ANNUITY APPLICATION. State. State

2. Full Name of Proposed Annuitant

State

State

10. Beneficiaries (to name additional Primary and Contingent Beneficiaries, sign, date and list names on separate sheet of paper) Share % 1.

2. 3.

Share % 1.

2.

Annuity App-2013 Page 1

POLISH NATIONAL UNION of AMERICA

referred to as the PNU - A Fraternal Benefit Society

1002 Pittston Avenue Scranton, PA 18505

1-800-724-6352 or 570-344-1513

8c. At what frequency will the income be paid?  Annually  Semi-annually  Quarterly  Monthly 8b. Under which option will it be paid? Option 1: Fixed Period for ___ years. Option 2: Life with ___ years certain 8a. At what date will income from the proceeds of this contract begin? ______/______/ ________

If an income date is not selected, income will begin on the Proposed Annuitant's [90th] birthday. If an option is not selected, income will be paid under Option 2 with 10 years certain.

1. Is Proposed Annuitant a member of the PNU?  Yes  No If No please apply for membership.

Please print clearly

ANNUITY APPLICATION

6. E-mail Address

7. Plan:  Flexible Premium Annuity Initial Deposit $ 5. Gender  Male  Female

Company Amount

12. Is the insurance being applied for intended to replace or change any existing life insurance or annuities If Yes, give details and name of companies in REMARKS below. If additional space is needed, please list on

in this or any other company?  Yes  No 11. List amounts of life insurance and annuities now in force on the Proposed Annuitant.

List company Names and Amount. If there is additional insurance beyond those listed, please list on a separate sheet. Contingent Beneficiary Relationship to Insured Social Security #

a separate sheet of paper.

REMARKS Primary Beneficiary Relationship to Insured

9. How will any dividends be credited?  Cash  Added to Account Value

Social Security # 3. Address

City

Social Security # Date of Birth

Zip Code 4. Optional Secondary Addressee: Full Name

Address

Approved for Issue Date

Massachusetts, New Jersey and Ohio: Any person who includes any false or misleading information

FRAUD WARNING:

on an application for an insurance policy is subject to criminal and civil penalties.

Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an

Annuity App-2013 Page 2 Certificate Number

Branch Number

Date Admitted

Is this insurance being applied for intended to replace or change any existing life

If Yes, provide required disclosure notices to the Proposed Annuitant.

Signature of Branch Secretary or Agent

Branch Secretary or Agent License # Branch Number or Agent Contract # Signature of Proposed Annuitant Date Signed by Proposed Annuitant

DECLARATION OF BRANCH SECRETARY/AGENT

I understand that the PNU's Constitution and By-Laws are a part of any contract issued to me.

ORGANIZER'S INFORMATION

application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and

subjects such person to criminal and civil penalties.

Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. Rhode Island: Any person who knowingly presents a false or fradulent claim for payment of a loss or benefit or knowingly

presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Date Received Date Processed

HOME OFFICE USE ONLY

Address

Organizer's Name Signature

insurance or annuity contract? Yes  No

Date Signed by Branch Secretary or Agent

PROPOSED ANNUITANT STATEMENT

I declare that the statements and answers given in this application are true, complete and correctly recorded to the best of

I understand that coverage will not be effective until the Initial Deposit has been paid and the contract has been delivered.

Annuity Disclosure – 2013 1

POLISH NATIONAL UNION OF AMERICA

Flexible Premium Deferred Annuity Contract Disclosure PNU Flexible Premium Annuity – Form # FAPDA-93

This document reviews important points to think about before you buy this PNU annuity. This annuity is a flexible-premium annuity which means you can make additional deposits while the contract is in force. After the first premium deposit, you have the right to make additional premium deposits, but you are not required to do so. Additional deposits must be at least equal to $100 and cannot exceed $50,000. It is classified as a fixed annuity because it earns a specified interest rate while the contract is in force. This annuity is deferred, which means payouts begin at a future date. You don’t pay taxes on the interest it earns until the money is paid to you.

You can use an annuity to save money for retirement and to receive retirement income for life. It is not meant to be used to meet short-term financial goals.

If you have any questions about this annuity, please ask one of the PNU’s agents or contact the home office at (570) 344-1513.

THE ANNUITY CONTRACT

How will the value of my annuity grow?

Your annuity earns tax-deferred interest. Premium deposits are added to the account value. Interest is credited to the account value based on an annually compounded interest rate determined as of each policy anniversary by the PNU; the interest rate will never be less than the guaranteed rate of 3%. The declared credited rate will be in effect from one policy anniversary to the next; any premium deposits made between policy anniversaries will earn interest at that rate up until the next policy anniversary, at which time a new declared rate will apply. The account value will be reduced by any partial cash surrenders. Other than for partial cash surrenders, the account value of your annuity cannot go down.

BENEFITS

How do I get income (payouts) from my annuity?

When you apply for your annuity, you choose a maturity date which is the date when you will start to get income from your annuity. Your maturity start date can be changed at any time by writing to the PNU, although the date can not be later than the policy anniversary nearest your 85th _{birthday. You also choose how to get the income – the} payout option. Your choices now are:

■ Life: Guarantees income for as long as you live.

■ Life income with period certain: Guarantees income for as long as you live. If you die within the “period certain” (usually 10 or 20 years), it pays income to your beneficiary for the rest of the period.

■ Fixed period of time: Pays income for that period (e.g., 5 years, 10 years).

■ Lump sum: One payout.

You may change both the maturity date and the payout option up until payout begins. On the maturity date, the account balance will be multiplied by the purchase rate for the payout option you select in order to determine the amount of income you will receive. The guaranteed purchase rates are shown in the annuity contract. On the maturity date, if the PNU provides current purchase rates that are greater than the guaranteed purchase rates, then you will receive the larger benefit.

What happens if I die?

If you die before we start to pay you income from your annuity, we pay the account value of your annuity (without deducting any surrender charges) to your beneficiary. However, if your surviving spouse or civil union partner is the beneficiary, then the annuity can be continued in that individual’s name (and therefore taxes would not have to be paid at the time of your death). If your beneficiary is other than your spouse or civil union partner, then the interest in the annuity must be distributed within 5 years of your death.

If you die after the payouts start, depending on the type of payout you chose, we pay the remaining value in the annuity, if any, to your beneficiary.

FEES, EXPENSES & OTHER CHARGES

What happens if I take out some or all the money from my annuity?

You can’t take any of the money out of your annuity after the payout begins. Before it begins, you can take out all of your annuity’s value (full surrender) or part of it (partial surrender). You can take a partial surrender as long as the amount you take is at least $250.

Annuity Disclosure – 2013 2

We take a “surrender charge” from amounts you withdraw before the end of the fifth contract year. Here’s how the charge is calculated:

Contract Year 1 2 3 4 5 6+

Surrender Charge 5% 4% 3% 2% 1% 0%

Example: If you withdraw $5,000 from your annuity in the third contract year, your surrender charge is $5,000 x 0.03 = $150. If you take out any amount after the end of the fifth contract year, there’s no charge.

We will not deduct the surrender charge if we pay the account balance to a beneficiary after your death. Do I pay any other fees or charges?

No. There aren’t any other fees or charges on this annuity. TAXES

How will payouts and withdrawals from my annuity be taxed?

This annuity is tax-deferred, which means you do not pay taxes on the interest it earns until the money is paid to you. When you make a full or partial cash surrender, you pay ordinary income taxes on the amount of earned interest that is withdrawn. When taking a partial cash surrender, the IRS assumes that you withdraw interest earnings first (which are taxable). You also pay a 10% federal income tax penalty on any earnings you withdraw before age 59 ½. Payments upon death are taxed in a similar manner as other withdrawals, although there is no 10% federal

income tax penalty if death occurs before age 59 ½. If you are receiving income payouts, then each payment is considered as part interest earnings and part return of principal; you pay ordinary income taxes on the amount that is considered interest earnings.

You can exchange one tax-deferred annuity for another without paying taxes on the earnings when you make the exchange. Before you do, compare the benefits, features and costs of the two annuities. You may pay a surrender charge if you make the exchange during the first five years you own this annuity. Also, you may pay a surrender charge if you make withdrawals from the new annuity during the first years you own it.

Does buying an annuity in a retirement plan provide extra tax benefits?

Buying an annuity within an IRA, 401(k), or other tax deferred retirement plan doesn’t give you any extra tax benefits. Choose your annuity based on its other features and benefits as well as its risks and costs, not just its tax benefits.

OTHER INFORMATION What else do I need to know? Changes to your contract

We may change your annuity contracts from time to time to follow federal or state laws and regulations. If we do, we’ll tell you about the changes in writing.

Compensation

We pay the PNU agent or representative for selling the annuity to you. They receive the same compensation for selling this annuity contract as they do for selling any other annuity contracts offered by the PNU.

Free Look

The owner has 10 days notice to cancel this contract from the date the contract is delivered. Within that 10-day period, the owner can return the annuity contract to the PNU or through the agent it was purchased and the PNU will provide a prompt refund of the premium paid, including any contract fees or charges.

What should I know about the PNU?

The PNU is a fraternal benefit society that offers traditional life insurance products and a flexible premium deferred annuity plan.

Polish National Union of America 1002 Pittston Avenue

Scranton, PA 18505-4191 (570) 344-1513

www.pnu.org

This is a summary document and not part of your contract with the PNU. The sale and suitability of annuities is regulated by the New Jersey Department of Banking and Insurance and you may obtain assistance from the Department by contacting them at 609-292-7272 or 1-800-446-7467, or by visiting the Department’s website at www.njdobi.org.

Please Note

Anyone of age 65 or older

who is applying for a PNU Annuity

must also complete the next page

ANNUITY SUITABILITY QUESTIONNAIRE

Thank you for your interest in a PNU annuity. PNU would like to ensure that the annuity you are purchasing is suitable for you with consideration to your financial status and investment objectives. Therefore, this form must be completed and sub-mitted with the application before we can process your policy.

Contract Owner’s Name (Print) Contract Owner’s Current Age

PNU Annuity Product Name Initial Deposit Amount

Owner Financial Status

$0-$24,999 $25,000-$49,999 $50,000-$99,999 $100,000+

Net Worth $0-$49,999

$50,000-$99,999 $100,000-$249,999 $250,000- $499,999

$500,000-$749,999 $750,000-$999,999 $1,000,000+

Federal Tax Status 10% 33% 15% 35% 25% Other 28%

Investment Objectives

Your investment objectives in purchasing the above-named annuity are for (check all that apply):

Income Flow Tax Deferral

Growth, possible income Preservation of Principal

Flexibility

Growth followed by income Pass on to Beneficiaries

Other ______________________

With the exception of any withdrawals (i.e. required minimum distributions, penalty-free withdrawals, interest, withdrawals,

and partial surrenders):

How do you expect to take money out of this annuity? Regular income stream Lump Sum N/A When do you expect to take money out of this annuity?

Under one year

Between one and five years Between six and nine years

Ten or more years N/A

Do you now own, or have previously owned, the following financial products? (Check all that apply.)

CDs Fixed Annuities Variable Annuities Stocks/Bonds/Mutual Funds

What is your source for this annuity’s premium? (Check all that apply.)

Annuity Life Insurance CDs Other Investments Other: ___________________

Client refused to provide some or all of the information on this questionnaire. Contract Owner’s Signature

Producer’s Signature

Date Date

For Home Office Use Only Date Reviewed ____________ Reviewed By ______________