Items to Note before Selling an Annuity (Fixed Indexed, Fixed and Variable) In Good Order Requirements To ensure your new business application will be complete and in good order, please provide Security Benefit the following documents. Please ensure all parts of the document are completed and each document is signed or initialed in the appropriate places. Fully completed application Original, signed Incoming Funds Request form, including a signature guarantee if required by the transferring company If applicable in your state, a State Replacement form and in most states the Sales Literature Confirmation form (if a replacement). State specific forms (if applicable) Contact the transferring company to ensure delivery of funds and identify if any additional requirements are necessary If applicable, and if a replacement, please provide a copy of any individualized sales materials used in the sale. Required Training Before a financial professional can solicit business for an annuity (fixed indexed, fixed or variable) they may have to complete training, refer to Annuity Training Requirements (22-79750-00) for complete details. Locking in Your Client's Interest Rate Security Benefit Life Insurance Company (SBL) and First Security Benefit Life Insurance and Annuity Company of New York (FSBL), referred to herein as Security Benefit, offer a rate lock program that helps lock-in the current rate for 60 days while working through the paper process. Below are some questions and answers to help you take advantage of the rate lock. The rate lock is available for 60 days from date of the client signature on the application for new purchases. To ensure your client qualifies for the rate lock, you must meet all of the following requirements, including the In Good Order requirements. Use the list below to ensure that your application submission meets the requirements. Security Benefit must receive all original paperwork within five business days of client signature in good order. Money transferring from another carrier must be received at Security Benefit within 60 days of client signature. Representatives should consider sending copies of original paperwork to your compliance staff for approval while sending originals to Security Benefit to meet the rate lock deadline. For further questions and assistance, please call your internal sales consultant at 800.888.2461. 22-79750-01 2012/11/06
Security Benefit Advanced Choice Annuity Application Issued by Security Benefit Life Insurance Company. Questions? Call our National Service Center at 1-800-888-2461. 1. Provide Owner Information Name of Contract Owner Male Female First MI Last Mailing Address Street Address City State ZIP Code Residential Address (if different from mailing address) Street Address City State ZIP Code Social Security Number/Tax I.D. Number Daytime Phone Number Home Phone Number 2 2. Provide Joint Owner Information Name of Joint Owner Male Female First MI Last Mailing Address Street Address City State ZIP Code Residential Address (if different from mailing address) Street Address City State ZIP Code Social Security Number/Tax I.D. Number Daytime Phone Number Home Phone Number Date of Birth (mm/dd/yyyy) Date of Birth (mm/dd/yyyy) 3. Provide Annuitant Information Same as Owner Name of Annuitant Male Female First MI Last Mailing Address Street Address City State ZIP Code Residential Address (if different from mailing address) Street Address City State ZIP Code Social Security Number/Tax I.D. Number Date of Birth (mm/dd/yyyy) Daytime Phone Number Home Phone Number Please Continue 5201 DC (9-13) Advanced Choice 15-96040-07 2013/09/01 (1/4)
4. Provide Primary and Contingent Beneficiary(ies) For additional Primary Beneficiaries, please attach a separate list to the end of this application. 1. 2. 3. 4. For additional Contingent Beneficiaries, please attach a separate list to the end of this application. 1. 2. 3. 4. Primary Beneficiary Name Address (city, state, zip) Phone No. Contingent Beneficiary Name Address (city, state, zip) Phone No. Social Security No. Social Security No. DOB (mm/dd/yyyy) DOB (mm/dd/yyyy) Relationship to Contract Annuitant Relationship to Contract Annuitant % of Benefit % of Benefit 5. Choose Type of Annuity Contract Please select the annuity type: Non-Qualified Traditional IRA Roth IRA Other Purchase Payment $ (Minimum $10,000) For IRAs only: Current Year $ Prior Year $ Annuity Start Date (mm/dd/yyyy) Rollover $ Transfer $ Please select the Guarantee Period: only one Guarantee Period may be selected. 3 Year 4 Year 5 Year 6 Year 7 Year 8 Year 9 Year 10 Year This contract is a single premium annuity. It is typically issued upon receipt of the Purchase Payment and does not accept Purchase Payments after the effective date of the contract. 6. Purchase Payment Information Please indicate below whether the Purchase Payment listed in section five above will be from a single source or from multiple sources. You must check one of the options below. In addition, if the Purchase Payment is from multiple sources, you must indicate that you understand and agree to the conditions of such transactions. The entire Purchase Payment is being received from a single deposit. The Purchase Payment is being received from multiple sources. If you indicated that the Purchase Payment is being received from multiple sources, you must complete the section below. By checking this box, I (we) direct Security Benefit to: Hold Purchase Payments received by it until the last of such Purchase Payments is received; and upon receipt of the last Purchase Payment, to apply all of the transfer payments as a single Purchase Payment for the new contract. By checking this box, I (we) understand and agree: The new contract will not be issued until the last Purchase Payment is received by Security Benefit; if last Purchase Payment is not received within 60 days of receipt of application, then the contract will be issued effective on the 60th day following application receipt, as long as funds received are more than the minimum required premium amount; no interest will be paid or credited by Security Benefit with respect to the Purchase Payments held by it for any period that is before the effective date of the new contract; and Interest will only begin to accrue on the issue or effective date of the new contract. Please Continue 5201 DC (9-13) Advanced Choice 15-96040-07 2013/09/01 (2/4)
State Fraud Disclosure WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits, if false information materially related to a claim was provided by the applicant. 7. Provide Replacement Information Do you have any existing annuity or life insurance policies? Yes No Does this proposed contract replace or change any existing annuity or life insurance policy? Yes No If Yes, please list the company and policy number. Company Name Company Name Policy Number Policy Number 8. Incentives and Other Considerations Have you or the annuitant been offered any cash incentive or other consideration (such as free insurance) as an inducement to apply for this annuity contract? Yes No Does the owner have an insurable interest in the annuitant? Yes No 9. Provide Signature My signature below indicates that the information provided within the application is accurate and true, including my tax identification number. I understand and agree that no amount will be credited to my annuity with Security Benefit until the funds are received by Security Benefit in cash. I further understand the interest crediting rate for the new contract is subject to change and will not be determined until the issue or effective date. I assume the risk that such interest crediting rate may decrease between the date I sign the application and the issue or effective date of the new contract. I understand that any amount allocated to the annuity contract for which I am applying may be subject to a market value adjustment, which may cause the values to increase or decrease in dollar amount if withdrawn or surrendered prior to a specified date or dates as stated in the contract. Tax Identification Number Certification Instructions: You must cross out item (2) in the below paragraph if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest or dividends on your tax return. For contributions to an individual retirement arrangement (IRA), and generally payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct Tax Identification Number. Under penalties of perjury I certify that (1) The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and (2) I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends or the IRS has notified me that I am no longer subject to backup withholding; and (3) I am a U.S. citizen or other U.S. person (as defined in the IRS Form W-9 instructions). The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. x Signature of Owner Date (mm/dd/yyyy) Signed at (City/State) x Signature of Joint Owner Date (mm/dd/yyyy) Please Continue 5201 DC (9-13) Advanced Choice 15-96040-07 2013/09/01 (3/4)
Agent s Statement Will the Annuity being purchased replace any prior insurance or annuities of this or any other Company? No, to the best of my knowledge, this application is not involved in the replacement of any life insurance or annuity contract, as defined in applicable insurance department regulations. Yes. If yes, please comment below. I have complied with the requirements for disclosure and/or replacements. (Submit a copy of the Replacement Notice with this application and leave the applicant a copy of any written material presented to the applicant.) I have used only insurer approved sales materials and I have left copies with the applicant. Print Name of Agent Code x Signature of Agent Date (mm/dd/yyyy) Print Agency Name Important Information About Procedures for Purchasing a New Contract Code To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify and record information that identifies each person who purchases a contract. What this means to you: When you purchase a contract, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver s license or other identifying documents. Mailing Instructions Checks should be made payable to: Security Benefit Life Insurance Company P.O. Box 750497 Topeka, Kansas 66675-0497 Mail to: For expedited or overnight delivery: Security Benefit Life Insurance Company Security Benefit P.O. Box 750497 Mail Zone 497 Topeka, Kansas 66675-0497 One Security Benefit Place Fax to: 1-785-368-1772 Topeka, Kansas 66636-0001 Visit us online at www.securitybenefit.com 5201 DC (9-13) Advanced Choice 15-96040-07 2013/09/01 (4/4)
Sales Literature Confirmation Contractowner Name: Annuitant/Participant: Contract Number: Tax ID Number: This form is to be completed by the writing agent and must be submitted with all replacement cases. Applications for new contracts that are considered replacements and/or a 1035/Transfers will not be processed until all requirements, including this completed form, are received in proper order at Security Benefit. 1. Did you utilize any individualized sales materials (including illustrations) in your presentation to the client? YES NO Note: If you answered yes, copies of all material must be submitted to Security Benefit. 2. Security Benefit requires that a client receive the contents of a sales kit in order to make the sale. The contents of the kit should be left with the client. Please identify the product being sold and the state of issue below: Kit given to Client: Product Name Issue State I certify that the responses herein are, to the best of my knowledge, accurate and complete: Agent's Signature Printed Name Date Mail to: Security Benefit PO Box 750497 Topeka, KS 66675-0497 National Service Center: 1-800-888-2461 www.securitybenefit.com 8031 Model (R3-08) 1st Copy Home Office - 2nd Copy Applicant - 3rd Copy Agent 38-08033-00 (1/1)
Electronic Authorization Questions? Call our National Service Center at 1-800-888-2461. Instructions Use this form to activate electronic services. Transactions may be requested via telephone, Internet, or other electronic means by the Owner and/or servicing sales representative based on instructions of the Owner. Authorization must be on file with Security Benefit before we will activate electronic services. Please type or print. 1. Provide General Account Information Contract/Account Number Plan Number or Name (Applicable to Employer Retirement Plans only) Name of Owner/Participant First MI Last Mailing Address Street Address City State ZIP Code Social Security Number/Tax I.D. Number Daytime Phone Number Home Phone Number 2. Provide Signature I understand and agree to the terms set forth on this form. x x Signature of Owner/Participant Date (mm/dd/yyyy) Signature of Joint Owner (if applicable) Date (mm/dd/yyyy) x Signature of Representative (optional) Date (mm/dd/yyyy) Print Name of Representative Mail to: For expedited or overnight delivery: Security Benefit Security Benefit P.O. Box 750497 Mail Zone 497 Topeka, Kansas 66675-0497 One Security Benefit Place Fax to: 1-785-368-1772 Topeka, Kansas 66636-0001 Visit us online at www.securitybenefit.com 7794 L (R5-06) 32-77941-12 2013/11/21 (1/1)
Questions? Call our National Service Center at 1-800-888-2461. Advanced Choice Annuity Incoming Funds Request Instructions Use this form to transfer funds from your current carrier to Security Benefit Life Insurance Company (SBL). Complete the entire form. Please type or print. 1. The Owner should complete this Incoming Funds Request form and any applicable state-required replacement forms. 2. Please contact your current carrier for any requirements it may have for transferring money to another company. 3. Obtain Signature Guarantee if required by your current carrier. 4. The documents mentioned above should be mailed to: Security Benefit P.O. Box 750497 Topeka, KS 66675-0497 5. Upon receiving this material Security Benefit will send an acceptance letter to the carrier. 6. If you are completing this form for a 403(b) or 403(b)(7) account/contract please contact your employer for any processing instructions the employer or third party administrator may require. Notice to Current Carrier Please make check(s) payable to Security Benefit for the benefit of the Owner listed on this form and mail to: Security Benefit regular mail Security Benefit overnight mail P.O. Box 750500 Mail Zone 500 Topeka, KS 66675-0500 One Security Benefit Place Topeka, KS 66636-0001 1. Provide Security Benefit Account Information Application Attached or Contract Number Name of Owner First MI Last Mailing Address Street Address City State ZIP Code Social Security Number/Tax I.D. Number Daytime Phone Number Home Phone Number Name of Joint Owner First MI Last Social Security Number/Tax I.D. Number Name of Annuitant/Participant (If different from Owner) First MI Last Social Security Number/Tax I.D. Number Please indicate the type of account you would like to transfer your funds to (check one). 403(b) TSA Roth 403(b) TSA Non-qualified Annuity Roth IRA Traditional IRA SEP-IRA 7691 32-79450-00 2013/09/01 (1/4)
2. Provide Your Current Carrier Information Please fill out the name and contact information for your current carrier. Current Carrier s Name Mailing Address Street Address City State ZIP Code Phone Number Account Number for Current Carrier Please indicate the account type you have with your current carrier (check one). 401(a) 403(b)(7) Roth 403(b)(7) 457 Roth 403(b) TSA Non-qualified Annuity Non-qualified CD, Stock 1 Non-qualified Mutual Fund 1 Life Insurance SEP-IRA SIMPLE IRA Traditional IRA Roth IRA Roth 401(k) 403(b) TSA Other 401(k) 1 This transfer is a taxable event. Please indicate the investment type you have with your current carrier (check one). Annuity Bank CD Mutual Fund Life Policy Money Market Brokerage Account 401(k)/Pension Plan Other If this request involves your entire account balance, please check one of the following. My policy is: Enclosed Lost/destroyed 3. Set Up Transfer/Exchange/Rollover Option Please indicate one of the following. 1035 Exchange: I hereby make complete and absolute assignment and transfer all or the portion specified of my rights, title and interest of every nature and character in and to the Current Carrier Account in Section 2 to Security Benefit Life Insurance Company (SBL) in an exchange intended to qualify under Section 1035 of the Internal Revenue Code. I understand that by executing this assignment, I irrevocably waive all rights, claims and demands under the above policy for the portion specified. If you effect, or have effected, a partial exchange from a previously existing annuity contract with another carrier to an annuity contract with SBL under IRC Section 1035, any withdrawals from or changes in ownership to your SBL contract within 180 days of such partial exchange may have adverse tax consequences. Please consult your tax advisor. Exchange (exchange of 403(b)/403(b)(7) assets from one provider to another provider within your current employer s Plan) Rollover (not like-to-like, for example 457 to IRA, etc.) Transfer (like-to-like, for example, 457 to 457, IRA to IRA, prior employer 403(b) Plan to current employer 403(b) Plan) Please Transfer Immediately On date Transfer must occur within 30 calendar days from Date (mm/dd/yyyy) the Incoming Funds Request form signing date and 45 calendar days from the Application receipt date. Transfer request will be mailed two business days prior to date listed here. Amount Liquidate my entire Account: Estimated Value $ Liquidate a specified amount: Amount to Transfer $ or % Distribution Requirements (if applicable) I certify that applicable requirements have been met for distribution. Check all that apply: Age 59 1 /2 Disabled Severance from employment on Date (mm/dd/yyyy) Please Continue 7691 32-79450-00 2013/09/01 (2/4)
4. Required Minimum Distribution (if applicable) Current carrier should distribute my RMD to me prior to transferring/rolling over my account. Current carrier should proceed with the transfer/rollover because the requirements for the current year have been met. 5. Purchase Information Funds will be allocated as indicated on the enclosed application. Incoming transfers are not allowed for existing Advanced Choice contracts. If this transfer is one of multiple funding sources, Security Benefit will: Hold Purchase Payments received by it until the last of such Purchase Payments is received; and upon receipt of the last Purchase Payment, apply all of the transfer payments as a single Purchase Payment for the new contract. In addition: The new contract will not be issued until the last Purchase Payment is received by Security Benefit; If the last Purchase Payment is not received within 60 days of Security Benefit s receipt of the application, then the contract will be issued effective on the 60th day after application receipt, as long as the funds received are at least equal to the minimum required purchase amount; No interest will be paid or credited by Security Benefit with respect to the Purchase Payments held by it for any period that is before the effective date of the new contract; and Interest will only begin to accrue on the issue or effective date of the new contract. 6. Provide Signatures As the contractowner, I understand, acknowledge and certify that: I am responsible for tax consequences which could include the imposition of penalties, additional taxes and interest. Security Benefit assumes no responsibility or liability for any effects of this transaction. I am aware of my right to receive information regarding my current contract, including contract values. I certify that the information provided is correct and complete. x Signature of Owner Date (mm/dd/yyyy) Signature of Joint Owner Date (mm/dd/yyyy) x Signature of Plan Sponsor or Date (mm/dd/yyyy) Title Third Party Administrator (if applicable Please consult your financial representative or employer) x Signature of Representative Date (mm/dd/yyyy) Print Name of Representative Spousal Consent for Community Property States: If the owner/participant is a resident of AZ, CA, ID, LA, NM, NV, TX, WA or WI, spousal consent is required, unless the owner/participant has no legal spouse. x Signature of Spouse Date (mm/dd/yyyy) Please Continue 7691 32-79450-00 2013/09/01 (3/4)
7. Obtain Signature Guarantee Please obtain a Signature Guarantee ONLY if required by your Current Carrier. You can obtain a Signature Guarantee from a bank, broker or other acceptable financial institution. A Notary Public cannot provide a Signature Guarantee. x Signature of Guarantor Date (mm/dd/yyyy) Title or Name of Institution Place Signature Guarantee Stamp Here 8. Security Benefit Acceptance To be completed by Security Benefit. Security Benefit hereby agrees to accept the transfer of the proceeds identified on this form. x Signature of Accepting Carrier Date (mm/dd/yyyy) Title Mail to: For expedited or overnight delivery: Security Benefit Life Insurance Company Security Benefit P.O. Box 750497 Mail Zone 497 Topeka, Kansas 66675-0497 One Security Benefit Place Fax to: 1-785-368-1772 Topeka, Kansas 66636-0001 Visit us online at www.securitybenefit.com 7691 32-79450-00 2013/09/01 (4/4)
SECURITY BENEFIT PRIVACY POLICY The privacy of Security Benefit s customers is of utmost importance to us. You provide nonpublic personal information ( NPI ) to us in the course of doing business. We treat this information as confidential and restrict access to it. We collect NPI about you from: (1) your requests for literature; (2) your applications and forms; (3) your financial advisor; and (4) your transactions with us. We do not sell information about current or former customers. We disclose information among our affiliates and to third parties as needed to process transactions or service your account. For example, we may contract with third parties to send you statements. Also, we disclose information as required or permitted by law. Except with regard to California residents, we also may disclose information to companies: (1) that help us sell our products; and (2) with whom we jointly offer products. When we contract with others, we will require them to adhere to our privacy standards. At Security Benefit, we restrict access to your NPI. Such information is given only to those who need it to provide products or services to you. We also maintain: (1) physical; (2) electronic; and (3) procedural safeguards to guard your NPI. This Privacy Policy applies to the following companies: Security Benefit Life Insurance Company, Security Benefit Corporation, Security Distributors, Inc., First Security Benefit Life Insurance and Annuity Company of New York, and Security Financial Resources, Inc. THIS PAGE IS NOT PART OF YOUR CONTRACT 7929S 22-79291-19 2012/02/27