Premier Choice Annuity Application

(1)

Issued by First Security Benefit Life Insurance and Annuity Company of New York. Questions? Call our Customer Service Center at 1-800-888-2461.

Premier Choice Annuity

®

_Application

Please select the annuity type:

❍

Non-Qualified

❍

408 IRA

❍

408A Roth

❍

Other ________________________________ Initial Purchase Payment $ _____________________________ Annuity Start Date____________________________________

(Minimum NQ $5,000; Q $2,000) (mm/dd/yyyy)

For IRAs only: Current Year $_____________________ Prior Year $_____________________ Rollover $_____________________ Initial Guarantee Period(s): minimum allocation per Guarantee Period is $1,000.

________% 1 Year ________% 2 Years ________% 3 Years ________% 4 Years ________% 5 Years ________% 6 Years ________% 7 Years ________% 8 Years ________% 9 Years ________% 10 Years ________% Other ______________________

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 __________________________________

FSB232 (12-11) Premier Choice 15-94994-65 2011/12/01 (1/3)

2. Provide Annuitant Information

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Same as Owner

Name of Owner___________________________________ ________ ____________________________________

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Male

❍

Daytime Phone Number___________________________________ Home Phone Number __________________________________ 3. Provide Owner Information

1. Choose Type of Annuity Contract

Name of Joint Owner__________________________________ ________ ________________________________

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Male

❍

Daytime Phone Number___________________________________ Home Phone Number __________________________________ 4. Provide Joint Owner Information

5. Provide Primary and Contingent Beneficiary(ies)

Primary Beneficiary Name Social Security No. DOB (mm/dd/yyyy) Relationship to Owner % of Benefit 1.

Contingent Beneficiary Name Social Security No. DOB (mm/dd/yyyy) Relationship to Owner % of Benefit 1.

For additional Primary Beneficiaries, please attach a separate list to the end of this application.

(2)

Do you currently have any existing annuity or insurance policies?

❍

Yes

❍

No

Does this proposed contract replace or change any existing annuity or insurance policy?

❍

Yes

❍

No If Yes, please list the following for all life insurance or annuity contracts to be replaced:

Current Carrier Name Contract/Policy Number

_____________________________________________________________________ ____________________________________________ _____________________________________________________________________ ____________________________________________

FSB232 (12-11) Premier Choice 15-94994-65 2011/12/01 (2/3)

6. Provide Replacement Information

My signature below indicates that the information provided within the application is accurate and true, including my tax identification number.

I have read the important disclosures on page 3. Tax Identification Number Certification

Instructions: You must cross out item (2) in the below paragraph if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest or dividends on your tax return. For contributions to an individual retirement arrangement (IRA), and generally payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct Tax Identification Number. Under penalties of perjury I certify that (1) The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and (2) I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends or the IRS has notified me that I am no longer subject to backup withholding; and (3) I am a U.S. citizen or other U.S. person (as defined in the IRS Form W-9 instructions).

The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.

x

_________________________________________ ________________ ________________________________________________________ Signature of Owner Date (mm/dd/yyyy) Signed at (City/State)

x_________________________

Signature of Joint Owner Date (mm/dd/yyyy) 8. Provide Signature

Please Continue Pursuant to Section 3 of the federal Defense of Marriage Act (“DOMA”), same-sex marriages currently are not

recognized for purposes of federal law. Therefore, the favorable income-deferral options afforded by federal tax law to an opposite-sex spouse under Internal Revenue Code sections 72(s) and 401(a)(9) are currently NOT available to a same-sex spouse. Same-sex spouses who own or are considering the purchase of annuity products that provide benefits based upon status as a spouse should consult a tax advisor. To the extent that an annuity contract or certificate accords to spouses other rights or benefits that are not affected by DOMA, same-sex spouses remain entitled to such rights or benefits to the same extent as any annuity holder’s spouse.

Important Notice Concerning Tax Treatment for Same-Sex Spouses

Have you been offered any cash incentive or other consideration (such as free insurance) as an inducement to apply for this annuity contract?

❍

Yes

❍

No

To the best of your knowledge and belief, has the annuitant been offered any cash incentive or other consideration (such as free insurance) as an inducement to apply for this annuity contract?

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Yes

❍

No

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FSB232 (12-11) Premier Choice 15-94994-65 2011/12/01 (3/3) At the end of the Withdrawal Charge period associated with a Guarantee Period: (1) the Owner will have the option to withdraw his or her money from that Guarantee Period without a Withdrawal Charge, (2) the Owner can reinvest in one or more of the other Guarantee Periods then made available by FSBL, which are subject to a Withdrawal Charge, or (3) the Owner can reinvest in a Guarantee Period that has no Withdrawal Charge, referred to in the annuity contract as the “One Year Renewal Guarantee Period.” Thus, at the end of the Withdrawal Charge period for each Guarantee Period, you will have the ability to put the money from that Guarantee Period into an option which has no Withdrawal Charge (i.e., the One Year Renewal Guarantee Period).

Important Disclosures

Checks should be made payable to:

First Security Benefit Life Insurance and Annuity Company of New York P.O. Box 750497

Topeka, Kansas 66675-0497 Mailing Instructions

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.

Important Information About Procedures for Purchasing a New Contract

Mail to: First Security Benefit Life Insurance and Annuity Company of New York •_{Administrative Office}•_{PO Box 750497}•_{Topeka, KS 66675-0497 or} Fax to: 1-785-368-1772

Visit us online at www.securitybenefit.com

Will the Annuity being purchased replace any prior insurance or annuities of this or any other Company?

❍

No, to the best of my knowledge, this application is not involved in the replacement of any life insurance or annuity contract, as defined in applicable Insurance Department Regulations. I have complied with the requirements for disclosure and/or replacement.

❍

Yes. If Yes, please enclose a completed and signed (i) Disclosure Statement; (ii) Important Notice form; and (iii) Incoming Funds Transfer form. The agent is required to leave with the applicant a copy of the Disclosure Statement and Important Notice form.

____________________________________________________________________________________________________________________ This application was completed and signed in my presence.

Print Name of Agent___________________________________________________________________________________ ________________ Code

x

____________________________________________________________________________________________________ ________________

Signature of Agent Date (mm/dd/yyyy)

Print Agency Name____________________________________________________________________________________ ________________ Code

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(5)

Appendix 10C

Insurance Department of the State of New York

IMPORTANT Notice Regarding Replacement or Change of Life Insurance Policies

or Annuity Contracts

This Notice is for Your Benefit and Required by Regulation No. 60

You are contemplating the purchase of a life insurance policy or annuity contract in connection with the surrender, lapse or change of existing life insurance policies or annuity contracts. The agent is required to give you this notice together with a signed disclosure statement containing the summary result comparison for the new life insurance policy or annuity contract and any life insurance policies or annuity contracts to be changed that sets forth the facts of the transaction and its advantages and disadvantages to you. Your decision could be a good one – or a mistake – so make sure you understand the facts. You should:

1. Carefully study the Disclosure Statement, which includes a Summary Result Comparison, until you are sure you understand fully the effect of the transaction.

2. Ask the company or agent from whom you bought your existing life insurance policies or annuity contracts to review with you the transaction and the Disclosure Statement. You may be able to effect the changes you desire more advantageously with them. Their customer service telephone number is contained in the Disclosure Statement.

3. Consult your tax advisor. There may be unfavorable tax implications associated with the contemplated changes to your existing life insurance policies or annuity contracts.

As a general rule, it is often not advantageous to drop or change existing coverage in favor of new coverage, whether issued by the same or a different insurance company. Some of the reasons it may be disadvantageous are:

1. The amount of the annual premium under an existing life insurance policy may be lower than that called for by a new life insurance policy having the same or similar benefits. Any replacement of the same type of policy will normally be at a higher premium rate based upon the insured’s then attained age.

2. Since the initial cost of a life insurance policy are charged against the cash value increases in the earlier life insurance policy years, the replacement of an old life insurance policy by a new one results in the policyholder sustaining the burden of these costs twice. Annuity contract usually contain provision for surrender charges, therefore a replacement involving annuity contracts may result in the imposition of surrender charges.

3. The incontestable and suicide clauses begin anew in a new life insurance policy. This could result in a claim being denied under the new life insurance policy that would have been paid under the life insurance policy that was replaced.

4. An existing life insurance policy or annuity contract often has more favorable provisions than a new life insurance policy or annuity contract in areas such as loan interest rate, settlement options, disability benefits and tax treatment.

5. There may have been changes in your health since the purchase of the existing coverage.

6. The insurance company with which you have existing coverage can often make a desired change on terms that would be more favorable than if you replaced existing coverage with new coverage.

7920 NY (R11-06) 1st Copy Home Office - 2nd Copy Applicant - 3rd Copy Agent 22-79202-16 (1/2)

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You have the right, within 60 days from the date of delivery of a new life insurance policy or annuity contract, to return it to the insurer and receive an unconditional full refund of all premiums or considerations paid on it, or in the case of a variable or market value adjustment policy or contract, a payment of the cash surrender benefits provided under the policy or contract, plus the amount of all fees and other charges deducted from gross considerations or imposed under the life insurance policy or annuity contract, and may have the right to reinstate or restore any life insurance policies and annuity contracts that were surrendered, lapsed or changed in the transaction to their former status to the extent possible and in accordance with the insurer’s published reinstatement rules to the extent such rules are not inconsistent with the provisions of this part.

IMPORTANT: This right should not be viewed as reinstating or restoring your life insurance policy or annuity contract to the same condition as if it had never been replaced. There may be consequences in reinstating or restoring your life insurance policy or annuity contract, including but not limited to:

• The right to reinstate or restore your life insurance policy or annuity contract applies only to companies subject to New York insurance laws;

• Your life insurance policy or annuity contract is subject to your specific company’s reinstatement rules, which may vary from company to company. These rules may require payment of both premium and interest; however, you will not be subject to evidence of insurability, or a new contestable or suicide period; • You may not receive the interest or investment performance during the period the life insurance policy or

annuity contract was replaced; and

• There may be unfavorable Federal Income Tax consequences as a result of the reinstatement of your Life Insurance policy or annuity contract.

IMPORTANT: In the case of a variable or market value adjustment policy or contract, the value of the policy or contract may increase or decrease during the 60 day period depending on the performance of the underlying investments, which may effect the value of the refund you receive.

I hereby acknowledge that I read the above “IMPORTANT NOTICE”and have received a copy of same.

Date: _________________________ Signature of Applicant:_________________________________________

Mail to: First Security Benefit Life Insurance and Annuity Company of New York • Administrative Office PO Box 750497 • Topeka, KS 66675-0497

Customer Service Center: 1-800-888-2461 www.securitybenefit.com

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You have the right, within 60 days from the date of delivery of a new life insurance policy or annuity contract, to return it to the insurer and receive an unconditional full refund of all premiums or considerations paid on it, or in the case of a variable or market value adjustment policy or contract, a payment of the cash surrender benefits provided under the policy or contract, plus the amount of all fees and other charges deducted from gross considerations or imposed under the life insurance policy or annuity contract, and may have the right to reinstate or restore any life insurance policies and annuity contracts that were surrendered, lapsed or changed in the transaction to their former status to the extent possible and in accordance with the insurer’s published reinstatement rules to the extent such rules are not inconsistent with the provisions of this part.

IMPORTANT: This right should not be viewed as reinstating or restoring your life insurance policy or annuity contract to the same condition as if it had never been replaced. There may be consequences in reinstating or restoring your life insurance policy or annuity contract, including but not limited to:

• The right to reinstate or restore your life insurance policy or annuity contract applies only to companies subject to New York insurance laws;

• Your life insurance policy or annuity contract is subject to your specific company’s reinstatement rules, which may vary from company to company. These rules may require payment of both premium and interest; however, you will not be subject to evidence of insurability, or a new contestable or suicide period; • You may not receive the interest or investment performance during the period the life insurance policy or

annuity contract was replaced; and

• There may be unfavorable Federal Income Tax consequences as a result of the reinstatement of your Life Insurance policy or annuity contract.

IMPORTANT: In the case of a variable or market value adjustment policy or contract, the value of the policy or contract may increase or decrease during the 60 day period depending on the performance of the underlying investments, which may effect the value of the refund you receive.

I hereby acknowledge that I read the above _{“IMPORTANT NOTICE”}and have received a copy of same.

Date: _________________________ Signature of Applicant:_________________________________________

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APPENDIX 11 INSURANCE DEPARTMENT OF THE STATE OF NEW YORK

DEFINITION OF REPLACEMENT

In order to determine whether you are replacing or otherwise changing the status of existing life insurance policies or annuity contracts, and in order to receive the valuable information necessary to make a careful comparison if you are contemplating replacement, the agent is required to ask you the following questions and explain any items that you do not understand.

As part of your purchase of a new life insurance policy or a new annuity contract, has existing coverage been, or is it likely to be:

(1) Lapsed, surrendered, partially surrendered, forfeited, assigned to the insurer replacing the life insurance policy or annuity contract, or otherwise terminated?

❍

Yes

_❍

No

(2) Changed or modified into paid-up insurance; continued as extended term insurance or under another form of nonforfeiture benefit; or otherwise reduced in value by the use of nonforfeiture benefits, dividend accumulations, dividend cash values or other cash values?

❍

Yes

_❍

No

(3) Changed or modified so as to effect a reduction either in the amount of the existing life insurance or annuity benefit or in the period of time the existing life insurance or annuity benefit will continue

in force?

_❍

Yes

_❍

No

(4) Reissued with a reduction in amount such that any cash values are released, including all

transactions wherein an amount of dividend accumulations or paid-up additions is to be released

on one or more of the existing policies?

_❍

Yes

_❍

No

(5) Assigned as collateral for a loan or made subject to borrowing or withdrawal of any portion of the loan value, including all transactions wherein any amount of dividend accumulations or paid-up additions is to be borrowed or withdrawn on one or more existing policies?

❍

Yes

_❍

No

(6) Continued with a stoppage of premium payments or reduction in the amount of premium paid?

❍

Yes

_❍

No

If you have answered yes to any of the above questions, a replacement as defined by New York Insurance Department Regulation No. 60 has occurred or is likely to occur and your agent is required to provide you with a completed Disclosure Statement and the IMPORTANTNotice Regarding Replacement or Change of Life Insurance Policies and Annuity Contracts.

Date: _________________________ Signature of Applicant:__________________________________________________________________________

To the best of my knowledge, a replacement is involved in this transaction:

_❍

Yes

_❍

No

Date: _________________________ Signature of Agent: ______________________________________________________________________________

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SECURITY BENEFIT PRIVACY POLICY

The privacy of Security Benefit’s customers is of utmost importance to us. You provide nonpublic personal infor-mation (“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

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Steps to Lock-In An Interest Rate

Security Benefi t Life Insurance Company (SBL) and First Security Benefi t Life Insurance and Annuity Company of New York (FSBL) (referred to herein as “Security Benefi t”) offer a rate lock program that helps lock-in the current rate for 60 days while working through the paper process. Below are some questions and answers to help you take advantage of the rate lock.

How do I lock the rate for my client?

The rate lock is available for 60 days from date of the client signature on the application for new purchases. To ensure your client qualiﬁ es for the rate lock, you must meet all of the following requirements, including the In Good Order requirements. Use the check boxes below to ensure that your application submission meets the requirements.

  Security Beneﬁ t must receive all original paperwork within 5 business days of client signature

in good order.

  Money transferring from another carrier must be received at Security Beneﬁ t 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 Beneﬁ t to meet the rate lock deadline.

In Good Order Requirements:

  Fully completed Incoming Funds Request and/or application

  Original signed Incoming Funds Request including a signature guarantee if required by the transferring company

  State Replacement form and Sales Literature form if transfer is replacing an existing annuity   Representatives may consider contacting transferring company to identify other additional

requirements

If you have questions or need assistance, please call our service center at 800-888-2461.

The Premier Choice Annuity (Form FSB233 (12-02)) is a fl exible purchase payment deferred annuity, and is issued by First Security Benefi t Life Insurance and Annuity Company of New York, Rye Brook, New York.

The Security Benefi t Choice, Multi-Choice, and Select Annuities (Form 4585) are fl exible purchase payment deferred annuities, issued by Security Benefi t Life Insurance Company. Not available in all states.

Security Benefi t Life Insurance Company is not admitted in the state of New York and is not authorized to transact insurance business in New York.

Annuities are not insured by the FDIC or otherwise insured or guaranteed by the Federal government or any of its agencies. They are not obligations of, or guaranteed by, any bank, savings and loan or credit union.

22-90190-00 2012/07/10 To and Through Retirement

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Issued by First Security Benefit Life Insurance and Annuity Company of New York. Questions? Call our Customer Service Center at 1-800-888-2461.

Premier Choice Annuity

®

Incoming Funds Request

❑

Application Attached or Contract Number __________________________________________________________________________

Name of Owner______________________________________________ ________ ______________________________________________ First MI Last

Social Security Number/Tax I.D. Number___________________________________

Name of Joint Owner___________________________________________ ________ ____________________________________________ First MI Last

Name of Annuitant/Participant__________________________________________ ________ ____________________________________ (if different from Owner) First MI Last

Please indicate the type of account you would like to transfer your funds to (check one).

❍

403(b) TSA

❍

Roth IRA

❍

Roth 403(b) TSA

❍

Traditional IRA

❍

Non-qualified Annuity

FSBL 7937 A 32-79373-01 2012/08/31 (1/4)

Use this form to transfer funds from your current carrier to First Security Benefit Life Insurance and Annuity Company of New York (“FSBL”). Complete the entire form. Please type or print.

1. The Owner should complete this Incoming Funds Request form and any applicable state-required replacement forms. 2. Please contact your current carrier for any requirements it may have for transferring money to another company. 3. Obtain Signature Guarantee if required by your current carrier.

4. The documents mentioned above should be mailed to: First Security Benefit Life Insurance and Annuity Company of New York Administrative Office

P.O. Box 750497 Topeka, KS 66675-0497 5. Upon receiving this material, FSBL will send an acceptance letter to the carrier.

6. If you are completing this form for a 403(b) or 403(b)(7) account/contract please contact your employer for any processing instructions the employer or third party administrator may require.

Instructions

1. Provide First Security Benefit Account Information

Please make check(s) payable to First Security Benefit Life Insurance and Annuity Company of New York for

the benefit of the Owner listed on this form and mail to: First Security Benefit Life Insurance and Annuity Company of New York Administrative Office

P.O. Box 750500 Topeka, KS 66675-0500 Notice to Current Carrier

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32-79373-01 2012/08/31 (2/4)

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, Stock1

❍

_{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 2. Provide Your Current Carrier Information

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 FSBL in an exchange intended to qualify under Section 1035 of the Internal Revenue Code. I understand that by executing this assignment, I irrevocably waive all rights, claims and demands under the above policy for the portion specified.

If you effect, or have effected, a partial exchange from a previously existing annuity contract with another carrier to an annuity contract with FSBL under IRC Section 1035, any withdrawals from or changes in ownership to your FSBL contract within 180 days of such partial exchange may have adverse tax consequences. Please consult your tax advisor.

❍

Exchange (exchange of 403(b)/403(b)(7) assets from one provider to another provider within your current employer’s Plan)

❍

Rollover (not like-to-like, for example 457 to IRA, etc.)

❍

Transfer (like-to-like, for example IRA to IRA, prior employer 403(b) Plan to current employer 403(b) Plan) Please Transfer

❑

Immediately

❑

On date___________________ (transfer must occur within 30 calendar days from

Date (mm/dd/yyyy) _{signing date and will be mailed two business days}

prior to date listed here) Amount

❍

Liquidate my entire Account: Estimated Value $ ___________________

❍

Liquidate a specified amount: Amount to Transfer $ ___________________ or % ___________________

❍

Transfer over _______years

❍

Monthly

❍

Quarterly

❍

Semi-annually

❍

Annually

Distribution Requirements (if applicable)

I certify that applicable requirements have been met for distribution. Check all that apply:

❑

Age 591_/

2

❑

Disabled

❑

Severance from employment on ______________________

Date (mm/dd/yyyy)

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32-79373-01 2012/08/31 (3/4)

Please invest the funds (check one):

❍

As indicated on the enclosed application; or for an existing account, to the allocations on file.

❍

According to the Investment Allocations indicated below. Indicate whole percentages totaling 100%.

The minimum allocation per guarantee period is $1000. Check with your representative as to which Guarantee Periods are available.

5. Provide Investment Directions

As the Contractowner, I understand, acknowledge and certify that:

– I am responsible for tax consequences which could include the imposition of penalties, additional taxes and interest. FSBL assumes no responsibility or liability for any effects of this transaction.

– I am aware of my right to receive information regarding my current contract, including contract values. – I certify that the information provided is correct and complete.

x

_______________________________________ _________________ ________________________________________ _________________ Signature of Owner Date (mm/dd/yyyy) Signature of Joint Owner Date (mm/dd/yyyy)

x

_______________________________________ _________________ __________________________________________________________ Signature of Plan Sponsor or Date (mm/dd/yyyy) Title

Third Party Administrator

(if applicable – Please consult your financial representative or employer)

x

_______________________________________ _________________ __________________________________________________________ Signature of Representative Date (mm/dd/yyyy) Print Name of Representative

6. Provide Signatures

Please Continue 

___________% One Year Guarantee Period

___________% Two Year Guarantee Period ___________% Three Year Guarantee Period ___________% Four Year Guarantee Period

___________% Five Year Guarantee Period ___________% Six Year Guarantee Period

___________% Seven Year Guarantee Period

___________% Eight Year Guarantee Period ___________% Nine Year Guarantee Period ___________% Ten Year Guarantee Period Must Total 100%

❍

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.

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32-79373-01 2012/08/31 (4/4)

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

7. Obtain Signature Guarantee

To be completed by FSBL. FSBL hereby agrees to accept the transfer of the proceeds identified on this form.

x

________________________________________ _________________ _________________________________________________________ Signature of Accepting Carrier Date (mm/dd/yyyy) Title

8. FSBL Acceptance

Mail to: First Security Benefit Life Insurance and Annuity Company of New York •Administrative Office •PO Box 750497 •Topeka, KS 66675-0497 or Fax to: 1-785-368-1772

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Sales Literature Confirmation

Contractowner Name: ____________________________________ Annuitant/Participant:____________________________________

Contract Number: ____________________________________ Tax ID Number: ____________________________________

This form is to be completed by the writing agent and must be submitted with all replacement cases.

Applications for new contracts that are considered replacements and/or a 1035/Transfer will not be processed until all requirements, including this completed form, are received in proper order at First Security Benefit Life Insurance and Annuity Company of New York (FSBL).

1. Did you utilize any individualized sales materials (including illustrations) in your presentation to the client? ___ YES ___ NO Note: If you answered yes, copies of all material must be submitted to FSBL.

2. Security Benefit requires that a client receive the contents of a sales kit in order to make the sale. The contents of the kit should be left with the client. Please identify the product being sold and the state of issue below:

Kit given to Client: ______________________________________________________________________________________________________________ Product Name

I certify that the responses herein are, to the best of my knowledge, accurate and complete:

_____________________________________________________________ _______________________________________________ Agent's Signature Printed Name

________________________________ Date

Mail to: First Security Benefit Life Insurance and Annuity Company of New York Administrative Office • PO Box 750497 • Topeka, KS 66675-0497

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New York Replacement Process (Reg 60)

New York requires speciﬁ c steps be taken when transferring money from one ﬁ nancial tool to another (i.e. 1035 exchange). These steps will help ensure you cover each area necessary.

Step 1:

Complete the following and send to First Security Beneﬁ t Life Insurance and Annuity Company of New York (FSBL)



Information Authorization form



Deﬁ nition of Replacement form

Step 2 (Transfer paperwork):

Upon receipt of the disclosure document from FSBL, please complete the following steps and send to FSBL: 1



Review the disclosure document with the client



Complete Part D of the disclosure document



Representative and Client must sign the disclosure document



Complete and sign the application



Review and have client sign Appendix 10C – Important Notice



Complete and sign Incoming Funds Transfer Form



Complete and sign Sales Literature Conﬁ rmation form

Rate Lock

The rate lock begins when FSBL receives, in good order, the paperwork required in Step 1; and, the rate lock end date is 60 days from receipt of the transfer paperwork, in good order, that is listed in Step 2.

For questions about this process, please call 800.888.2461.

Financial Professional Use Only

The Premier Choice Annuity (Form FSB233 (12-02)) is a ﬂ exible purchase payment deferred annuity issued by First Security Beneﬁ t Life Insurance and Annuity Company of New York, Rye Brook, New York.

Annuities are not insured by the FDIC or otherwise insured or guaranteed by the Federal government or any of its agencies. They are not obligations of, or guaranteed by, any bank, savings and loan or credit union.

______________________________

1_{Please note that the Application, Incoming Funds Transfer Form, Appendix 10C and Sales Literature Conﬁ rmation Form may not be received or dated}

prior to the completed and signed Disclosure Document.

99-00467-51 2013/02/01

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Issued by First Security Benefit Life Insurance and Annuity Company of New York. Questions? Call our Service Center at 1-800-888-2461.

Information Authorization

7920 R 32-79204-18 2012/03/08 (1/2)

1. Please complete a separate Information Authorization and Definition of Replacement form for each insurer whose policy/contract will be replaced.

2. Upon receiving these completed forms, First Security Benefit Life Insurance and Annuity Company of New York (“FSBL”) will forward a copy of the Information Authorization and Definition of Replacement forms to the current insurer(s). FSBL will also request that the current insurer(s) complete a Disclosure Statement in order for the Owner to review relevant coverage comparisons between the existing coverage and the proposed coverage to be issued by FSBL.

Please type or print. Instructions

Name of Owner______________________________________________ ______ ________________________________________________ First MI Last

Mailing Address______________________________________________________ _____________________ ______ __________________ Street Address City State ZIP Code

Daytime Phone Number___________________________________ Home Phone Number __________________________________ 1. Provide General Account Information

Company Name______________________________________________________________________________________________________ Mailing Address______________________________________________________ _____________________ ______ __________________

Street Address City State ZIP Code Carrier’s Phone No. _____________________________

Contract/Policy Number(s) ____________________________________________ Estimated Value(s) $ ________________________ Please indicate the account type at the current carrier:

❍

401(a)

❍

401(k)

❍

403(b) TSA

❍

403(b)(7) TSA

❍

457

❍

Non-qualified

❍

Roth IRA

❍

SEP-IRA

❍

SIMPLE IRA

❍

Traditional IRA If this request involves the entire account balance, my policy is:

❍

Enclosed

❍

Lost/Destroyed 2. Current Carrier Information

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7920 R 32-79204-18 2012/03/08 (2/2)

Mail to: First Security Benefit Life Insurance and Annuity Company of New York •Administrative Office •PO Box 750497 •Topeka, KS 66675-0497 or Fax to: 1-785-368-1772

Visit us online at www.securitybenefit.com

I hereby acknowledge that I have read the “Definition of Replacement” form and have received a copy of the form for my records. I hereby authorize FSBL to obtain, from the insurer listed above, the information necessary to complete a “Disclosure Statement” with respect to the policies or contracts listed in order to provide me with relevant coverage comparisons between my existing coverage and the proposed coverage to be issued by FSBL. This Information Authorization remains in effect until the current carrier, as identified in Section 2, has transferred my account balance to FSBL.

x

___________________________________________ _______________

x

______________________________________________________ Signature of Owner Date (mm/dd/yyyy) Signature of Joint Owner (if applicable) Date (mm/dd/yyyy)

x

___________________________________________ _______________ _______________________________________________________

Signature of Financial Advisor Date (mm/dd/yyyy) Print Name of Financial Advisor 4. Provide Signatures

One of the products listed below MUST be selected.

Please indicate below the product selection to be used in the Disclosure Statement calculations and any additional

riders/optional benefits you plan to select. Refer to the information included in the sales kit for rider limitations. (For Premier Choice, also select the Guarantee Periods.)

❑

AdvisorDesigns®

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_{SecureDesigns}®

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_{Premier Choice}

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Annual Stepped Up Death Benefit

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Annual Stepped Up Death Benefit Guarantee Period(s)

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Credit Enhancement Rider:

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Credit Enhancement Rider:

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2 year

❑

7 year

❑

4%

❑

4%

❑

3 year

❑

8 year

❑

0-Year Alternate Withdrawal

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4 year

❑

9 year

Charge Rider Charge Rider

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5 year

❑

10 year

❑

6 year

Charge Rider Charge Rider Other_____________________

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EliteDesigns®

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Return of Premium Death Benefit Rider

Premier Choice Annuity Application