Items to Note before Selling an Annuity (Fixed Indexed, Fixed and Variable)

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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

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Issued by Security Benefit Life Insurance Company. Questions? Call our National Service Center at 1-800-888-2461.

Security Benefit Advanced Choice Annuity Application

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 __________________________________

5201 CA (9-13) Advanced Choice 15-96040-05 2013/09/01 (1/4)

3. Provide Annuitant Information

_❑

Same as Owner

2

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

2. Provide Joint Owner Information

Name of Contract Owner _______________________________ ______ ________________________________

_❍

Male

_❍

Female

First MI Last

Residential Address_____________________________________________ _____________________ ______ ______________________ (if different from mailing address) Street Address City State ZIP Code

1. Provide Owner Information

Please Continue

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Please select the annuity type:

_❍

Non-Qualified

_❍

Traditional IRA

_❍

Roth IRA

_❍

Other____________________________

Purchase Payment $ _____________________________ Annuity Start Date__________________________________________ (Minimum $10,000) (mm/dd/yyyy)

For IRAs only: Current Year $_____________ Prior Year $_____________ 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.

5. Choose Type of Annuity Contract

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.

6. Purchase Payment Information

4. Provide Primary and Contingent Beneficiary(ies)

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

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

Name Address (city, state, zip) Phone No.

Social Security No.

DOB (mm/dd/yyyy)

Relationship to Contract Annuitant

% of Benefit 1.

2. 3. 4.

Contingent

Beneficiary Name Address (city, state, zip) Phone No.

Social Security No.

DOB (mm/dd/yyyy)

Relationship to Contract Annuitant

% of Benefit 1.

2. 3. 4.

Please Continue

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Any person who, with intent to defraud or knowing that he/she is facilitating fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

State Fraud Disclosure

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______________________________________ Policy Number ______________________________________________

7. Provide Replacement Information

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 8. Incentives and Other Considerations

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)

9. Provide Signature

Please Continue

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Checks should be made payable to: Security Benefit Life Insurance Company 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

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.

____________________________________________________________________________________________________________________ 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____________________________________________________________________________________ ________________ Code

Agent’s Statement

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

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One Security Benefit Place • Topeka, Kansas 66636-0001

IMPORTANT NOTICE

Two California Senior Forms & Processing Procedures

Important Notice to California Residents Age 65 or Older

32-80740-79 Tax Consequences Form

Processing Procedures

•

To be presented when meeting with the Senior

•

Customer and representative signature required

•

Triplicate provided for easy post meeting distribution

•

One to Customer

•

One for Representative

•

One for Security Benefit

Requirements

•

The tax consequences form must be sent in with each

application for customers who are age 65 or older.

Notice to Seniors Age 65 or Older Regarding Insurance Sales Meeting

32-80740-78 In Home Notice Form

Processing Procedures

•

Form not Branded so you can use it even if you don’t know if a

Security Benefit product is the right fit for your Customer

•

New Customers – provide 24 hours before home visit

•

Existing Customers – provide before meeting starts

•

Customer signature required

•

Triplicate provided for easy post meeting distribution

•

One to Customer

•

One for Representative

•

One for insurance company

Requirements

•

The notice to seniors form must be sent in with the application if the

meeting occurred in the customer’s home.

Security Benefit Distributors, Inc. (9-07) 38-10460-00

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Notice to Seniors Regarding Insurance Sales Meeting

A visit in your home has been scheduled by:

____________________________________________________________

Name of Prospect or Client

____________________________________________________________

Name of Representative/Agent

The visit has been scheduled for: This notice was delivered:

___________ _ ___ _

Date (mm/dd/yyyy) Time Date (mm/dd/yyyy) Time

(1) I am a licensed insurance agent. My purpose for coming to your

home is to sell, discuss, and/or deliver one of the following

[indicate all that apply]:

❑

❑ Life insurance, including annuities.

❑

❑ Other insurance products [specify]: ________________________.

(2) You have the right to have other persons present at the meeting,

including family members, financial advisors or attorneys.

(3) You have the right to end the meeting at any time.

(4) You have the right to contact the California Department of

Insurance for information, or to file a complaint.

The consumer assistance telephone numbers at the

department are:

Inside California: (800) 927-4357

Outside California: (213) 897-8921

TDD (800) 482-4833

8074 CA 1st Copy Home Office – 2nd Copy Applicant – 3rd Copy Agent 32-80740-78 2013/01/11 (1/2)

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(5) The following individuals will be coming to your home: (list all

attendees, and insurance license information, if applicable):

Name California Insurance License No.

Existing client? _❍ _{❍ Yes ❍} _{❍ No} Agent business card provided _❑ _❑

Agent’s Mailing Address (as shown on insurance license)

____________________________________________________________

Street Address

_____

City State Zip

Agent’s Telephone Number (as shown on insurance license)

____________________________________________________________

Agent’s Mailing Address (as shown on insurance license)

____________________________________________________________

Street Address

_____

City State Zip

Agent’s Telephone Number (as shown on insurance license)

____________________________________________________________

For new prospects, this notice must be delivered 24 hours before the

home visit. For existing clients, this notice must be given before the

meeting starts.

I certify that I received this notice on the date and time noted above. I

also certify that I have read and understand this form.

_________________________ _

Signature of Prospect or Client Date (mm/dd/yyyy)

Mail to: Security Benefit • PO Box 750497 • Topeka, KS 66675-0497

National Service Center: 1-800-888-2461

www.securitybenefit.com

8074 CA 1st Copy Home Office – 2nd Copy Applicant – 3rd Copy Agent 32-80740-78 2013/01/11 (2/2)

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Important Notice to California Residents Age 65 or Older

Pursuant to California law, I am required to provide you with the following notice:

The sale or liquidation of any stock, bond, individual retirement account (IRA), certificate of deposit (CD), mutual fund, annuity or other asset to fund the purchase of a life insurance policy or an annuity contract may have tax consequences, early withdrawal penalties, or other costs or penalties as a result of the sale or liquidation.

Prior to the purchase of any life insurance policy or annuity contract, you may wish to obtain independent legal or financial advice before selling or liquidating any assets.

I have read and I understand this “Important Notice to California Residents Age 65 or Older.” I also acknowledge receipt of a copy of this form.

__________________________________________________________________________ ____________________________

Signature of Owner Date (mm/dd/yyyy)

__________________________________________________________________________ Print Name

__________________________________________________________________________ ____________________________

Signature of Joint Owner Date (mm/dd/yyyy)

__________________________________________________________________________ Print Name

__________________________________________________________________________ ____________________________

Signature of Representative Date (mm/dd/yyyy)

__________________________________________________________________________ Print Name

Security Benefit • PO Box 750497 • Topeka, KS 66675-0497 National Service Center: 1-800-888-2461

www.securitybenefit.com

8074 CA (6-07) 1st Copy Home Office - 2nd Copy Applicant - 3rd Copy Agent 32-80740-79 (1/1)

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NOTICE REGARDING REPLACEMENT

REPLACING YOUR LIFE INSURANCE POLICY OR ANNUITY

Are you thinking about buying a new life insurance policy or annuity and discontinuing or changing an existing one? If you are, your decision could be a good one - or a mistake. You will not know for sure unless you make a careful comparison of your existing benefits and the proposed benefits.

Make sure you understand the facts. You should ask the company or agent that sold you your existing policy to give you information about it.

Hear both sides before you decide. This way you can be sure you are making a decision that is in your best interest.

We are required by law to notify your existing company that you may be replacing their policy.

COMPANY CONTRACT NUMBER INSURED

____________________________________________________ ___________________________ ______________________________________ ____________________________________________________ ___________________________ ______________________________________ ____________________________________________________ ___________________________ ______________________________________ ____________________________________________________ ___________________________ ______________________________________ ____________________________________________________ ___________________________ ______________________________________ ____________________________________________________ ___________________________ ______________________________________ ____________________________________________________ ___________________________ ______________________________________ ____________________________________________________ ___________________________ ______________________________________

______________________________________ __________________ ______________________________________ __________________ REPLACING AGENT (SIGNATURE) DATE (MM/DD/YYYY) CONTRACT OWNER (SIGNATURE) DATE (MM/DD/YYYY)

___________________________________________________________ _______________________________________________________ EXISTING POLICY #

_______________________________________________________ ADDRESS

Mail to: Security Benefit • PO Box 750497 • Topeka, KS 66675-0497 National Service Center: 1-800-888-2461

8074 CA (R2-05) 1st Copy Home Office - 2nd Copy Applicant - 3rd Copy Agent 32-80742-77 2012/02/23 (1/1)

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Questions? Call our National Service Center at 1-800-888-2461.

Electronic Authorization

®

7794 L (R5-06) 32-77941-12 2013/11/21 (1/1)

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.

Instructions

Contract/Account Number _______________________________ Plan Number or Name______________________________________ (Applicable to Employer Retirement Plans only)

Name of Owner/Participant_________________________________________ ______ __________________________________________ First MI Last

Social Security Number/Tax I.D. Number___________________________________

1. Provide General Account Information

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

2. Provide Signature

Security Benefit Security Benefit

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Questions? Call our National Service Center at 1-800-888-2461.

Advanced Choice Annuity

Incoming Funds Request

®

❑

Application Attached or Contract Number __________________________________________________________________________

Name of Owner__________________________________________________ ______ ____________________________________________ First MI Last

Mailing Address_________________________________________________ _____________________ ______ ________________________ Street Address City State ZIP Code

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 403(b) TSA

_❍

Non-qualified Annuity

❍

^{Roth IRA}

❍

Traditional IRA

_❍

SEP-IRA

7691 32-79450-00 2013/09/01 (1/4)

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.

Instructions

1. Provide Security Benefit Account Information

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 Notice to Current Carrier

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7691 32-79450-00 2013/09/01 (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 Fund¹

❍

Life Insurance

_❍

SEP-IRA

_❍

SIMPLE IRA

_❍

Traditional IRA

❍

^{Roth IRA}

❍

Roth 401(k)

_❍

403(b) TSA

_❍

Other

❍

^401(k)

1This 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 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)

3. Set Up Transfer/Exchange/Rollover Option

Please Continue

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7691 32-79450-00 2013/09/01 (3/4)

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.

5. Purchase Information

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)

6. Provide Signatures

Please Continue

❍

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.

4. Required Minimum Distribution (if applicable)

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7691 32-79450-00 2013/09/01 (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 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

8. Security Benefit Acceptance

Security Benefit Life Insurance Company Security Benefit

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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/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

8031 Model (R3-08) 1st Copy Home Office - 2nd Copy Applicant - 3rd Copy Agent 38-08033-00 (1/1)

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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 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

Items to Note before Selling an Annuity (Fixed Indexed, Fixed and Variable)