6) Any other form acceptable to the appropriate GAIG company.

Transcription

1 Member Companies: Great American Life Insurance Company Annuity Investors Life Insurance Company Manhattan National Life Insurance Company Administrator for: Loyal American Life Insurance Company United Teacher Associates Insurance Company Fixed Annuities: PO Box 5420, Cincinnati OH / / Fax Variable Annuities: PO Box 5423, Cincinnati OH / / Fax Overnight Address: 10 th Floor, 301 E Fourth St, Cincinnati OH SETTLEMENT OPTION ELECTION AGREEMENT 1. INSTRUCTIONS All forms should be returned at least 30 days prior to the effective date of the settlement option. The effective date of the settlement option will be between the 4 th and the 27 th of a month. Please be certain that no further contributions are made to your annuity. All Contract Owner(s) MUST sign the form. If you have questions, please call your agent or our Client Relations Dept. IMPORTANT NOTE: An election to annuitize your contract will terminate riders to the contract, which include income benefit riders, death benefit riders, extended care waiver riders, and terminal illness waiver riders. Name of Owner(s) (or certificate holder) Contract/Certificate Number Street Address Social Security Number City, State and ZIP Is this the owner s new address? YES NO Daytime Phone Number ( ) 2. SETTLEMENT OPTION ELECTION CHECK ONLY ONE OPTION (DESCRIPTIONS ON PAGE 4) All options may not be available for a particular annuity contract. Please review your contract for available options. A. FIXED OPTIONS: Based upon a set time frame or payment amount. 1) Payments for a fixed period. Indicate below the period over which annuity payments are to be made: 3 years 5 years 7 years 10 years 15 years other: years 2) Payments for a fixed amount. Amount elected $ before tax withholdings (if applicable) IMPORTANT NOTE: Some contracts have a minimum fixed period annuitization. If you have elected a fixed period that is shorter than this minimum, we will annuitize your contract for the minimum fixed period. Irrevocable Election: You may make your fixed period or fixed amount settlement option election irrevocable by checking the following box. If made irrevocable, any right to take the commuted value or modify the scheduled annuity payments is waived and cannot be changed once payments commence. Check here to make your fixed settlement option election irrevocable. 3) Life Expectancy Guaranteed Income - monthly payments for a fixed period based on your life expectancy according to the tables used to determine whether a transfer is made under the Medicaid rules of your state. Proof of age and name changes are required. This option is irrevocable. Payee and amount may not be changed. Payments may not be assigned or transferred. Once payments begin, there is no value that can be surrendered, loaned, commuted, or withdrawn. In many cases, the State must be the contingent payee for any payments remaining after the payee s death to the extent of any medical assistance paid on behalf of the payee. This option is NOT available for all contracts. In order to process this election, you MUST initial below where indicated: Independent Legal Counsel Retained: By initialing in the box to the left, I represent that I have retained independent legal counsel to assist with Medicaid eligibility planning and that this settlement election option is consistent with such Medicaid eligibility plan. Initial Above ML2084 (Rev 8/26/2015) 1

2 B. LIFE OPTIONS: Based upon the life expectancy of the payee(s) unless otherwise specified. Proof of age required for payee and any joint payee required in the form of a birth certificate, driver s license, or passport, together with proof of any name change. All life option elections are irrevocable. 1) Payments for life; with the option of a minimum fixed period. Indicate the minimum period: no minimum 5 years 10 years 15 years other: years *2) Joint and Survivor Payments for lives of joint payees, with the full payment amount continuing for the life of the surviving payee. *3) Joint and 1/2 Survivor Payments for the life of the primary payee, with 1/2 of the initial payment amount continuing thereafter for the remaining life of the joint payee, if surviving. *4) Joint and 2/3 Survivor Payments for the lives of joint payees, with 2/3rds of the initial payment amount continuing thereafter for the remaining life of the surviving payee. *5) Joint and Survivor, with minimum fixed period of 10 years. Payments for the lives of joint payees, with the full payment amount continuing for the life of the surviving payee, and with payments for a minimum of 10 years. 6) Any other form acceptable to the appropriate GAIG company. *Life Options 2, 3, 4, and 5 are based on joint lives and you must designate a joint payee below. Joint payee name Male Female Social security number Date of birth Relationship 3. PAYMENT FREQUENCY IMPORTANT NOTE: Most annuity contracts state that annuity payments will be made at the END of each payment period. For example, if you elect an annual frequency, your first payment will be made to you one year from the maturity date of the contract. Please refer to your contract for the applicable schedule for the settlement option elected. If a payment frequency is not marked, monthly payments will be made. PAYMENTS TO BE MADE: Monthly Quarterly Semi-annually Annually 4. FOR 403(b) TSA CONTRACTS The owner certifies that these payments requested are permitted as a result of: (MUST CHECK ONE) A) AGE 59½: The owner is now age 59½ or older B) SEVERANCE FROM EMPLOYMENT: Date of Severance: Name of employer through which 403(b) TSA contributions were made: C) DISABILITY: Unable to engage in customary or comparable substantial gainful activity by reason of medically determinable physical or mental impairment expected to result in death or be of long-continued and indefinite duration. (attach documentation if no plan administrator) D) QDRO: Payments to an alternate payee under a qualified domestic relations order. (attach copy of court order) E) CONTRACT EXCHANGE: Contract exchange within the same employer 403(b) TSA plan. (if permitted by annuity contract) F) ROLLOVER ACCOUNT: Payments are only to be made from Separate account for rollover contributions. G) EMPLOYER CONTRIBUTIONS: Payments are only to be made from: (MUST CHECK ONE) Segregated account for employer contributions under a contract issued on or before 12/31/2008. Segregated account for employer contributions, and permitted based on occurrence of event specified by plan document. ML2084 (Rev 8/26/2015) 2

3 5. TYPES OF DISTRIBUTION AND PAYEE No annuity payments may be made to a payee who is not a natural person except for (1) Direct Rollovers specified below, or (2) payments to a plan where a corresponding payment is then owed to the plan participant or beneficiary. Distributions before age 59½ may be subject to a 10% federal penalty tax (or 25% for some SIMPLE IRA distributions) in addition to other applicable income taxes. A. PAYMENT TO OWNER(S) By check. Make payment by check mailed to owner(s) shown at top of page 1 By Automatic/Direct Deposit. I authorize the appropriate GAIG company and the financial institution to deposit my annuity payments into my account identified below, and to adjust my account for any overpayments. Please complete the information below AND attach a void check, account statement copy, or a letter from your financial institution providing owner(s) name(s), routing number and account number. Financial Institution Address (City/State/Zip) Phone number ( ) Type of account Checking Savings List Names of ALL Owners on the Financial Institution Account Routing number Account number Important Notes: Direct Deposit normally takes 2-3 business days for the funds to be credited to your financial institution account. Direct Deposits may only be made to a bank or savings & loan account. Direct Deposits may not be made to an IRA or other tax-qualified account or to an insurance company. For requests signed by a Power of Attorney: 1) Deposits can only be made to an account where the person who gave the POA is a named owner of the account; and 2) payment will be made to the Principal and not to the Attorney in Fact. For contracts owned by a Trust: Deposits can only be made to an account owned by the Trust unless additional documentation is provided showing that these distributions from the Trust are permitted. B. PAYMENT TO OTHER PAYEE. For Non-Qualified annuities, 401 Pension/Profit Sharing/401(k) Plans, and Governmental 457 Plans ONLY. Any designation under the annuity contract will be adjusted accordingly. The owner will retain the right to change payee to owner unless Form INCTX is attached. Payee Name(s) Male Female Social security number Date of birth Address City State ZIP C. DIRECT ROLLOVER. For Eligible Rollover Distributions from 403(b) TSAs, 401 Pension/Profit Sharing/401(k) Plans, and Governmental 457 Plans ONLY. Annuity payment must be a fixed option with a term of less than 10 years. Pursuant to Treasury Regulations Section 1.402(c)-2; Q&A-7, an annuity payment made on or after January 1 of the year the owner will reach age 70½ or retire (whichever is later) is not an eligible rollover distribution. to Traditional IRA to 403(b) TSA to 401 Pension/Profit Sharing/401(k) Plan to Governmental 457 Plan A letter of acceptance from the new trustee, custodian, or insurer MUST be provided. Bank/Company Name Account number Address City State ZIP ML2084 (Rev 8/26/2015) 3

4 6. SPECIAL TAX NOTICE REGARDING FOR ELIGIBLE ROLLOVER DISTRIBUTIONS FROM 403(b) TSA policies, 401 Pension/Profit Sharing/401(k) Plans, or Governmental 457 plans FOR ELIGIBLE ROLLOVER DISTRIBUTIONS (ERDs) from 403(b) TSA policies, 401 Pension/Profit Sharing/401(k) Plans, and Governmental 457 Plans. (Most annuitization payments are ERDs unless made under a life option, under a fixed option of 10 years or more, or at age 70 ½ and above.) By signing this settlement option election agreement, the Owner/Annuitant/Participant acknowledges receipt of the Special Tax Notice Regarding Plan Payments. [Please contact our office prior to submitting this form if you did not receive this Special Tax Notice.] Initial Above By initialing in the box to the left, I waive my 30-day consideration period. I understand that I have 30 days to consider whether or not to make a direct rollover, and my request must be delayed unless I waive this right. This election applies to the waiver of the 30-day consideration period, NOT the actual processing time for your request. 7. INCOME TAX WITHHOLDING For distributions to the annuitant/participant of a 403(b) TSA, 401 Pension/Profit Sharing/401(k) Plan, or a Governmental 457 Plan, a minimum of 20% federal income tax withholding is required by law unless your distribution is made under a life option or a fixed option of 10 years or more, or you are 70 ½ or above. For all other distributions, tax withholding is not mandatory. If a withholding election is not indicated OR if you choose to have taxes withheld but a percentage is not indicated, federal tax withholding will be based on tables for a married taxpayer with 3 exemptions (which excludes over $24,000 per year from withholding). Withhold % for federal income tax (or any mandatory amount, if greater). DO NOT Withhold federal or state income tax, if permitted. Whether or not taxes are withheld, you will be liable for payment of all applicable federal and state income taxes on the taxable portion of the distribution. You may also be subject to penalties under the estimated tax rules if your withholding and estimated tax payments, if any, are not adequate. NOTE: State income tax withholding may also apply. Any withholding election will remain in effect until revoked. You may revoke any withholding election for annuity payments not yet distributed by notifying the appropriate GAIG company in writing at any time. 8. CONTINGENT PAYEE (BENEFICIARY) DESIGNATION IMPORTANT NOTE: For Fixed Options and for those Life Options with a minimum fixed period, payments may continue to be payable after your death. Once annuity payments begin, your prior Beneficiary designation will no longer apply. After the death of the payee (and joint payee, if any), any remaining payments will be made to the Contingent Payee(s) designated below. Unless otherwise indicated, benefits will be paid to a secondary Contingent Payee only if no primary Contingent Payee is surviving, and if more than one payee has equal priority, benefits will be paid in equal shares or all to the survivor. If the Contingent Payee listed below is not designated as a primary or secondary Contingent Payee, it will automatically default to a primary designation. If no primary Contingent Payee is designated below, the secondary Contingent Payee will be treated as the primary. If a Contingent Payee designation is not made, then the Contingent Payee will be the owner(s)/participant or the estate of the owner(s)/participant. Please show full name, address, relationship to owner(s)/participant, date of birth, social security number, and phone number of all Contingent Payees. A failure to do so may result in the death benefit being escheated to the state. If a trust is designated as a Contingent Payee, provide the name of the trust, date of the trust, and name of the current trustee(s). If the owner of the contract is a trust, we may reject the designation of any Contingent Payee other than the trust itself. If additional space is needed, please attach a separate sheet SIGNED and DATED by the owner(s)/participant. ML2084 (Rev 8/26/2015) 4

5 8. CONTINGENT PAYEE (BENEFICIARY) DESIGNATION (Continued) Contingent Payee(s) Type: Primary Secondary Contingent Payee(s) Type: Primary Secondary Name(s) Name(s) Relationship / Social Security # / Date of Birth / Phone # Relationship / Social Security # / Date of Birth / Phone # Address Address Caution for Life Expectancy Guaranteed Income Option: You must generally name your State as the contingent payee to the extent of any medical assistance that it pays on your behalf. The interest of the State may be secondary only to the interest of a community spouse or a minor or disabled child. If you fail to name the State as required, your settlement option election may be treated as a disposal of an asset for less than fair market value under 42 U.S.C. 1396p(c)(1)(F). Please seek legal advice when designating a contingent payee under this option. 9. OWNER/ANNUITANT/PARTICIPANT CERTIFICATION AND AUTHORIZATION The Owner/Annuitant/Participant agrees and certifies that the appropriate GAIG company is authorized to process this settlement option election as indicated above, agree that all payments will be subject to the terms and conditions of the annuity contract, and agree to hold the appropriate GAIG company harmless against any and all claims made by reason of compliance with this election. Signature of Owner/Annuitant/Participant Date Signature of Joint Owner (if applicable) Date IMPORTANT NOTES: For requests signed by a Power of Attorney we must receive a copy of the Power of Attorney document. The Affidavit Related to Power of Attorney, Form #AAG2816, must also be completed or a valid affidavit must be on file. Payment will be made to the Principal and not to the Attorney in Fact. In addition, if this form is signed using a Power of Attorney, then a Contingent Payee designation naming the attorney in fact will be subject to additional review. For contracts owned by a Trust, the acting Trustee(s) must sign. In addition, if there has been a change of Trustee(s) from the Trustee(s) on file, then either a new trust certification form (#X NW) or trust pages showing the Successor trustee(s) together with documentation of the resignation, removal, incapacity, or death of the prior trustee(s) must be submitted. 10. PLAN ADMINISTRATOR CERTIFICATION AND AUTHORIZATION (if applicable) Name of Employer Plan Name of Plan Administrator Plan Administrator Phone ( ) The Plan Administrator certifies that the settlement option election requested is permitted under the employer s plan and authorizes the appropriate GAIG company to process the request as indicated above. Signature of Plan Administrator Date ML2084 (Rev 8/26/2015) 5

6 11. SIGNATURE NOTARIZATION (if applicable) Your signature on this Settlement Option Election Agreement must be notarized below if: 1) Requested by the home office, or 2) You purchased your contract electronically with an e-signature and you have not previously submitted a notarized or verified signature. Should we receive this form and a notarized or verified signature is not on file, we will then request your signature be notarized, which will delay processing of your request. STATE OF ) ) SS: COUNTY OF ) On this day of in the year before me, the undersigned, a Notary Public in and for said county and state, personally appeared who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the foregoing Settlement Option Election Agreement and acknowledged to me that he/she/they signed the same. My Commission expires: MM/DD/YYYY Signature of Notary Public SEAL ML2084 (Rev 8/26/2015) 6

7 SETTLEMENT OPTION DESCRIPTIONS All options are subject to minimum and maximum requirements of each specific policy. All options may not be available for a particular annuity contract. Please consult your contract, your agent, or our office for details. FIXED OPTIONS: Based upon a set time frame or payment amount. Payments for a fixed period. The payments can be made monthly, quarterly, semi-annually, or annually. The amount of the payment will depend on: (1) the amount applied under the option, (2) the length of time over which you choose to receive payments (the longer the period of time over which payments will last, the smaller the amount of each payment); and (3) whether or not you make the settlement option irrevocable. If you should die before the end of the fixed period, the remaining payments will be made to your Contingent Payee(s) on the same schedule, or if allowed by your policy contract as a lump sum payment of the commuted value if the settlement option is not irrevocable. Payments for a fixed amount. You choose the amount of each payment you want to receive monthly, quarterly, semi-annually or annually. The duration of the payments will depend on (1) the amount applied under the options, (2) the amount of each payment (the larger the payment, the shorter the period of time over which payments will last); and (3) whether or not you make the settlement option irrevocable. If you should die before all payments have been made, the remaining payments will be made to your Contingent Payee(s) on the same schedule, or if allowed by your policy contract as a lump sum payment of the commuted value if the settlement option is not irrevocable. Irrevocable Election: You may make your fixed period or fixed amount settlement option election irrevocable by checking the applicable box on the Settlement Option Election Agreement. If made irrevocable, any right to take the commuted value or modify the scheduled annuity payments is waived and cannot be changed once payments commence. Life Expectancy Guaranteed Income monthly payments for a fixed period based on your life expectancy according to the tables used to determine whether transfer is made under the Medicaid rules of your state. This option is irrevocable. The Primary Payee and amount may not be changed. Payments may not be assigned or transferred. Once payments begin, there is no value that can be surrendered, loaned, commuted, or withdrawn. If you should die before all payments have been made, the remaining payments will be made to your Contingent Payee(s) with no commuted value of these payments. In many cases, the State must be the contingent payee for any payments remaining after the payee s death to the extent of any medical assistance paid on behalf of the payee. NOTE: This option should only be elected for Medicaid planning purposes. You should retain independent legal counsel to assist with Medicaid eligibility planning and confirm that this settlement option election is consistent with such Medicaid eligibility plan. We will require you to certify in the applicable section of the Settlement Option Election Agreement that you have done so should this option be elected. In non-medicaid planning situations, a fixed option with a period payout of equal duration should be elected. LIFE OPTIONS: Based upon the life expectancy of the payee(s) unless otherwise specified. All life option elections are irrevocable. Payments for life with the option of a minimum fixed period. The amount of the payments will depend upon your age, sex,* the amount applied under the option and the length of the fixed period that you choose. If you should die before the end of the fixed period, the remaining guaranteed payments will be made to your Contingent Payee(s) on the same schedule, or as a lump sum payment of the commuted value (if allowed by your policy contract). Joint and Survivor Payments for lives of joint payees with the full payment amount continuing for the life of the surviving payee. Payment amount will be determined by the age and sex* of each payee and by the amount applied under this option on the maturity date. There is no benefit to be paid to Contingent Payee(s) after the death of both payees. Joint and 1/2 Survivor Payments for the life of the primary payee, with 1/2 of the initial payment amount continuing thereafter for the remaining life of the joint payee, if surviving. Payment amount will be determined by the age and sex* of each payee and by the amount applied under this option on the maturity date. There is no benefit to be paid to Contingent Payee(s) after the death of both payees. Joint and 2/3 Survivor Payments for the lives of joint payees, with 2/3rds of the initial payment amount continuing thereafter for the remaining life of the surviving payee. Payment amount will be determined by the age and sex* of each payee and by the amount applied under this option on the maturity date. There is no benefit to be paid to Contingent Payee(s) after the death of both payees. Joint and Survivor, with minimum fixed period of 10 years. Payments for the lives of joint payees, with the full payment amount continuing for the life of the surviving payee, and with payments for a minimum of 10 years. Should both payees die within this ten-year period, the remaining guaranteed payments will be made to your Contingent Payee(s) on the same schedule, or in a lump sum payment of the commuted value (if allowed by your policy contract). *Only for those contracts that provide for sex-distinct use unisex annuitization rates. ML2084 (Rev 8/26/2015) 7