Average - Invests in securities on a frequent basis. Has a number of years experience investing in securities. Has a general knowledge of the risks and rewards of investing in securities. Active - Invests in securities on a frequent basis. Has a number of years experience investing in securities. Has extensive knowledge of the risks and rewards of investing in securities. PM1151 Page 2 of 7 Version 01/06

5 6. OWNER SUITABILITY (Continued) B. Risk Profile Conservative-Accepts a low return potential. Maintain a low degree of risk Moderate-Accepts fair degree of risk including lack of liquidity, in order to pursue the potential for a modest return Aggressive-Accepts high degree of risk, including a limited loss of principal, in order to pursue the potential for a higher return Very Aggressive-Accepts maximum degree of risk, including total loss of principal, in order to pursue the maximum possible return C. Primary Investment Objective Safety of Principal Preservation of investment Principal Income-Regular, current income stream. May need investment principal within next five years. Growth and Income-Moderate growth. Current Income Stream. May need investment principal within next five years Growth-Grow assets moderately or slightly above rate of inflation. Will not need investment principal for at least ten years Aggressive Growth-Desire to grow assets substantially. Will not need investment principal for at least ten years. Reinvestment of income Speculation-Grow assets substantially in a short time frame. Higher than average possibility of total loss of principal. Will not need investment principal for at least ten years D. Primary Source of Funds (for this transaction) Current Income Gift/Inheritance Proceeds from sale of mutual funds Other Rollover from pension/retirement fund Proceeds from sale of stocks or bonds Policy Values from existing life/annuity contract Surrender of life insurance/annuity contract Savings Personal Loan E. Financial Needs/Benefits (check all that apply) Death Benefit/Enhanced Death Benefit Asset Rebalancing Retirement Funding Estate Planning Tax Deferral/Tax Advantage Savings, Accumulation Diversification of Investments Education/College Funding Business Purposes Annuitization Options Debt Protection Charitable Giving Current Income Other Please provide the anticipated holding period for the product purchased: years PM1151 Page 3 of 7 Version 01/06

6 7. BENEFICIARY: PRIMARY BENEFICIARY: NAME If more than one, indicate whole %. List additional beneficiaries in Remarks Section. If no beneficiary is indicated, the default will be the Estate of the Annuitant. If the contract is issued to a qualified plan, the beneficiary is the Plan Trustee. DATE OF BIRTH: (mm/dd/yyyy) / / SOCIAL SECURITY / TAX ID # PERCENT OF PROCEEDS RELATIONSHIP TO OWNER PRIMARY BENEFICIARY: NAME DATE OF BIRTH: (mm/dd/yyyy) CONTINGENT BENEFICIARY: NAME / / SOCIAL SECURITY / TAX ID # PERCENT OF PROCEEDS RELATIONSHIP TO OWNER PRIMARY BENEFICIARY: NAME DATE OF BIRTH: (mm/dd/yyyy) CONTINGENT BENEFICIARY: NAME / / SOCIAL SECURITY / TAX ID # PERCENT OF PROCEEDS RELATIONSHIP TO OWNER 8. ANNUITY DATE: If no date entered, Annuity Date will be the later of the 1st day of the month after the annuitant s 95 th birthday. WRITE IN DATE: (mm/01/yyyy) / 01 / 9. REPLACEMENT INFORMATION YES NO Do you have existing annuity or life insurance contracts? (For NAIC Model Replacement States, if yes, an Important Notice Regarding Replacement Form is required - PM0479) YES NO Will the annuity applied for replace (in whole or in part) one or more existing annuity or life insurance contracts? If yes, please indicate carrier and contract number(s) in Remarks. For all states, if yes, a Replacement Form is required 10. REMARKS PM1151 Page 4 of 7 Version 01/06

7 11. FRAUD NOTICES Applies to all states except those specifically listed: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or a statement of claim containing any materially false information or conceals for the purpose of misleading information concerning any fact material thereto commits a fraudulent insurance act which is a crime and subjects such person to criminal and civil penalties. Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, and denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies. District of Columbia: WARNING It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. Florida: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or application containing any false, incomplete, or misleading information is guilty of a felony in the third degree. Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals for the purpose of misleading information concerning any fact material thereto commits a fraudulent insurance act which is a crime. Louisiana: 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. Massachusetts: 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. Maine & Tennessee: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purposes of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. New Jersey: Any person who includes false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. New Mexico: 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 civil fines and criminal penalties. Ohio: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. Oklahoma: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds for an insurance policy containing any false, incomplete or misleading information is guilty of a felony. Oregon: Any person who, knowingly and with intent to defraud any insurance company or other person, files an application for insurance or a statement of claim containing any materially false information or conceals for the propose of misleading information concerning any fact material may be guilty of a fraudulent insurance act which is a crime and may subject such person to criminal and civil penalties. Pennsylvania: All applications for insurance and all claim forms shall contain or have attached thereto the following notice: "Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Virginia: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submit an application or files a claim containing a false or deceptive statement may have violated state law. Vermont: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be proven guilty of fraud. Washington: Any person who knowingly presents a false or fraudulent claim for payment of a loss or knowingly makes a false statement in an application for insurance may be guilty of a criminal offense under state law. PM1151 Page 5 of 7 Version 01/06

8 12. DISCLOSURES IRS Annuity Aggregation Rules Under IRS regulations, all deferred annuity contracts issued by the same insurance company to the same policyholder during a calendar year are treated as one annuity contract. Under the IRS aggregation rules, all amounts received from such annuities are aggregated for tax calculation and tax reporting purposes. Notice for Annuity Purchases in Qualified Plans The reasons for the purchase of a variable annuity should not include tax deferral when the annuity is intended for use in a tax-qualified retirement plan such as a 401(k), IRA, SEP, or 403(b). The tax deferral is already provided by the tax-qualified retirement plan. In these situations, the reasons for the purchase of a variable annuity should focus on other benefits, such as lifetime income payments, family protection through an enhanced death benefit, multiple fund managers and guaranteed fees. Qualified Plan/Charitable Remainder Trust Tax Reporting The Penn Mutual Life Insurance Company will not be responsible for any administration or tax reporting for any of the contracts or policies that it issues for the Trust. The Plan Trustee will be responsible for all administration, including tax reporting, trust accounting, calculation of trust distribution requirements, annual trust return filings, etc. The Trustee may, at his/her discretion, retain a qualified third-party administrator (TPA) to perform administration and tax reporting. Deferred Annuity Contracts Owned by Non-Natural Entities Deferred annuity contracts owned by non-natural entities do not qualify for tax-deferred treatment of gains in the contract. Section 403(b) Annuity Contract Restriction for Contract Owners under 59 1 / 2 In connection with my application for a 403(b) Contract, I understand the restrictions on withdrawals from the contract or account as imposed by Section 403(b)(11) of the Internal Revenue Code. I understand that this contract is not subject to the requirements of ERISA. Further, I understand the other investment alternatives, if any, that may be available to me under my employerʼs Sections 403(b) arrangement to which I may elect to transfer my contract or account value and I understand that the same restrictions on withdrawals would apply to such investment alternatives. 13. SIGNATURE(S) AND ACKNOWLEDGEMENTS I hereby represent that my answers to the above Sections are correct and true to the best of my knowledge and belief. By signing below, I understand that: a) This annuity is a long term commitment to meet insurance needs and financial goals. The annuity applied for is suitable for my investment objectives and my financial situation and needs; b) My signature certifies, under penalty of perjury: 1) The number shown in this application as my social secruity number or taxpayer identification number is correct; and 2) I am not subject to backup withholding because I have not been notified by the IRS that I am subject to backup withholding as a failure to report all interest or dividends and, or the IRS has notified me that I am no longer subject to backup withholding, or I am exempt from backup withholding. Check this box if you are subject to backup withholding under section 3406(a)(1)(c) of the Internal Revenue Code. PRIMARY OWNER SIGNATURE DATE: (mm/dd/yyyy) / / JOINT OWNER SIGNATURE DATE: (mm/dd/yyyy) ANNUITANT SIGNATURE (IF NOT OWNER) JOINT ANNUITANT SIGNATURE / / DATE: (mm/dd/yyyy) / / APPLICATION SIGNED AT: CITY STATE BROKERAGE ACCOUNT # (IF APPLICABLE) PM1151 Page 6 of 7 Version 01/06

9 14. PRIMARY AGENT CERTIFICATION AND INFORMATION This contract is replacing an existing life insurance policy or annuity contract. This contract is not replacing an existing life insurance policy or annuity contract. SIGNATURE OF AGENT PRINTED NAME OF AGENT TELEPHONE # BUSINESS NAME BROKER DEALER OR MARKETING ORGANIZATION ( ) 15. HOME OFFICE AMENDMENTS AND CORRECTIONS Not applicable in any state where written consent is required by law. Send Application, Check & Other Required Forms To: Penn Mutual Life Insurance Company Annuity New Business - C2L 600 Dresher Road Horsham, PA (800) PM1151 Page 7 of 7 Version 01/06

10 The Penn Mutual Life Insurance Company 1. ANNUITANT Supplemental Application for Single Premium Immediate Annuity ANNUITANT NAME 2. PAYMENT INFORMATION Payments must start within one year from annuity date. Income Payment Mode: Monthly Quarterly Semi-Annually Annually The first payment date will be one mode (i.e. monthly, quarterly) from the receipt of all money unless a specific date is indicated here: 3. PLAN TYPE Proof of birth is required for the first 5 plan types. Proof of birth is required for all annuitants. 1. Single Life Income (I fully understand that I am purchasing a NO REFUND ANNUITY. There is no Death Benefit at the time of my death.) 2. Single Life Income with Guaranteed Payments 3. Life with Installment Refund Annuity (guarantees the return of premium) 4. Joint & Survivor Annuity (without Death Benefit) 5. Joint & Survivor Annuity with Guaranteed Payments Payments will reduce to % at the death of either Annuitant Payments will reduce to % at the death of the Primary Annuitant (Joint and Contingent) 6. Annuity Certain with Payments Cost of Living Adjustment for Non-Qualified Contracts % compounded annually (Not available on Installment Refund Plan types) 4. FEDERAL INCOME TAX WITHHOLDING CERTIFICATE Complete the following applicable lines: A. I elect to have no income tax withheld from my annuity. (Do not complete Options B or C) B. I want my withholding from each annuity payment to be figured using the number of allowances and marital status shown Single Married Married, but withhold at higher single rate Enter number of allowances C. I want the following additional amount withheld from each annuity payment $ (You must complete Option B) Your annuity payments are subject to Federal income tax withholding unless you elect not to have withholding apply. Your election will remain in effect until you revoke it. You may revoke your election at any time by sending Penn Mutual Life an IRS Form W-4P. Depending on your state of residency, state withholding may be withheld if you elect B or C above. PM1154 Page 1 of 2 Version 01/06

11 5. DIRECT DEPOSIT AUTHORIZATION BANK NAME BANK ROUTING NUMBER ACCOUNT NUMBER Checking Account (attach a voided check) Savings Account (attach a deposit slip) The Penn Mutual Life Insurance Company (PML) is authorized to credit payments to the above account at the bank indicated. The payments are valid only if the payee is (are) alive on the payment date. I, for myself, my heirs, executors, administrators and assignees do hereby agree that any sums of money deposited to my account in error, shall be refunded to PML. This authorization applies to all repetitive payments made to me (us) by PML. 6. SIGNATURES PRIMARY OWNER SIGNATURE SIGNATURE OF AGENT DATE: (mm/dd/yyyy) / / DATE: (mm/dd/yyyy) / / PM1154 Page 2 of 2 Version 01/06

12 The Penn Mutual Life Insurance Company Agents Certification and Signatures 1. ANNUITANT ANNUITANT NAME 2. AGENT 1. I have complied with all state licensing and educational requirements. 2. I have complied with all required Commission Disclosures. 3. For Fixed Annuity Sales, I have provided the client with the Disclosure and Buyer s Guide for Fixed Annuities as required by certain state regulations. 4. If a replacement is involved, all agents associated with this sale certify that replacement is in the best interests of the Contract owner. ALL AGENTS RECEIVING COMMISSION MUST COMPLETE THE INFORMATION BELOW AND SIGN THIS FORM. AGENT S NAME (PRINT NAME) PML OFFICE CODE (3 DIGIT) PML REP CODE (5 DIGIT) % OF COMMISSION SERVICING AGENT INDICATE WITH X AGENT S ADDRESS COMMISSION OPTION SELECTED FOR PRODUCTS (Choose Option 1, 2 or 3 Default is Option 1) Option 1 Option 2 Option 3 I certify to the best of my knowledge the answers to the questions in all parts of this application are true and correct. X Agent Signature X Agent Signature X Agent Signature X Agent Signature X Agent Signature 3. VERIFICATION OF IDENTITIES OWNER Driver s License Passport Birth Certificate Other Government Issued ID ID Number Issuing Authority Issue Date: Expiration Date: JOINT OWNER Driver s License Passport Birth Certificate Other Government Issued ID ID Number Issuing Authority Issue Date: Expiration Date: Review ID and verify that the photograph on the ID is the individual. Record ID information above. If individual does not have a Driver s License, Passport, or unexpired Government Issued photo ID, secure a copy of the individual s birth certificate. ID information must be obtained for ALL owners. For entities (trusts, corporations, partnerships) secure the appropriate documentation (Certification of Trust, Articles of Incorporation, Corporate Resolution, Partnership Agreement) ADDITIONALY FOR ENTITIES AND TRUSTS AND PARTNERSHIPS: Please obtain ID for each Owner, Trustee, or Partner Please complete the New Business Marketing Checklist on the back of this form. PM1152 Page 1 of 2 Version 01/06

13 4. NEW BUSINESS MARKETING INFORMATION If you used elements of any of these marketing programs or tools to support your sale please check all that apply. Penn Mutual Marketing Brochures BBP The Business Building Partners Program BOSS - Business Owner Success Strategies Small Business, Big Mistakes Seminar Marketing Women s Niche Marketing Program The Healthcare Niche Marketing Program Referral Marketing Concepts Newsletters Trade Shows Please check the sales support services and sales concepts used to acquire the sale: Sales Support Services Used Marketing Consultation Advanced Sales Support Product Sales Support (Life or Annuity) Sales Concepts Protection (Death Benefit) Wealth Accumulation (College Funding, Retirement Savings, etc.) Retirement Planning (IRA or Qualified Plan, Retirement Distributions, etc.) Estate Planning (Estate Liquidity, Wealth Transfer, Charitable Giving, etc.) Business Continuation (Buy-Sell Agreement, Key Person, PASS/PASS Plus, etc.) Selective Employee Benefits (Deferred Comp, Split Dollar, Executive Bonus, etc.) PM1152 Page 2 of 2 Version 01/06

14 PML Fixed & Variable Annuity Suitability Questionnaire 600 Dresher Road Horsham, PA Product Name: Contract Owner s Name: Date of Birth Owner s Tax ID Number: Owner s Occupation: Approximate Liquid Net Worth*: Marginal Tax Bracket % *Exclude home Holding Period (# of Years) Earned Income: Unearned Income: No. Dependents: Investment Objective (Check all that apply) 1 Safety of Principal Preservation of investment Principal. 1 Income-Regular, current income stream. May need investment principal within next five years. 1 Growth and Income-Moderate growth. Current Income Stream. May need investment principal within next five years. 1 Growth-Grow assets moderately or slightly above rate of inflation. Will not need investment principal for at least ten years. 1 Aggressive Growth-Desire to grow assets substantially. Will not need investment principal for at least ten years. Reinvestment of income. 1 Speculation-Grow assets substantially in short time frame. Higher than average possibility of total loss of principal. Will not need investment principal for at least ten years. Investment Experience (Check one) 1 None - No investment experience. Previous holdings were generally limited to bank savings accounts and CD s. 1 Average-Invests in securities on an infrequent basis. Has 1-2 years experience investing in securities. General knowledge of the risks and rewards of investing in securities. 1 Above Average-Invests in securities on a frequent basis. Has a number of years experience investing in securities. Has a general knowledge of the risks and rewards of investing in securities. 1 Active-Invests in securities on a frequent basis. Has a number of years experience investing in securities. Has extensive knowledge of the risks and rewards of investing in securities. Risk Profile (Check one) 1Conservative-Accepts a low return potential. Maintain a low degree of risk. 1Moderate-Accepts fair degree of risk including lack of liquidity, in order to pursue the potential for a modest return. 1Aggressive-Accepts high degree of risk, including partial loss of principal, in order to pursue the potential for a higher return. 1Very Aggressive-Accepts maximum degree of risk, including total loss of principal, in order to pursue the maximum possible return. Primary Source of Funds: 1 Current Income 1 Savings 1 Gift/Inheritance 1 Rollover from pension/retirement plan 1 Policy Values from existing life/annuity contract** 1 Surrender of life insurance/annuity contract** 1 Proceeds from sale of stocks or bonds 1 Proceeds from sale of mutual funds** 1 Personal Loan 1 Other ** Investor consent form or appropriate switching forms must be attached (HTK Producers Only) Financial Needs/Benefits (Check all that apply) 1 Death Benefit/Enhanced Death Benefit 1 Tax deferral/tax advantage 1 Annuitization Options 1 Diversification of Investments 1 Asset Rebalancing 1 Charitable Giving 1 Business Purposes 1 Retirement Funding 1Savings, Accumulation 1 Education/College Funding 1 Current Income 1 Estate Planning 1 Other 1 I ELECT NOT TO PROVIDE THE INFORMATION NECESSARY FOR MY AGENT TO MAKE A RECOMMENDATION REGARDING THIS FIXED ANNUITY PURCHASE OR EXCHANGE. INFORMATION MUST BE PROVIDED FOR VARIABLE SALES. Owner Initial Joint Owner Initial The reasons for the purchase of an annuity should not include tax deferral when the annuity is intended for use in a taxqualified retirement plan such as a 401(k), IRA, SEP, or 403(b). The tax deferral feature is already provided by the taxqualified retirement plan. In these situations, the reasons for the purchase of an annuity should focus on other benefits, such as lifetime income payments, family protection through an enhanced death benefit, multiple fund managers and guaranteed fees. Owner Signature Joint Owner Signature Date The representative(s) certifies that the above information is correct and complete and that the client is known to the representative(s). All contract features; charges and expenses have been fully explained to the client. Additionally, the client has sufficient assets to meet short-term liquidity needs and has a long - term investment objective. Producer (1) Producer (2) Date Supervising Principal Date (HOME OFFICE USE ONLY) PM1058A Contract Number:

15 Instructions PML Fixed & Variable Annuity Suitability Questionnaire PM1058A This questionnaire/supplement must be completed for ALL Penn Mutual annuity sales (fixed or variable) made to clients, who reside in applicable states. The questionnaire must be completed for the OWNER of the annuity contract. Exemptions Unless otherwise specifically included, this questionnaire shall not apply to recommendations involving: Contracts used to fund: o An employee pension or welfare benefit plan that is covered by the Employee Retirement and Income Security Act (ERISA) o A plan described by Sections 401(a) (Government Plan), 401(k), 403(b) (TSA), 408(k) (SEP) or 408(p) (Simple IRA) of the Internal Revenue Code (IRC), as amended, if established or maintained by an employer o A government or church plan defined in Section 414 of the IRC, a government or church welfare benefit plan, or a deferred compensation plan of a state or local government or tax exempt organization under Section 457 of the IRC o A non-qualified deferred compensation arrangement established or maintained by an employer or plan sponsor o Settlements of or assumptions of liabilities associated with personal injury litigation or any dispute or claim resolution process PM1058A

16 Statement on Existing Policies or Contracts Do you have any existing insurance policies or annuity contracts? Yes No If you answered yes above, please complete PM0479 the Important Notice: Replacement of Life Insurance and Annuities form. I certify that the above response, to the best of my knowledge, is accurate. Applicant s Signature Date Producer s Signature Date PM0479A

17 IMPORTANT NOTICE: REPLACEMENT OF LIFE INSURANCE AND ANNUITIES This document must be signed by the applicant and the producer, if there is one, and a copy left with the applicant. You are contemplating the purchase of a life insurance policy or annuity contract. In some cases this purchase may involve discontinuing or changing an existing life insurance policy or annuity contract. If so, a replacement is occurring. Financed purchases are also considered replacements. A replacement occurs when a new life insurance policy or annuity contract is purchased and, in connection with the sale, you discontinue making premium payments on the existing life insurance policy or annuity contract, or an existing life insurance policy or annuity contract is surrendered, forfeited, assigned to the replacing insurer, or otherwise terminated or used in a financed purchase. A financed purchase occurs when the purchase of a new life insurance policy or annuity contract involves the use of funds obtained by the withdrawal or surrender of or by borrowing some or all of the policy values, including accumulated dividends, of an existing life insurance policy or annuity contract, to pay all or part of any premium or payment due on the new life insurance policy or annuity contract. A financed purchase is a replacement. You should carefully consider whether a replacement is in your best interest. You will pay acquisition costs and there may be surrender costs deducted from your life insurance policy or annuity contract. You may be able to make changes to your existing life insurance policy or annuity contract to meet your insurance needs at less cost. A financed purchase will reduce the value of your existing life insurance policy or annuity contract and may reduce the amount paid upon the death of the insured. We want you to understand the effects of replacements before you make your purchase decision and ask that you answer the following questions and consider the questions on the back of this form. 1. Are you considering discontinuing making premium payments, surrendering, forfeiting, assigning to the insurer,or otherwise terminating your existing life insurance policy or annuity contract? YES NO 2. Are you considering using funds from your existing life insurance policy or annuity contract to pay premiums due on the new life insurance policy or annuity contract? YES NO If you answered "yes" to either of the above questions, list each existing life insurance policy or annuity contract you are contemplating replacing (include the name of the insurer, the insured or annuitant, and the policy or contract number if available) and whether each life insurance policy or annuity contract will be replaced or used as a source of financing. Page 1 of 4 PM0479TX 09/08

18 INSURER CONTRACT OR INSURED OR REPLACED ( R ) OR NAME POLICY # ANNUITANT FINANCING ( F ) Make sure you know the facts. Contact your existing company or its insurance producer for information about the old life insurance policy or annuity contract. If you request one, an in-force illustration, policy summary or available disclosure documents must be sent to you by the existing insurer. Ask for and retain all sales material used by the insurance producer in the sales presentation. Be sure that you are making a informed decision. You have the right to return the new life insurance policy or annuity contract within 30 days of the delivery of the life insurance policy or annuity contract and receive an unconditional full refund of all premiums or considerations paid on it including any policy fees or charges or, in the case of a variable or market value adjustment policy or contract, a payment of the cash surrender value provided under the life insurance policy or annuity contract plus the fees or other charges deducted from the gross premiums or considerations imposed under such life insurance policy or annuity contract. The existing life insurance policy or annuity contract is being replaced because I certify that the responses herein are, to the best of my knowledge, accurate: The insurance producer (check one) did did not read aloud this notice to the applicant. Applicant s Signature and Printed Name Date Producer s Signature and Printed Name Date I do not want this notice read aloud to me. not want the notice read aloud.) (Applicant must initial only if they do A replacement may not be in your best interest, or your decision could be a good one. You should make a careful comparison of the costs and benefits of your existing life insurance policy or annuity contract and the proposed life insurance policy or annuity contract. One way to do this is to ask the company or insurance producer that sold you your existing life insurance policy or annuity contract to provide you with information concerning your existing life insurance policy or annuity contract. This may include an illustration of how your existing life insurance policy or annuity contract is working now and how it would perform in the future based on certain assumptions. Illustrations should not, however, be used as a sole basis to compare policies or contracts. You should discuss the following with your insurance producer to determine whether replacement or financing your purchase makes sense. Page 2 of 4 PM0479TX 09/08

19 PREMIUMS: Are they affordable? Could they change? How long will you have to pay premiums on the new policy? On the old policy? POLICY VALUES: New policies usually take longer to build cash values and to pay dividends. Acquisition costs for the old policy may have been paid. You will incur costs for the new one. What surrender charges do the policies have? What expense and sales charges will you pay on the new policy? Does the new policy provide more insurance coverage? INSURABILITY: If your health has changed since you bought your old policy, the new one could cost you more, or you could be turned down. You may need a medical exam for a new policy. Claims on most new policies for up to the first two years can be denied based on inaccurate statements. Suicide limitations may begin anew on the new coverage. IF YOU ARE KEEPING THE OLD POLICY AS WELL AS THE NEW POLICY: How are premiums for both policies being paid? How will the premiums on your existing policy be affected? Will a loan be deducted from death benefits? What values from the old policy are being used to pay the premium? Page 3 of 4 PM0479TX 09/08

20 IF YOU ARE SURRENDERING AN ANNUITY OR INTEREST SENSITIVE LIFE PRODUCT: Will you pay surrender charges on the old contract? What are the interest rate guarantees for the new contract? Have you compared the contract charges or other policy expenses? OTHER ISSUES TO CONSIDER FOR ALL TRANSACTIONS: What are the tax consequences of buying the new policy? Is this a tax-free exchange? (See your tax advisor.) Is there a benefit from favorable grandfathered treatment of the old policy under the federal tax code? Will the existing insurer be willing to modify the old policy? How does the quality and financial stability of the new company compare with the existing company? Page 4 of 4 PM0479TX 09/08