Security Benefit Advanced Choice Annuity Application Individual Single Purchase Payment Deferred Annuity

Transcription

1 Security Benefit Advanced Choice Annuity Application Individual Single Purchase Payment Deferred Annuity Issued by Security Benefit Life Insurance Company. Questions? Call our National Service Center at One Security Benefit Place Topeka, KS Provide Owner Information Name of Owner Male Female First MI Last Mailing Address Street Address City State ZIP Code Residential Address (if different from mailing address) Street Address City State ZIP Code Social Security Number/Tax I.D. Number Daytime Phone Number Home Phone Number 2. Provide Joint Owner Information Date of Birth (mm/dd/yyyy) Name of Joint Owner Male Female First MI Last Mailing Address Street Address City State ZIP Code Residential Address (if different from mailing address) Street Address City State ZIP Code Social Security Number/Tax I.D. Number Daytime Phone Number Home Phone Number Date of Birth (mm/dd/yyyy) 3. Provide Annuitant Information Same as Owner Name of Annuitant Male Female First MI Last Mailing Address Street Address City State ZIP Code Residential Address (if different from mailing address) Street Address City State ZIP Code Social Security Number/Tax I.D. Number Date of Birth (mm/dd/yyyy) Daytime Phone Number Home Phone Number Please Continue ICC M (9-13) IIPRC New Model/Generic Advanced Choice IC 2013/09/01 (1/4)

2 4. Provide Primary and Secondary Beneficiary(ies) For additional Primary Beneficiaries, please attach a separate list to the end of this application. 1. Primary Beneficiary Name Address (city, state, zip) Phone No. Social Security No. DOB (mm/dd/yyyy) Relationship to Contract Annuitant % of Benefit For additional Contingent Beneficiaries, please attach a separate list to the end of this application Contingent Beneficiary Name Address (city, state, zip) Phone No. Social Security No. DOB (mm/dd/yyyy) Relationship to Contract Annuitant % of Benefit 5. Choose Type of Annuity Contract Please select the annuity type: Non-Qualified Traditional IRA Roth IRA Other Purchase Payment $ Annuity Start Date (Minimum $10,000) (mm/dd/yyyy) For IRAs only: Current Year $ Prior Year $ Rollover $ Transfer $ Please select the Guarantee Period: only one Guarantee Period may be selected. 3 Year 4 Year 5 Year 6 Year 7 Year 8 Year 9 Year 10 Year This contract is a single premium annuity. It is typically issued upon receipt of the Purchase Payment and does not accept Purchase Payments after the effective date of the contract. 6. Purchase Payment Information Please indicate below whether the Purchase Payment listed in section five above will be from a single source or from multiple sources. You must check one of the options below. In addition, if the Purchase Payment is from multiple sources, you must indicate that you understand and agree to the conditions of such transactions. The entire Purchase Payment is being received from a single deposit. The Purchase Payment is being received from multiple sources. If you indicated that the Purchase Payment is being received from multiple sources, you must complete the section below. By checking this box, I (we) direct Security Benefit to: Hold Purchase Payments received by it until the last of such Purchase Payments is received; and upon receipt of the last Purchase Payment, to apply all of the transfer payments as a single Purchase Payment for the new contract. By checking this box, I (we) understand and agree: The new contract will not be issued until the last Purchase Payment is received by Security Benefit; if last Purchase Payment is not received within 60 days of receipt of application, then the contract will be issued effective on the 60th day following application receipt, as long as funds received are more than the minimum required premium amount; no interest will be paid or credited by Security Benefit with respect to the Purchase Payments held by it for any period that is before the effective date of the new contract; and Interest will only begin to accrue on the issue or effective date of the new contract. Please Continue ICC M (9-13) IIPRC New Model/Generic Advanced Choice IC 2013/09/01 (2/4)

3 7. Provide Replacement Information Do you have any existing annuity or life insurance policies? Yes No Does this proposed contract replace or change any existing annuity or life insurance policy? Yes No If Yes, please list the company and policy number. Company Name Company Name Policy Number Policy Number 8. Incentives and Other Considerations Have you or the annuitant been offered any cash incentive or other consideration (such as free insurance) as an inducement to apply for this annuity contract? Yes No Does the owner have an insurable interest in the annuitant? Yes No 9. Provide Signature My signature below indicates that the information provided within the application is accurate and true, including my tax identification number. I understand and agree that no amount will be credited to my annuity with Security Benefit until the funds are received by Security Benefit in cash. I further understand the interest crediting rate for the new contract is subject to change and will not be determined until the issue or effective date. I assume the risk that such interest crediting rate may decrease between the date I sign the application and the issue or effective date of the new contract. I understand that any amount allocated to the annuity contract for which I am applying may be subject to a market value adjustment, which may cause the values to increase or decrease in dollar amount if withdrawn or surrendered prior to a specified date or dates as stated in the contract. Tax Identification Number Certification Instructions: You must cross out item (2) in the below paragraph if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest or dividends on your tax return. For contributions to an individual retirement arrangement (IRA), and generally payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct Tax Identification Number. 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 the IRS has notified me that I am no longer subject to backup withholding; and (3) I am a U.S. citizen or other U.S. person (as defined in the IRS Form W-9 instructions). The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. x Signature of Owner Date (mm/dd/yyyy) Signed at (City/State) x Signature of Joint Owner Date (mm/dd/yyyy) Agent s Statement To the best of your knowledge, does the applicant currently have any existing life insurance policies or annuity contracts? Yes No If Yes, please comment below. (Submit a copy of the Replacement Notice with this application and leave the applicant a copy of any written material presented to the applicant.) Will the Annuity being purchased replace any prior insurance or annuities of this or any other Company? No, to the best of my knowledge, this application is not involved in the replacement of any life insurance or annuity contract, as defined in applicable insurance department regulations. Yes. If Yes, please comment below. I have complied with the requirements for disclosure and/or replacements. I have used only insurer approved sales materials and I have left copies with the applicant. Print Name of Agent Code x Signature of Agent Date (mm/dd/yyyy) Print Agency Name Code ICC M (9-13) IIPRC New Model/Generic Advanced Choice IC 2013/09/01 (3/4)

4 Fraud Disclosure Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law. Important Information About Procedures for Purchasing a New Contract 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 who purchases a contract. What this means to you: When you purchase a contract, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver s license or other identifying documents. Mailing Instructions Checks should be made payable to: Security Benefit Life Insurance Company P.O. Box Topeka, Kansas Mail to: For expedited or overnight delivery: Security Benefit Life Insurance Company Security Benefit P.O. Box Mail Zone 497 Topeka, Kansas One Security Benefit Place Fax to: Topeka, Kansas Visit us online at ICC M (9-13) IIPRC New Model/Generic Advanced Choice IC 2013/09/01 (4/4)

5 Items to Note before Selling an Annuity (Fixed Indexed, Fixed and Variable) In Good Order Requirements To ensure your new business application will be complete and in good order, please provide Security Benefit the following documents. Please ensure all parts of the document are completed and each document is signed or initialed in the appropriate places. Fully completed application Original, signed Incoming Funds Request form, including a signature guarantee if required by the transferring company If applicable in your state, a State Replacement form and in most states the Sales Literature Confirmation form (if a replacement). State specific forms (if applicable) Contact the transferring company to ensure delivery of funds and identify if any additional requirements are necessary If applicable, and if a replacement, please provide a copy of any individualized sales materials used in the sale. Required Training Before a financial professional can solicit business for an annuity (fixed indexed, fixed or variable) they may have to complete training, refer to Annuity Training Requirements ( ) for complete details. Locking in Your Client's Interest Rate Security Benefit Life Insurance Company (SBL) and First Security Benefit Life Insurance and Annuity Company of New York (FSBL), referred to herein as Security Benefit, offer a rate lock program that helps lock-in the current rate for 60 days while working through the paper process. Below are some questions and answers to help you take advantage of the rate lock. The rate lock is available for 60 days from date of the client signature on the application for new purchases. To ensure your client qualifies for the rate lock, you must meet all of the following requirements, including the In Good Order requirements. Use the list below to ensure that your application submission meets the requirements. Security Benefit must receive all original paperwork within five business days of client signature in good order. Money transferring from another carrier must be received at Security Benefit within 60 days of client signature. Representatives should consider sending copies of original paperwork to your compliance staff for approval while sending originals to Security Benefit to meet the rate lock deadline. For further questions and assistance, please call your internal sales consultant at /11/06

6 Questions? Call our National Service Center at Advanced Choice Annuity Incoming Funds Request Instructions Use this form to transfer funds from your current carrier to Security Benefit Life Insurance Company (SBL). Complete the entire form. Please type or print. 1. The Owner should complete this Incoming Funds Request form and any applicable state-required replacement forms. 2. Please contact your current carrier for any requirements it may have for transferring money to another company. 3. Obtain Signature Guarantee if required by your current carrier. 4. The documents mentioned above should be mailed to: Security Benefit P.O. Box Topeka, KS Upon receiving this material Security Benefit will send an acceptance letter to the carrier. 6. If you are completing this form for a 403(b) or 403(b)(7) account/contract please contact your employer for any processing instructions the employer or third party administrator may require. Notice to Current Carrier Please make check(s) payable to Security Benefit for the benefit of the Owner listed on this form and mail to: Security Benefit regular mail Security Benefit overnight mail P.O. Box Mail Zone 500 Topeka, KS One Security Benefit Place Topeka, KS Provide Security Benefit Account Information Application Attached or Contract Number Name of Owner First MI Last Mailing Address Street Address City State ZIP Code Social Security Number/Tax I.D. Number Daytime Phone Number Home Phone Number Name of Joint Owner First MI Last Social Security Number/Tax I.D. Number Name of Annuitant/Participant (If different from Owner) First MI Last Social Security Number/Tax I.D. Number Please indicate the type of account you would like to transfer your funds to (check one). 403(b) TSA Roth 403(b) TSA Non-qualified Annuity Roth IRA Traditional IRA SEP-IRA /09/01 (1/4)

7 2. Provide Your Current Carrier Information Please fill out the name and contact information for your current carrier. Current Carrier s Name Mailing Address Street Address City State ZIP Code Phone Number Account Number for Current Carrier Please indicate the account type you have with your current carrier (check one). 401(a) 403(b)(7) Roth 403(b)(7) 457 Roth 403(b) TSA Non-qualified Annuity Non-qualified CD, Stock 1 Non-qualified Mutual Fund 1 Life Insurance SEP-IRA SIMPLE IRA Traditional IRA Roth IRA Roth 401(k) 403(b) TSA Other 401(k) 1 This transfer is a taxable event. Please indicate the investment type you have with your current carrier (check one). Annuity Bank CD Mutual Fund Life Policy Money Market Brokerage Account 401(k)/Pension Plan Other If this request involves your entire account balance, please check one of the following. My policy is: Enclosed Lost/destroyed 3. Set Up Transfer/Exchange/Rollover Option Please indicate one of the following Exchange: I hereby make complete and absolute assignment and transfer all or the portion specified of my rights, title and interest of every nature and character in and to the Current Carrier Account in Section 2 to Security Benefit Life Insurance Company (SBL) in an exchange intended to qualify under Section 1035 of the Internal Revenue Code. I understand that by executing this assignment, I irrevocably waive all rights, claims and demands under the above policy for the portion specified. If you effect, or have effected, a partial exchange from a previously existing annuity contract with another carrier to an annuity contract with SBL under IRC Section 1035, any withdrawals from or changes in ownership to your SBL contract within 180 days of such partial exchange may have adverse tax consequences. Please consult your tax advisor. Exchange (exchange of 403(b)/403(b)(7) assets from one provider to another provider within your current employer s Plan) Rollover (not like-to-like, for example 457 to IRA, etc.) Transfer (like-to-like, for example, 457 to 457, IRA to IRA, prior employer 403(b) Plan to current employer 403(b) Plan) Please Transfer Immediately On date Transfer must occur within 30 calendar days from Date (mm/dd/yyyy) the Incoming Funds Request form signing date and 45 calendar days from the Application receipt date. Transfer request will be mailed two business days prior to date listed here. Amount Liquidate my entire Account: Estimated Value $ Liquidate a specified amount: Amount to Transfer $ or % Distribution Requirements (if applicable) I certify that applicable requirements have been met for distribution. Check all that apply: Age 59 1 /2 Disabled Severance from employment on Date (mm/dd/yyyy) Please Continue /09/01 (2/4)

8 4. Required Minimum Distribution (if applicable) Current carrier should distribute my RMD to me prior to transferring/rolling over my account. Current carrier should proceed with the transfer/rollover because the requirements for the current year have been met. 5. Purchase Information Funds will be allocated as indicated on the enclosed application. Incoming transfers are not allowed for existing Advanced Choice contracts. If this transfer is one of multiple funding sources, Security Benefit will: Hold Purchase Payments received by it until the last of such Purchase Payments is received; and upon receipt of the last Purchase Payment, apply all of the transfer payments as a single Purchase Payment for the new contract. In addition: The new contract will not be issued until the last Purchase Payment is received by Security Benefit; If the last Purchase Payment is not received within 60 days of Security Benefit s receipt of the application, then the contract will be issued effective on the 60th day after application receipt, as long as the funds received are at least equal to the minimum required purchase amount; No interest will be paid or credited by Security Benefit with respect to the Purchase Payments held by it for any period that is before the effective date of the new contract; and Interest will only begin to accrue on the issue or effective date of the new contract. 6. Provide Signatures As the contractowner, I understand, acknowledge and certify that: I am responsible for tax consequences which could include the imposition of penalties, additional taxes and interest. Security Benefit assumes no responsibility or liability for any effects of this transaction. I am aware of my right to receive information regarding my current contract, including contract values. I certify that the information provided is correct and complete. x Signature of Owner Date (mm/dd/yyyy) Signature of Joint Owner Date (mm/dd/yyyy) x Signature of Plan Sponsor or Date (mm/dd/yyyy) Title Third Party Administrator (if applicable Please consult your financial representative or employer) x Signature of Representative Date (mm/dd/yyyy) Print Name of Representative Spousal Consent for Community Property States: If the owner/participant is a resident of AZ, CA, ID, LA, NM, NV, TX, WA or WI, spousal consent is required, unless the owner/participant has no legal spouse. x Signature of Spouse Date (mm/dd/yyyy) Please Continue /09/01 (3/4)

9 7. Obtain Signature Guarantee Please obtain a Signature Guarantee ONLY if required by your Current Carrier. You can obtain a Signature Guarantee from a bank, broker or other acceptable financial institution. A Notary Public cannot provide a Signature Guarantee. x Signature of Guarantor Date (mm/dd/yyyy) Title or Name of Institution Place Signature Guarantee Stamp Here 8. Security Benefit Acceptance To be completed by Security Benefit. Security Benefit hereby agrees to accept the transfer of the proceeds identified on this form. x Signature of Accepting Carrier Date (mm/dd/yyyy) Title Mail to: For expedited or overnight delivery: Security Benefit Life Insurance Company Security Benefit P.O. Box Mail Zone 497 Topeka, Kansas One Security Benefit Place Fax to: Topeka, Kansas Visit us online at /09/01 (4/4)

10 ARKANSAS REPLACEMENT FORM 1. Name of Insured 2. Age of Insured 3. Existing Life Insurance Contract or Annuity YES NO 4. Existing Life Insurance and/or Annuity Contract(s) 5. Investment Objectives 6. Risk Tolerance, Financial Status, & Current Assets Discussed YES NO (See Question 18 to document details leading to determination of suitability) 7. Monthly Financial Needs 8. Will the owner need access to cash values in the near future? YES NO 9. Tax Implications Fees, costs, and surrender or penalty charges associated with partial withdrawals/surrenders 11. Limits or conditions for waiving those penalties or charges 12. Amount of premium enhancement to be credited 13. Amount of bonus credits, if any 14. Are bonus credits dependent on any preconditions being met? YES NO If YES, explain: 1 These are the ones known at the time of the contract. The insured should also be advised to contact his or her personal tax advisor AR 1st Copy Home Office - 2nd Copy Applicant - 3rd Copy Agent /07/15 (1/2)

11 15. Did the insured enter into the transaction against the advice of the producer? YES NO 16. Was notice sent to the existing contract provider? YES NO 17. Why is the replacing contract in the best interest of the insured? 18. Any other information that may reasonably show suitability of the product Death Benefit Suitability Chart Comparing New and Existing Contracts Existing Contract New Contract Sub-account Choices Withdrawal Privileges Liquidity Special Features Costs Fees Features Surrender Charges Benefits Rate of Return Current/Initial Value Signature of Producer/Insurer s Representative Signature of Applicant Date Mail to: Security Benefit PO Box Topeka, KS National Service Center: AR 1st Copy Home Office - 2nd Copy Applicant - 3rd Copy Agent /07/15 (2/2)

12 Security Benefit Advanced Choice Annuity Disclosure Document Thank you for your interest in the Advanced Choice Annuity from Security Benefit Life Insurance Company ("SBL"). This summary describes the key features of the Advanced Choice Annuity so you can determine if it will meet your financial goals. For more specific information, please refer to the contract as it is the legal document setting forth our obligation to you. What is the Advanced Choice Annuity? The Advanced Choice Annuity is a single premium, deferred fixed annuity with a market value adjustment. It guarantees interest based upon the interest rate and period you choose, the "Guarantee Periods." If you take out funds during a Guarantee Period, surrender charges and a market value adjustment may apply. You may receive guaranteed periodic payouts from the annuity after 10 contract years (after one contract year for contracts issued in Florida). It is designed as a long-term holding. You should not purchase the Advanced Choice Annuity if you will need the funds during the Guarantee Period. How do I buy the Advanced Choice Annuity? You must complete an application and pay a purchase payment. You may use funds from multiple sources, but we must receive all the funds before we issue the annuity. Once we issue your annuity, no further purchase payments can be accepted. The purchase payment may not exceed $1,000,000 without prior approval by SBL. Can I change my mind after purchasing the Advanced Choice Annuity? You have a specific number of days to review an annuity after you buy it. During that time if you decide that you do not want the annuity, you can return it for your entire purchase payment. Your free look period is shown on the contract cover page. If you replaced a previous annuity contract owned by you, the free look period may be different than that listed on the cover page of your contract (varies by state). If so, there will be an additional notice for the free look period that was included with your contract. What interest is credited to my funds in the Advanced Choice Annuity? Interest is credited daily based on the interest rate for the Guarantee Period you pick. Guarantee Periods range from one year to ten years during which the interest rate is guaranteed. The surrender charge period matches the term of the Guarantee Period. So, in choosing the Guarantee Period, you should also consider when you intend to withdraw funds from your annuity or to start an annuity option. Prior to the start of a Guarantee Period, we declare the interest rate that applies for the entire term of the Guarantee Period. The interest rate varies among the different Guarantee Periods, but the interest rate for a Guarantee Period will never be less than the guaranteed minimum interest rate. The guaranteed minimum interest rate will be at least 1.0%. Can I pick a different Guarantee Period? Yes, if you decide to continue your annuity at the end of a Guarantee Period, you pick a new Guarantee Period. We will send you a notice that your Guarantee Period is ending and the interest rates for available Guarantee Periods. If you take no action, SBL will automatically apply your annuity value to the same Guarantee Period you selected previously. If the Guarantee Period of the same term is not available, SBL will automatically apply the amount to the Guarantee Period with the next shortest term. What is the value of my Advanced Choice Annuity? We compute the account value of your Advanced Choice Annuity. The account value is equal to the purchase payment made to the annuity, less any premium or other taxes that apply, plus interest credited, 4200 (9-13) 1

13 less any rider charges, less any prior withdrawals paid or amounts applied to an annuity option, which includes any surrender charge and market value adjustment. We also compute the cash surrender value of your Advanced Choice Annuity. The cash surrender value is equal to the greater of: (i) the guaranteed minimum cash surrender value or (ii) the account value, (a) minus any surrender charge, (b) minus any premium or other taxes that apply, (c) minus any rider charge that applies, and (d) adjusted by the market value adjustment. The guaranteed minimum cash surrender value is equal to 87.5% of the purchase payment, increased by interest credited at the guaranteed minimum interest rate, less withdrawals, and less any premium or other taxes that apply. Can I access funds from my annuity without penalty? Yes, if you take a "Free Withdrawal" or take a withdrawal during the "Window Period" no surrender charge or market value adjustment applies. A withdrawal or surrender may be subject to premium or other taxes we must pay. After the first anniversary of your contract, and each year thereafter, you may take from your annuity, as one or multiple withdrawals, up to 10% of the funds in your annuity as of the beginning of the contract year ("Free Withdrawals"). If the full amount of Free Withdrawals not taken within a contract year, it cannot be carried forward to future contract years. For withdrawals in excess of the Free Withdrawal amount, your account value will be reduced by the total amount of the withdrawal paid to you as well as any applicable surrender charge or market value adjustment. During the 30 days immediately after the end of a Guarantee Period (the "Window Period"), you may withdrawal funds from your annuity or surrender your annuity and no surrender charge or market value adjustment applies. What are the Surrender Charges? Each Guarantee Period has its own surrender charge schedule. The surrender charge rate that applies is based upon the Guarantee Period you choose, and the time since the start of the Guarantee Period when the withdrawal is taken, surrender occurs or the account value is applied to an annuity option. Each time a new Guarantee Period starts, a new surrender charge period starts, except during the Window Period. Guarantee Period* Three Year 9% 8% 7% 0%+ Four Year 9% 8% 7% 6% 0%+ Five Year 9% 8% 7% 6% 5% 0%+ Six Year 9% 8% 7% 6% 5% 4% 0%+ Seven Year 9% 8% 7% 6% 5% 4% 3% 0%+ Eight Year 9% 8% 7% 6% 5% 4% 3% 2% 0%+ Nine Year 9% 8% 7% 6% 5% 4% 3% 2% 1.5% 0%+ Ten Year 9% 8% 7% 6% 5% 4% 3% 2% 1.5% 0.75% 0%+ * Not all Guarantee Periods may be available from time to time. Example: You purchase your Advanced Choice Annuity for $100,000 and you choose the three year Guarantee Period. At the start of year two, the account value is $104,000, you take a withdrawal of $25,000. The Free Withdrawal amount is $10,400, so a surrender charge applies on $14,600 ($25,000 - $10,400). An 8% surrender charge applies. The surrender charge is $1,168. What is a market value adjustment? A market value adjustment reflects changes in interest rates since the start of a Guarantee Period and when the withdrawal is taken, a surrender occurs or the account value is applied to an annuity option. If the market interest rates are higher than the start of the Guarantee Period, an additional amount is 4200 (9-13) 2

14 deducted. If market interest rates are lower than the start of the Guarantee Period, an additional amount is added. There is a limit on a positive and negative market value adjustment equal to the absolute value of the maximum negative market value adjustment that will not cause the Cash Surrender Value to be less than the Guaranteed Minimum Cash Surrender Value. The market value adjustment applies during each Guarantee Period. When does a surrender charge or market value adjustment apply? A surrender charge and market value adjustment apply to any partial withdrawal, surrender or when annuity payouts start,* unless: 1. The total amount withdrawn during the contract year is equal to or less than the Free Withdrawal amount. 2. It occurs during the Window Period; or 3. You qualify for the Nursing Home or Terminal Illness Waiver. * In Florida, these do not apply when annuity payouts start. How do I get income (payouts) from my annuity? Under your annuity, you may receive annuity payments from your annuity based upon the eight different annuity options we currently offer, except in Florida. If you purchased the annuity in Florida, and (i) you decide to take annuity payments during the Guarantee Period, you may only elect options 1 through 4 or option 8; or (ii) you decide to take annuity payments during the Window Period, you may elect any one of the eight options. The annuity options are: Option 1 Life Option: For the life of the annuitant. Upon death, no further payments will be made. Option 2 Life with Fixed Period Option: For the later of: (i) life of the annuitant or (ii) the end of a 5, 10, 15, or 20 contract year period that you choose.* Option 3 Life with Installment or Unit Refund Option: For the later of: (i) life of the annuitant or (ii) the end of the period equal to the annuity start amount divided by the first payment.* Option 4 Joint and Last Survivor Option: For as long as either the annuitant and joint annuitant is living. Option 5 Fixed Period Option: For a fixed number of contract years between 5 and 20.* Option 6 Fixed Payment Option: Of a fixed amount. If the annuitant dies before the amount applied plus daily interest credits is paid, the beneficiary receives the remaining annuity payments. Option 7 Period Certain Option: Until the end of a 10, 15, or 20 contract year period that you choose.* Option 8 Joint and Contingent Survivor Option: For the life of the primary annuitant and if the joint annuitant is living at the death of the primary annuitant, for the life of the joint annuitant. * If the annuitant dies before the end of the period, the beneficiary receives the remaining annuity payments. If you do not pick a payout option, the Life with 10-Year Fixed Period Option applies. Up to 30 days prior to the annuity start date, you may change the payout option. After the 30 days prior to the annuity start date, the Cash Surrender Value will be applied to the annuity option and you cannot change the payout option or surrender your annuity (9-13) 3

15 When can I receive annuity payments? You may start receiving annuity payments any time after your 10th contract anniversary as long as we receive your written request at least 30 days prior to that date. If you buy your annuity in Florida, you may start receiving annuity payments after the first contract year. Annuity payments must start before the anniversary after the annuitant reaches the age of 100. What happens upon a death? If the entire value of the annuity has been applied to an annuity option then, upon the death of an annuitant, we will continue to make annuity payments, if any, as may apply under the annuity option chosen. If the entire value of the annuity has not been applied to an annuity option, then a death benefit is payable upon the death of a natural person owner. If the owner is not a natural person, then a death benefit is paid upon the death of the annuitant or any natural person joint owner. The death benefit is equal to the account value on the date we receive due proof of death, less any premium or other taxes we must pay. In certain circumstances, the contract can be continued and no death benefit is paid as shown in the "Distribution Rules for Death Benefits" of your contract. What benefit riders are available? The Advanced Choice Annuity offers both a Nursing Home Waiver and a Terminal Illness Waiver. This means that we will waive the surrender charge and market value adjustment on any partial withdrawals or surrender after the 3rd contract year if you meet the following requirements: 1. Nursing Home Waiver. If you are confined to a hospital or nursing facility for 90 or more consecutive days immediately preceding the withdrawal or surrender and continue to be confined at the time we receive your request. The confinement must begin after the issue date of the contract. We require proof of confinement. This endorsement is form 6054 (5-11) (not available in all states). 2. Terminal Illness Waiver. If you have been diagnosed with a terminal illness by a licensed doctor and the terminal illness is first diagnosed after the issue date of the contract. We require proof of the terminal illness. This endorsement is form 6055 (5-11) (not available in all states). How will annuity payments and withdrawals from my annuity be taxed? Interest credited on your annuity is tax-deferred. This means you do not pay taxes on the interest credited to your annuity until the money is paid to you. When you take annuity payments or make a withdrawal, you pay ordinary income taxes on the interest credited. If the annuity is tax qualified, you also pay ordinary income taxes on the purchase payment received. You may also pay a 10% federal income tax penalty on amounts you withdraw before attaining age 59½ if they do not meet certain exceptions such as disability, health insurance expenses, medical expenses, or first time home buyer expenses. However, this document is not intended to provide tax advice. You should consult your tax adviser to determine if your particular circumstances qualify as an exception to the 10% penalty tax. If your state imposes a premium tax, it will be deducted from the money you receive. What happens if I exchange my annuity? You can exchange one tax-deferred annuity for another without paying income taxes on the earnings when you make the exchange. Taxes may be assessed if you take withdrawals from the annuity that you exchanged into prior to the expiration of a 12-month period. Before you make such an exchange, compare the benefits, features, and costs of the two annuities. You may also want to consider consulting a tax adviser before making exchanges or withdrawals to determine any potential tax consequences (9-13) 4

16 Does buying an annuity in a retirement plan provide extra tax benefits? No. Buying an annuity within an IRA, 401(k), or other tax-deferred retirement plan does not give you any extra tax benefits. You should choose your annuity based on its features and benefits as well as its risks and costs, not on tax benefits alone. How can I reach Security Benefit? You can reach us in several ways: By Phone: By aawf-fi@securitybenefit.com By mail: One Security Benefit Place Topeka, KS On the web: The Advanced Choice Annuity is not: (i) a deposit, (ii) FDIC insured, (iii) guaranteed by a bank or credit union, or (iv) insured by any federal government agency or NCUA/NCUSIF. This Disclosure Document describes the Security Benefit Advanced Choice Annuity, a single premium, deferred fixed annuity contract with a market value adjustment. The Advanced Choice Annuity is issued on contract form ICC (9-13), 5200 (9-13), 5200 AZ (9-13), 5200 CA (9-13) and 5200 FL (9-13) (9-13) 5

17 Sales Literature Confirmation Contractowner Name: Annuitant/Participant: Contract Number: Tax ID Number: This form is to be completed by the writing agent and must be submitted with all replacement cases. Applications for new contracts that are considered replacements and/or a 1035/Transfers will not be processed until all requirements, including this completed form, are received in proper order at Security Benefit. 1. Did you utilize any individualized sales materials (including illustrations) in your presentation to the client? YES NO Note: If you answered yes, copies of all material must be submitted to Security Benefit. 2. Security Benefit requires that a client receive the contents of a sales kit in order to make the sale. The contents of the kit should be left with the client. Please identify the product being sold and the state of issue below: Kit given to Client: Product Name Issue State I certify that the responses herein are, to the best of my knowledge, accurate and complete: Agent's Signature Printed Name Date Mail to: Security Benefit PO Box Topeka, KS National Service Center: Model (R3-08) 1st Copy Home Office - 2nd Copy Applicant - 3rd Copy Agent (1/1)

18 SECURITY BENEFIT PRIVACY POLICY The privacy of Security Benefit s customers is of utmost importance to us. You provide nonpublic personal information ( NPI ) to us in the course of doing business. We treat this information as confidential and restrict access to it. We collect NPI about you from: (1) your requests for literature; (2) your applications and forms; (3) your financial advisor; and (4) your transactions with us. We do not sell information about current or former customers. We disclose information among our affiliates and to third parties as needed to process transactions or service your account. For example, we may contract with third parties to send you statements. Also, we disclose information as required or permitted by law. Except with regard to California residents, we also may disclose information to companies: (1) that help us sell our products; and (2) with whom we jointly offer products. When we contract with others, we will require them to adhere to our privacy standards. At Security Benefit, we restrict access to your NPI. Such information is given only to those who need it to provide products or services to you. We also maintain: (1) physical; (2) electronic; and (3) procedural safeguards to guard your NPI. This Privacy Policy applies to the following companies: Security Benefit Life Insurance Company, Security Benefit Corporation, Security Distributors, Inc., First Security Benefit Life Insurance and Annuity Company of New York, and Security Financial Resources, Inc. THIS PAGE IS NOT PART OF YOUR CONTRACT 7929S /02/27

19 Electronic Authorization Questions? Call our National Service Center at Instructions Use this form to activate electronic services. Transactions may be requested via telephone, Internet, or other electronic means by the Owner and/or servicing sales representative based on instructions of the Owner. Authorization must be on file with Security Benefit before we will activate electronic services. Please type or print. 1. Provide General Account Information Contract/Account Number Plan Number or Name (Applicable to Employer Retirement Plans only) Name of Owner/Participant First MI Last Mailing Address Street Address City State ZIP Code Social Security Number/Tax I.D. Number Daytime Phone Number Home Phone Number 2. Provide Signature I understand and agree to the terms set forth on this form. x x Signature of Owner/Participant Date (mm/dd/yyyy) Signature of Joint Owner (if applicable) Date (mm/dd/yyyy) x Signature of Representative (optional) Date (mm/dd/yyyy) Print Name of Representative Mail to: For expedited or overnight delivery: Security Benefit Security Benefit P.O. Box Mail Zone 497 Topeka, Kansas One Security Benefit Place Fax to: Topeka, Kansas Visit us online at L (R5-06) /11/21 (1/1)