Minimum Premium: Qualified [$5,000] Non-Qualified [$10,000] Maximum Premium: [$250,000]

Transcription

1 2721 North Central Avenue, Phoenix, Arizona (866) Oxford Life Insurance Company Single Premium Multi-Year Guarantee Annuity With Market Value Adjustment Feature Benefit Summary and Disclosure (Policy Form ICC11-MYGA-MVA) Minimum Premium: Qualified [$5,000] Non-Qualified [$10,000] Maximum Premium: [$250,000] ACCUMULATION VALUE The beginning Accumulation Value for any Policy Year refers to the value as of the end of the prior Policy Year. For the first Policy Year, the beginning Accumulation Value for the Policy Year shall be the Premium. At any time after the Policy is issued, the Accumulation Value is equal to: The Accumulation Value at the start of the current Policy Year, less Any Withdrawals, including any Withdrawal Charges and Market Value Adjustments thereon, from the Accumulation Value since the prior Policy Anniversary, plus Interest on the Accumulation Value since the prior Policy Anniversary. DEATH BENEFIT If the Owner dies before the Maturity Date, the death benefit is equal to the greater of the Accumulation Value or the Guaranteed Minimum Value determined as of the date of death. WITHDRAWALS AND SURRENDER Each Withdrawal must be at least [$600]. The Accumulation Value remaining after any withdrawal must be at least [$2,000]. You may take up to two Withdrawals in any Policy Year. However, the first Withdrawal in each Policy Year may be paid periodically as specified in the Policy. Withdrawals taken and any Surrender during the first ten Policy Years are subject to Surrender/Withdrawal Charges and Market Value Adjustments. The Policy specifies a penalty-free amount that may be withdrawn during a Policy Year or received in Surrender without incurring a Surrender/Withdrawal Charge or a Market Value Adjustment. Surrender/Withdrawal Charges are equal to the Surrender/Withdrawal Charge percentage times the excess of the Withdrawal or Surrender over the penalty-free Withdrawal or Surrender limit. Surrender/Withdrawal Charge percentages by Policy Year are: Policy Year Surrender/ Withdrawal Charge % 10% 9% 8% 7% 6% 5% 4% 3% 2% 1% 0% FEDERAL TAX STATUS OF THE POLICY Federal income tax is deferred on interest credited to the Policy until Withdrawal or Surrender. Withdrawals and Surrenders are subject to federal income tax. Withdrawals taken or a Surrender of the Policy prior to the Owner s age 59½ may be subject to a 10% federal tax penalty, in addition to federal income tax. State taxes may also apply. ICC11-MYGA-MVA

2 MARKET VALUE ADJUSTMENTS A Market Value Adjustment may increase or reduce the amount withdrawn or the Cash Surrender Value based on changes in the 5-year U.S. Treasury Constant Maturity rate published by the Federal Reserve. If the MVA Index Rate at the time of Withdrawal is lower than the MVA Index Rate at the beginning of the current Guarantee Period, then the Market Value Adjustment will increase the Withdrawal amount. If the MVA Index Rate at the time of Withdrawal is higher than the MVA Index Rate at the beginning of the current Guarantee Period, then the Market Value Adjustment will reduce the Withdrawal amount. The sample calculation of values on the next page includes a sample Market Value Adjustment calculation. The Market Value Adjustment equals the amount surrendered or withdrawn, minus the Penalty-Free Amount for Surrender or the Penalty-Free Amount for Withdrawal, multiplied by the Market Value Adjustment factor. We use the following formula to calculate the Market Value Adjustment factor: [(1+ i)/(1+ j)] N/12 1 where i = The MVA Index Rate at the beginning of the current Guarantee Period j = The MVA Index Rate on the date of the Withdrawal or Surrender N = The number of full months remaining from the Withdrawal or Surrender date until the end of the current Guarantee Period WAIVER OF SURRENDER/WITHDRAWAL CHARGES AND MARKET VALUE ADJUSTMENT The Policy provides 30 days after the expiration date of each Guarantee Period to Surrender the Policy or make a Withdrawal without incurring a Surrender/Withdrawal Charge or a Market Value Adjustment. GUARANTEED LIFETIME WITHDRAWAL BENEFIT RIDER We will attach a Guaranteed Lifetime Withdrawal Benefit Rider to the Policy only if the Annuitant is an Owner, unless the Owner is not a natural person. If the Policy has Joint Owners, we will attach a Guaranteed Lifetime Withdrawal Benefit Rider only if the Joint Owners are spouses. After the first Policy Year, the Rider allows the Owner to take annual Withdrawals in the amount of the Guaranteed Lifetime Withdrawal Benefit for the Owner s lifetime (or for the joint lifetimes of the Owner and the Owner s spouse if the Owner elects a joint lifetime payout), even if the Policy s Accumulation Value has been reduced to zero. The person whose lifetime determines the Guaranteed Lifetime Withdrawal Benefit (or the youngest person for a joint lifetime payout) must be at least 50 years old to qualify to begin receiving Guaranteed Lifetime Withdrawal Benefits. The amount of the Guaranteed Lifetime Withdrawal Benefit is equal to a payout factor percentage specified in the Rider multiplied by the Income Account Value at the time the Owner elects to receive the first Guaranteed Lifetime Withdrawal Benefit. The initial Income Account Value is equal to the Premium. During the first ten Policy Years, We will credit interest to the Income Account Value at an effective annual interest rate that is [5.00%] higher than the interest rate credited to the Accumulation Value. We will not credit any more interest to the Income Account Value after the first Guaranteed Lifetime Withdrawal Benefit. Withdrawals will reduce the Income Account Value by the same percentage as the reduction on the Accumulation Value. The Income Account Value is only used to determine the amount of the Guaranteed Lifetime Withdrawal Benefits. The Income Account Value cannot be withdrawn as a partial or a lump sum and it is not payable as a death benefit. Guaranteed Lifetime Withdrawal Benefits are only guaranteed if the total amount withdrawn in a Policy Year is less than or equal to the Guaranteed Lifetime Withdrawal Benefit. Any Withdrawal above that amount will permanently reduce future Guaranteed Lifetime Withdrawal Benefits and may terminate the Rider. ICC11-MYGA-MVA

3 Oxford Life Insurance Company Multi-Year Guarantee Annuity Form Number ICC11-MYGA-MVA Sample Calculation of Interest Credits and Values for the First Policy Year End of Year Accumulation Value Premium $10, Annual Interest Rate for Premium 2.00% Interest Credited Amount for Premium $ End of Year Accumulation Value $10, End of Year Market Value Adjustment (MVA) Beginning of Guarantee Period Five Year U.S. Treasury Constant Maturity rate 3.00% End of Year Five Year U.S. Treasury Constant Maturity rate 4.00% Remaining Months From the Surrender/Withdrawal Date Until the End of the Guarantee Period 48 MVA Factor -3.79% MVA -$ End of Year Cash Surrender Value End of Year Accumulation Value $10, First Year Maximum Free Partial Withdrawal $ Maximum Free Surrender 1 Value $1, Additional Free Surrender 2 $ Remaining Accumulation Value Subject to Surrender Charge and MVA $9, Surrender Charge % 10.00% MVA -$ Surrender Charge $ End of Year Cash Surrender Value $8, Free Surrender is the Accumulation Value that is not subject to surrender charge when a full surrender is requested. Please refer to the Surrender Charges section in the Contract for details. 2. Additional Free Surrender is the difference between the Maximum Free Surrender Value and First Year Maximum Free Partial Withdrawal. End of Year Accumulation Value = $10, End of Year Accumulation Value minus Surrender Charge plus or minus MVA = Cash Surrender Value OR $10, $ $ = $8, Total Interest Credited Amount: This is the interest credited on the Accumulation Value since the prior Policy Anniversary. It is credited on a daily basis. The current interest rate is [2.00%]. The Guaranteed Minimum Annual Interest Rate is [2.00%]. The example above is purely hypothetical and is not an indication of the annuity s past or future performance. I have read and understand this summary of the annuity Policy features. Owner s Signature Date Joint Owner s Signature Date Producer s Signature/Producer Number Date Producer s State License Number ICC11-MYGA-MVA

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25 1 Ownership & Annuitant / Insured Information (please print) TRANSFER / 1035 EXCHANGE REQUEST FORM Owner(s) and Annuitant(s)/Insured(s) must be exactly the same as the Owner(s) and Annuitant(s)/Insured(s) on the existing contract with the Surrendering Company. Please attach a copy of your latest statement. Owner Co-Owner (if applicable) Annuitant / Insured Co-Annuitant / Insured (if applicable) Social Security Number Social Security Number Social Security Number Social Security Number 2 Surrendering Company Information and Transfer / Exchange Instructions Contact the Surrendering Company to determine if specific forms are required to initiate the transfer / exchange. Company Name Overnight Address (street address required) City State Zip If no selection is made, transfer will be initiated immediately. Apply Proceeds To: Account Number Phone Number Initiate transfer / exchange: Immediately upon receipt OR After A new Contract / Certificate OR An existing Oxford Life Contract / Certificate Number: 3 Source of Transfer / Exchange Type of Transfer / Exchange Full Transfer / Exchange $ (estimated amount) I have enclosed the contract OR I certify that the contract has been lost or destroyed. Partial Transfer / Exchange $ (exact amount) Plan Type From: Non-Qualified (1035 Exchange) IRA Roth IRA SEP IRA 401(k) Other To: Non-Qualified (1035 Exchange) IRA Roth IRA SEP IRA Other For 403(b) Plans 4 Surrendered Account Type 403(b) to IRA Rollover OR 403(b) to Roth IRA Variable Annuity Fixed Annuity Fixed Indexed Annuity Life Insurance Brokerage Account / Mutual Funds / Certificate of Deposit (CD) - I authorize the Surrendering Company listed above to liquidate my account and send the proceeds to Oxford Life Insurance Company. Form # (Rev. 1/2010) Page 1 of 2

26 5 Acceptance By Contract Owner / Participant For Qualified Transfer: I intend that this transfer be accomplished as a trustee-to-trustee transfer in a nontaxable manner in accordance with IRS rulings and not constitute actual or constructive receipt by me for federal income tax purposes. I hereby request and direct the transfer of the net proceeds of the account listed on the previous page. I understand that I am purchasing this annuity in an IRA or other tax-qualified plan as identified in Section 3 of this form. Since IRAs and other tax-qualified plans are already afforded tax-deferred status, there is no additional tax deferral benefit in this annuity. I am purchasing this annuity because I value other features, such as lifetime income payments, principal protection or death benefit protection. I understand that the proposed transfer may have important tax consequences and/or surrender or withdrawal penalties. I acknowledge that Oxford Life Insurance Company assumes no responsibility or liability for any tax treatment on this transfer under the Internal Revenue Code or otherwise. 403(b) Transfer Only: I acknowledge and agree that I have sole responsibility (1) for compliance with the Internal Revenue Service s Section 403(b) Regulations and my employer s or former employer s 403(b) plan, if applicable, and (2) in determining and notifying Oxford Life Insurance Company as to whether the requested distribution is an eligible rollover distribution. For 1035 Exchange: I hereby assign and transfer the specified portion of my right, title, and interest in the above Contract ( the Contract ) to Oxford Life Insurance Company. I irrevocably waive all rights, claims, and demands under the Contract. The purpose of this transfer is to effect a direct nontaxable exchange of contracts pursuant to Section 1035 of the Internal Revenue Code. I understand and agree that the cost basis in the contract issued by Oxford Life Insurance Company shall be determined based upon the cost basis information provided by the above-referenced company ( Surrendering Company ). I further understand and agree that Oxford Life Insurance Company assumes no responsibility in determining or verifying the cost basis of the new contract issued by it. I acknowledge and agree that if Oxford Life Insurance Company does not receive cost basis information acceptable to it, the cost basis of the contract issued by Oxford Life Insurance Company will be zero. I hereby declare that the Contract is not subject to any assignment, pledge, collateral assignment, or other lien and that no proceedings in bankruptcy or insolvency, voluntary or involuntary, have been instituted by or against me and that I am not under guardianship or any legal disability. I understand and agree that Oxford Life Insurance Company will request that the Surrendering Company totally or partially surrender the original Contract and that Oxford Life Insurance Company assumes no responsibility for any delay by the Surrendering Company in paying the surrender proceeds or for any changes in the amount. Owner s Initials I understand that the proposed transfer or rescission of the Contract may have important tax consequences, and/or surrender or withdrawal penalties, and I represent and agree that Oxford Life Insurance Company is furnishing this form and participating in this transaction at my request. I understand and agree that Oxford Life Insurance Company makes no representations concerning my tax treatment under Internal Revenue Code Section 1035 or otherwise and that Oxford Life Insurance Company has no responsibility or liability for the validity of this assignment. Signature (Contract Owner) X Signature (Co-Owner) X Date Date Signature Guarantee (If required by Surrendering Company) Acceptance By Oxford Life Insurance Company - Home Office Use Only Oxford Life Insurance Company requests the liquidation and/or transfer of the account listed in Section 2. By our signature below, we represent that the account described is or is intended to be an account of the type indicated and that we accept the Section 1035 exchange / transfer on behalf of the person(s) named on this form. Please provide us with a report of the pre- and post-tefra cost basis in the current contract, if applicable. Authorized Signature: Title: Date: Form # (Rev. 1/2010) Page 2 of 2

27 OXFORD LIFE INSURANCE COMPANY 2721 North Central Avenue Phoenix, Arizona (602) or (800) IMPORTANT NOTICE: REPLACEMENT OF LIFE INSURANCE OR 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 policy or contract. If so, a replacement is occurring. Financed purchases are also considered replacements. A replacement occurs when a new policy or contract is purchased and, in connection with the sale, you discontinue making premium payments on an existing policy or contract, or an existing policy or 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 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 policy or contract to pay all or part of any premium or payment due on the new policy. 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 policy or contract. You may be able to make changes to your existing policy or contract to meet your insurance needs at less cost. A fi nanced purchase will reduce the value of your existing policy 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 policy or contract? YES NO 2. Are you considering using funds from your existing policies or contracts to pay premiums due on the new policy or contract? YES NO If you answered YES to either one of the above questions, list each existing policy or 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 policy or contract will be replaced or used as a source of financing: INSURER NAME CONTRACT OR POLICY # INSURED OR ANNUITANT REPLACED (R) OR FINANCING (F) Make sure you know the facts. Contact your existing company or its agent for information about the old policy or 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 agent in the sales presentation. Be sure that you are making an informed decision. The existing policy or contract is being replaced because. I certify that the responses herein are, to the best of my knowledge, accurate: (Applicant s Signature and Printed Name) (Date) (Producer s Signature and Printed Name) (Date) I do not want this notice read aloud to me. (Applicant must initial only if they do not want the notice read aloud.) RN100 (5/09) [AL, AK, AR, AZ, CO, IA, KY, LA, ME, MD, MS, MT, NC, NE, NH, NJ, NM, OH, OR, RI, TX, UT, VA, WV] WHITE Applicant YELLOW Home Office PINK Agent GOLDENROD Existing Insurer

28 ANNUITY SUITABILITY ACKNOWLEDGMENT 2721 North Central Avenue Phoenix, AZ SECTION 1A Owner s Name Owner s Social Security Number Joint Owner s Name Joint Owner s Social Security Number Annuity Product Name Financial Status, Objectives, and Investment profile What annual income does the applicant require to maintain their current lifestyle? $0 - $24,999 (1) $25,000 - $49,999 (2) $50,000 - $99,999 (3) $100,000 or higher (4) Refused (5) What is the applicant s current annual income? $0 - $24,999 (1) $25,000 - $49,999 (2) $50,000 - $99,999 (3) $100,000 or higher (4) Refused (5) What is the applicant s primary source of annual income? Salary (1) Retirement Plan (2) Investments (3) Social Security (4) Refused (5) What is the applicant s Federal Income Tax Bracket? 10% (1) 15% (2) 25% (3) 28% (4) 33% (5) 35% (6) Refused (7) What is the applicant s approximate net worth (excluding car and primary residence)? $0 - $74,999 (1) $75,000 - $149,999 (2) $150,000 - $249,999 (3) $250,000 - $499,999 (4) $500,000 - $999,999 (5) $1,000,000 - or higher (6) Refused (7) Estimated Premium Amount How is the applicant s net worth distributed? (Must total 100%) Stocks, Bonds and Mutual Funds: % Real Estate: % Annuities and Life Insurance: % CDs and Cash: % Other: % Refused What is the applicant s primary goal in purchasing an annuity with us? Tax Savings (1) Growth for Future (2) Save for Emergencies (3) Safety of Principal (4) Current Income (5) Retirement Income (6) Refused (7) How does the applicant rate his or her investment knowledge? Limited (1) Average (2) Extensive (3) Refused (4) When does the applicant anticipate needing access to these funds? 6 Years (1) 7 Years (2) 8 Years (3) 9 Years (4) Never (5) Refused (6) Does the applicant have sufficient funds available in case of an emergency (not including this annuity)? Yes (1) No (2) Refused (3) What is the source of funds for this annuity policy? Annuity* Life Insurance* CDs and Cash Other Investments Other: * The Owner must complete Section 1B if the source of funds includes a life insurance or annuity policy. Owner s Initials Suitability 200 Page 1 of 3 OLIC 2011 Rev $ Joint Owner s Initials

29 SECTION 1B Replacement Policy Comparison Worksheet Product Data and Features Replaced Policy 2nd Replaced Policy (If applicable) Proposed Policy Name of Company Type of Policy Fixed Indexed Variable Life Insurance Fixed Indexed Variable Life Insurance Fixed Indexed Date of Issue Premium $ $ $ Premium Bonus % % % Premium Bonus Recapture Amount $ $ $ Current Accumulation Value $ $ N/A Current Surrender Value $ $ N/A Surrender Charge Schedule for Remaining Years Free Withdrawal Percentage % % % Market Value Adjustment Yes No Yes No Yes No Guaranteed Minimum Interest Rate % % % Death Benefit Surrender Value Full Accumulation Value Other: $ Surrender Value Full Accumulation Value Other: $ Surrender Value Full Accumulation Value Enhanced Benefits Writing Producer 1. Please list other features compared and considered, if any: 2. How will the replacement policy better assist the applicant in meeting the applicant s insurance needs and financial objectives? Immediate Income Interest Rate Index Credit Options Enhanced Benefits Full Accumulation Value Death Benefit Change in Purpose for Annuity Lifetime Income 3. Has the applicant surrendered or exchanged any annuities within the preceding 36 months? Yes No If Yes, please explain: Owner s Initials Joint Owner s Initials Suitability 200 Page 2 of 3 OLIC 2011 Rev

30 SECTION 2 Owner s Certification The Owner must review and sign the Owner s Acknowledment of Suitability if the producer has recommended this annuity product as suitable for the Owner. If the producer did not recommend this product as suitable, skip this section and proceed to the Acknowledgment of No Suitability Recommendation section. Pick only one. Owner s Acknowledgment of Suitability By signing this Acknowledgment of Suitability, I acknowledge and agree that: All information provided above is true and may be relied upon by the producer and Oxford Life. The annuity product recommended by the producer is suitable for my financial needs and objectives. I do not need the funds used to purchase this product for my daily living expenses or emergencies. If I am surrendering or exchanging another annuity or a life insurance policy to fund this annuity purchase, this transaction may result in a taxable event and surrender charges. Neither Oxford Life nor any of its affiliates or representatives may provide tax or legal advice. I should consult my tax advisor or legal counsel for specific advice regarding my individual situation. My producer relied on the information I provided to make a recommendation and any information I withheld (including marking refused on any questions above) could have affected the producer s decision to recommend this product as suitable for my situation. Oxford Life does not make suitability recommendations. The producer is responsible for reviewing the Owner s suitability information and determining whether to make a recommendation. Owner s Signature Date Joint Owner s Signature Date Owner s Acknowledgment of No Suitability Recommendation The Owner must review and sign this section if the producer did not recommend this annuity product as suitable. Neither my producer nor Oxford Life has made any recommendation as to the suitability of the proposed annuity purchase. I have determined that this annuity is suitable for my financial needs and objectives and I wish to purchase this product without a recommendation. If any responses to questions above are marked refused, I confirm that I refused to provide that suitability information. Owner s Signature Date Joint Owner s Signature Date Producer Certification Annuity Recommended as Suitable Prior to making any recommendation to the Owner, I gathered all information reasonably appropriate to determine the suitability of my recommendation. I recommended the annuity product as suitable for this Owner on the basis of the facts disclosed by the Owner as to his or her investments and other insurance products and as to his or her financial situation and needs. I have reasonably informed the Owner of material features of the product, such as the surrender period, surrender charges, potential tax penalties, and expense charges. If this purchase involves a replacement, I have gathered all relevant information regarding the replaced product and determined that the transaction as a whole is suitable. Producer s Signature / Producer s Number Date No Suitability Recommendation I did not recommend the proposed annuity purchase as suitable for this Owner. I made reasonable efforts to gather the Owner s suitability information before declining to make a suitability recommendation. I did not make a suitability recommendation for this annuity purchase because: Producer s Signature / Producer s Number Date Suitability 200 Page 3 of 3 OLIC 2011 Rev

31 OWNER 2721 North Central Avenue Phoenix, AZ (866) SINGLE PREMIUM MULTI-YEAR GUARANTEE DEFERRED ANNUITY APPLICATION JOINT OWNER Name Address City State Zip Name Address City State Zip Date of Birth Age Gender M F Date of Birth Age Gender M F SSN/Taxpayer ID Phone ( ) Driver s License No. State SSN/Taxpayer ID Phone ( ) Driver s License No. State ANNUITANT (If other than OWNER) Name Relationship Address City State Zip Date of Birth Age Gender M F SSN/Taxpayer ID Phone ( ) Driver s License No. State PRIMARY BENEFICIARY Name Address, City, State, Zip Code Relationship Date of Birth SSN/Taxpayer ID Share %* CONTINGENT BENEFICIARY Name Address, City, State, Zip Code Relationship Date of Birth SSN/Taxpayer ID Share %* * Share % must equal 100%. If no share % is specified, payments will be made in equal shares. PREMIUM Single Premium $ Tax Status of Single Premium IRA Roth IRA Non-Qualified Other OLIC 2011 ICC11-MYGA-MVA-APP 1 of 2 Rev

32 FRAUD NOTICE Any person who knowingly submits a false statement in an Application or files a claim containing false or deceptive statements may be guilty of insurance fraud and subject to penalties under state law. I have read, understand and acknowledge the Fraud Notice. Owner s Initials Joint Owner s Initials MARKET VALUE ADJUSTMENT - SURRENDER CHARGE The annuity policy applied for is subject to a market value adjustment during the first ten policy years. I understand that the market value adjustment may reduce or increase the amount I receive from a withdrawal or surrender of the annuity policy based on changes in the interest rate index identified in the annuity policy. I understand that withdrawal/surrender charges may also apply during the first ten policy years. Owner s Initials Joint Owner s Initials ELECTRONIC DOCUMENT DELIVERY By selecting yes to one of the options below and providing your address on page 1 of this application, you consent to receive communications and/or documents related to your policy electronically instead of by U.S. Mail. You may revoke your consent to electronic delivery and switch to delivery by U.S. Mail by sending a written request to our home office or by using any electronic revocation procedure that we may make available on our website. You must call or write to Oxford Life to notify us if your address changes. To use electronic delivery, you will need an account and a computer with internet access and an operating system that can support PDF format documents. Call or write to Oxford Life if you wish to obtain a paper copy of any items delivered electronically. If you do not consent to electronic delivery or if you revoke your consent to electronic delivery, Oxford Life may charge a reasonable fee for paper copies. Yes, I want to receive the following by electronic delivery when electronic delivery is available (any items not checked will be sent in paper format): My policy (including any riders, endorsements and amendments) Disclosures Other communications No, I want to receive all communications and documents by U.S. Mail. REPLACEMENT The Owner and Joint Owner Do Do Not have an existing insurance policy or annuity contract. All of the undersigned state that the Annuity Does Does Not replace an existing insurance policy or annuity. Name of the Company Policy or Contract Number Address Estimated Transfer Amount ACKNOWLEDGEMENT The statements and answers in this Application are true and complete. All answers in this Application are representations and not warranties. I agree they shall be the basis for any annuity issued. I certify that the Social Security Number(s) and/or Taxpayer s Identification Number(s) provided in this Application are correct and that I am not subject to backup withholding. Signature of Proposed Owner Signed at Date City, State Signature of Proposed Joint Owner Signed at Date City, State I certify that I have correctly recorded the information supplied by the Owner, Joint Owner and Annuitant (if other than Owner) in this Application. To the best of my knowledge and belief the proposed Owner and Joint Owner Do Do Not have any existing life insurance or annuity coverage and the annuity coverage applied for will will not replace any existing life insurance or annuity coverage. Producer s Signature Date Producer s Printed Name Producer s Number Second Producer s Signature Date Second Producer s Printed Name Second Producer s Number OLIC 2011 ICC11-MYGA-MVA-APP 2 of 2 Rev