SERFF Tracking #: AERL-129974517 State Tracking #: Company Tracking #: TRIOSOURCE SALES PROPOSAL 275607-A 2015...

SERFF Tracking #: AERL-129974517 State Tracking #: Company Tracking #: TRIOSOURCE SALES PROPOSAL 27567-A 215... State: District of Columbia Filing Company: TOI/Sub-TOI: LTC3I Individual Long Term Care/LTC3I.1 Qualified Product Name: TrioSource Sales Proposal - 215 Project Name/Number: TrioSource Sales Proposal - 215/27567-A Filing at a Glance Company: Product Name: TrioSource Sales Proposal - 215 State: TOI: Sub-TOI: Filing Type: District of Columbia LTC3I Individual Long Term Care LTC3I.1 Qualified Form Date Submitted: 5/27/215 SERFF Tr Num: SERFF Status: State Tr Num: State Status: Co Tr Num: Implementation Date Requested: Author(s): Reviewer(s): AERL-129974517 Closed-APPROVED TRIOSOURCE SALES PROPOSAL 27567-A 215 FILING On Approval Disposition Date: 6/5/215 Disposition Status: Jeff Pederson, Cheryl Meyer, Kathleen Felton, Peg VanDrisse Colin Johnson (primary) APPROVED Implementation Date: 6/5/215 PDF Pipeline for SERFF Tracking Number AERL-129974517 Generated 7/1/216 1:12 AM

SERFF Tracking #: AERL-129974517 State Tracking #: Company Tracking #: TRIOSOURCE SALES PROPOSAL 27567-A 215... State: District of Columbia Filing Company: TOI/Sub-TOI: LTC3I Individual Long Term Care/LTC3I.1 Qualified Product Name: TrioSource Sales Proposal - 215 Project Name/Number: TrioSource Sales Proposal - 215/27567-A General Information Project Name: TrioSource Sales Proposal - 215 Project Number: 27567-A Requested Filing Mode: Review & Approval Explanation for Combination/Other: Submission Type: New Submission Status of Filing in Domicile: Not Filed Date Approved in Domicile: Domicile Status Comments: Market Type: Individual Individual Market Type: Overall Rate Impact: Filing Status Changed: 6/5/215 Deemer Date: Submitted By: Kathleen Felton Filing Description: Advertising Form Submitted for Review: Form: 27567-A Sales Proposal State Status Changed: Created By: Kathleen Felton Corresponding Filing Tracking Number: Dear Sir or Madam: The above-listed advertising form 27567-A is submitted for review and approval by your department. This form replaces the previously approved form 27567 Sales Proposal, approved on 2/18/14 under SERFF tracking #AEMN-1294152. This submission contains no unusual or controversial items from the standpoint of normal company or industry standards. This form is an invitation to inquire. This form will be available through our agents in print or electronic format. It will also be available on our website, RiverSource.com. The advertising is intended for use with the following form filings: 1. Individual Flexible Premium Adjustable Life Insurance Policy forms 13249-DC, Policy Data 13249-DP, Application form 134924 and Application Supplement-Part II form 134932. These forms were approved on 1/28/13 under SERFF tracking #12918932. 2. Rider forms 13241 and 132411, previously approved on 11/7/13 under SERFF tracking #AEMN-12927793. Included with this submission is the statement of variability. This advertising form will be used upon your approval of this filing. The contact person for this filing is: Kathleen M. Felton Senior Contract Analyst 955 Minneapolis, MN 55474 (612) 671-2127 Kathleen.M.Felton@ampf.com To the best of my knowledge and belief this filing complies with the state regulations. Thank you for your assistance in reviewing this filing. Respectfully, PDF Pipeline for SERFF Tracking Number AERL-129974517 Generated 7/1/216 1:12 AM

SERFF Tracking #: AERL-129974517 State Tracking #: Company Tracking #: TRIOSOURCE SALES PROPOSAL 27567-A 215... State: District of Columbia Filing Company: TOI/Sub-TOI: LTC3I Individual Long Term Care/LTC3I.1 Qualified Product Name: TrioSource Sales Proposal - 215 Project Name/Number: TrioSource Sales Proposal - 215/27567-A Stephen M. Riesterer Director, Insurance Marketing Communications Insurance Marketing Strategy Company and Contact Filing Contact Information Kathleen Felton, Sr. Contract Analyst 955 Ameriprise Financial Center H25/955 Minneapolis, MN 55474 Filing Company Information RiverSource Life Insurance Company 955 Ameriprise Financial Center H25/955 Minneapolis, MN 55474 (612) 671-2465 ext. [Phone] kathleen.m.felton@ampf.com 612-671-2127 [Phone] 612-678-34 [FAX] CoCode: 655 Group Code: 4 Group Name: FEIN Number: 41-823832 State of Domicile: Minnesota Company Type: Life State ID Number: Filing Fees Fee Required? Retaliatory? Fee Explanation: No No PDF Pipeline for SERFF Tracking Number AERL-129974517 Generated 7/1/216 1:12 AM

SERFF Tracking #: AERL-129974517 State Tracking #: Company Tracking #: TRIOSOURCE SALES PROPOSAL 27567-A 215... State: District of Columbia Filing Company: TOI/Sub-TOI: LTC3I Individual Long Term Care/LTC3I.1 Qualified Product Name: TrioSource Sales Proposal - 215 Project Name/Number: TrioSource Sales Proposal - 215/27567-A Correspondence Summary Dispositions Status Created By Created On Date Submitted APPROVED Colin Johnson 6/5/215 6/5/215 PDF Pipeline for SERFF Tracking Number AERL-129974517 Generated 7/1/216 1:12 AM

SERFF Tracking #: AERL-129974517 State Tracking #: Company Tracking #: TRIOSOURCE SALES PROPOSAL 27567-A 215... State: District of Columbia Filing Company: TOI/Sub-TOI: LTC3I Individual Long Term Care/LTC3I.1 Qualified Product Name: TrioSource Sales Proposal - 215 Project Name/Number: TrioSource Sales Proposal - 215/27567-A Disposition Disposition Date: 6/5/215 Implementation Date: 6/5/215 Status: APPROVED Comment: Rate data does NOT apply to filing. Schedule Schedule Item Schedule Item Status Public Access Supporting Document SOV APPROVED Yes Supporting Document 27567-A Redline to show changes APPROVED Yes Supporting Document Cover letter APPROVED Yes Form TrioSource Sales Proposal APPROVED Yes PDF Pipeline for SERFF Tracking Number AERL-129974517 Generated 7/1/216 1:12 AM

SERFF Tracking #: AERL-129974517 State Tracking #: Company Tracking #: TRIOSOURCE SALES PROPOSAL 27567-A 215... State: District of Columbia Filing Company: TOI/Sub-TOI: LTC3I Individual Long Term Care/LTC3I.1 Qualified Product Name: TrioSource Sales Proposal - 215 Project Name/Number: TrioSource Sales Proposal - 215/27567-A Form Schedule Lead Form Number: 27567-A Item Schedule Item No. Status 1 APPROVED 6/5/215 Form Name TrioSource Sales Proposal Form Form Form Action Specific Number Type Action Data 27567-A ADV Revised Previous Filing Number: Replaced Form Number: AEMN- 1294152 27567 Readability Score Attachments 27567-A.pdf Form Type Legend: ADV Advertising AEF Application/Enrollment Form CER Certificate CERA Certificate Amendment, Insert Page, Endorsement or Rider DDP Data/Declaration Pages FND Funding Agreement (Annuity, Individual and Group) MTX Matrix NOC Notice of Coverage OTH Other OUT Outline of Coverage PJK Policy Jacket POL Policy/Contract/Fraternal Certificate POLA Policy/Contract/Fraternal Certificate: Amendment, Insert Page, Endorsement or Rider SCH Schedule Pages PDF Pipeline for SERFF Tracking Number AERL-129974517 Generated 7/1/216 1:12 AM

RiverSource TrioSource SM universal life insurance A Universal Life Insurance Proposal for: John Doe 77 2nd Ave South, Minneapolis, MN 55474-245 Representing RIVERSOURCE LIFE INSURANCE COMPANY (RiverSource Life) 2 Ameriprise Financial Center, Minneapolis MN 55474 The Confident Retirement approach is not a guarantee of future financial results. This is a proposal, not a policy, for presentation in Minnesota. Its purpose is to show how policy values, cash surrender values and death benefits can change based on specific assumptions about interest rates, expenses, risk classification of the insured, death benefit, and premiums. Any change in these assumptions will change the proposed results. They should not be viewed as a prediction of future results. Issued by, Minneapolis, Minnesota. Affiliated with Ameriprise Financial Services, Inc. DB Version 29539.1 213-214. All rights reserved. Version 2.95.15 931 Prepared on 9/28/14 This proposal not complete without all pages. 27567-A Page 1 of 14

Universal Life Insurance Proposal What is it? RiverSource TrioSource SM insurance provides a simple way to protect your retirement from unexpected expenses. With at least 7% of people over 65 needing long-term care service at some point, having a strategy to protect against unexpected events is critical to achieving a more confident retirement. TrioSource insurance puts your money to work to protect your retirement assets from the impact of long-term care. It lets you: Access tax-free benefits for long-term care expenses or Pass on an income-tax free death benefit to loved ones or Get your money back if you ever change your mind The Ameriprise Financial Confident Retirement approach looks at four principles of retirement. TrioSource insurance can help you prepare for the unexpected, which includes events such as long-term care expenses, pre-retirement disability, property loss and personal liability and premature death. (1) Medicare & You, National Medicare Handbook, Centers for Medicare and Medicaid Services Revised November 212. (2) Return of Premium is 9% in years 1-2 and 1% in years 3 and later. It is net of any partial surrenders, outstanding policy loans and long-term care benefits paid. DB Version 29539.1 Version 2.95.15 Prepared on 9/28/14 Page 2 of 14

Benefits Universal Life Insurance Proposal TrioSource insurance puts your money to work to protect your retirement assets from long-term care expenses. TrioSource insurance can provide you with the following: $367,338 1 TrioSource insurance will reimburse you for home health care, nursing home care, adult day care, some equipment purchases, home modifications and even care received outside of the U.S. $17,855 2 If you don't use any or all of your long-term care benefits the unused portion of your death benefit will pass income tax-free to your beneficiaries. $75, 3 If you change your mind or your plans change, you can receive 1% of your premium back. Additional benefits include: Simple one-time payment. This design eliminates the need for ongoing premiums. No rate increases, guaranteed. The cost for long-term care benefits will never increase on the policy. An easy application process. With TrioSource insurance, underwriting is quick and painless. A simple phone interview will gather health information and conduct cognitive tests. This provides the information needed to underwrite the policy and make a decision on the coverage. (1) Long-term care benefit is the maximum amount you will receive over the benefit duration of the policy based on the immediate acceleration of long-term care benefits. This amount includes any Inflation Protection Option chosen. The Accelerated Benefits Rider for Long-Term Care will pay benefits for some services, subject to policy requirements and limitations. Benefits paid for services outside the U.S. are limited to a daily benefit of 5% of your maximum monthly benefit divided by 3 for each day the insured is confined to a nursing home facility. (2) Death benefit is the minimum amount that will be received at death based on no acceleration of long-term care benefits, loans, or partial surrenders. (3) Money-back guarantee is the Return of Premium, which is 9% of the initial premium in years 1-2 and 1% in years 3 and later and is net of any partial surrenders, outstanding policy loans and long-term care benefits paid. DB Version 29539.1 Version 2.95.15 Prepared on 9/28/14 Page 3 of 14

Universal Life Insurance Proposal How it works When you receive qualified long-term care services your policy reimburses you up to your monthly long-term care benefit limit. To be eligible for benefits, a licensed health care practitioner must certify you are chronically ill and on a prescribed plan of care within the previous twelve months. Chronically ill generally means you are unable to perform two out of six activities of daily living without substantial assistance from another individual for at least 9 days, or that you need substantial supervision due to severe cognitive impairment. Because TrioSource insurance reimburses for actual expenses, if you use less than the maximum monthly benefit amount, your benefit period will extend until your entire benefit is depleted. Once you qualify for benefits TrioSource insurance offers a zero-day elimination period for home care and a 9-day elimination period for facility care. In addition TrioSource insurance includes Care Coordination Services, an optional benefit that helps tailor the types of care and providers you may need. (1) Qualified long-term care services include but are not limited to nursing home, assisted living, and home health care. (2) Activities of Daily Living are bathing, continence, eating, dressing, toileting and transferring. DB Version 29539.1 Version 2.95.15 Prepared on 9/28/14 Page 4 of 14

Universal Life Insurance Proposal Initial Specified Amount: $17,855 $75, About the Universal Life Policy Proposal The product proposed on the accompanying pages is A LIFE INSURANCE POLICY offered by RiverSource Life. The name of the life insurance policy is RiverSource TrioSource SM universal life insurance with long-term care benefits, a Flexible Premium Adjustable Life Insurance Policy (Insurance Policy Form #ICC13 13249 and state variations). All values proposed are based on the assumptions including guaranteed expenses and interest rates. Be sure to ask your sales representative about the life insurance policy's features, benefits, and fees, and whether this insurance is appropriate for you, based on your financial situation and objectives. Definition of Key Terms and Column Headings Throughout this proposal the following terms will be used. Before reviewing the proposal, become familiar with these terms: Age EOY is the insured's age at the end of the policy year. One-Time Premium is the amount paid at the time the policy is issued. This is the only amount paid for the policy. Cash Available Upon Surrender is the maximum amount available if the policy is surrendered in full. It is equal to the greater of the Return of Premium or the policy value less any surrender charges and outstanding loan amounts. Death Benefit is the amount payable upon the death of John Doe. It is the death benefit minus any outstanding loans. Total Long-Term Care Benefits is the total amount of lifetime benefits payable to reimburse covered long-term care expenses based on the Accelerated Benefit Rider for Long-Term Care (ABR) and the optional Extension of Benefits Rider for Long-Term Care (EBR). This amount includes any additional benefits provided by the Inflation Protection Option, when chosen. Maximum Monthly LTC Benefit is the maximum amount that will be paid in a calendar month to reimburse covered long-term care expenses. This amount includes any additional benefits provided by the Inflation Protection Option, when chosen. DB Version 29539.1 931 This proposal not complete without all pages. Version 2.95.15 Prepared on 9/28/14 Page 5 of 14

Universal Life Insurance Proposal Initial Specified Amount: $17,855 $75, Policy Highlights Return of Premium: 1 $75, $75, Initial Specified Amount: $17,855 Accelerated Benefit Rider for Long-Term Care: $17,855 Extension of Benefits Rider for Long-Term Care: $17,855 Inflation Protection Option: + $25,628 2 Total At Issue Long-Term Care Benefits: $367,338 Initial Maximum Monthly LTC Benefit: Benefit Duration: Inflation Protection Option: $7,118 4 Years 5% Simple 1 Policy Features Return of Premium is the minimum amount received at the time of full surrender. In years 1-2, this is equal to 9% of the initial premium paid. In years 3 and later, this is equal to 1% of the initial premium paid. This amount will be reduced by any loans, partial surrenders and benefit payments made under the ABR and EBR prior to the full surrender of the policy. International Benefit is the expenses eligible for benefit payment under the long-term care portion of this policy while the insured is confined to a nursing home facility outside of the United States. Daily benefits will be paid up to 5% of the maximum monthly benefit divided by 3 for each day under the Accelerated Benefit Rider for Long-Term Care only. Inflation Protection Option is an optional benefit that will increase the ABR and EBR (when elected) monthly and lifetime benefit amounts on each policy anniversary, while it is in effect. For a graphical representation of the effects of the available Inflation Protection Options on this policy, please see the Optional Coverage Report that may be included in this proposal. Residual Death Benefit is the minimum death benefit that will be paid upon death of the insured after the acceleration of the ABR benefits has exhausted the life insurance death benefit. This is equal to 5% of the initial specified amount net of loans. (2) Total At Issue Long-Term Care Benefits amount is the maximum amount you will receive over the benefit duration of the policy based on the immediate acceleration of long-term care benefits. This amount includes any Inflation Protection Option chosen. DB Version 29539.1 931 This proposal not complete without all pages. Version 2.95.15 Prepared on 9/28/14 Page 6 of 14

Universal Life Insurance Proposal Initial Specified Amount: $17,855 $75, Policy Features continued Covered Expenses are the expenses eligible for reimbursement under the long-term care portion of this policy. The following services are eligible: Day Elimination Period* Home health care Care coordination Caregiver training Home modification Durable medical equipment Home hospice care 9 Day Elimination Period Nursing home facility Assisted living facility Adult day care center Facility hospice care International benefit * The services listed as eligible during the -Day Elimination Period above will count towards the 9-Day Elimination Period. 9-Day Elimination Period is the one-time elimination period that applies to the services listed above. Rider Description Accelerated Benefit Rider for Long-Term Care (ABR): The ABR is a rider that reimburses for long-term care services that include nursing home care, assisted living care, home health care services, adult day care services and hospice care. The rider will provide an initial maximum monthly benefit amount of $7,118 and a lifetime maximum benefit amount of $17,855. These amounts will be increased each policy anniversary if an available Inflation Protection Option has been chosen and is in effect. This rider is intended to be federally tax-qualified long-term care insurance and to qualify for exclusion from income within the limits of the Internal Revenue Code. Extension of Benefits Rider for Long-Term Care (EBR): The EBR extends the benefits provided under the ABR. The benefits of this rider become effective after benefits under the ABR are exhausted. The rider will provide an initial maximum monthly benefit amount of $7,118 and a lifetime maximum benefit amount of $17,855. These amounts will be increased each policy anniversary if an available Inflation Protection Option has been chosen and is in effect. This rider is intended to be federally tax-qualified long-term care insurance and to qualify for exclusion from income within the limits of the Internal Revenue Code. This benefit is optional and the additional expense is reflected. DB Version 29539.1 Version 2.95.15 Prepared on 9/28/14 Page 7 of 14

Universal Life Insurance Proposal Initial Specified Amount: $17,855 $75, Rider Description continued Accelerated Benefit Rider for Terminal Illness (ABR TI): The ABR TI allows you to receive benefits in advance from your life insurance policy should any insured become terminally ill with a limited life expectancy (generally 6 or 12 months, subject to state variations). The benefits can be used to help meet financial needs that arise during the insured's illness, or for any other purpose. The benefits are payable as a one time lump-sum payment up to $25, or 5% of the eligible death benefit, whichever is less. The rider is provided at no cost and there is no additional expense to having it added to your policy. You may choose to discontinue the rider at any time, for any reason. When you exercise the rider, it creates a lien against the benefit payable at death. The benefit payable at death is reduced by the amount of the lien including accumulated lien interest. You may also elect to repay the lien at any time if desired. This rider is included in all years. Proposal Assumptions This proposal assumes the entire premium is allocated to the policy value after the premium expense charge (1% for guaranteed expenses) is deducted. Each month the cost of insurance, rider charges, and an administrative charge are deducted from the policy value. Values assume guaranteed cost of insurance and expenses and the guaranteed interest rate of 3.75%. Stated interest rates are effective annual rates except where noted. This proposal assumes the one-time premium payment is made at the time the policy is issued. Policy values and benefit amounts are stated as of the end of the policy year in which they are shown. Surrender Information A surrender charge will apply to full surrenders taken in the first fifteen years after issue. Upon surrender, you will receive the greater of the Return of Premium or the policy value less any surrender charges and outstanding loan amounts. Policy Taxation Under current federal tax law Section 772, this policy will qualify as life insurance using the Cash Value Accumulation Test. Under the Cash Value Accumulation Test, the death benefit will be automatically increased when necessary so it is equal to the policy value divided by the attained age net single premium. The net single premium will vary according to the insured characteristics used in this proposal. This ensures your policy will maintain the favorable tax treatment associated with a life insurance policy. Your policy will become a Modified Endowment Contract (MEC) if the premiums you pay in the first 7 years of the policy exceed the sum of modified endowment premiums over the same period. Reduction of the death benefit within the first 7 policy years can potentially result in creating a MEC. Once a policy is a MEC, the IRS requires loans, partial surrenders, collateral assignments or other pre-death distributions to be paid from earnings first. Undistributed earnings within your life insurance policy, however, continue to accumulate on a tax-deferred basis and death benefits continue to pass to your beneficiary free of income tax. The modified endowment premium for this policy is $24,769.99 per year. Modified Endowment Premium $24,769.99 Note: This policy has become a Modified Endowment Contract. DB Version 29539.1 Version 2.95.15 Prepared on 9/28/14 Page 8 of 14

Universal Life Insurance Proposal Initial Specified Amount: $17,855 $75, Policy Taxation continued Although loans are generally not taxable, there may be tax consequences if the policy lapses or is surrendered with a loan (even as a part of a 135 exchange). It is possible that the amount of taxable income generated at the lapse or surrender of a policy with a loan may exceed the actual amount of cash received. Surrenders are generally taxable to the extent they exceed basis in the policy. If the policy is a modified endowment contract (MEC), predeath distribution, including loans from the policy are taxed on an income-first basis, and there may also be a 1% federal income tax penalty for distributions prior to your age 59 ½. DB Version 29539.1 Version 2.95.15 Prepared on 9/28/14 Page 9 of 14

Universal Life Insurance Proposal Initial Specified Amount: $17,855 $75, All values and benefits shown are guaranteed 1 Total Maximum 2 Policy Age One-Time Cash Available Death Long-Term Monthly Year EOY Premium Upon Surrender Benefit Care Benefits LTC Benefit 1 36 75, 67,5 258,519 367,338 7,118 2 37 67,5 251,1 385,75 7,474 3 38 75, 243,742 44,72 7,83 4 39 75, 236,75 422,439 8,186 5 4 75, 229,916 44,85 8,542 6 41 75, 223,338 459,172 8,898 7 42 75, 216,972 477,539 9,254 8 43 75, 21,85 495,96 9,61 9 44 75, 24,831 514,273 9,966 1 45 75, 199,5 532,64 1,322 11 46 75, 198,3 551,7 1,678 12 47 75, 197,561 569,374 11,34 13 48 75, 196,847 587,741 11,39 14 49 75, 196,157 66,18 11,746 15 5 75, 195,458 624,475 12,12 16 51 75, 194,744 642,841 12,458 17 52 75, 194,14 661,28 12,814 18 53 75, 193,271 679,575 13,17 19 54 75, 192,521 697,942 13,526 2 55 75,686 191,748 716,39 13,881 21 56 77,788 19,971 734,676 14,237 22 57 79,911 19,23 753,43 14,593 23 58 82,61 189,456 771,41 14,949 24 59 84,242 188,723 789,777 15,35 25 6 86,45 187,98 88,144 15,661 26 61 88,673 187,217 826,511 16,17 27 62 9,899 186,432 844,877 16,373 28 63 93,116 185,633 863,244 16,729 29 64 95,323 184,835 881,611 17,85 3 65 97,521 184,48 899,978 17,441 31 66 99,713 183,273 918,345 17,797 32 67 11,96 182,516 936,712 18,153 33 68 14,14 181,77 955,79 18,59 34 69 16,39 181,34 973,446 18,865 35 7 18,518 18,291 991,813 19,221 36 71 11,718 179,534 1,1,18 19,577 37 72 112,89 178,751 1,28,547 19,933 38 73 115,19 177,949 1,46,914 2,289 39 74 117,18 177,161 1,65,28 2,644 4 75 119,161 176,382 1,83,647 21, (1) All guarantees are based on the continued claims paying ability of the issuing company and are contingent upon no loans or partial surrenders being taken. (2) This value is the greater of the policy value less surrender charges and the Return of Premium surrender value. DB Version 29539.1 Version 2.95.15 Prepared on 9/28/14 Page 1 of 14

Universal Life Insurance Proposal Initial Specified Amount: $17,855 $75, All values and benefits shown are guaranteed 1 Policy Year Age EOY One-Time Premium 2 Cash Available Upon Surrender Death Benefit Total Long-Term Care Benefits Maximum Monthly LTC Benefit 41 76 121,175 175,67 1,12,14 21,356 42 77 123,142 174,826 1,12,381 21,712 43 78 125,46 174,27 1,138,748 22,68 44 79 126,868 173,29 1,157,115 22,424 45 8 128,586 172,37 1,175,482 22,78 46 81 13,169 171,485 1,193,849 23,136 47 82 131,576 17,855 1,212,216 23,492 48 83 132,784 17,855 1,23,583 23,848 49 84 133,75 17,855 1,248,95 24,24 5 85 134,412 17,855 1,267,316 24,56 51 86 134,682 17,855 1,285,683 24,916 52 87 134,44 17,855 1,34,5 25,272 53 88 133,526 17,855 1,322,417 25,628 54 89 131,714 17,855 1,34,784 25,984 55 9 128,677 17,855 1,359,151 26,34 56 91 123,969 17,855 1,377,518 26,696 57 92 116,927 17,855 1,395,885 27,52 58 93 16,474 17,855 1,414,252 27,47 59 94 9,92 17,855 1,432,619 27,763 6 95 75, 17,855 1,45,986 28,119 65 1 75, 17,855 1,542,82 29,899 7 15 75, 17,855 1,634,655 31,679 75 11 75, 17,855 1,726,489 33,459 8 115 75, 17,855 1,818,324 35,238 85 12 75, 17,855 1,91,158 37,18 (1) All guarantees are based on the continued claims paying ability of the issuing company and are contingent upon no loans or partial surrenders being taken. (2) This value is the greater of the Policy Value less surrender charges and the Return of Premium surrender value. DB Version 29539.1 Version 2.95.15 Prepared on 9/28/14 Page 11 of 14

Universal Life Insurance Proposal Initial Specified Amount: $17,855 $75, Supplemental Notes Birthdate of John Doe is 9/21/1979. Initial Maximum Surrender Charge: $13,785.. All premiums and values quoted on this proposal are based on the current age. If the policy is applied for after 9/2/215, when John Doe turns insurance age 36, these premiums and values may vary. This proposal assumes the insured qualifies for the Couple Status rates. As proposed this policy will become a Modified Endowment Contract in Year 1. This proposal assumes the 135 exchange amount of $1, is applied in the first month of the first year. If this proposal is different from the policy issued please contact your advisor. DB Version 29539.1 Version 2.95.15 Prepared on 9/28/14 Page 12 of 14

Policy Year Universal Life Insurance Proposal Age EOY Coverage Summary One-Time Premium Cash Available Upon Surrender Death Benefit Initial Specified Amount: $17,855 $75, Total Long-Term Care Benefits Maximum Monthly LTC Benefit 1 36 75, 75, 258,519 367,338 7,118 2 37 75, 251,1 385,75 7,474 3 38 75, 243,742 44,72 7,83 4 39 75, 236,75 422,439 8,186 5 4 75, 229,916 44,85 8,542 1 45 75, 199,5 532,64 1,322 2 55 75,686 191,748 716,39 13,881 3 65 97,521 184,48 899,978 17,441 45 8 128,586 172,37 1,175,482 22,78 OWNER: I have received a copy of this proposal dated 9/28/214. Signature of Policyowner Date FINANCIAL ADVISOR: I certify that this proposal has been presented to the applicant. I have made no statements that are inconsistent with the proposal. Signature of Financial Advisor ADVISOR NAME Date DB Version 29539.1 Version 2.95.15 Prepared on 9/28/14 Page 13 of 14

Important Additional Information Universal Life Insurance Proposal Initial Specified Amount: $17,855 $75, RiverSource TrioSource SM universal life with long-term care benefits is a smart solution to help you cover the unexpected in retirement. When you meet with your advisor, he or she can help review your financial situation and provide additional details about costs, benefit conditions, limitations and exclusions. Confident Retirement is not a guarantee of future financial results. The long-term care benefits provided by TrioSource insurance are provided through the Accelerated Benefit Rider for Long-Term Care (ABR) or a combination of the ABR and the Extension of Benefits Rider for Long-Term Care (EBR). The ABR and EBR riders are intended to be federally tax-qualified long-term care insurance under Section 772B(b) of the Internal Revenue Code ("the Code"). The riders' benefits are intended to qualify for exclusion from federal income taxation within the limits of the Code. Any rider charges deducted from the life insurance policy's cash value will not be included in taxable income; however, the investment in the policy is reduced (but not below zero) by the amount of the charges. Accessing policy cash value through loans and surrenders may cause a permanent reduction of policy cash values and death benefit and negate any guarantees against lapse. The amount that can be borrowed or surrendered will be affected by the surrender charges applicable to the policy. Loans may be subject to interest charges. Although loans are generally not taxable, there may be tax consequences if the policy lapses or is surrendered with a loan (even as part of a 135 exchange). It is possible that the amount of taxable income generated at the lapse or surrender of a policy with a loan may exceed the actual amount of cash received. Surrenders are generally taxable to the extent they exceed basis in the policy. If the policy is a modified endowment contract (MEC), pre-death distributions, including loans, from the policy are taxed on an income-first basis, and there may also be a 1% federal income tax penalty for distributions prior to age 59-1/2. Certain policy ownership arrangements may result in unintended tax consequences or require changes to existing legal documents to allow long-term care benefits from the insurance policy to be paid to the policyowner. If the policy is intended to be owned by an irrevocable trust, new or existing, or by a business for the benefit of an owner or employee you should consult with a tax adviser or attorney to determine if payment of long-term care benefits will result in adverse tax consequences. Neither RiverSource Life Insurance Company, nor RiverSource Life Insurance Co. of New York, nor their affiliates or representatives, offer tax or legal advice. The information and conclusions contained in this communication are not intended as legal or tax advice. Please consult with your legal and tax advisers regarding your individual situation. The values and benefits are guaranteed as proposed. This supplement must be accompanied by a basic proposal that contains guaranteed elements and other important information and is not complete without all pages. TrioSource universal life insurance is issued by RiverSource Life Insurance Company of Minneapolis, MN. DB Version 29539.1 Version 2.95.15 Prepared on 9/28/14 Page 14 of 14

Universal Life Insurance Proposal Optional Coverage Report Initial Specified Amount: $17,855 $75, The following coverage options are available based on the one-time premium of $75,. Inflation Protection Option Monthly Benefit Amount ABR Benefits EBR Benefits Total LTC Benefits Specified Amount 2 Years None None $9,352 $224,448 $224,448 2 Years None 3% Simple $8,466 $26,233 $23,184 2 Years None 3% Compound $6,398 $157,58 $153,552 2 Years None 5% Simple $7,859 $193,342 $188,616 2 Years None 5% Compound $5,65 $138,997 $135,6 2 Years 1 Year None $9,149 $329,391 $219,576 2 Years 1 Year 3% Simple $8,62 $298,969 $193,488 2 Years 1 Year 3% Compound $5,496 $2,653 $131,94 2 Years 1 Year 5% Simple $7,362 $278,3 $176,688 2 Years 1 Year 5% Compound $4,84 $181,757 $115,296 2 Years 2 Years None $9,33 $433,62 $216,792 2 Years 2 Years 3% Simple $7,862 $394,368 $188,688 2 Years 2 Years 3% Compound $5,428 $255,386 $13,272 2 Years 2 Years 5% Simple $7,118 $367,338 $17,855 2 Years 2 Years 5% Compound $4,477 $231,64 $17,448 2 Years 3 Years None $8,956 $537,387 $214,944 2 Years 3 Years 3% Simple $7,729 $491,61 $185,496 2 Years 3 Years 3% Compound $4,98 $31,586 $117,792 2 Years 3 Years 5% Simple $6,962 $459,539 $167,88 2 Years 3 Years 5% Compound $4,234 $28,751 $11,616 2 Years 4 Years None $8,99 $641,463 $213,816 2 Years 4 Years 3% Simple $7,65 $592,164 $183,6 2 Years 4 Years 3% Compound $4,83 $366,484 $115,272 2 Years 4 Years 5% Simple $6,868 $556,378 $164,832 2 Years 4 Years 5% Compound $4,61 $331,484 $97,464 See the next page for further information on the future effects of the available Inflation Protection Options for the benefit period selected in this proposal. (1) The amount shown is the maximum monthly benefit available in Year 1 to reimburse qualified long-term care expenses. (2) Total LTC Benefits amount is the maximum amount you may receive over the benefit duration of the policy based on the immediate acceleration of long-term care benefits. This amount includes any Inflation Protection Option chosen. The values and benefits are guaranteed as proposed. This supplemental report must be accompanied by a basic proposal that contains guaranteed elements and other important information and is not complete without all pages. DB Version 29539.1 Version 2.95.15 Prepared on 9/28/14 Page 1 of 2

Universal Life Insurance Proposal Initial Specified Amount: $17,855 $75, Inflation Protection Option Effects An Inflation Protection Option can help your LTC benefit keep up with potential increases in the cost of LTC services. Below is a graphical representation of the effects of the Inflation Protection Options available with the ABR and EBR options used in this proposal. It shows how the available options compare over time and what the maximum monthly benefit amount would be by age 85 based on the proposal assumptions. Age The values and benefits are guaranteed as proposed. This supplemental report must be accompanied by a basic proposal that contains guaranteed elements and other important information and is not complete without all pages. DB Version 29539.1 Version 2.95.15 Prepared on 9/28/14 Page 2 of 2

Supplemental Life Insurance Report Internal Rate of Return (IRR) Initial Specified Amount: $17,855 $75, 1 Cumulative Total 2 Total Policy Year Age EOY Net Annual Outlay Net Annual Outlay Long-Term Care Benefits Long-Term Care Benefits IRR 1 36 75, 75, 367,338 111.97% 2 37 75, 385,75 65.49% 3 38 75, 44,72 47.71% 4 39 75, 422,439 38.7% 5 4 75, 44,85 31.96% 6 41 75, 459,172 27.72% 7 42 75, 477,539 24.59% 8 43 75, 495,96 22.17% 9 44 75, 514,273 2.24% 1 45 75, 532,64 18.67% 11 12 13 46 47 48 49 14 15 5 16 51 17 52 18 53 19 54 2 55 75, 75, 75, 75, 75, 75, 75, 75, 75, 75, 551,7 569,374 587,741 66,18 624,475 642,841 661,28 679,575 697,942 716,39 17.36% 16.25% 15.29% 14.46% 13.73% 13.8% 12.5% 11.97% 11.5% 11.7% 21 56 22 57 23 58 24 59 25 6 26 61 27 62 28 63 29 64 3 65 75, 75, 75, 75, 75, 75, 75, 75, 75, 75, 734,676 753,43 771,41 789,777 88,144 826,511 844,877 863,244 881,611 899,978 1.68% 1.31% 9.98% 9.67% 9.38% 9.12% 8.87% 8.63% 8.41% 8.21% 31 32 33 34 35 66 75, 918,345 8.1% 67 75, 936,712 7.83% 68 75, 955,79 7.65% 69 75, 973,446 7.48% 7 75, 991,813 7.33% (1) CUMULATIVE NET ANNUAL OUTLAY is the cumulative annualized premiums. (2) TOTAL LONG-TERM CARE BENEFITS IRR is the cumulative rate of return on your premium assuming your long-term care benefits are accelerated beginning in that given year. This IRR assumes you receive the Total Long-Term Care Benefits and that no death benefit is paid. The values and benefits are guaranteed as proposed. This supplemental report must be accompanied by a basic proposal that contains guaranteed elements and other important information and is not complete without all pages. DB Version 29539.1 Version 2.95.15 Prepared on 9/28/14 Page 1 of 2

Policy Year 36 37 38 39 4 41 76 42 77 43 78 44 79 45 8 Supplemental Life Insurance Report Internal Rate of Return (IRR) Initial Specified Amount: $17,855 $75, 1 Cumulative Total 2 Total Age EOY Net Annual Outlay Net Annual Outlay Long-Term Care Benefits Long-Term Care Benefits IRR 71 75, 1,1,18 7.18% 72 75, 1,28,547 7.3% 73 75, 1,46,914 6.9% 74 75, 1,65,28 6.77% 75 75, 1,83,647 6.64% 75, 1,12,14 6.52% 75, 1,12,381 6.41% 75, 1,138,748 6.3% 75, 1,157,115 6.2% 75, 1,175,482 6.9% 46 81 47 82 48 83 49 84 5 85 51 86 52 87 53 88 54 89 55 9 75, 75, 75, 75, 75, 75, 75, 75, 75, 75, 1,193,849 1,212,216 1,23,583 1,248,95 1,267,316 1,285,683 1,34,5 1,322,417 1,34,784 1,359,151 6.% 5.9% 5.81% 5.72% 5.64% 5.56% 5.48% 5.4% 5.33% 5.26% 56 91 57 92 58 93 59 94 6 95 75, 75, 75, 75, 75, 1,377,518 1,395,885 1,414,252 1,432,619 1,45,986 5.19% 5.12% 5.6% 4.99% 4.93% 65 7 75 8 85 1 75, 1,542,82 4.65% 15 75, 1,634,655 4.4% 11 75, 1,726,489 4.18% 115 75, 1,818,324 3.99% 12 75, 1,91,158 3.81% (1) CUMULATIVE NET ANNUAL OUTLAY is the cumulative annualized premiums. (2) TOTAL LONG-TERM CARE BENEFITS IRR is the cumulative rate of return on your premium assuming your long-term care benefits are accelerated beginning in that given year. This IRR assumes you receive the Total Long-Term Care Benefits and that no death benefit is paid. The values and benefits are guaranteed as proposed. This supplemental report must be accompanied by a basic proposal that contains guaranteed elements and other important information and is not complete without all pages. DB Version 29539.1 Version 2.95.15 Prepared on 9/28/14 Page 2 of 2

Policy Year Age EOY 1 36 2 37 3 38 4 39 5 4 6 41 7 42 8 43 9 44 1 45 Supplemental Life Insurance Report Cost of Insurance Initial Specified Amount: $17,855 $75, Admin 1 3 4 5 Net Base Policy Charge/ Total Base Policy Average 2 6 Annual Cost of Policy Rider Annual Annual Cost Amount at Policy Outlay Insurance + Fees + Charges = Deduction Per $1, Risk Value 75, 85 87 89 9 87 92 94 98 13 18 1,273 1,275 1,277 1,278 1,275 1,28 1,282 1,286 1,291 1,296.4.43.45.48.52.56.6.65.7.75 24,321 198,311 189,978 18,113 172,355 164,982 156,389 148,789 141,992 134,924 53,873 54,61 55,289 56,19 56,93 57,79 58,613 59,657 6,85 62,223 Death Benefit 258,519 251,1 243,742 236,75 229,916 223,338 216,972 21,85 24,831 199,5 11 12 13 46 47 48 49 14 15 5 16 51 17 52 18 53 19 54 2 55 113 119 123 13 138 147 155 168 184 199 1,31 1,37 1,311 1,318 1,326 1,335 1,343 1,356 1,372 1,387.81.86.92 1.1 1.9 1.16 1.23 1.32 1.49 1.63 132,751 131,611 129,456 128,973 128,37 126,826 125,984 124,19 122,874 12,916 63,57 64,817 66,128 67,243 68,62 7,19 71,486 72,899 74,257 75,686 198,3 197,561 196,847 196,157 195,458 194,744 194,14 193,271 192,521 191,748 21 56 22 57 23 58 24 59 25 6 29 225 241 262 292 1,397 1,413 1,429 1,45 1,48 1.79 1.98 2.2 2.48 2.81 116,887 112,962 18,74 14,112 12,315 77,788 79,911 82,61 84,242 86,45 19,971 19,23 189,456 188,723 187,98 (1) NET ANNUAL OUTLAY is the cumulative annualized premiums. (2) RIDER CHARGES includes the cost of insurance for the ABR, EBR, and any Inflation Protection Option chosen. (3) TOTAL ANNUAL DEDUCTION includes cost of insurance associated with the base policy (the amount at risk multiplied by the cost per thousand), cost of insurance for any riders and the administrative charge and policy fee if applicable. (4) BASE POLICY ANNUAL COST PER $1, is the cost of coverage per thousand dollars at risk for the primary insured at the specified age, gender (except in Montana), and underwriting rating. (5) AVERAGE AMOUNT AT RISK is the amount used to calculate the actual base policy cost of insurance. (6) Policy values are end of year and are based on total monthly deduction and a guaranteed interest rate of 3.75%. The values and benefits are guaranteed as proposed. This supplemental report must be accompanied by a basic proposal that contains guaranteed elements and other important information and is not complete without all pages. DB Version 29539.1 Version 2.95.15 Prepared on 9/28/14 Page 1 of 3

Policy Year 26 27 28 29 3 31 32 33 34 35 Age EOY 61 62 63 64 65 66 67 68 69 7 Supplemental Life Insurance Report Cost of Insurance Initial Specified Amount: $17,855 $75, Admin 1 3 4 5 Net Base Policy Charge/ Total Base Policy Average 2 6 Annual Cost of Policy Rider Annual Annual Cost Amount at Policy Outlay Insurance + Fees + Charges = Deduction Per $1, Risk Value 345 393 472 564 645 722 785 855 912 989 1,533 1,581 1,66 1,752 1,833 1,91 1,973 2,43 2,1 2,177 3.35 3.92 4.88 6.1 7.13 8.16 9.25 1.32 11.51 12.69 1,522 97,789 93,552 9,112 88,332 85,792 83,91 79,823 76,239 73,599 88,673 9,899 93,116 95,323 97,521 99,713 11,96 14,14 16,39 18,518 Death Benefit 187,217 186,432 185,633 184,835 184,48 183,273 182,516 181,77 181,34 18,291 36 37 38 39 4 41 42 43 44 45 71 72 73 74 75 76 77 78 79 8 1,47 1,87 1,125 1,178 1,214 1,231 1,291 1,364 1,456 1,542 2,235 2,275 2,313 2,366 2,42 2,419 2,479 2,552 2,644 2,73 13.84 15.17 16.59 18.4 19.69 21.12 23.3 25.81 29.16 33.23 71,982 68,349 65,28 62,392 59,19 56,329 53,983 5,882 48,356 44,852 11,718 112,89 115,19 117,18 119,161 121,175 123,142 125,46 126,868 128,586 179,534 178,751 177,949 177,161 176,382 175,67 174,826 174,27 173,29 172,37 46 47 48 49 5 81 82 83 84 85 1,67 1,796 2,1 2,274 2,658 2,858 2,984 3,198 3,462 3,846 38.9 43.15 49.2 57.8 68.92 42,693 4,587 39,962 38,934 38,29 13,169 131,576 132,784 133,75 134,412 171,485 17,855 17,855 17,855 17,855 (1) NET ANNUAL OUTLAY is the cumulative annualized premiums. (2) RIDER CHARGES includes the cost of insurance for the ABR, EBR, and any Inflation Protection Option chosen. (3) TOTAL ANNUAL DEDUCTION includes cost of insurance associated with the base policy (the amount at risk multiplied by the cost per thousand), cost of insurance for any riders and the administrative charge and policy fee if applicable. (4) BASE POLICY ANNUAL COST PER $1, is the cost of coverage per thousand dollars at risk for the primary insured at the specified age, gender (except in Montana), and underwriting rating. (5) AVERAGE AMOUNT AT RISK is the amount used to calculate the actual base policy cost of insurance. (6) Policy values are end of year and are based on total monthly deduction and a guaranteed interest rate of 3.75%. The values and benefits are guaranteed as proposed. This supplemental report must be accompanied by a basic proposal that contains guaranteed elements and other important information and is not complete without all pages. DB Version 29539.1 Version 2.95.15 Prepared on 9/28/14 Page 2 of 3

Supplemental Life Insurance Report Cost of Insurance Initial Specified Amount: $17,855 $75, Policy Year Age EOY Admin 1 3 4 5 Net Base Policy Charge/ Total Base Policy Average 2 6 Annual Cost of Policy Rider Annual Annual Cost Amount at Policy Outlay Insurance + Fees + Charges = Deduction Per $1, Risk Value Death Benefit 51 52 53 54 55 56 57 58 59 6 86 87 88 89 9 91 92 93 94 95 2,879 3,193 3,647 4,259 5,267 6,866 1,59 13,13 19,57 28,652 4,67 4,382 4,835 5,447 6,455 8,54 11,247 14,291 2,695 29,84 77.56 85.38 95.17 15.92 121.75 142.59 167.68 198.57 241.24 296.51 37,33 37,346 38,233 4,19 43,115 47,852 54,834 65,273 8,72 96,617 134,682 134,44 133,526 131,714 128,677 123,969 116,927 16,474 9,92 75, 17,855 17,855 17,855 17,855 17,855 17,855 17,855 17,855 17,855 17,855 65 7 75 8 85 1 15 11 115 12 75, 75, 75, 75, 75, 17,855 17,855 17,855 17,855 17,855 (1) NET ANNUAL OUTLAY is the cumulative annualized premiums. (2) RIDER CHARGES includes the cost of insurance for the ABR, EBR, and any Inflation Protection Option chosen. (3) TOTAL ANNUAL DEDUCTION includes cost of insurance associated with the base policy (the amount at risk multiplied by the cost per thousand), cost of insurance for any riders and the administrative charge and policy fee if applicable. (4) BASE POLICY ANNUAL COST PER $1, is the cost of coverage per thousand dollars at risk for the primary insured at the specified age, gender (except in Montana), and underwriting rating. (5) AVERAGE AMOUNT AT RISK is the amount used to calculate the actual base policy cost of insurance. (6) Policy values are end of year and are based on total monthly deduction and a guaranteed interest rate of 3.75%. The values and benefits are guaranteed as proposed. This supplemental report must be accompanied by a basic proposal that contains guaranteed elements and other important information and is not complete without all pages. DB Version 29539.1 Version 2.95.15 Prepared on 9/28/14 Page 3 of 3

Advisor Information Only The sale of life insurance products and the use of sales proposals is a heavily regulated practice. To help you comply with the many requirements, has developed this simple checklist for you to use. Check off each item as you complete it. The appropriate state licenses and registrations must be in place before the insurance needs and solutions are discussed with your client. Review with your client the information on page 5 of the Life Insurance Proposal. It is important that your client understand that you are proposing a life insurance policy which contains only guaranteed values. Review the remaining pages of the Life Insurance Proposal with your client. Answer any questions your client may have about the life insurance policy. Then, have your client sign the Coverage Summary acknowledging their understanding of the life insurance product. After your client has signed you also need to sign this page. Make 2 copies of the complete Life Insurance Proposal including the signatures. Provide the client with one copy, retain one for your records, and send the original into the Corporate Office along with the completed life insurance application. Insurance and annuity products are issued by. 213-214. All rights reserved. 931 Version 2.95.15

Advisor Information Only GDC Summary Page Proposal Assumptions: Primary insured: John Doe Insurance Age: 35 Gender: Male Risk Class: Nontobacco Specified Amount: $17,855 Riders included: $75, Target Premium: $75, Estimated Time of Sale GDC: Time of Sale GDC at 6.% is $4,5 st Total Estimated 1 Year Time of Sale GDC: $4,5* * GDC amounts do not reflect internal exchange transactions. See the Compensation Reference Guide for GDC on internal exchange. * Assumes full first year premium is paid and the policy is issued as proposed. st * The Total Estimated 1 Year Time of Sale GDC does not include Asset Based Compensation and will not be your actual compensation received. To find your actual compensation see the Compensation Reference Guide. Insurance and annuity products are issued by. 213-214. All rights reserved. 931 Version 2.95.15

SERFF Tracking #: AERL-129974517 State Tracking #: Company Tracking #: TRIOSOURCE SALES PROPOSAL 27567-A 215... State: District of Columbia Filing Company: TOI/Sub-TOI: LTC3I Individual Long Term Care/LTC3I.1 Qualified Product Name: TrioSource Sales Proposal - 215 Project Name/Number: TrioSource Sales Proposal - 215/27567-A Supporting Document Schedules Satisfied - Item: SOV Comments: Attachment(s): SOV 27567-A.pdf Item Status: APPROVED Status Date: 6/5/215 Satisfied - Item: 27567-A Redline to show changes Comments: Attachment(s): 27567-A Redline.pdf Item Status: APPROVED Status Date: 6/5/215 Satisfied - Item: Cover letter Comments: Attachment(s): DC Cover letter - 5-27-215.pdf Item Status: APPROVED Status Date: 6/5/215 PDF Pipeline for SERFF Tracking Number AERL-129974517 Generated 7/1/216 1:12 AM

Statement of Variability Dated: 1/28/214 (Updates noted at bottom of this document) Form: 27567-A, Sales Proposal This page outlines the definitions of the variable sections of the proposal marked with letters/numbers. Any change or modification requiring prior approval will be submitted to the Department. Changes to the variable factors will be limited to new issues only. In addition, we reserve the right to correct typographical errors, change the font, paper, weight and ink color to accommodate future generations of the form. Any adaptation we make will not involve changes to the text without prior approval and will always meet or exceed the requirements of the Department. Administrative Information: Advisor name and address is bracketed in multiple places throughout the proposal and will vary based on the advisor running the proposal. Bracketed print dates will change based on current dating of proposals. Bracketed system versioning may change as the system is updated. Bracketed copyright years may update with future proposal updates. Bracketed product marketing name and all variations throughout the document to allow for changes to the product marketing name or variations in the future. Variability Labeled in Proposal A. The state that displays here will reflect the state for which the proposal was run based on user inputs. B. The amounts shown on pages 3 and 6 will vary depending on the user inputs. C. The Name, Gender, Age, and Risk Class listed here are variable based on the proposed insured s characteristics. Available Risk Classes are Standard Nontobacco and Standard Tobacco. D. The riders displayed can vary depending on the user inputs to create the proposal. The following riders could appear in this section based on the user inputs: (future rider),, and. E. The Inflation Protection Option value shown here will be N/A if the Inflation Protection Option is not chosen by the user. F. The Accelerated Benefit Rider for Long-Term care will always be included, as it is required with this product. The maximum monthly benefit and lifetime maximum benefit amount are variable based on the user inputs and resulting proposal. G. The Extension of Benefits Rider for Long-Term care will only be included when chosen by the user. The maximum monthly benefit and lifetime maximum benefit amount are variable based on the user inputs and resulting proposal. H. The Accelerated Benefit Rider for Terminal Illness (future rider) will only be included when it is available in the Issue State of the proposal. I. The Modified Endowment Premium is variable based on the proposal specifics.

J. The statement in the Policy Taxation section will only be included if the policy will be considered a Modified Endowment Contract based on the user inputs. Similarly, if the policy will be considered a Modified Endowment Contract, the statement in the Supplemental Notes section will be included. Note that the year will vary depending on the year the policy becomes a Modified Endowment Contract. K. All ledger, Internal Rate of Return, and Cost of Insurance report values will vary based on user inputs and proposal characteristics. L. The birthdate is variable based on user input. M. The surrender charge shown is variable based on the proposal specifics. N. The date and age provided are variable based on user input. O. This statement is only included when the user chooses the Couple Status. P. The 135 exchange statement will only be included when the policy proposed will be the result of a 135 exchange, based on user input. Q. The Optional Coverage Report is an optional supplemental report. R. The Initial Specified Amount and One-Time Premium shown are variable based on user inputs and proposal specifics. S. The premium shown is variable based on proposal specifics. T. The values shown in the Optional Coverage Report are variable based on client gender, age, and Risk Class. U. The values shown in the Inflation Protection Option Effects graph are variable based on client specifics and user inputs. V. The Internal Rate of Return report is an optional supplemental report. All insured/policy characteristics and values provided are variable based on the base proposal. W. The Cost of Insurance report is an optional supplemental report. All insured/policy characteristics and values provided are variable based on the base proposal. X. The Advisor Information report is an optional supplemental report. All insured/policy characteristics and any values provided on page 2 are variable based on the base proposal. Y. The logo may change at a later date. Z. The Inflation Protection Option will show as None, 3% Simple, 3% Compound, 5% Simple, or 5% Compound. The number and availability of options may change and will remain consistent based on product design. Any new product features would be filed with the IIPRC, if required, for prior approval.

The following changes were made to our previously approved proposal: 1. The cover page was updated with a new design. In addition to changes to the cover graphics, we added the Confident Retirement triangle, along with a short paragraph describing Confident Retirement and an associated disclosure. 2. The wording of the main disclosure at the bottom of the cover page was updated for clarity. 3. On page 2 of the proposal, the descriptive wording to the right of each layer of the Confident Retirement triangle image was updated. 4. The words except in Montana were added in parentheses after the word gender within footnote #4 on the Cost of Insurance Supplemental Report (pages 19-21 of proposal). This was previously reviewed by the state of Montana only for approval.

RiverSource TrioSource SM universal life insurance A Universal Life Insurance Proposal for: John Doe 77 2nd Ave South, Minneapolis, MN 55474-245 Representing RIVERSOURCE LIFE INSURANCE COMPANY (RiverSource Life) 2 Ameriprise Financial Center, Minneapolis MN 55474 The Confident Retirement approach is not a guarantee of future financial results. This is a proposal, not a policy, for presentation in Minnesota. Its purpose is to show how policy values, cash surrender values and death benefits can change based on specific assumptions about interest rates, expenses, risk classification of the insured, death benefit, and premiums. Any change in these assumptions will change the proposed results. They should not be viewed as a prediction of future results. Issued by, Minneapolis, Minnesota. Affiliated with Ameriprise Financial Services, Inc. DB Version 29539.1 213-214. All rights reserved. Version 2.95.15 931 Prepared on 9/28/14 This proposal not complete without all pages. 27567-A Page 1 of 14

Universal Life Insurance Proposal What is it? RiverSource TrioSource SM insurance provides a simple way to protect your retirement from unexpected expenses. With at least 7% of people over 65 needing long-term care service at some point, having a strategy to protect against unexpected events is critical to achieving a more confident retirement. TrioSource insurance puts your money to work to protect your retirement assets from the impact of long-term care. It lets you: Access tax-free benefits for long-term care expenses or Pass on an income-tax free death benefit to loved ones or Get your money back if you ever change your mind The Ameriprise Financial Confident Retirement approach looks at four principles of retirement. TrioSource insurance can help you prepare for the unexpected, which includes events such as long-term care expenses, pre-retirement disability, property loss and personal liability and premature death. (1) Medicare & You, National Medicare Handbook, Centers for Medicare and Medicaid Services Revised November 212. (2) Return of Premium is 9% in years 1-2 and 1% in years 3 and later. It is net of any partial surrenders, outstanding policy loans and long-term care benefits paid. DB Version 29539.1 Version 2.95.15 Prepared on 9/28/14 Page 2 of 14

Benefits Universal Life Insurance Proposal TrioSource insurance puts your money to work to protect your retirement assets from long-term care expenses. TrioSource insurance can provide you with the following: $367,338 1 TrioSource insurance will reimburse you for home health care, nursing home care, adult day care, some equipment purchases, home modifications and even care received outside of the U.S. $17,855 2 If you don't use any or all of your long-term care benefits the unused portion of your death benefit will pass income tax-free to your beneficiaries. $75, 3 If you change your mind or your plans change, you can receive 1% of your premium back. Additional benefits include: Simple one-time payment. This design eliminates the need for ongoing premiums. No rate increases, guaranteed. The cost for long-term care benefits will never increase on the policy. An easy application process. With TrioSource insurance, underwriting is quick and painless. A simple phone interview will gather health information and conduct cognitive tests. This provides the information needed to underwrite the policy and make a decision on the coverage. (1) Long-term care benefit is the maximum amount you will receive over the benefit duration of the policy based on the immediate acceleration of long-term care benefits. This amount includes any Inflation Protection Option chosen. The Accelerated Benefits Rider for Long-Term Care will pay benefits for some services, subject to policy requirements and limitations. Benefits paid for services outside the U.S. are limited to a daily benefit of 5% of your maximum monthly benefit divided by 3 for each day the insured is confined to a nursing home facility. (2) Death benefit is the minimum amount that will be received at death based on no acceleration of long-term care benefits, loans, or partial surrenders. (3) Money-back guarantee is the Return of Premium, which is 9% of the initial premium in years 1-2 and 1% in years 3 and later and is net of any partial surrenders, outstanding policy loans and long-term care benefits paid. DB Version 29539.1 Version 2.95.15 Prepared on 9/28/14 Page 3 of 14

Universal Life Insurance Proposal How it works When you receive qualified long-term care services your policy reimburses you up to your monthly long-term care benefit limit. To be eligible for benefits, a licensed health care practitioner must certify you are chronically ill and on a prescribed plan of care within the previous twelve months. Chronically ill generally means you are unable to perform two out of six activities of daily living without substantial assistance from another individual for at least 9 days, or that you need substantial supervision due to severe cognitive impairment. Because TrioSource insurance reimburses for actual expenses, if you use less than the maximum monthly benefit amount, your benefit period will extend until your entire benefit is depleted. Once you qualify for benefits TrioSource insurance offers a zero-day elimination period for home care and a 9-day elimination period for facility care. In addition TrioSource insurance includes Care Coordination Services, an optional benefit that helps tailor the types of care and providers you may need. (1) Qualified long-term care services include but are not limited to nursing home, assisted living, and home health care. (2) Activities of Daily Living are bathing, continence, eating, dressing, toileting and transferring. DB Version 29539.1 Version 2.95.15 Prepared on 9/28/14 Page 4 of 14

Universal Life Insurance Proposal Initial Specified Amount: $17,855 $75, About the Universal Life Policy Proposal The product proposed on the accompanying pages is A LIFE INSURANCE POLICY offered by RiverSource Life. The name of the life insurance policy is RiverSource TrioSource SM universal life insurance with long-term care benefits, a Flexible Premium Adjustable Life Insurance Policy (Insurance Policy Form #ICC13 13249 and state variations). All values proposed are based on the assumptions including guaranteed expenses and interest rates. Be sure to ask your sales representative about the life insurance policy's features, benefits, and fees, and whether this insurance is appropriate for you, based on your financial situation and objectives. Definition of Key Terms and Column Headings Throughout this proposal the following terms will be used. Before reviewing the proposal, become familiar with these terms: Age EOY is the insured's age at the end of the policy year. One-Time Premium is the amount paid at the time the policy is issued. This is the only amount paid for the policy. Cash Available Upon Surrender is the maximum amount available if the policy is surrendered in full. It is equal to the greater of the Return of Premium or the policy value less any surrender charges and outstanding loan amounts. Death Benefit is the amount payable upon the death of John Doe. It is the death benefit minus any outstanding loans. Total Long-Term Care Benefits is the total amount of lifetime benefits payable to reimburse covered long-term care expenses based on the Accelerated Benefit Rider for Long-Term Care (ABR) and the optional Extension of Benefits Rider for Long-Term Care (EBR). This amount includes any additional benefits provided by the Inflation Protection Option, when chosen. Maximum Monthly LTC Benefit is the maximum amount that will be paid in a calendar month to reimburse covered long-term care expenses. This amount includes any additional benefits provided by the Inflation Protection Option, when chosen. DB Version 29539.1 931 This proposal not complete without all pages. Version 2.95.15 Prepared on 9/28/14 Page 5 of 14

Universal Life Insurance Proposal Initial Specified Amount: $17,855 $75, Policy Highlights Return of Premium: 1 $75, $75, Initial Specified Amount: $17,855 Accelerated Benefit Rider for Long-Term Care: $17,855 Extension of Benefits Rider for Long-Term Care: $17,855 Inflation Protection Option: + $25,628 2 Total At Issue Long-Term Care Benefits: $367,338 Initial Maximum Monthly LTC Benefit: Benefit Duration: Inflation Protection Option: $7,118 4 Years 5% Simple 1 Policy Features Return of Premium is the minimum amount received at the time of full surrender. In years 1-2, this is equal to 9% of the initial premium paid. In years 3 and later, this is equal to 1% of the initial premium paid. This amount will be reduced by any loans, partial surrenders and benefit payments made under the ABR and EBR prior to the full surrender of the policy. International Benefit is the expenses eligible for benefit payment under the long-term care portion of this policy while the insured is confined to a nursing home facility outside of the United States. Daily benefits will be paid up to 5% of the maximum monthly benefit divided by 3 for each day under the Accelerated Benefit Rider for Long-Term Care only. Inflation Protection Option is an optional benefit that will increase the ABR and EBR (when elected) monthly and lifetime benefit amounts on each policy anniversary, while it is in effect. For a graphical representation of the effects of the available Inflation Protection Options on this policy, please see the Optional Coverage Report that may be included in this proposal. Residual Death Benefit is the minimum death benefit that will be paid upon death of the insured after the acceleration of the ABR benefits has exhausted the life insurance death benefit. This is equal to 5% of the initial specified amount net of loans. (2) Total At Issue Long-Term Care Benefits amount is the maximum amount you will receive over the benefit duration of the policy based on the immediate acceleration of long-term care benefits. This amount includes any Inflation Protection Option chosen. DB Version 29539.1 931 This proposal not complete without all pages. Version 2.95.15 Prepared on 9/28/14 Page 6 of 14

Universal Life Insurance Proposal Initial Specified Amount: $17,855 $75, Policy Features continued Covered Expenses are the expenses eligible for reimbursement under the long-term care portion of this policy. The following services are eligible: Day Elimination Period* Home health care Care coordination Caregiver training Home modification Durable medical equipment Home hospice care 9 Day Elimination Period Nursing home facility Assisted living facility Adult day care center Facility hospice care International benefit * The services listed as eligible during the -Day Elimination Period above will count towards the 9-Day Elimination Period. 9-Day Elimination Period is the one-time elimination period that applies to the services listed above. Rider Description Accelerated Benefit Rider for Long-Term Care (ABR): The ABR is a rider that reimburses for long-term care services that include nursing home care, assisted living care, home health care services, adult day care services and hospice care. The rider will provide an initial maximum monthly benefit amount of $7,118 and a lifetime maximum benefit amount of $17,855. These amounts will be increased each policy anniversary if an available Inflation Protection Option has been chosen and is in effect. This rider is intended to be federally tax-qualified long-term care insurance and to qualify for exclusion from income within the limits of the Internal Revenue Code. Extension of Benefits Rider for Long-Term Care (EBR): The EBR extends the benefits provided under the ABR. The benefits of this rider become effective after benefits under the ABR are exhausted. The rider will provide an initial maximum monthly benefit amount of $7,118 and a lifetime maximum benefit amount of $17,855. These amounts will be increased each policy anniversary if an available Inflation Protection Option has been chosen and is in effect. This rider is intended to be federally tax-qualified long-term care insurance and to qualify for exclusion from income within the limits of the Internal Revenue Code. This benefit is optional and the additional expense is reflected. DB Version 29539.1 Version 2.95.15 Prepared on 9/28/14 Page 7 of 14

Universal Life Insurance Proposal Initial Specified Amount: $17,855 $75, Rider Description continued Accelerated Benefit Rider for Terminal Illness (ABR TI): The ABR TI allows you to receive benefits in advance from your life insurance policy should any insured become terminally ill with a limited life expectancy (generally 6 or 12 months, subject to state variations). The benefits can be used to help meet financial needs that arise during the insured's illness, or for any other purpose. The benefits are payable as a one time lump-sum payment up to $25, or 5% of the eligible death benefit, whichever is less. The rider is provided at no cost and there is no additional expense to having it added to your policy. You may choose to discontinue the rider at any time, for any reason. When you exercise the rider, it creates a lien against the benefit payable at death. The benefit payable at death is reduced by the amount of the lien including accumulated lien interest. You may also elect to repay the lien at any time if desired. This rider is included in all years. Proposal Assumptions This proposal assumes the entire premium is allocated to the policy value after the premium expense charge (1% for guaranteed expenses) is deducted. Each month the cost of insurance, rider charges, and an administrative charge are deducted from the policy value. Values assume guaranteed cost of insurance and expenses and the guaranteed interest rate of 3.75%. Stated interest rates are effective annual rates except where noted. This proposal assumes the one-time premium payment is made at the time the policy is issued. Policy values and benefit amounts are stated as of the end of the policy year in which they are shown. Surrender Information A surrender charge will apply to full surrenders taken in the first fifteen years after issue. Upon surrender, you will receive the greater of the Return of Premium or the policy value less any surrender charges and outstanding loan amounts. Policy Taxation Under current federal tax law Section 772, this policy will qualify as life insurance using the Cash Value Accumulation Test. Under the Cash Value Accumulation Test, the death benefit will be automatically increased when necessary so it is equal to the policy value divided by the attained age net single premium. The net single premium will vary according to the insured characteristics used in this proposal. This ensures your policy will maintain the favorable tax treatment associated with a life insurance policy. Your policy will become a Modified Endowment Contract (MEC) if the premiums you pay in the first 7 years of the policy exceed the sum of modified endowment premiums over the same period. Reduction of the death benefit within the first 7 policy years can potentially result in creating a MEC. Once a policy is a MEC, the IRS requires loans, partial surrenders, collateral assignments or other pre-death distributions to be paid from earnings first. Undistributed earnings within your life insurance policy, however, continue to accumulate on a tax-deferred basis and death benefits continue to pass to your beneficiary free of income tax. The modified endowment premium for this policy is $24,769.99 per year. Modified Endowment Premium $24,769.99 Note: This policy has become a Modified Endowment Contract. DB Version 29539.1 Version 2.95.15 Prepared on 9/28/14 Page 8 of 14

Universal Life Insurance Proposal Initial Specified Amount: $17,855 $75, Policy Taxation continued Although loans are generally not taxable, there may be tax consequences if the policy lapses or is surrendered with a loan (even as a part of a 135 exchange). It is possible that the amount of taxable income generated at the lapse or surrender of a policy with a loan may exceed the actual amount of cash received. Surrenders are generally taxable to the extent they exceed basis in the policy. If the policy is a modified endowment contract (MEC), predeath distribution, including loans from the policy are taxed on an income-first basis, and there may also be a 1% federal income tax penalty for distributions prior to your age 59 ½. DB Version 29539.1 Version 2.95.15 Prepared on 9/28/14 Page 9 of 14

Universal Life Insurance Proposal Initial Specified Amount: $17,855 $75, All values and benefits shown are guaranteed 1 Total Maximum 2 Policy Age One-Time Cash Available Death Long-Term Monthly Year EOY Premium Upon Surrender Benefit Care Benefits LTC Benefit 1 36 75, 67,5 258,519 367,338 7,118 2 37 67,5 251,1 385,75 7,474 3 38 75, 243,742 44,72 7,83 4 39 75, 236,75 422,439 8,186 5 4 75, 229,916 44,85 8,542 6 41 75, 223,338 459,172 8,898 7 42 75, 216,972 477,539 9,254 8 43 75, 21,85 495,96 9,61 9 44 75, 24,831 514,273 9,966 1 45 75, 199,5 532,64 1,322 11 46 75, 198,3 551,7 1,678 12 47 75, 197,561 569,374 11,34 13 48 75, 196,847 587,741 11,39 14 49 75, 196,157 66,18 11,746 15 5 75, 195,458 624,475 12,12 16 51 75, 194,744 642,841 12,458 17 52 75, 194,14 661,28 12,814 18 53 75, 193,271 679,575 13,17 19 54 75, 192,521 697,942 13,526 2 55 75,686 191,748 716,39 13,881 21 56 77,788 19,971 734,676 14,237 22 57 79,911 19,23 753,43 14,593 23 58 82,61 189,456 771,41 14,949 24 59 84,242 188,723 789,777 15,35 25 6 86,45 187,98 88,144 15,661 26 61 88,673 187,217 826,511 16,17 27 62 9,899 186,432 844,877 16,373 28 63 93,116 185,633 863,244 16,729 29 64 95,323 184,835 881,611 17,85 3 65 97,521 184,48 899,978 17,441 31 66 99,713 183,273 918,345 17,797 32 67 11,96 182,516 936,712 18,153 33 68 14,14 181,77 955,79 18,59 34 69 16,39 181,34 973,446 18,865 35 7 18,518 18,291 991,813 19,221 36 71 11,718 179,534 1,1,18 19,577 37 72 112,89 178,751 1,28,547 19,933 38 73 115,19 177,949 1,46,914 2,289 39 74 117,18 177,161 1,65,28 2,644 4 75 119,161 176,382 1,83,647 21, (1) All guarantees are based on the continued claims paying ability of the issuing company and are contingent upon no loans or partial surrenders being taken. (2) This value is the greater of the policy value less surrender charges and the Return of Premium surrender value. DB Version 29539.1 Version 2.95.15 Prepared on 9/28/14 Page 1 of 14

Universal Life Insurance Proposal Initial Specified Amount: $17,855 $75, All values and benefits shown are guaranteed 1 Policy Year Age EOY One-Time Premium 2 Cash Available Upon Surrender Death Benefit Total Long-Term Care Benefits Maximum Monthly LTC Benefit 41 76 121,175 175,67 1,12,14 21,356 42 77 123,142 174,826 1,12,381 21,712 43 78 125,46 174,27 1,138,748 22,68 44 79 126,868 173,29 1,157,115 22,424 45 8 128,586 172,37 1,175,482 22,78 46 81 13,169 171,485 1,193,849 23,136 47 82 131,576 17,855 1,212,216 23,492 48 83 132,784 17,855 1,23,583 23,848 49 84 133,75 17,855 1,248,95 24,24 5 85 134,412 17,855 1,267,316 24,56 51 86 134,682 17,855 1,285,683 24,916 52 87 134,44 17,855 1,34,5 25,272 53 88 133,526 17,855 1,322,417 25,628 54 89 131,714 17,855 1,34,784 25,984 55 9 128,677 17,855 1,359,151 26,34 56 91 123,969 17,855 1,377,518 26,696 57 92 116,927 17,855 1,395,885 27,52 58 93 16,474 17,855 1,414,252 27,47 59 94 9,92 17,855 1,432,619 27,763 6 95 75, 17,855 1,45,986 28,119 65 1 75, 17,855 1,542,82 29,899 7 15 75, 17,855 1,634,655 31,679 75 11 75, 17,855 1,726,489 33,459 8 115 75, 17,855 1,818,324 35,238 85 12 75, 17,855 1,91,158 37,18 (1) All guarantees are based on the continued claims paying ability of the issuing company and are contingent upon no loans or partial surrenders being taken. (2) This value is the greater of the Policy Value less surrender charges and the Return of Premium surrender value. DB Version 29539.1 Version 2.95.15 Prepared on 9/28/14 Page 11 of 14

Universal Life Insurance Proposal Initial Specified Amount: $17,855 $75, Supplemental Notes Birthdate of John Doe is 9/21/1979. Initial Maximum Surrender Charge: $13,785.. All premiums and values quoted on this proposal are based on the current age. If the policy is applied for after 9/2/215, when John Doe turns insurance age 36, these premiums and values may vary. This proposal assumes the insured qualifies for the Couple Status rates. As proposed this policy will become a Modified Endowment Contract in Year 1. This proposal assumes the 135 exchange amount of $1, is applied in the first month of the first year. If this proposal is different from the policy issued please contact your advisor. DB Version 29539.1 Version 2.95.15 Prepared on 9/28/14 Page 12 of 14

Policy Year Universal Life Insurance Proposal Age EOY Coverage Summary One-Time Premium Cash Available Upon Surrender Death Benefit Initial Specified Amount: $17,855 $75, Total Long-Term Care Benefits Maximum Monthly LTC Benefit 1 36 75, 75, 258,519 367,338 7,118 2 37 75, 251,1 385,75 7,474 3 38 75, 243,742 44,72 7,83 4 39 75, 236,75 422,439 8,186 5 4 75, 229,916 44,85 8,542 1 45 75, 199,5 532,64 1,322 2 55 75,686 191,748 716,39 13,881 3 65 97,521 184,48 899,978 17,441 45 8 128,586 172,37 1,175,482 22,78 OWNER: I have received a copy of this proposal dated 9/28/214. Signature of Policyowner Date FINANCIAL ADVISOR: I certify that this proposal has been presented to the applicant. I have made no statements that are inconsistent with the proposal. Signature of Financial Advisor ADVISOR NAME Date DB Version 29539.1 Version 2.95.15 Prepared on 9/28/14 Page 13 of 14

Important Additional Information Universal Life Insurance Proposal Initial Specified Amount: $17,855 $75, RiverSource TrioSource SM universal life with long-term care benefits is a smart solution to help you cover the unexpected in retirement. When you meet with your advisor, he or she can help review your financial situation and provide additional details about costs, benefit conditions, limitations and exclusions. Confident Retirement is not a guarantee of future financial results. The long-term care benefits provided by TrioSource insurance are provided through the Accelerated Benefit Rider for Long-Term Care (ABR) or a combination of the ABR and the Extension of Benefits Rider for Long-Term Care (EBR). The ABR and EBR riders are intended to be federally tax-qualified long-term care insurance under Section 772B(b) of the Internal Revenue Code ("the Code"). The riders' benefits are intended to qualify for exclusion from federal income taxation within the limits of the Code. Any rider charges deducted from the life insurance policy's cash value will not be included in taxable income; however, the investment in the policy is reduced (but not below zero) by the amount of the charges. Accessing policy cash value through loans and surrenders may cause a permanent reduction of policy cash values and death benefit and negate any guarantees against lapse. The amount that can be borrowed or surrendered will be affected by the surrender charges applicable to the policy. Loans may be subject to interest charges. Although loans are generally not taxable, there may be tax consequences if the policy lapses or is surrendered with a loan (even as part of a 135 exchange). It is possible that the amount of taxable income generated at the lapse or surrender of a policy with a loan may exceed the actual amount of cash received. Surrenders are generally taxable to the extent they exceed basis in the policy. If the policy is a modified endowment contract (MEC), pre-death distributions, including loans, from the policy are taxed on an income-first basis, and there may also be a 1% federal income tax penalty for distributions prior to age 59-1/2. Certain policy ownership arrangements may result in unintended tax consequences or require changes to existing legal documents to allow long-term care benefits from the insurance policy to be paid to the policyowner. If the policy is intended to be owned by an irrevocable trust, new or existing, or by a business for the benefit of an owner or employee you should consult with a tax adviser or attorney to determine if payment of long-term care benefits will result in adverse tax consequences. Neither RiverSource Life Insurance Company, nor RiverSource Life Insurance Co. of New York, nor their affiliates or representatives, offer tax or legal advice. The information and conclusions contained in this communication are not intended as legal or tax advice. Please consult with your legal and tax advisers regarding your individual situation. The values and benefits are guaranteed as proposed. This supplement must be accompanied by a basic proposal that contains guaranteed elements and other important information and is not complete without all pages. TrioSource universal life insurance is issued by RiverSource Life Insurance Company of Minneapolis, MN. DB Version 29539.1 Version 2.95.15 Prepared on 9/28/14 Page 14 of 14

Preliminary Statement of Policy Cost RiverSource Life insurance Company 2 Ameriprise Financial Center Minneapolis, Minnesota 55474 Proposed Insured: John Doe Policy Name: Flexible Premium Adjustable Life Insurance Age: 35 Sex: Male IMPORTANT NOTICE Before your buy any Life Insurance, you should: Decide how much life insurance you need. Figure out how much you can afford to pay in premium. You should not buy a policy unless you can afford the premiums and intend to stick with it. A policy which is a good buy when held for 2 years can be very costly if you quit during the early years of the policy. If you surrender such a policy during the first few years, you may get little or nothing back and much of your premium may have been used for company expenses. Find out what type of policy best fits your individual and family needs. Note that the cost of protection varies depending on when and how the policy stops, that is by death of the insured or by surrender of the policy. Compare cost of similar insurance policies using the index number shown on the second page of this notice. COMPARISON SHOPPING SAVES MONEY! Try to determine how well the insurance company and agent will provide service to you in the future. READ THE BUYER'S GUIDE. It will help you make a good purchase decision. READ THE SECOND PAGE OF THIS NOTICE! Financial Advisor 9/28/14 Date Prepared Insurance and annuity products are issued by. Page 1 of 2 of Preliminary Statement of Policy Cost 33583 D 212-214. All rights reserved. Version 2.95.15

Preliminary Statement of Policy Cost RiverSource Life insurance Company 2 Ameriprise Financial Center Minneapolis, Minnesota 55474 PLAN OF INSURANCE: TrioSource universal life insurance Amount of Insurance: $17,855 Single Premium: $75, Cost Indexes: When comparing the cost of two or more policies: LOOK FOR POLICIES WITH LOW INDEX NUMBERS: In general, they will cost less than policies with higher index numbers. COMPARE POLICIES OF SIMILAR PLANS AND FACE AMOUNT ONLY. Net Payment Cost Index (Cost of protection if insured dies at end of): Surrender Cost Index (Cost of protection if the policy is surrendered at the end of): Guaranteed Basis 1 th Year 2 th Year 22.47 22.47 19.1 19.1 Dividends: This policy is guaranteed cost (does not pay dividends). Remember to compare the Cost Indexes above with those which will appear in your Policy Summary. Request an explanation of differences. By the time the Policy is delivered, you will be given a complete Policy Summary, including cost data, which will be based on the benefits, premiums, and costs of the Policy as issued. The figures shown in this Preliminary Statement of Policy Cost are based on the assumption that a Proposed Policy is issued as applied for. Adjustments will be necessary if the Policy is actually issued on some other basis. You may return any life insurance policy delivered in Maine within 1 days of delivery and obtain a full refund of all premium paid. Insurance and annuity products are issued by. Page 1 of 2 of Preliminary Statement of Policy Cost 33583 D 212-214. All rights reserved. Version 2.95.15

DISCLOSURE STATEMENT FOR FLEXIBLE PREMIUM ADJUSTABLE LIFE POLICY RiverSource Life insurance Company, 2 Ameriprise Financial Center, Minneapolis, Minnesota 55474 This Disclosure Statement with all applicable blanks filled in is for your protection. It provides basic information about the cost and coverage of the insurance policy being solicited. Please read this statement carefully before signing any agreement to buy life insurance. This Disclosure Statement shall not be considered as an offer to contract or as altering or modifying any policy or rider that may be issued. All correspondence should be directed to RiverSource Life Insurance Company at the address shown above. Name of Proposed Insured: This statement has been prepared by: Address of preparing representative: John Doe 77 2 nd Ave South Minneapolis, MN 55474 Male Age: 35 Phone: 612/678-1111 DESCRIPTION OF COVERAGE: This FLEXIBLE PREMIUM ADJUSTABLE LIFE insurance policy provides life insurance along with long-term care benefits through the rider(s) listed below. The policy cash values are accumulated from the payment of the initial premium and any unscheduled premium payments. Interest is credited to the policy s cash value each day. The payment of the initial premium guarantees the coverage will remain inforce as long as no partial surrenders or loans are taken from the policy's cash value. Each month, a monthly charge (cost of insurance) is deducted from the policy s cash value to cover the cost of the life insurance policy and the rider(s). Coverage Types Base Policy Initial Specified Amount Accelerated Benefit Rider for Long-Term Care** Extension of Benefits Rider for Long-Term Care** Initial Benefit Amounts $17,855 $17,855 1st Year Cost of Insurance $17,855 $271.49 Guaranteed Duration of Coverage* $473.7 Lifetime $528.73 $1,273.29 Lifetime Lifetime * Any loans or partial surrenders may shorten the Guaranteed Duration of Coverage. ** The cost of insurance includes any Inflation Protection Option chosen on the rider(s). The death benefit is the greater of the specified amount, the residual death benefit or the policy s cash value multiplied by a factor which varies by the insured s age, gender, Risk Class, and Policy Year. The initial premium is $75,. Unscheduled premium payments of at least $25 may be made and will be applied to the policy value. We reserve the right to limit the number and amount of these unscheduled premium payments. Accelerated Benefit Rider for Long-Term Care: This rider provides an initial maximum monthly benefit of $7,118 and a lifetime maximum benefit amount of $17,855 to help pay for qualified long-term care expenses by accelerating the life insurance specified amount. These amounts will be increased each policy anniversary if an available inflation protection option has been chosen and is in effect. The cost of insurance rates for this rider and any inflation protection option chosen remain level for the life of the policy. Extension of Benefits Rider for Long-Term Care: This rider extends the benefits provided under the Accelerated Benefit Rider for Long-Term Care and has an initial maximum monthly benefit of $7,118 and a lifetime maximum benefit amount of $17,855 to help pay for qualified long-term care expenses after the benefits under the Accelerated Benefits Rider for Long-Term Care have been exhausted. These amounts will be increased policy anniversary if an available inflation protection option has been chosen and is in effect. The cost of insurance rates for this rider and any inflation protection option chosen remain level for the life of the policy. Insurance and annuity products are issued by. 134923 213-214. All rights reserved. Version 2.95.15

GUARANTEED CASH AVAILABLE UPON SURRENDER: The guaranteed cash available upon surrender amounts shown below are the greater of the return of premium amount and the policy value less surrender charges. The values are based on the coverage amounts listed above, payment of the initial premium, no loans or partial surrenders are taken and no long-term care benefits are paid. The policy values are based on the policy's guaranteed minimum annual interest rate of 3.75% and the guaranteed maximum cost of insurance rates. These charges continue to age 95. Based on guaranteed interest and cost of insurance, the policy will remain inforce for the lifetime of the insured. We reserve the right to credit interest in excess of the guaranteed interest rate. Interest of 3.75% will be credited on any policy value that is taken as a loan. The guaranteed maximum loan interest rate charged is 6.75% per year for all policy years. Cost of insurance rates will never be higher than those shown in this proposal. Number of Years Policy Has Been in Force: 5 Yrs 1 Yrs 2 Yrs Age 65 Guaranteed Surrender Value: $75, $75, $75,686.13 $99,713.42 A Surrender Comparison Index will be provided upon delivery of the policy, or earlier, if requested. This index provides one means of comparing the relative costs of two or more similar policies. Please sign this statement when you are satisfied that it has been completed and you understand it s contents. Date Applicant I confirm that the Disclosure Statement was provided to the applicant no later than the time that the application was signed by the applicant Date Representative s Signature ONE COPY-APPLICANT ONE COPY- FINANCIAL ADVISOR ONE COPY CORPORATE OFFICE Insurance and annuity products are issued by. 134923 213-214. All rights reserved. Version 2.95.15

Universal Life Insurance Proposal Optional Coverage Report Initial Specified Amount: $17,855 $75, The following coverage options are available based on the one-time premium of $75,. Inflation Protection Option Monthly Benefit Amount ABR Benefits EBR Benefits Total LTC Benefits Specified Amount 2 Years None None $9,352 $224,448 $224,448 2 Years None 3% Simple $8,466 $26,233 $23,184 2 Years None 3% Compound $6,398 $157,58 $153,552 2 Years None 5% Simple $7,859 $193,342 $188,616 2 Years None 5% Compound $5,65 $138,997 $135,6 2 Years 1 Year None $9,149 $329,391 $219,576 2 Years 1 Year 3% Simple $8,62 $298,969 $193,488 2 Years 1 Year 3% Compound $5,496 $2,653 $131,94 2 Years 1 Year 5% Simple $7,362 $278,3 $176,688 2 Years 1 Year 5% Compound $4,84 $181,757 $115,296 2 Years 2 Years None $9,33 $433,62 $216,792 2 Years 2 Years 3% Simple $7,862 $394,368 $188,688 2 Years 2 Years 3% Compound $5,428 $255,386 $13,272 2 Years 2 Years 5% Simple $7,118 $367,338 $17,855 2 Years 2 Years 5% Compound $4,477 $231,64 $17,448 2 Years 3 Years None $8,956 $537,387 $214,944 2 Years 3 Years 3% Simple $7,729 $491,61 $185,496 2 Years 3 Years 3% Compound $4,98 $31,586 $117,792 2 Years 3 Years 5% Simple $6,962 $459,539 $167,88 2 Years 3 Years 5% Compound $4,234 $28,751 $11,616 2 Years 4 Years None $8,99 $641,463 $213,816 2 Years 4 Years 3% Simple $7,65 $592,164 $183,6 2 Years 4 Years 3% Compound $4,83 $366,484 $115,272 2 Years 4 Years 5% Simple $6,868 $556,378 $164,832 2 Years 4 Years 5% Compound $4,61 $331,484 $97,464 See the next page for further information on the future effects of the available Inflation Protection Options for the benefit period selected in this proposal. (1) The amount shown is the maximum monthly benefit available in Year 1 to reimburse qualified long-term care expenses. (2) Total LTC Benefits amount is the maximum amount you may receive over the benefit duration of the policy based on the immediate acceleration of long-term care benefits. This amount includes any Inflation Protection Option chosen. The values and benefits are guaranteed as proposed. This supplemental report must be accompanied by a basic proposal that contains guaranteed elements and other important information and is not complete without all pages. DB Version 29539.1 Version 2.95.15 Prepared on 9/28/14 Page 1 of 2

Universal Life Insurance Proposal Initial Specified Amount: $17,855 $75, Inflation Protection Option Effects An Inflation Protection Option can help your LTC benefit keep up with potential increases in the cost of LTC services. Below is a graphical representation of the effects of the Inflation Protection Options available with the ABR and EBR options used in this proposal. It shows how the available options compare over time and what the maximum monthly benefit amount would be by age 85 based on the proposal assumptions. Age The values and benefits are guaranteed as proposed. This supplemental report must be accompanied by a basic proposal that contains guaranteed elements and other important information and is not complete without all pages. DB Version 29539.1 Version 2.95.15 Prepared on 9/28/14 Page 2 of 2

Supplemental Life Insurance Report Internal Rate of Return (IRR) Initial Specified Amount: $17,855 $75, 1 Cumulative Total 2 Total Policy Year Age EOY Net Annual Outlay Net Annual Outlay Long-Term Care Benefits Long-Term Care Benefits IRR 1 36 75, 75, 367,338 111.97% 2 37 75, 385,75 65.49% 3 38 75, 44,72 47.71% 4 39 75, 422,439 38.7% 5 4 75, 44,85 31.96% 6 41 75, 459,172 27.72% 7 42 75, 477,539 24.59% 8 43 75, 495,96 22.17% 9 44 75, 514,273 2.24% 1 45 75, 532,64 18.67% 11 12 13 46 47 48 49 14 15 5 16 51 17 52 18 53 19 54 2 55 75, 75, 75, 75, 75, 75, 75, 75, 75, 75, 551,7 569,374 587,741 66,18 624,475 642,841 661,28 679,575 697,942 716,39 17.36% 16.25% 15.29% 14.46% 13.73% 13.8% 12.5% 11.97% 11.5% 11.7% 21 56 22 57 23 58 24 59 25 6 26 61 27 62 28 63 29 64 3 65 75, 75, 75, 75, 75, 75, 75, 75, 75, 75, 734,676 753,43 771,41 789,777 88,144 826,511 844,877 863,244 881,611 899,978 1.68% 1.31% 9.98% 9.67% 9.38% 9.12% 8.87% 8.63% 8.41% 8.21% 31 32 33 34 35 66 75, 918,345 8.1% 67 75, 936,712 7.83% 68 75, 955,79 7.65% 69 75, 973,446 7.48% 7 75, 991,813 7.33% (1) CUMULATIVE NET ANNUAL OUTLAY is the cumulative annualized premiums. (2) TOTAL LONG-TERM CARE BENEFITS IRR is the cumulative rate of return on your premium assuming your long-term care benefits are accelerated beginning in that given year. This IRR assumes you receive the Total Long-Term Care Benefits and that no death benefit is paid. The values and benefits are guaranteed as proposed. This supplemental report must be accompanied by a basic proposal that contains guaranteed elements and other important information and is not complete without all pages. DB Version 29539.1 Version 2.95.15 Prepared on 9/28/14 Page 1 of 2

Policy Year 36 37 38 39 4 41 76 42 77 43 78 44 79 45 8 Supplemental Life Insurance Report Internal Rate of Return (IRR) Initial Specified Amount: $17,855 $75, 1 Cumulative Total 2 Total Age EOY Net Annual Outlay Net Annual Outlay Long-Term Care Benefits Long-Term Care Benefits IRR 71 75, 1,1,18 7.18% 72 75, 1,28,547 7.3% 73 75, 1,46,914 6.9% 74 75, 1,65,28 6.77% 75 75, 1,83,647 6.64% 75, 1,12,14 6.52% 75, 1,12,381 6.41% 75, 1,138,748 6.3% 75, 1,157,115 6.2% 75, 1,175,482 6.9% 46 81 47 82 48 83 49 84 5 85 51 86 52 87 53 88 54 89 55 9 75, 75, 75, 75, 75, 75, 75, 75, 75, 75, 1,193,849 1,212,216 1,23,583 1,248,95 1,267,316 1,285,683 1,34,5 1,322,417 1,34,784 1,359,151 6.% 5.9% 5.81% 5.72% 5.64% 5.56% 5.48% 5.4% 5.33% 5.26% 56 91 57 92 58 93 59 94 6 95 75, 75, 75, 75, 75, 1,377,518 1,395,885 1,414,252 1,432,619 1,45,986 5.19% 5.12% 5.6% 4.99% 4.93% 65 7 75 8 85 1 75, 1,542,82 4.65% 15 75, 1,634,655 4.4% 11 75, 1,726,489 4.18% 115 75, 1,818,324 3.99% 12 75, 1,91,158 3.81% (1) CUMULATIVE NET ANNUAL OUTLAY is the cumulative annualized premiums. (2) TOTAL LONG-TERM CARE BENEFITS IRR is the cumulative rate of return on your premium assuming your long-term care benefits are accelerated beginning in that given year. This IRR assumes you receive the Total Long-Term Care Benefits and that no death benefit is paid. The values and benefits are guaranteed as proposed. This supplemental report must be accompanied by a basic proposal that contains guaranteed elements and other important information and is not complete without all pages. DB Version 29539.1 Version 2.95.15 Prepared on 9/28/14 Page 2 of 2

Policy Year Age EOY 1 36 2 37 3 38 4 39 5 4 6 41 7 42 8 43 9 44 1 45 Supplemental Life Insurance Report Cost of Insurance Initial Specified Amount: $17,855 $75, Admin 1 3 4 5 Net Base Policy Charge/ Total Base Policy Average 2 6 Annual Cost of Policy Rider Annual Annual Cost Amount at Policy Outlay Insurance + Fees + Charges = Deduction Per $1, Risk Value 75, 85 87 89 9 87 92 94 98 13 18 1,273 1,275 1,277 1,278 1,275 1,28 1,282 1,286 1,291 1,296.4.43.45.48.52.56.6.65.7.75 24,321 198,311 189,978 18,113 172,355 164,982 156,389 148,789 141,992 134,924 53,873 54,61 55,289 56,19 56,93 57,79 58,613 59,657 6,85 62,223 Death Benefit 258,519 251,1 243,742 236,75 229,916 223,338 216,972 21,85 24,831 199,5 11 12 13 46 47 48 49 14 15 5 16 51 17 52 18 53 19 54 2 55 113 119 123 13 138 147 155 168 184 199 1,31 1,37 1,311 1,318 1,326 1,335 1,343 1,356 1,372 1,387.81.86.92 1.1 1.9 1.16 1.23 1.32 1.49 1.63 132,751 131,611 129,456 128,973 128,37 126,826 125,984 124,19 122,874 12,916 63,57 64,817 66,128 67,243 68,62 7,19 71,486 72,899 74,257 75,686 198,3 197,561 196,847 196,157 195,458 194,744 194,14 193,271 192,521 191,748 21 56 22 57 23 58 24 59 25 6 29 225 241 262 292 1,397 1,413 1,429 1,45 1,48 1.79 1.98 2.2 2.48 2.81 116,887 112,962 18,74 14,112 12,315 77,788 79,911 82,61 84,242 86,45 19,971 19,23 189,456 188,723 187,98 (1) NET ANNUAL OUTLAY is the cumulative annualized premiums. (2) RIDER CHARGES includes the cost of insurance for the ABR, EBR, and any Inflation Protection Option chosen. (3) TOTAL ANNUAL DEDUCTION includes cost of insurance associated with the base policy (the amount at risk multiplied by the cost per thousand), cost of insurance for any riders and the administrative charge and policy fee if applicable. (4) BASE POLICY ANNUAL COST PER $1, is the cost of coverage per thousand dollars at risk for the primary insured at the specified age, gender (except in Montana), and underwriting rating. (5) AVERAGE AMOUNT AT RISK is the amount used to calculate the actual base policy cost of insurance. (6) Policy values are end of year and are based on total monthly deduction and a guaranteed interest rate of 3.75%. The values and benefits are guaranteed as proposed. This supplemental report must be accompanied by a basic proposal that contains guaranteed elements and other important information and is not complete without all pages. DB Version 29539.1 Version 2.95.15 Prepared on 9/28/14 Page 1 of 3

Policy Year 26 27 28 29 3 31 32 33 34 35 Age EOY 61 62 63 64 65 66 67 68 69 7 Supplemental Life Insurance Report Cost of Insurance Initial Specified Amount: $17,855 $75, Admin 1 3 4 5 Net Base Policy Charge/ Total Base Policy Average 2 6 Annual Cost of Policy Rider Annual Annual Cost Amount at Policy Outlay Insurance + Fees + Charges = Deduction Per $1, Risk Value 345 393 472 564 645 722 785 855 912 989 1,533 1,581 1,66 1,752 1,833 1,91 1,973 2,43 2,1 2,177 3.35 3.92 4.88 6.1 7.13 8.16 9.25 1.32 11.51 12.69 1,522 97,789 93,552 9,112 88,332 85,792 83,91 79,823 76,239 73,599 88,673 9,899 93,116 95,323 97,521 99,713 11,96 14,14 16,39 18,518 Death Benefit 187,217 186,432 185,633 184,835 184,48 183,273 182,516 181,77 181,34 18,291 36 37 38 39 4 41 42 43 44 45 71 72 73 74 75 76 77 78 79 8 1,47 1,87 1,125 1,178 1,214 1,231 1,291 1,364 1,456 1,542 2,235 2,275 2,313 2,366 2,42 2,419 2,479 2,552 2,644 2,73 13.84 15.17 16.59 18.4 19.69 21.12 23.3 25.81 29.16 33.23 71,982 68,349 65,28 62,392 59,19 56,329 53,983 5,882 48,356 44,852 11,718 112,89 115,19 117,18 119,161 121,175 123,142 125,46 126,868 128,586 179,534 178,751 177,949 177,161 176,382 175,67 174,826 174,27 173,29 172,37 46 47 48 49 5 81 82 83 84 85 1,67 1,796 2,1 2,274 2,658 2,858 2,984 3,198 3,462 3,846 38.9 43.15 49.2 57.8 68.92 42,693 4,587 39,962 38,934 38,29 13,169 131,576 132,784 133,75 134,412 171,485 17,855 17,855 17,855 17,855 (1) NET ANNUAL OUTLAY is the cumulative annualized premiums. (2) RIDER CHARGES includes the cost of insurance for the ABR, EBR, and any Inflation Protection Option chosen. (3) TOTAL ANNUAL DEDUCTION includes cost of insurance associated with the base policy (the amount at risk multiplied by the cost per thousand), cost of insurance for any riders and the administrative charge and policy fee if applicable. (4) BASE POLICY ANNUAL COST PER $1, is the cost of coverage per thousand dollars at risk for the primary insured at the specified age, gender (except in Montana), and underwriting rating. (5) AVERAGE AMOUNT AT RISK is the amount used to calculate the actual base policy cost of insurance. (6) Policy values are end of year and are based on total monthly deduction and a guaranteed interest rate of 3.75%. The values and benefits are guaranteed as proposed. This supplemental report must be accompanied by a basic proposal that contains guaranteed elements and other important information and is not complete without all pages. DB Version 29539.1 Version 2.95.15 Prepared on 9/28/14 Page 2 of 3

Supplemental Life Insurance Report Cost of Insurance Initial Specified Amount: $17,855 $75, Policy Year Age EOY Admin 1 3 4 5 Net Base Policy Charge/ Total Base Policy Average 2 6 Annual Cost of Policy Rider Annual Annual Cost Amount at Policy Outlay Insurance + Fees + Charges = Deduction Per $1, Risk Value Death Benefit 51 52 53 54 55 56 57 58 59 6 86 87 88 89 9 91 92 93 94 95 2,879 3,193 3,647 4,259 5,267 6,866 1,59 13,13 19,57 28,652 4,67 4,382 4,835 5,447 6,455 8,54 11,247 14,291 2,695 29,84 77.56 85.38 95.17 15.92 121.75 142.59 167.68 198.57 241.24 296.51 37,33 37,346 38,233 4,19 43,115 47,852 54,834 65,273 8,72 96,617 134,682 134,44 133,526 131,714 128,677 123,969 116,927 16,474 9,92 75, 17,855 17,855 17,855 17,855 17,855 17,855 17,855 17,855 17,855 17,855 65 7 75 8 85 1 15 11 115 12 75, 75, 75, 75, 75, 17,855 17,855 17,855 17,855 17,855 (1) NET ANNUAL OUTLAY is the cumulative annualized premiums. (2) RIDER CHARGES includes the cost of insurance for the ABR, EBR, and any Inflation Protection Option chosen. (3) TOTAL ANNUAL DEDUCTION includes cost of insurance associated with the base policy (the amount at risk multiplied by the cost per thousand), cost of insurance for any riders and the administrative charge and policy fee if applicable. (4) BASE POLICY ANNUAL COST PER $1, is the cost of coverage per thousand dollars at risk for the primary insured at the specified age, gender (except in Montana), and underwriting rating. (5) AVERAGE AMOUNT AT RISK is the amount used to calculate the actual base policy cost of insurance. (6) Policy values are end of year and are based on total monthly deduction and a guaranteed interest rate of 3.75%. The values and benefits are guaranteed as proposed. This supplemental report must be accompanied by a basic proposal that contains guaranteed elements and other important information and is not complete without all pages. DB Version 29539.1 Version 2.95.15 Prepared on 9/28/14 Page 3 of 3

Advisor Information Only The sale of life insurance products and the use of sales proposals is a heavily regulated practice. To help you comply with the many requirements, has developed this simple checklist for you to use. Check off each item as you complete it. The appropriate state licenses and registrations must be in place before the insurance needs and solutions are discussed with your client. Review with your client the information on page 5 of the Life Insurance Proposal. It is important that your client understand that you are proposing a life insurance policy which contains only guaranteed values. Review the remaining pages of the Life Insurance Proposal with your client. Answer any questions your client may have about the life insurance policy. Then, have your client sign the Coverage Summary acknowledging their understanding of the life insurance product. After your client has signed you also need to sign this page. Make 2 copies of the complete Life Insurance Proposal including the signatures. Provide the client with one copy, retain one for your records, and send the original into the Corporate Office along with the completed life insurance application. Insurance and annuity products are issued by. 213-214. All rights reserved. 931 Version 2.95.15

Advisor Information Only GDC Summary Page Proposal Assumptions: Primary insured: John Doe Insurance Age: 35 Gender: Male Risk Class: Nontobacco Specified Amount: $17,855 Riders included: $75, Target Premium: $75, Estimated Time of Sale GDC: Time of Sale GDC at 6.% is $4,5 st Total Estimated 1 Year Time of Sale GDC: $4,5* * GDC amounts do not reflect internal exchange transactions. See the Compensation Reference Guide for GDC on internal exchange. * Assumes full first year premium is paid and the policy is issued as proposed. st * The Total Estimated 1 Year Time of Sale GDC does not include Asset Based Compensation and will not be your actual compensation received. To find your actual compensation see the Compensation Reference Guide. Insurance and annuity products are issued by. 213-214. All rights reserved. 931 Version 2.95.15

May 27, 215 NAIC # 655 FEIN # 41-823832 District of Columbia Department of Insurance Re: LTC3I Individual Long Term Care LTC3I.1 Qualified SERFF Tracking #AERL-129974517 Advertising Form Submitted for Review: Form: 27567-A Sales Proposal Dear Sir or Madam: The above-listed advertising form 27567-A is submitted for review and approval by your department. This form replaces the previously approved form 27567 Sales Proposal, approved on 2/18/14 under SERFF tracking #AEMN-1294152. This submission contains no unusual or controversial items from the standpoint of normal company or industry standards. This form is an invitation to inquire. This form will be available through our agents in print or electronic format. It will also be available on our website, RiverSource.com. The advertising is intended for use with the following form filings: 1. Individual Flexible Premium Adjustable Life Insurance Policy forms 13249-DC, Policy Data 13249-DP, Application form 134924 and Application Supplement-Part II form 134932. These forms were approved on 1/28/13 under SERFF tracking #12918932. 2. Rider forms 13241 and 132411, previously approved on 11/7/13 under SERFF tracking #AEMN-12927793. Included with this submission is the statement of variability. This advertising form will be used upon your approval of this filing. The contact person for this filing is: Kathleen M. Felton Senior Contract Analyst 955 Minneapolis, MN 55474 (612) 671-2127 Kathleen.M.Felton@ampf.com To the best of my knowledge and belief this filing complies with the state regulations. Thank you for your assistance in reviewing this filing. Respectfully, Stephen M. Riesterer Director, Insurance Marketing Communications Insurance Marketing Strategy