Attached are BOTH the Midland Variable Annuity and Midland Variable Life Insurance Investment Advisor Investment Forms. Please note that Form Number 8218Y is used for the Midland National Variable Annuity Only. This form is 4 pages. Form Number 12331 is used for the Midland National Variable Universal Life Only. This form is 2 pages.
Investment Advisor Declaration Form Instructions: Please complete sections I, III, IV, VI, and VIII and read sections II, V, and VII. All information must be typed or printed in ink. A separate request form must be submitted for each annuity contract. I. ANNUITY AND ADVISORY INFORMATION Annuity Number (only one contract number per form) Investment Advisor s Name Effective Firm Owner Name Firm Address Owner Tax I.D. Number City, State, Zip Co-Owner Name (if applicable) Firm- Daytime Phone Number Firm - Fax Number Advisor or Firm - E-mail Address (if available) II. TRANSFER AUTHORIZATION I/We, the undersigned Annuity Owner, hereby authorize Midland National ( Midland ) to (a) release account information to the investment Advisor named above ( Advisor ) and (b) comply with transfer and allocation instructions that may be communicated to Midland through electronic, written, telephone, facsimile or by other acceptable means at Midland s sole discretion ( Transfer Requests ) by the Advisor with respect to the Annuity. This Authorization will remain in effect until the earlier of (1) the termination of this Authorization by either the owner(s) or Advisor or (2) the total distribution of the Annuity or (3) notification of a death claim. I/We acknowledge and accept by entering into this agreement that Midland s Electronic Services, as defined herein, are provided as-is without warranty of any kind. Midland s Electronic Services means any and all electronic services provided by Midland and used by the Advisor to conduct Transfer Requests for Owners. The definition of Midland s Electronic Services EXPRESSLY DOES NOT INCLUDE any internal or external servers, hardware, software, electronics or other electronic components related thereto, originating with, acquired, owned, leased, rented or otherwise used by the Advisor, its employees or agents, (except for Midland s Electronic Services), or any services provided by or through the Advisor s internal or external server(s) or internet service provider. MIDLAND DOES NOT MAKE ANY, AND DISCLAIMS ANY AND ALL REPRESENTATIONS OR WARRANTIES, EXPRESS OR IMPLIED, ORAL OR WRITTEN, WITH RESPECT TO MIDLAND S ELECTRONIC SERVICES INCLUDING WITHOUT LIMITATION ALL IMPLIED WARRANTIES OR MER- CHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE, OR NON-INFRINGEMENT AND ALL WARRANTIES IMPLIED FROM ANY COURSE OF DEALING, COURSE OF PERFORMANCE OR USAGE OF TRADE. No oral or written information or advice given by any representative of Midland shall create a warranty, in any way increase, or modify the scope of this warranty. I/We acknowledge and accept that access to Midland s Electronic Services may be interrupted, delayed, limited, or unavailable at any time, including without limitation, during peak demand periods, market volatility, systems upgrades, maintenance, or for other reasons. Neither Midland, nor its employees and agents warrant that Midland s Electronic Services will meet your or your Advisor s requirements or that use of and/or access to Midland s Electronic Services will be interrupted or error free. IF SERIVCE IS UNAVAILABLE OR DELAYED AT ANY TIME, MIDLAND MAY PROVIDE AN ALTERNATE MEANS VIA FACSIMILE OR OTHER MEANS TO BE DETERMINED BY MIDLAND AT ITS SOLE DISCRETION TO PLACE TRANSACTION REQUESTS. MIDLAND WILL NOT BE LIABLE AND/OR RESPONSIBLE FOR ANY TRANSACTION REQUESTS THAT ARE UNABLE TO BE COMMUNICATED TO MIDLAND OR THAT ARE UNABLE TO BE SUCCESSFULLY PROCESSED BY MIDLAND DUE TO INTERRUPTION, DELAY, LIMITATIONS OR UNAVAILABILITY OF THE MIDLAND ELECTRONIC SERVICES OR ANY ALTERNATIVE MEANS MADE AVAILABLE TO YOU OR YOUR ADVISOR FOR COMMUNICATING TRANSFER REQUESTS. 8218Y Page 1 of 4 Rev. 11/04
INVESTMENT ADVISOR DECLARATION FORM (Continued) Annuity Number (only one contract number per form) Investment Advisor s Name III. FEE PAYMENT AUTHORIZATION I/We hereby authorize Midland to comply with Transfer Requests by Advisor to liquidate a given dollar amount in the annuity to pay advisory fees ( Fees ) under an advisory service agreement executed by the Owner(s). All parties expressly acknowledge Midland has no responsibility or liability to determine that instructions received from the Advisor are in compliance with such an agreement. The fees will be deducted pro-rata from the funds in variable sub-accounts of the Annuity. I/We acknowledge and understand that partial surrenders may incur surrender charges, which will require Midland to liquidate a larger percentage or dollar amount than the amount required to pay the fees. I/We expressly authorize Midland to liquidate such percentage or dollar amounts. Midland has no duty to inquire into the amount of the annuity value withdrawn. I/We authorize the Fee payments described above. IV. NON-QUALIFIED ANNUITIES Non-qualified annuity: I/We understand that liquidation of contract units to pay Fees for non-qualified Annuities is considered to be constructive income to the extent of any gain distributed and therefore may be subject to income tax withholding and an IRS early distribution penalty. Income Tax Withholding Notice and Election (Your request cannot be processed unless this section is completed.) Withdrawals are subject to income tax withholding unless you elect not to have withholding apply. Withholding applies only to the portion of your payment that is subject to federal income tax. You may elect not to have withholding apply by checking the box below. Your election will remain in effect until revoked. If you elect no withholding, or if you do not have enough tax withheld from your distribution, you may have to pay an estimated tax. If your withholding and estimated tax payments are insufficient, you may be penalized under the estimated tax rules. You may revoke your election at any time. Other federal or state mandatory withholding rules may apply to your withdrawal. Yes Withhold % Federal tax from the taxable portion of the annuity withdrawal for the purpose of Fee payment. No Do not withhold Federal tax from any withdrawal for the purpose of Fee payment. V. INVESTOR ALLOCATION AGREEMENT If the Annuity is issued as a 401 funding vehicle, 403(b) custodial account, SEP/IRA account or IRA custodial account, I/We declare that the Annuity is solely responsible for the Fees and that I/We have executed a separate agreement with the Advisor, which so states. If the Annuity is issued as an IRA, SEP/IRA, or 403(b) Annuity, I/We declare that the Annuity is solely responsible for the Fees and that I/We have executed a separate agreement with the Advisor, which so states. Midland will not report fee liquidations from the IRA, SEP/IRA, and 403(b) annuities, but reserves the right to change this tax reporting position at any time upon written notice to the Owner and Advisor. Such a change will not alter future payments authorized under this form. VI. OPTIONAL PROGRAMS Please place a check in the boxes below to delete the following optional programs on the annuity as they may conflict with Investment Advisor s Activity: Dollar Cost Averaging Portfolio Rebalancing Fixed Account Earnings Sweep Program (if available) 8218Y Page 2 of 4 Rev. 11/04
INVESTMENT ADVISOR DECLARATION FORM (Continued) Annuity Number (only one contract number per form) Investment Advisor s Name VII. DISCLAIMER AND RELEASE Midland makes no representations, warranties, or covenants, express or implied, oral or written, including without limitation all implied warranties of merchantability or fitness for a particular purpose and all warranties implied from any course of dealing, course of performance or usage of trade, concerning the tax treatment of the payment of any fees or other amounts, under the Internal Revenue Code, as may be amended from time to time, or under any other similar law or set of laws, by accepting instructions in connection with this Authorization. Midland has no responsibility or liability for any taxes, fees, penalties, and/or interest, or for any other claims, actions, damages (including indirect, incidental, consequential, punitive, special or exemplary damages), expenses, costs (including reasonable legal costs) and other liabilities, including without limitation, damages for loss of revenue or lost profits, arising from any transaction contemplated by this Authorization whether such transaction is Advisor-initiated or otherwise (individually and collectively referred to as Loss ), which may be assessed by the Internal Revenue Service or other agency, by any tribunal or court, or otherwise incurred by Owner(s), even though Owner and/or Advisor may have been advised of the possibility of such Loss, unless such Loss occurs as a direct result of the willful misconduct of Midland, its employees or agents. In no event and under no circumstances will Midland, its employees, agents or affiliates be liable and/or responsible for any Loss incurred by Advisor and/or Owner as a result of any services, electronic or otherwise, which do not qualify as Midland Electronic Services as defined herein. I/We hereby agree to indemnify Midland, its employees, agents and any independent provider/transmitter of electronic information, from, and hold Midland and other such parties harmless against, and agree that Midland and such other parties have no responsibility or liability for, any Loss which may directly or indirectly arise from or be caused by (a) any inaccuracy, delay, error or omission in any transmission or delivery of information, including without limitation any communication failure or electronic failure, not caused by the willful misconduct of Midland, its employees or agents; (b) non-performance; (c) any force majeure, including but not limited to flood, earthquake, fire, war, insurrection, riot, labor dispute, accident, power failure, equipment or software malfunction or failure, extraordinary weather conditions or other act of God; or (d) any other cause beyond the reasonable control of Midland, its employees, agents and/or any independent provider or transmitter of electronic information. VIII. SIGNATURE(S) AND CERTIFICATION OF TAXPAYER IDENTIFICATION NUMBER This authorization will remain in full force and effect until revoked by me/us by a written, signed notice received at Midland s Principal Office. The Owner(s) hereby certifies, under penalty of perjury, that such taxpayer is not subject to backup withholding order under section 3406(c) of the Internal Revenue Code. In addition, the taxpayer hereby certifies under penalty of perjury that the social security or tax identification shown on this form is correct. The Owner hereby represents that he/she has read the terms and conditions herein and agrees to be bound by such terms and conditions as currently in effect and as may be amended from time to time. The Owner understands that an Arbitration Agreement, which appears on page 4, governs this account. Owner hereby acknowledges that he/she has read, understood and received a copy receipt of the Arbitration Agreement. Owner Signature Owner Signature Investment Advisor Signature For more information, please contact us at (866) 270-9564. Please return form to: Midland National Annuity Division Variable Annuity Dept. PO BOX 79907 Des Moines, IA 50325-0907. For Overnight Delivery: Midland Nation Annuity Division Variable Annuity Dept. 4601 Westown Parkway, Suite 300 West Des Moines, IA 50266-1071. 8218Y Page 3 of 4 Rev. 11/04
INVESTMENT ADVISOR DECLARATION FORM (Continued) Annuity Number (only one contract number per form) Investment Advisor s Name ARBITRATION CLAUSE AND AGREEMENT THIS ACCOUNT IS SUBJECT TO THE ARBITRATION RULES OF THE NATIONAL ASSOCIATION OF SECURITIES DEALERS, INC. ARBITRATION IS USED TO RESOLVE A DISPUTE BETWEEN TWO PARTIES. BECAUSE CONTROVERSIES INVOLVING BROKERAGE FIRMS OFTEN INVOLVE COM- PLICATED ISSUES, ARBITRATION FORUMS WERE CONCEIVED BY THE SECURITIES AND EXCHANGE COMMISSION, THE NEW YORK STOCK EXCHANGE, INC. AND THE NATIONAL ASSOCIATION OF SECURITIES DEALERS, INC. TO PROVIDE AN ALTERNATIVE DISPUTE RESOLUTION MECHANISM FOR INVESTORS WHICH IS USUALLY MORE EFFICIENT AND LESS COSTLY THAN COURT LITIGATION. YOU ARE AWARE OF THE FOLLOWING. A. ARBITRATION IS FINAL AND BINDING ON THE PARTIES. B. THE PARTIES ARE WAIVING THEIR RIGHT TO SEEK REMEDIES IN COURT, INCLUDING THE RIGHT TO JURY TRIAL. C. PRE-ARBITRATION DISCOVERY IS GENERALLY MORE LIMITED THAN AND DIFFERENT FROM COURT PROCEEDINGS. D. THE ARBITRATORS AWARD IS NOT REQUIRED TO INCLUDE FACTUAL FINDINGS OR LEGAL REASONING AND ANY PARTY S RIGHT TO APPEAL OR TO SEEK MODIFICATION OF RULINGS BY THE ARBITRATORS IS STRICTLY LIMITED. E. THE PANEL OF ARBITRATORS WILL TYPICALLY INCLUDE A MINORITY OF ARBITRATORS WHO WERE OR ARE AFFILIATED WITH THE SECURITIES INDUSTRY. YOU AGREE THAT ALL CONTROVERSIES THAT MAY ARISE BETWEEN US CONCERNING ANY ORDER OR TRANSACTION, OR THE CONTINUA- TION, PERFORMANCE OR BREACH OF THIS OR ANY OTHER AGREEMENT BETWEEN US, WHETHER ENTERED INTO BEFORE, ON, OR AFTER THE DATE THIS ACCOUNT IS OPENED, SHALL BE DETERMINED BY ARBITRATION BEFORE A PANEL OF INDEPENDENT ARBITRATORS SET UP BY THE NATIONAL ASSOCIATION OR ANY OTHER INDUSTRY FORUM ONLY TO THE EXTENT EXPRESSLY PROVIDED AS AN ALTERNATIVE UNDER THE SECURITIES LAWS OF YOUR STATE OF RESIDENCE. IF YOU DO NOT NOTIFY US IN WRITING OF YOUR DESIGNATION WITHIN FIVE DAYS AFTER YOU RECEIVE FROM US A WRITTEN DEMAND FOR ARBITRATION, THEN YOU AUTHORIZE US TO MAKE SUCH DESIGNA- TION ON YOUR BEHALF. YOU UNDERSTAND THAT JUDGEMENT UPON ANY ARBITRATION AWARD MAY BE ENTERED IN ANY COURT OF COMPETENT JURISDICTION. No person shall bring a punitive or certified class action to arbitration, nor seek to enforce any pre-dispute arbitration agreement against any person who has initiated in court a punitive class action; or who is a member of a punitive class who has not opted out of the class with respect to any claims encompassed by the punitive class action until: (i) the class certification is denied; or (ii) the class is decertified; or (iii) the customer is excluded from the class by the court. Such forbearance to enforce an agreement to arbitrate shall not constitute a waiver of any rights under this agreement except to the extent stated herein. OTHER INFORMATION The Variable Annuity SM issued on Form Series A053A1, the Variable Annuity II SM issued on Form Series A057A1 and the National Advantage Variable Annuity issued on Form Series AS087A or appropriate state variations are underwritten by Midland National. The broker/dealer for Midland National s variable products is Sammons Securities Company, LLC, member NASD/SIPC. Sammons Securities Company is a registered broker/dealer under the Securities Exchange Act of 1934. Sammons Securities Company is an indirect wholly owned subsidiary of Sammons Enterprises, Inc., of Dallas, Texas, the ultimate parent company of Midland National. For questions regarding your policy, please call Midland National at 1-866-270-9564. 1 4 8 2 1 8 Y Leave Page 4 with the Annuity Owner(s) 8218Y Page 4 of 4 Rev. 11/04
MIDLAND NAT I O N A L Life Insurance Company A Member of the Sammons Financial Group Investment Advisor Authorization Form All information must be typed or printed in ink. Please complete a separate form for each contract. Questions? Please call our Variable Service Department at (800) 272-1642 Ext. 32207. *12331* 1. Variable Life Insurance Policy Information Policy Number Owner SSN or TIN Owner Name(s) Owner Mailing Address Daytime Phone Number Home Phone Number 2. Investment Advisor Name of Advisor Mailing Address Type of Advisor: Firm Individual Daytime Phone Number Fax Number 3. Advisor Authorization Investment Transfer, Premium Allocation, and Investment Direction Authorization I (we) authorize Midland National Life Insurance Company ( Midland ) to release account information to the Advisor and to comply with written, telephone, Internet, or faxed instructions from the Advisor listed for the Account. I (we) further authorize Midland to release account information to authorized named employees of the Advisor s Firm and to comply with written, telephone, Internet, or faxed instructions from authorized named employee of the Advisor s Firm. 4. Written Confirmation I understand that Rule 10b-10 under the Securities Exchange Act, as amended, requires that all transactions involving my variable life insurance policy be confirmed in writing to me. I understand that such written confirmations will be provided as follows: Please insert your initials on one of the two lines below after confirming whether your Advisor will provide this service. (Owner s initials) Advisor confirmations. I have been informed by my Advisor that s/he will provide consolidated financial reports for me. In lieu of receiving such written confirmation from Midland, I expect and will rely on the consolidated financial reports, which will include my variable life insurance policy, prepared and provided by my Advisor to me. I acknowledge that by waiving my right to written confirmation from Midland, I release Midland from any loss incurred by me as a result of the Advisor providing this information to me. (Owner s initials) Midland confirmations. I have been informed by my Advisor that s/he will NOT provide consolidated financial reports for me that include my variable life insurance policy. Therefore, I understand that Midland will provide such written confirmations to me at least quarterly. 5. Advisor Fee Payment Authorization (Owner s initials) I authorize Midland to comply with requests by the Advisor to automatically process a loan against my variable life insurance policy values to pay Advisory Fees ( Fees ) upon receipt of an invoice from my Advisor. Checks will be made payable to the Advisor. I acknowledge and understand that: Midland has no responsibility or liability to determine that instruction received from the Advisor comply with my Agreement with my Advisor, including frequency or reasonableness of Fees. Fees will be deducted pro-rata from the funds in the variable sub-accounts of my policy and moved to the general account to establish the loan for payment of the Fees. Page 1 of 2 MIDLAND NATIONAL LIFE INSURANCE COMPANY ONE MIDLAND PLAZA SIOUX FALLS, SD 57193-0001 12331 Phone: (605) 335-5700 Fax Center: (605) 335-3621 Internet: www.mnlife.com Prt. 5/08
Investment Advisor Authorization Form Policy loans are subject to all the terms and conditions outlined in the policy pages and disclosed in the policy s prospectus. Policy loans, if not repaid, reduce my policy s cash value and death benefits. 6. Tax Status (Owner s initials) I understand and acknowledge that: Policy loans from life insurance policies generally are not subject to income tax; nonetheless, Midland strongly recommends that I consult with my tax advisor prior to taking any loan on my policy or surrendering my policy with an outstanding loan to determine any tax consequences. A policy loan from a life insurance policy that is considered to be a modified endowment contract (MEC) may be taxable upon disbursement of the loaned proceeds. Midland does not provide tax advice and strongly recommends I consult with my tax advisor prior to authorizing any policy loans on my variable life insurance policy. 7. Disclaimer and Release I understand and agree that: Midland is not affiliated with and does not endorse any Advisor. Midland does not provide investment advice. Midland does not provide legal or tax advice and recommends that I consult with appropriate counsel before entering into an agreement with an Advisor. I agree to hold harmless Midland and its officers, directors, and employees from and against any claims, liabilities, losses, expenses (including reasonable attorney s fees), or alleged claims relating to the value of my variable life insurance policy with respect to transactions or instructions initiated by my Advisor. Midland shall have no responsibility to determine the appropriateness or suitability of any transaction or instructions initiated by my Advisor. Midland does not make any representation or warranty, by accepting instructions concerning the tax treatment of payment of Fees under the Internal Revenue Code of 1986, as amended or otherwise. Midland has no responsibility or liability for any taxes, penalties, and/or interest that may be assessed by the Internal Revenue Service or other administrative tribunal or court arising out of this Advisor authorization. I hereby release Midland from any taxes, penalties, and/or interest arising out of any Advisor initiated investment transfer or partial surrender. 8. Signatures This authorization shall remain in full force and effect until the earlier of: (1) written notice to Midland revoking this authorization; (2) notice of change in ownership of the policy; (3) full surrender or distribution of the policy; or (4) death of the Insured. Owner Signature Joint Owner Signature (if applicable) Investment Advisor Signature Please be advised that Midland National is not a party to your agreement with your investment advisor. To terminate any agreement you have with your investment advisor, you must contact your investment advisor and follow their procedures for termination of that agreement. Return Completed Form to: Midland National Life Insurance Company One Midland Plaza Sioux Falls, SD 57193 Fax (605) 373-8557 Page 2 of 2 MIDLAND NATIONAL LIFE INSURANCE COMPANY ONE MIDLAND PLAZA SIOUX FALLS, SD 57193-0001 12331 Phone: (605) 335-5700 Fax Center: (605) 335-3621 Internet: www.mnlife.com Prt. 5/08