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.

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Issued by Security Benefit Life Insurance Company. Questions? Call our National Service Center at 1-800-888-2461. One Security Benefit Place • Topeka, KS 66636-0001

Security Benefit Advanced Choice Annuity Application

Individual Single Purchase Payment

Deferred Annuity

ICC13 5201-NM (9-13) IIPRC – Generic Advanced Choice 15-96050-IC 2013/09/01 (1/4) 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 __________________________________

3. Provide Annuitant Information

❑

Same as Owner

Name of Owner ____________________________________ ______ ____________________________________

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Male

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Female First MI Last

Mailing Address _________________________________________________ _____________________ ______ ______________________ Street Address City State ZIP Code

1. Provide Owner Information

Name of Joint Owner _________________________________ ______ _________________________________

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Male

❍

Female First MI Last

Mailing Address _________________________________________________ _____________________ ______ ______________________ Street Address City State ZIP Code

2. Provide Joint Owner Information

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ICC13 5201-NM (9-13) IIPRC – Generic Advanced Choice 15-96050-IC 2013/09/01 (2/4) 4. Provide Primary and Secondary 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.

Please select the annuity type:

❍

Non-Qualified

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Traditional IRA

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Roth IRA

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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.

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3 Year

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4 Year

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5 Year

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6 Year

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7 Year

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8 Year

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9 Year

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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.

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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 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.

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ICC13 5201-NM (9-13) IIPRC – Generic Advanced Choice 15-96050-IC 2013/09/01 (3/4) Will the Annuity being purchased replace any prior insurance or annuities of this or any other Company?

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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.

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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____________________________________________________________________________________ ________________ Code

Agent’s Statement

Do you have any existing annuity or life insurance policies?

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Yes

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No

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

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Yes

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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?

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Yes

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No

Does the owner have an insurable interest in the annuitant?

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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)

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ICC13 5201-NM (9-13) IIPRC – Generic Advanced Choice 15-96050-IC 2013/09/01 (4/4) Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal

offense and subject to penalties under state law. Fraud Disclosure

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

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

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Important Notice

Definition: REPLACEMENT is any transaction where, in connection with the purchase of New Insurance or a New Annuity, you LAPSE, SURRENDER, CONVERT to Paid-up Insurance, Place on Extended Term, or BORROW all or part of the policy loan values on an existing insurance policy or an annuity. (See reverse side for DEFINITIONS.)

If You Intend to Replace Coverage:

In connection with the purchase of this insurance or annuity, if you have REPLACED or intend to REPLACE your present life insurance coverage or annuity(ies), you should be certain that you understand all the relevant factors involved.

You should BE AWARE that you may be required to provide EVIDENCE OF INSURABILITY and

1. If your HEALTH condition has CHANGED since the application was taken on your present policies, you may be required to pay ADDITIONAL PREMIUMS under the NEW POLICY, or be DENIED coverage.

2. Your present occupation or activities may not be covered or could require additional premiums.

3. The INCONTESTABLE and SUICIDE CLAUSE will begin anew in a new policy. This could RESULT in a CLAIM

under the new policy BEING DENIED that would otherwise have been paid.

4. Current law DOES NOT REQUIRE your present insurer(s) to REFUND any premiums.

5. It may be to your advantage to OBTAIN INFORMATION regarding your existing policies or annuity contracts from

the insurer or agent from whom you purchased the policy or annuity contract.

(If you are purchasing an annuity, clauses 1., 2. and 3. above would not apply to the new annuity contract.) THE INSURANCE OR ANNUITY I INTEND TO PURCHASE FROM SECURITY BENEFIT LIFE INSURANCE COMPANY MAY REPLACE OR ALTER EXISTING LIFE INSURANCE POLICY(IES) OR ANNUITY CONTRACT(S). The following policy(ies) or annuity contract(s) may be replaced as a result of this transaction:

Insurer - as it appears on the policy or contract________ Insured - as it appears on the policy or contract______________

__________________________________________________________________ ___________________________________________________________________________ __________________________________________________________________ ___________________________________________________________________________ __________________________________________________________________ ___________________________________________________________________________ __________________________________________________________________ ___________________________________________________________________________ __________________________________________________________________ ___________________________________________________________________________

Policy or Contract Number_______________________ Insured Birthdate

__________________________________________________________________ ___________________________________________________________________________ __________________________________________________________________ ___________________________________________________________________________ __________________________________________________________________ ___________________________________________________________________________ __________________________________________________________________ ___________________________________________________________________________

The proposed or contract is:

___________________________________________________________________________________________________________ $__________________________________

Type of policy- or contract-generic name Face amount

____________________________________________________________________________________________________________ __________________________________

Signature of applicant Date

_____________________________________________________________________ _____________________________________ ____________ ________________________

Address of applicant City State Zip Code

I certify that this form was given to me and completed by________________________________________________________________________________

(Applicant–please print or type)

prior to taking an application and that I am leaving a signed copy for the applicant.

_____________________________________________________________________________________________________________ _________________________________

Agent’s Signature Date

_____________________________________________________________________ _____________________________________ ____________ ________________________

Address City State Zip Code

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

www.securitybenefit.com

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Definitions

Premiums: Premiums are the payments you make in exchange for an insurance policy or annuity contract. They are unlike deposits in a savings or investment program, because if you drop the policy or contract, you might get back less than you paid in.

Cash This is the amount of money you can get in cash if you surrender your life insurance policy or annuity. Surrender If there is a policy loan, the cash surrender value is the difference between the cash value printed in the Value: policy and the loan value. Not all policies have cash surrender values.

Lapse: A life insurance policy may lapse when you do not pay the premiums within the grace period. If you had a cash surrender value, the insurer might change your policy to as much extended term insurance or paid-up insurance as the cash surrender value will buy. Sometimes the policy lets the insurer borrow from the cash surrender value to pay the premiums.

Surrender: You surrender a life insurance policy when you either let it lapse or tell the company you want to drop it. Whenever a policy has a cash surrender value, you can get it in cash if you return the policy to the company with a written request. Most insurers will also let you exchange the cash value of th policy for paid-up or extended term insurance.

Convert to This means you use your cash surrender value to change your insurance to a paid-up policy with the Paid-Up same insurer. The death benefit generally will be lower than under the old policy, but you will not have

Insurance: to pay any more premiums.

Place on This means you use your cash surrender value to change your insurance to term insurance with the Extended same insurer. In this case, the net death benefit will be the same as before. However, you will Term: only be covered for a specified period of time stated in the policy.

Borrow If your life insurance policy has a cash surrender value, you can almost always borrow all or part Policy of it from the insurer. Interest will be charged according to the terms of the policy, and if the loan Loan with unpaid interest ever exceeds the cash surrender value, your policy will be surrendered. If Values: you die, the amount of the loan and any unpaid interest due will be subtracted from the death benefits. Evidence of This means proof that you are an acceptable risk. You have to meet the insurer’s standards regarding Insurability: age, health, occupation, etc., to be eligible for coverage.

Incontestable This says that after two years, depending on the policy or insurer, the life insurer will not resist a Clause: claim because you made a false or incomplete statement when you applied for the policy. For the early

years, though, if there are wrong answers on the application and the insurer finds out about them, the insurer can deny a claim as if the policy had never existed.

Suicide This says that if you commit suicide after being insured for less than two years, depending on the policy Clause: and insurer, your beneficiaries will receive only a refund of the premiums that were paid.

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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

Mailing Address_________________________________________________ _____________________ ______ ______________________ Street Address City State ZIP Code

Social Security Number/Tax I.D. Number___________________________________

Daytime Phone Number___________________________________ Home Phone 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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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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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).

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403(b) TSA

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Roth 403(b) TSA

❍

Non-qualified Annuity

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Roth IRA

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Traditional IRA

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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

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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).

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401(a)

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403(b)(7)

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Roth 403(b)(7)

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457

❍

Roth 403(b) TSA

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Non-qualified Annuity

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Non-qualified CD, Stock1

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_{Non-qualified Mutual Fund}1

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Life Insurance

❍

SEP-IRA

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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

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Brokerage Account

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401(k)/Pension Plan

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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)

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

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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 $ ___________________

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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 591_/

2

❑

Disabled

❑

Severance from employment on ______________________

Date (mm/dd/yyyy) 3. Set Up Transfer/Exchange/Rollover Option

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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.

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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

www.securitybenefit.com