Premier Choice Annuity Application

Transcription

1 Premier Choice Annuity Application Issued by First Security Benefit Life Insurance and Annuity Company of New York. Questions? Call our Customer Service Center at Choose Type of Annuity Contract Please select the annuity type: Non-Qualified 408 IRA 408A Roth Other Initial Purchase Payment $ Annuity Start Date (Minimum NQ $5,000; Q $2,000) (mm/dd/yyyy) For IRAs only: Current Year $ Prior Year $ Rollover $ Initial Guarantee Period(s): minimum allocation per Guarantee Period is $1,000. % 1 Year % 2 Years % 3 Years % 4 Years % 5 Years % 6 Years % 7 Years % 8 Years % 9 Years % 10 Years % Other 2. 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 3. 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 Date of Birth (mm/dd/yyyy) Daytime Phone Number Home Phone Number 4. Provide Joint Owner Information 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 Date of Birth (mm/dd/yyyy) Daytime Phone Number Home Phone Number 5. Provide Primary and Contingent Beneficiary(ies) For additional Primary Beneficiaries, please attach a separate list to the end of this application. Primary Beneficiary Name Social Security No. DOB (mm/dd/yyyy) Relationship to Owner % of Benefit 1. For additional Contingent Beneficiaries, please attach a separate list to the end of this application. 1. Contingent Beneficiary Name Social Security No. DOB (mm/dd/yyyy) Relationship to Owner % of Benefit FSB232 (12-11) Premier Choice /12/01 (1/3)

2 6. Provide Replacement Information Do you currently have any existing annuity or insurance policies? Yes No Does this proposed contract replace or change any existing annuity or insurance policy? Yes No If Yes, please list the following for all life insurance or annuity contracts to be replaced: Current Carrier Name Contract/Policy Number 7. Incentives and Other Considerations Have you been offered any cash incentive or other consideration (such as free insurance) as an inducement to apply for this annuity contract? Yes No To the best of your knowledge and belief, has 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 Important Notice Concerning Tax Treatment for Same-Sex Spouses Pursuant to Section 3 of the federal Defense of Marriage Act ( DOMA ), same-sex marriages currently are not recognized for purposes of federal law. Therefore, the favorable income-deferral options afforded by federal tax law to an opposite-sex spouse under Internal Revenue Code sections 72(s) and 401(a)(9) are currently NOT available to a same-sex spouse. Same-sex spouses who own or are considering the purchase of annuity products that provide benefits based upon status as a spouse should consult a tax advisor. To the extent that an annuity contract or certificate accords to spouses other rights or benefits that are not affected by DOMA, same-sex spouses remain entitled to such rights or benefits to the same extent as any annuity holder s spouse. 8. Provide Signature My signature below indicates that the information provided within the application is accurate and true, including my tax identification number. I have read the important disclosures on page 3. 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) Please Continue FSB232 (12-11) Premier Choice /12/01 (2/3)

3 Agent s Statement 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. I have complied with the requirements for disclosure and/or replacement. Yes. If Yes, please enclose a completed and signed (i) Disclosure Statement; (ii) Important Notice form; and (iii) Incoming Funds Transfer form. The agent is required to leave with the applicant a copy of the Disclosure Statement and Important Notice form. This application was completed and signed in my presence. Print Name of Agent Code x Signature of Agent Date (mm/dd/yyyy) Print Agency Name Code Important Disclosures At the end of the Withdrawal Charge period associated with a Guarantee Period: (1) the Owner will have the option to withdraw his or her money from that Guarantee Period without a Withdrawal Charge, (2) the Owner can reinvest in one or more of the other Guarantee Periods then made available by FSBL, which are subject to a Withdrawal Charge, or (3) the Owner can reinvest in a Guarantee Period that has no Withdrawal Charge, referred to in the annuity contract as the One Year Renewal Guarantee Period. Thus, at the end of the Withdrawal Charge period for each Guarantee Period, you will have the ability to put the money from that Guarantee Period into an option which has no Withdrawal Charge (i.e., the One Year Renewal Guarantee Period). 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: First Security Benefit Life Insurance and Annuity Company of New York P.O. Box Topeka, Kansas Mail to: First Security Benefit Life Insurance and Annuity Company of New York Administrative Office PO Box Topeka, KS or Fax to: Visit us online at FSB232 (12-11) Premier Choice /12/01 (3/3)

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5 Appendix 10C Insurance Department of the State of New York IMPORTANT Notice Regarding Replacement or Change of Life Insurance Policies or Annuity Contracts This Notice is for Your Benefit and Required by Regulation No. 60 You are contemplating the purchase of a life insurance policy or annuity contract in connection with the surrender, lapse or change of existing life insurance policies or annuity contracts. The agent is required to give you this notice together with a signed disclosure statement containing the summary result comparison for the new life insurance policy or annuity contract and any life insurance policies or annuity contracts to be changed that sets forth the facts of the transaction and its advantages and disadvantages to you. Your decision could be a good one or a mistake so make sure you understand the facts. You should: 1. Carefully study the Disclosure Statement, which includes a Summary Result Comparison, until you are sure you understand fully the effect of the transaction. 2. Ask the company or agent from whom you bought your existing life insurance policies or annuity contracts to review with you the transaction and the Disclosure Statement. You may be able to effect the changes you desire more advantageously with them. Their customer service telephone number is contained in the Disclosure Statement. 3. Consult your tax advisor. There may be unfavorable tax implications associated with the contemplated changes to your existing life insurance policies or annuity contracts. As a general rule, it is often not advantageous to drop or change existing coverage in favor of new coverage, whether issued by the same or a different insurance company. Some of the reasons it may be disadvantageous are: 1. The amount of the annual premium under an existing life insurance policy may be lower than that called for by a new life insurance policy having the same or similar benefits. Any replacement of the same type of policy will normally be at a higher premium rate based upon the insured s then attained age. 2. Since the initial cost of a life insurance policy are charged against the cash value increases in the earlier life insurance policy years, the replacement of an old life insurance policy by a new one results in the policyholder sustaining the burden of these costs twice. Annuity contract usually contain provision for surrender charges, therefore a replacement involving annuity contracts may result in the imposition of surrender charges. 3. The incontestable and suicide clauses begin anew in a new life insurance policy. This could result in a claim being denied under the new life insurance policy that would have been paid under the life insurance policy that was replaced. 4. An existing life insurance policy or annuity contract often has more favorable provisions than a new life insurance policy or annuity contract in areas such as loan interest rate, settlement options, disability benefits and tax treatment. 5. There may have been changes in your health since the purchase of the existing coverage. 6. The insurance company with which you have existing coverage can often make a desired change on terms that would be more favorable than if you replaced existing coverage with new coverage. Please Continue 7920 NY (R11-06) 1st Copy Home Office - 2nd Copy Applicant - 3rd Copy Agent (1/2)

6 You have the right, within 60 days from the date of delivery of a new life insurance policy or annuity contract, to return it to the insurer and receive an unconditional full refund of all premiums or considerations paid on it, or in the case of a variable or market value adjustment policy or contract, a payment of the cash surrender benefits provided under the policy or contract, plus the amount of all fees and other charges deducted from gross considerations or imposed under the life insurance policy or annuity contract, and may have the right to reinstate or restore any life insurance policies and annuity contracts that were surrendered, lapsed or changed in the transaction to their former status to the extent possible and in accordance with the insurer s published reinstatement rules to the extent such rules are not inconsistent with the provisions of this part. IMPORTANT: This right should not be viewed as reinstating or restoring your life insurance policy or annuity contract to the same condition as if it had never been replaced. There may be consequences in reinstating or restoring your life insurance policy or annuity contract, including but not limited to: The right to reinstate or restore your life insurance policy or annuity contract applies only to companies subject to New York insurance laws; Your life insurance policy or annuity contract is subject to your specific company s reinstatement rules, which may vary from company to company. These rules may require payment of both premium and interest; however, you will not be subject to evidence of insurability, or a new contestable or suicide period; You may not receive the interest or investment performance during the period the life insurance policy or annuity contract was replaced; and There may be unfavorable Federal Income Tax consequences as a result of the reinstatement of your Life Insurance policy or annuity contract. IMPORTANT: In the case of a variable or market value adjustment policy or contract, the value of the policy or contract may increase or decrease during the 60 day period depending on the performance of the underlying investments, which may effect the value of the refund you receive. I hereby acknowledge that I read the above IMPORTANT NOTICE and have received a copy of same. Date: Signature of Applicant: Date: Signature of Applicant: Mail to: First Security Benefit Life Insurance and Annuity Company of New York Administrative Office PO Box Topeka, KS Customer Service Center: st Copy Home Office - 2nd Copy Applicant - 3rd Copy Agent (2/2)

7 You have the right, within 60 days from the date of delivery of a new life insurance policy or annuity contract, to return it to the insurer and receive an unconditional full refund of all premiums or considerations paid on it, or in the case of a variable or market value adjustment policy or contract, a payment of the cash surrender benefits provided under the policy or contract, plus the amount of all fees and other charges deducted from gross considerations or imposed under the life insurance policy or annuity contract, and may have the right to reinstate or restore any life insurance policies and annuity contracts that were surrendered, lapsed or changed in the transaction to their former status to the extent possible and in accordance with the insurer s published reinstatement rules to the extent such rules are not inconsistent with the provisions of this part. IMPORTANT: This right should not be viewed as reinstating or restoring your life insurance policy or annuity contract to the same condition as if it had never been replaced. There may be consequences in reinstating or restoring your life insurance policy or annuity contract, including but not limited to: The right to reinstate or restore your life insurance policy or annuity contract applies only to companies subject to New York insurance laws; Your life insurance policy or annuity contract is subject to your specific company s reinstatement rules, which may vary from company to company. These rules may require payment of both premium and interest; however, you will not be subject to evidence of insurability, or a new contestable or suicide period; You may not receive the interest or investment performance during the period the life insurance policy or annuity contract was replaced; and There may be unfavorable Federal Income Tax consequences as a result of the reinstatement of your Life Insurance policy or annuity contract. IMPORTANT: In the case of a variable or market value adjustment policy or contract, the value of the policy or contract may increase or decrease during the 60 day period depending on the performance of the underlying investments, which may effect the value of the refund you receive. I hereby acknowledge that I read the above IMPORTANT NOTICE and have received a copy of same. Date: Signature of Applicant: Date: Signature of Applicant: Mail to: First Security Benefit Life Insurance and Annuity Company of New York Administrative Office PO Box Topeka, KS Customer Service Center: st Copy Home Office - 2nd Copy Applicant - 3rd Copy Agent (2/2)

8 APPENDIX 11 INSURANCE DEPARTMENT OF THE STATE OF NEW YORK DEFINITION OF REPLACEMENT In order to determine whether you are replacing or otherwise changing the status of existing life insurance policies or annuity contracts, and in order to receive the valuable information necessary to make a careful comparison if you are contemplating replacement, the agent is required to ask you the following questions and explain any items that you do not understand. As part of your purchase of a new life insurance policy or a new annuity contract, has existing coverage been, or is it likely to be: (1) Lapsed, surrendered, partially surrendered, forfeited, assigned to the insurer replacing the life insurance policy or annuity contract, or otherwise terminated? Yes No (2) Changed or modified into paid-up insurance; continued as extended term insurance or under another form of nonforfeiture benefit; or otherwise reduced in value by the use of nonforfeiture benefits, dividend accumulations, dividend cash values or other cash values? Yes No (3) Changed or modified so as to effect a reduction either in the amount of the existing life insurance or annuity benefit or in the period of time the existing life insurance or annuity benefit will continue in force? Yes No (4) Reissued with a reduction in amount such that any cash values are released, including all transactions wherein an amount of dividend accumulations or paid-up additions is to be released on one or more of the existing policies? Yes No (5) Assigned as collateral for a loan or made subject to borrowing or withdrawal of any portion of the loan value, including all transactions wherein any amount of dividend accumulations or paid-up additions is to be borrowed or withdrawn on one or more existing policies? Yes No (6) Continued with a stoppage of premium payments or reduction in the amount of premium paid? Yes No If you have answered yes to any of the above questions, a replacement as defined by New York Insurance Department Regulation No. 60 has occurred or is likely to occur and your agent is required to provide you with a completed Disclosure Statement and the IMPORTANT Notice Regarding Replacement or Change of Life Insurance Policies and Annuity Contracts. Date: Signature of Applicant: Date: Signature of Applicant: To the best of my knowledge, a replacement is involved in this transaction: Yes No Date: Signature of Agent: Mail to: First Security Benefit Life Insurance and Annuity Company of New York Administrative Office PO Box Topeka, KS Customer Service Center: NY (R11-06) 1st Copy Home Office - 2nd Copy Applicant - 3rd Copy Agent (1/1)

9 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

10 Steps to Lock-In An 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. How do I lock the rate for my client? 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 check boxes below to ensure that your application submission meets the requirements. Security Benefit must receive all original paperwork within 5 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. In Good Order Requirements: Fully completed Incoming Funds Request and/or application Original signed Incoming Funds Request including a signature guarantee if required by the transferring company State Replacement form and Sales Literature form if transfer is replacing an existing annuity Representatives may consider contacting transferring company to identify other additional requirements If you have questions or need assistance, please call our service center at The Premier Choice Annuity (Form FSB233 (12-02)) is a flexible purchase payment deferred annuity, and is issued by First Security Benefit Life Insurance and Annuity Company of New York, Rye Brook, New York. The Security Benefit Choice, Multi-Choice, and Select Annuities (Form 4585) are flexible purchase payment deferred annuities, issued by Security Benefit Life Insurance Company. Not available in all states. Security Benefit Life Insurance Company is not admitted in the state of New York and is not authorized to transact insurance business in New York. Annuities are not insured by the FDIC or otherwise insured or guaranteed by the Federal government or any of its agencies. They are not obligations of, or guaranteed by, any bank, savings and loan or credit union. To and Through Retirement /07/10

11 Premier Choice Annuity Incoming Funds Request Issued by First Security Benefit Life Insurance and Annuity Company of New York. Questions? Call our Customer Service Center at Instructions Use this form to transfer funds from your current carrier to First Security Benefit Life Insurance and Annuity Company of New York ( FSBL ). 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: First Security Benefit Life Insurance and Annuity Company of New York Administrative Office P.O. Box Topeka, KS Upon receiving this material, FSBL 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 First Security Benefit Life Insurance and Annuity Company of New York for the benefit of the Owner listed on this form and mail to: First Security Benefit Life Insurance and Annuity Company of New York Administrative Office P.O. Box Topeka, KS Provide First 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 Mailing Address Street Address City State ZIP Code Social Security Number/Tax I.D. Number Daytime Phone Number Home Phone Number Name of Annuitant/Participant (if different from 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 Please indicate the type of account you would like to transfer your funds to (check one). 403(b) TSA Roth IRA Roth 403(b) TSA Traditional IRA Non-qualified Annuity FSBL 7937 A /08/31 (1/4)

12 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 FSBL 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 FSBL under IRC Section 1035, any withdrawals from or changes in ownership to your FSBL 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 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) signing date and 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 % Transfer over years Monthly Quarterly Semi-annually Annually 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) /08/31 (2/4)

13 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. Provide Investment Directions Please invest the funds (check one): As indicated on the enclosed application; or for an existing account, to the allocations on file. According to the Investment Allocations indicated below. Indicate whole percentages totaling 100%. The minimum allocation per guarantee period is $1000. Check with your representative as to which Guarantee Periods are available. % One Year Guarantee Period % Two Year Guarantee Period % Three Year Guarantee Period % Four Year Guarantee Period % Five Year Guarantee Period % Six Year Guarantee Period % Seven Year Guarantee Period % Eight Year Guarantee Period % Nine Year Guarantee Period % Ten Year Guarantee Period Must Total 100% 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. FSBL 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 Please Continue /08/31 (3/4)

14 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. FSBL Acceptance To be completed by FSBL. FSBL 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: First Security Benefit Life Insurance and Annuity Company of New York Administrative Office PO Box Topeka, KS or Fax to: Visit us online at /08/31 (4/4)

15 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/Transfer will not be processed until all requirements, including this completed form, are received in proper order at First Security Benefit Life Insurance and Annuity Company of New York (FSBL). 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 FSBL. 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 I certify that the responses herein are, to the best of my knowledge, accurate and complete: Agent's Signature Printed Name Date Mail to: First Security Benefit Life Insurance and Annuity Company of New York Administrative Office PO Box Topeka, KS Customer Service Center: FSBL 0803 (R5-08) 1st Copy Home Office - 2nd Copy Applicant - 3rd Copy Agent (1/1)

16 New York Replacement Process (Reg 60) New York requires specific steps be taken when transferring money from one financial tool to another (i.e exchange). These steps will help ensure you cover each area necessary. Step 1: Complete the following and send to First Security Benefit Life Insurance and Annuity Company of New York (FSBL) Information Authorization form Definition of Replacement form Step 2 (Transfer paperwork): Upon receipt of the disclosure document from FSBL, please complete the following steps and send to FSBL: 1 Review the disclosure document with the client Complete Part D of the disclosure document Representative and Client must sign the disclosure document Complete and sign the application Review and have client sign Appendix 10C Important Notice Complete and sign Incoming Funds Transfer Form Complete and sign Sales Literature Confirmation form Rate Lock The rate lock begins when FSBL receives, in good order, the paperwork required in Step 1; and, the rate lock end date is 60 days from receipt of the transfer paperwork, in good order, that is listed in Step 2. For questions about this process, please call Financial Professional Use Only The Premier Choice Annuity (Form FSB233 (12-02)) is a flexible purchase payment deferred annuity issued by First Security Benefit Life Insurance and Annuity Company of New York, Rye Brook, New York. Annuities are not insured by the FDIC or otherwise insured or guaranteed by the Federal government or any of its agencies. They are not obligations of, or guaranteed by, any bank, savings and loan or credit union. 1 Please note that the Application, Incoming Funds Transfer Form, Appendix 10C and Sales Literature Confirmation Form may not be received or dated prior to the completed and signed Disclosure Document. 800 Westchester Avenue Suite 641 N. Rye Brook, New York /02/01

17 Information Authorization Issued by First Security Benefit Life Insurance and Annuity Company of New York. Questions? Call our Service Center at Instructions 1. Please complete a separate Information Authorization and Definition of Replacement form for each insurer whose policy/contract will be replaced. 2. Upon receiving these completed forms, First Security Benefit Life Insurance and Annuity Company of New York ( FSBL ) will forward a copy of the Information Authorization and Definition of Replacement forms to the current insurer(s). FSBL will also request that the current insurer(s) complete a Disclosure Statement in order for the Owner to review relevant coverage comparisons between the existing coverage and the proposed coverage to be issued by FSBL. Please type or print. 1. Provide General Account Information 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 2. Current Carrier Information Company Name Mailing Address Street Address City State ZIP Code Carrier s Phone No. Contract/Policy Number(s) Please indicate the account type at the current carrier: 401(a) 401(k) 403(b) TSA 403(b)(7) TSA 457 Non-qualified Roth IRA SEP-IRA SIMPLE IRA Traditional IRA If this request involves the entire account balance, my policy is: Enclosed Lost/Destroyed Estimated Value(s) $ Please Continue 7920 R /03/08 (1/2)

18 3. Select Product Type One of the products listed below MUST be selected. Please indicate below the product selection to be used in the Disclosure Statement calculations and any additional riders/optional benefits you plan to select. Refer to the information included in the sales kit for rider limitations. (For Premier Choice, also select the Guarantee Periods.) AdvisorDesigns SecureDesigns Premier Choice Annual Stepped Up Death Benefit Annual Stepped Up Death Benefit Guarantee Period(s) Credit Enhancement Rider: Credit Enhancement Rider: 2 year 7 year 4% 4% 3 year 8 year 0-Year Alternate Withdrawal 0-Year Alternate Withdrawal 4 year 9 year Charge Rider Charge Rider 5 year 10 year 4-Year Alternate Withdrawal 4-Year Alternate Withdrawal 6 year Charge Rider Charge Rider Other EliteDesigns Return of Premium Death Benefit Rider 4. Provide Signatures I hereby acknowledge that I have read the Definition of Replacement form and have received a copy of the form for my records. I hereby authorize FSBL to obtain, from the insurer listed above, the information necessary to complete a Disclosure Statement with respect to the policies or contracts listed in order to provide me with relevant coverage comparisons between my existing coverage and the proposed coverage to be issued by FSBL. This Information Authorization remains in effect until the current carrier, as identified in Section 2, has transferred my account balance to FSBL. x x Signature of Owner Date (mm/dd/yyyy) Signature of Joint Owner (if applicable) Date (mm/dd/yyyy) x Signature of Financial Advisor Date (mm/dd/yyyy) Print Name of Financial Advisor Mail to: First Security Benefit Life Insurance and Annuity Company of New York Administrative Office PO Box Topeka, KS or Fax to: Visit us online at R /03/08 (2/2)