APPLICATION FOR ANNUITY. Proposed Annuitant Name: FIRST MIDDLE LAST. Address: STREET CITY STATE ZIP

Transcription

1 APPLICATION FOR ANNUITY Proposed Annuitant Name: FIRST MIDDLE LAST Address: STREET CITY STATE ZIP Social Security Number: Date of Birth: / / Sex: q Male q Female Proposed Second Annuitant Name: (if applicable - SPIA only) FIRST MIDDLE LAST Address: STREET CITY STATE ZIP Social Security Number: / / Date of Birth: Sex: q Male q Female Contingent Annuitant Name (if applicable): FIRST MIDDLE LAST Address: STREET CITY STATE ZIP Social Security Number: / / Date of Birth: Sex: q Male q Female Owner Name (if other than proposed annuitant): FIRST MIDDLE LAST Address: STREET CITY STATE ZIP / / Tax I.D./Social Security Number: Date of Birth: Sex: q Male q Female Payor Name (if different than Owner: FPA ONLY): Payor Address: Beneficiary Designation(s): Print full name of Beneficiary(ies) and Relationship to Owner. Applicable upon the death of the Owner or Annuitant as provided in the Contract. Primary: Relationship: Date of Birth: Address: Social Security #: Contingent: Relationship: Date of Birth: Address: Social Security #: NY 08/2013 Page 1 of 3

2 PRODUCT TYPE: q SPDA Initial Interest Rate Guarantee Period: q One Year q Three Year q Five Year Dividend Option: q Accums q Cash Bailout Option: q Yes q No q FPA Stipulated Premium: $ Premium Mode: Disability Benefit: q Yes q No If Yes complete Part 2 of Standard Life Insurance Application and Conditional Receipt, if applicable. Dividend Option: q Accums q Cash q SPIA (Complete for SPIAs Only) Riders to be attached. q 20% Withdrawal Rider q Annuity Income Advance Rider q Guarantee Period Withdrawal Rider (Only available with SPIAs which provide for guarantee period). CONTRACT q Nonqualified q IRA* q Qualified Pension or Profit Sharing q 403(b) TSA TYPE: *If IRA, select one: q Rollover q Transfer q Contribution for tax year Premium Paid: $ Make check payable to: Security Mutual Life Insurance Company of New York SPECIAL INSTRUCTIONS: Type of Annuity Benefit: q Fixed Period ( Years) q Life Income Years Certain q Life Annuity Only ( OPTIONS: 100%; 75%; 2/3 RDS; 50% ) q Joint and Survivor (other than SPIA) % to Survivor Joint and Survivor SPIA % to survivor (specify) q Selection Deferred Joint Payee Name: FIRST MIDDLE LAST / / Social Security Number: Date of Birth: Sex: q Male q Female Annuity Commencement Date (Maturity Date): q q q q Year q q Month Does APPLICANT have any life insurance or annuity contract in force with any insurer? q Yes q No Will the insurance or annuity now being applied for replace or change insurance or annuities in any Company? q Yes q No If Yes, list contracts to be replaced and attach required replacement forms. Name of Company: Policy No: NY 08/2013 Page 2 of 3

3 I hereby represent my answers to the above questions to be complete and true to the best of my knowledge and belief and agree that this application shall be a part of any contract issued by the Company. Signed at: Date: AGENT S STATEMENT: Does the applicant have existing life insurance policies or annuity contracts? q Yes q No To the best of your knowledge,does this annuity replace any existing insurance or annuity? q Yes q No If Yes, have you complied with all state replacement requirements? q Yes q No Signature of Proposed Annuitant Signature of Soliciting Agent Signature of Owner or Applicant (if other than Proposed Annuitant) Print or Type Name of Soliciting Agent Soliciting Agent License Number Print or Type Name of General Agent Agent/Broker Agency Percentage Name of Agent/Broker Code Number Code Number of Case NY 08/2013 Page 3 of 3

4 NOTICE TO CUSTOMERS IDENTITY VERIFICATION: To help the government fight the funding of terrorism and money laundering activities, federal law requires all financial institutions to obtain, verify, and record information that identifies each person with whom the institution has a customer relationship. What this means for you: When you apply for a policy or contract, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We are required to see your driver s license or other identifying documents or otherwise confirm your identity XX 04/2006

5 CERTIFICATION FOR TAXPAYER IDENTIFICATION NUMBER Policy Number: Name of Policyowner Address (Number, Street, and Apt. or Suite Number) City, State, and ZIP code Enter the taxpayer identification number in the appropriate box. For most individuals this is your social security number. Social Security Number (TIN) OR Employer Identification Number Certification Under penalties of perjury, I certify that: (1) The number shown 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 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 (including a U.S. resident alien). 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. Signature of U.S. Person: Date: XX 06/2008

6 AGENT S CERTIFICATE FOR ANNUITY AND FUND PRODUCTS OWNER IDENTIFICATION Natural Person Owner(s) Identification U.S. Driver s License Green Card Passport Other Issuer of ID ID Reference No. ID Issue Date ID Expiration Date Entity Owner s Identification Is entity a trust? Yes No If yes, please complete the Trust Certification (Form No XX) If no, is entity publicly traded? Yes No If no, please complete the Business Entity Ownership Certification (Form No XX). PAYOR IDENTIFICATION If Payor is other than Owner or Insured, list payor s: Date of Birth Social Security No. SOLICITING AGENT CERTIFICATION I certify that I personally met with the proposed Owner(s), or the authorized representative(s) of the proposed entity Owner, and reviewed the identification documents of the individual or entity. To the best of my knowledge the documents accurately reflect the identity of the individual or entity. OR I did not meet in person with the proposed Owner(s), or the authorized representative(s) of the proposed entity Owner, or I was otherwise unable to personally review the individual s or entity s identification documents. I certify that, to the best of my knowledge, the identification information provided by the individual or the authorized representative(s) of the entity is accurate. I certify that I have truly and accurately recorded on all parts of this application and supporting documents, including this Agent s Certificate, the information supplied by the Applicant(s). Signature of Soliciting Agent/SA# XX 04/2006

7 Producer Compensation Disclosure Statement Insured/Annuitant Name: Owner/Annuitant Name: The following disclosure is provided pursuant to New York State Insurance Department Regulation No. 194 (11 NYCRR 30.1 et seq.) (the producer ) is an insurance producer licensed by the State of (Agent Name) New York. Insurance producers are authorized by their license to confer with insurance purchasers about the benefits, terms and conditions of insurance contracts; to offer advice concerning the substantive benefits of particular insurance contracts; to sell insurance; and to obtain insurance for purchasers. The role of the producer in any particular transaction typically involves one or more of these activities. Compensation will be paid to the producer, based on the insurance contract the producer sells. Depending on the insurer(s) and insurance contract(s) the purchaser selects, compensation will be paid by the insurer(s) selling the insurance contract or by another third party. Such compensation may vary depending on a number of factors, including the insurance contract(s) and the insurer(s) the purchaser selects. In some cases, other factors such as the volume of business a producer provides to an insurer or the profitability of insurance contracts a producer provides to an insurer also may affect compensation. The insurance purchaser may obtain information about compensation expected to be received by the producer based in whole or in part on the sale of insurance to the purchaser, and (if applicable) compensation expected to be received based in whole or in part on any alternative quotes presented to the purchaser by the producer, by requesting such information from the producer. I have read and understand the information contained in this disclosure: Date (Purchaser Signature) Date (Producer Signature) Instructions: 1. Agent to retain the original; copy to be provided to purchaser. 2. A copy of this form is not required to be submitted to the Insurance Company. 3. Producer must keep a copy of this form for at least three years from the date the disclosure is given NY 01/2011

8 DEPARTMENT OF FINANCIAL SERVICES OF THE STATE OF NEW YORK DEFINITION OF REPLACEMENT IN ORDER TO DETERMINE WHETHER YOU ARE REPLACING OR OTHERWISE CHANGING THE STATUS OF EXISTING LIFE INSURANCE POLICIES OR ANNUITY CONTRACTS, AND IN ORDER TO RECEIVE THE VALUABLE INFORMATION NECESSARY TO MAKE A CAREFUL COMPARISON IF YOU ARE CONTEMPLATING REPLACEMENT, THE AGENT OR BROKER IS REQUIRED TO ASK YOU THE FOLLOWING QUESTIONS AND EXPLAIN ANY ITEMS THAT YOU DO NOT UNDERSTAND. AS PART OF YOUR PURCHASE OF A NEW LIFE INSURANCE POLICY OR A NEW ANNUITY CONTRACT, HAS EXISTING COVERAGE BEEN, OR IS IT LIKELY TO BE: (1) LAPSED, SURRENDERED, PARTIALLY SURRENDERED, FORFEITED, ASSIGNED TO THE INSURER REPLACING THE LIFE INSURANCE POLICY OR ANNUITY CONTRACT, OR OTHERWISE TERMINATED? YES NO (2) CHANGED OR MODIFIED INTO PAID-UP INSURANCE; CONTINUED AS EXTENDED TERM INSURANCE OR UNDER ANOTHER FORM OF NONFORFEITURE BENEFIT; OR OTHERWISE REDUCED IN VALUE BY THE USE OF NONFORFEITURE BENEFITS, DIVIDEND ACCUMULA- TIONS, DIVIDEND CASH VALUES OR OTHER CASH VALUES? YES NO (3) CHANGED OR MODIFIED SO AS TO EFFECT A REDUCTION EITHER IN THE AMOUNT OF THE EXISTING LIFE INSURANCE OR ANNUITY BENEFIT OR IN THE PERIOD OF TIME THE EXISTING LIFE INSURANCE OR ANNUITY BENEFIT WILL CONTINUE IN FORCE? YES NO (4) REISSUED WITH A REDUCTION IN AMOUNT SUCH THAT ANY CASH VALUES ARE RELEASED, INCLUDING ALL TRANSACTIONS WHEREIN AN AMOUNT OF DIVIDEND ACCUMULATIONS OR PAID-UP ADDITIONS IS TO BE RELEASED ON ONE OR MORE OF THE EXISTING POLICIES? YES NO (5) ASSIGNED AS COLLATERAL FOR A LOAN OR MADE SUBJECT TO BORROWING OR WITHDRAWAL OF ANY PORTION OF THE LOAN VALUE, INCLUDING ALL TRANSACTIONS WHEREIN ANY AMOUNT OF DIVIDEND ACCUMULATIONS OR PAID-UP ADDITIONS IS TO BE BORROWED OR WITHDRAWN ON ONE OR MORE EXISTING POLICIES? YES NO (6) CONTINUED WITH A STOPPAGE OF PREMIUM PAYMENTS OR REDUCTION IN THE AMOUNT OF PREMIUM PAID? YES NO IF YOU HAVE ANSWERED YES TO ANY OF THE ABOVE QUESTIONS, A REPLACEMENT AS DEFINED BY NEW YORK INSURANCE REGULATION NO. 60 HAS OCCURRED OR IS LIKELY TO OCCUR AND YOUR AGENT OR BROKER IS REQUIRED TO PROVIDE YOU WITH A COMPLETED DISCLOSURE STATEMENT AND THE IMPORTANT NOTICE REGARDING REPLACEMENT OR CHANGE OF LIFE INSURANCE POLICIES OR ANNUITY CONTRACTS. TO THE BEST OF MY KNOWLEDGE, A REPLACEMENT IS INVOLVED IN THIS TRANSACTION: YES NO Date: Date: Date: Signature of Applicant: Signature of Applicant: Signature of Agent or Broker: XX 06/2013

9 Trust Certification This Certification must be signed by ALL Grantor(s) and Trustee(s) The Company reserves the right to request a copy of the executed trust agreement. Corporate Office: 100 Court Street P.O. Box 1625 Binghamton, NY (607) Name(s) of Insured(s) or Annuitant Name of Trust Tax Identification Number of Trust Policy or Annuity Contract Number Date of Trust Agreement Grantor Name(s) and Date of Birth please type or print, include full name(s) Trustee Name(s) and Date of Birth please type or print, include full name(s) Address for receipt of policy communications: Check one: The Trust is Irrevocable Revocable The Grantor(s) and Trustee(s) certify to Security Mutual Life Insurance Company of New York (the Company ) that: 1. The Trust is in effect; 2. The Trust permits the Trustee(s) to purchase the above-referenced Policy or Annuity Contract; 3. The Trust permits the Trustee(s) to exercise all ownership rights provided by such Policy or Annuity Contract, including but not limited to, any right to surrender, make withdrawals from, collaterally assign or transfer ownership of the Policy or Annuity Contract; 4. Neither the Company nor anyone acting on behalf of the Company is responsible to determine the authority of the Trustee(s) or inquire into or review the provisions of the Trust and shall not be charged with knowledge of the terms of the Trust; 5. The Company will be informed in writing of any changes of Trustee(s) and other facts and events that would render inaccurate this Certification or information contained herein; 6. The Company is not responsible to determine that any change or appointment of any additional or successor Trustee(s) conforms to the Trust provisions; 7. All information contained herein is true and complete. Any form required to exercise any rights under the Policy or Annuity Contract (check one): must be signed by all Trustees. may be signed by alone, who is authorized to act alone for the Trust. may be signed by any one Trustee. SIGNATURES Grantor Grantor Date: Date: IMPORTANT NOTE: ALL TRUSTEES MUST SIGN We are ALL of the duly appointed Trustees of the Trust and do hereby, jointly and severally, indemnify the Company and hold the Company harmless from any liability for any action of any Trustee of the Trust. Trustee Trustee Trustee Date: Date: Date: Trustee Date: If more than four trustees, please attach a separate sheet for additional signatures and dates XX 04/2013

10 Business Entity Ownership Certification 1. Name(s) of Insured(s) or Annuitant 2. Policy or Annuity Contract Number Legal Name of Business Entity Date of Organization State of Organization Business Street Address Mailing Address, if different 8. Form of Business C Corporation S Corporation LLC Partnership Sole Proprietorship 9. Proposed insured(s)/annuitant s relationship to business entity/% ownership: 10. Nature of business: 11. Federal Tax I.D. No. 12. Please provide the following information regarding the business owners, partners, and executive officers: Required for new applications only Percent Amount of Insurance Name DOB Title Ownership In Force Applied For (Please attach additional sheets if necessary) 13. Purpose of insurance or annuity: Executive Bonus Keyperson Insurance Debt Collateral Split Dollar Buy/Sell Agt. Deferred Compensation Keyperson for Venture Capital Financing Other: (New applications only) If Buy/Sell: If insurance is not in force or applied for on each of the owners/stockholders, why not? XX 04/2013 Page 1 of 2

11 14. The undersigned certify to Security Mutual Life Insurance Company of New York ( Security Mutual ) that: 1. The business entity is in good standing under the laws of the jurisdiction in which it was organized; 2. The business entity has authorized the undersigned to sign documents on its behalf in connection with the purchase of the above-referenced Policy or Annuity Contract; 3. Those individuals named in Item 15 below are authorized to exercise all ownership rights provided by the Policy or Annuity Contract, including but not limited to, any right to surrender, make withdrawals from, collaterally assign or transfer ownership of the Policy or Annuity Contract; 4. Neither Security Mutual nor anyone acting on behalf of Security Mutual is responsible to determine the authority of the undersigned or the authority of any other person who purports to act on behalf of the business entity, or to inquire about or review the organizational documents of the business entity and shall not be charged with knowledge of any of them; 5. The undersigned will advise Security Mutual of any changes to Item 15 and agree that Security Mutual is not responsible to determine that any such change has been authorized by the business entity. 15. Any form required to exercise any rights under the Policy or Annuity Contract (check one): must be signed by all of the following: OR may be signed by any one of the following: Printed name and title Printed name and title Printed name and title Printed name and title Signature Signature Signature Signature may be signed by the following alone, who is authorized to act alone for the business entity: Printed name and title Signature The undersigned, jointly and severally, indemnify Security Mutual and hold Security Mutual harmless from any liability for any action of any of the undersigned or any person named in item 15 above. Name Title: Name Title: Date: Date: XX 04/2013 Page 2 of 2

12 Corporate Office: 100 Court Street P.O. Box 1625 Binghamton, NY (607) Annuity Suitability Statement Thank you for your interest in purchasing an annuity from Security Mutual. The following questions are intended to help you determine whether the purchase of an annuity contract is suitable for you in light of your investment goals and your current and anticipated financial situation. Please note that the annuity is not insured by the FDIC, the Federal Reserve Board or any other government agency. We recommend that you complete this form with your agent or financial advisor. If you decline to provide the information requested below, please check the box below, complete Section A, and then proceed to the Acknowledgement and Signature section of the form. Otherwise, please complete this form in its entirety. q I do not wish to provide responses to one or more of the questions below. I am responsible for determining the suitability of the annuity applied for given my needs and circumstances. SECTION A [Submit with Application] [Copy to be left with Applicant] Annuitant Name: Date of Birth: Applicant/Owner Name (leave blank if annuitant is also owner): Applicant/Owner Mailing Address: Last Four Digits of Social Security Number: XXX-XX- OR Employer Identification Number: Joint Applicant/Owner Name: Date of Birth Joint Applicant/Owner Mailing Address: Last Four Digits of Social Security Number: XXX-XX- Product applied for: q Single Premium Deferred Annuity Annuity Type: q Qualified q Non-Qualifed q Single Premium Immediate Annuity q Flexible Premium Deferred Annuity SECTION B: Facts Disclosure 1. The source of funds to purchase the annuity applied for is: q Bank CD q Savings/Checking q Replacement of an existing annuity or life insurance policy q Other (please specify) 2. Investment Risk Style: (check one) q Conservative (Safety of principal and minimizing risk are your most important concerns.) q Moderate (Capital appreciation and safety of principal are equally important. Moderate risk can be tolerated to boost returns.) q Aggressive (Capital appreciation is your most important concern. You are willing to assume a high level of risk to the safety of principal to obtain a higher than average return.) 3. Financial Goals/Objectives: (check all that apply) q Safety of Principal q Protection for Beneficiaries q Supplemental Retirement Income q Tax Planning q Tax Deferred Growth q Estate Planning q Guaranteed Income for Life q Other (Please Specify 4. What types of financial products do you currently own? (check all that apply) q Fixed Annuity q Money Market Account q Variable Annuity q Certificate of Deposit q Life Insurance q Securities (stocks, bonds, mutual funds, etc.) q Savings Account 5. Total Value of all annuities you own (include the purchase of this annuity). $ 6. Federal Income Tax Bracket: q 0%-15% q 15%-30% q Over 30% XX 03/2009 Page 1 of 2

13 7. Annual Gross Income: q Less than $30,000 q From $30,000 to $75,000 q From $75,000 to $150,000 q Over $150, Sources of Income: (check all that apply) q Interest on Savings Accounts or Certificates of Deposit q Retirement Plan(s) q Investments q Annuity Payments q Wages q Social Security 9. Liquid Household Assets: Assets that can be readily converted into cash without a major loss in value, such as checking, savings, money market accounts, short term CDs, bonds, annuities without surrender charges, etc. q Less than $25,000 q $25,000 - $50,000 q $50,000 - $100,000 q $100,000 - $250,000 q Over $250,000 SECTION C Acknowledgement and Signature I understand that: An annuity is a long-term investment. 10. Estimated Net Worth (Total assets less total debt) q Less than $100,000 q $100,000 - $250,000 q $250,000 - $500,000 q Greater than $500, Period of time before the money from the annuity is needed: q Immediately q 1-3 years q 4-6 years q 7-9 years q years q years q 16 or more years 12. How do you anticipate taking distributions from this annuity? (check all that apply) q Systematic withdrawals q Lump sum q Annuitize q Required Minimum Distribution q Leave to Beneficiary q Other 13. After purchasing the annuity, I will have sufficient cash or other liquid assets to cover my living expenses and any expenses for unexpected events, such as medical expenses. q Yes q No Withdrawals from the annuity during the early contract years may be subject to surrender charges, and withdrawals, in whole or in part, may be subject to ordinary income tax. I intend to keep the annuity contract at least through the contract s surrender charge period. (This item applies to deferred annuities; it does not apply to single premium immediate annuities.) Surrender charges, fees, penalties and income tax liabilities may be incurred as a result of liquidating certain existing accounts. If I am purchasing this annuity in an IRA or other tax-qualified plan, there is no additional tax deferral benefit because these plans are already afforded tax-deferred status. To the best of my knowledge and belief, all statements and answers on this form are true and complete. I have determined that the purchase of the annuity contract is appropriate and suitable for my needs and financial objectives. I understand that if I am not satisfied with the annuity contract once I receive it, I may return it during the free-look period provided in the annuity contract. Applicant/Owner s Signature Joint Applicant/Owner s signature (if applicable) Date: Date: Agent Statement: I have reasonable grounds for believing that my recommendation for this consumer to purchase the annuity applied for from Security Mutual is suitable for the consumer on the basis of all of the circumstances actually known to me, including the facts as disclosed above by the consumer as to his or her investments and other insurance products and as to his or her financial situation and needs. Agent Name: Agent Number: Agency Name: Agent Signature: Date: XX 03/2009 Page 2 of 2

14 DISCLOSURE STATEMENT SINGLE PREMIUM IMMEDIATE ANNUITY In connection with the purchase of my Security Mutual Life Single Premium Immediate Annuity I acknowledge and understand the following: 1. I understand the start date for annuity income payments cannot be changed after issue. 2. I understand the annuity option which I select cannot be changed after issue. 3. I understand that if I have selected an annuity that does not include a guarantee period, the annuity income payments will cease when the annuitant dies or if this is an annuity that is based upon two lives, upon the death of the annuitant last to die. 4. If the annuity which I have selected provides a guarantee period, I understand that if the annuitant dies before the end of the guarantee period, my beneficiary will receive any remaining guaranteed payments. If my annuity is based upon two lives, if both annuitants die before the end of the guarantee period, my beneficiary will receive any remaining guaranteed payments. 5. If the annuity which I have selected is based upon two lives and provides for a reduced amount to the survivor annuitant, I understand that after the death of either annuitant the income payable to the surviving annuitant will continue to be paid to the surviving annuitant in a reduced amount. 6. I understand that my annuity has no cash value, loan value or surrender value. However, my annuity does contain a rider or riders that permit the Owner to elect to receive some of the future expected payments under the contract while an annuitant is living in a lump sum in certain circumstances and at specific times. The Owner may also make a one-time election, after the first policy anniversary and while an annuitant is living, to accelerate fifty per cent of the next twelve months payments. If the Owner exercises any of these riders, the income which the annuitant or annuitants receive after exercise will be reduced. I further understand that the exercise of these riders has tax consequences and that I should consult my tax adviser before exercising these riders. 7. I understand that the annuity income payments are guaranteed at purchase and will neither increase nor decrease in response to changes in interest rates or inflation, but, after exercise of certain riders, the income the annuitant or annuitants receive after exercise will be reduced. Applicant Acknowledgement: I have read or been read this document and understand its contents. I have received a copy of the Buyer s Guide to Fixed Deferred Annuities. Owner Signature Date For use with Single Premium Immediate Annuity Policies: 2102-NY, 2102-GP-NY, 2103-NY, 2103-GP-NY, 2103-R-NY XX 09/2009