Application for FIXED DEFERRED ANNUITY

Transcription

1 Application for FIXED DEFERRED ANNUITY Protective Life Insurance Company Overnight U. S. Postal Mail Nashville, Tennessee 2801 Hwy 280 South P. O. Box Birmingham, Alabama Birmingham, Alabama For Arizona Applicants: We will provide you reasonable factual information about benefits and provisions of the contract within a reasonable time after we receive your written request. You may return the contract to us or the agent through whom it was purchased any time within 10 days of your receipt of the contract or within 30 days: if the contract is issued in replacement of an existing contract, or if you are 65 years of age or older on the date of application. All monies paid will then be refunded to you. Contract # PRIMARY OWNER: NAME: DAY PHONE: ADDRESS: CITY: STATE: ZIP: SSN/Tax ID: DOB: AGE: SEX: M F CITIZENSHIP: U.S.; Resident Alien ( ); Non-Resident Alien ( ) Country Country JOINT OWNER: (Where Applicable) NAME: DAY PHONE: ADDRESS: CITY: STATE: ZIP: SSN/Tax ID: DOB: AGE: SEX: M F CITIZENSHIP: U.S.; Resident Alien ( ); Non-Resident Alien ( ) Country Country ANNUITANT: (If different from Primary Owner)(Must be a natural person) NAME: DAY PHONE: ADDRESS: CITY: STATE: ZIP: SSN/Tax ID: DOB: AGE: SEX: M F CITIZENSHIP: U.S.; Resident Alien ( ); Non-Resident Alien ( ) Country Country BENEFICIARY DESIGNATION (If there is no surviving Owner): PRIMARY CONTINGENT: PERCENTAGE: RELATIONSHIP (to Owner): Spouse Nonspouse SSN/Tax ID: DOB/Trust date: PRIMARY CONTINGENT: PERCENTAGE: RELATIONSHIP (to Owner): Spouse Nonspouse SSN/Tax ID: DOB/Trust date: ADDITIONAL BENEFICIARIES Use 'REMARKS' section, below. INITIAL PURCHASE PAYMENT (check payable to Protective Life Insurance Company): WITH FUNDS FUNDS WILL FOLLOW (minimum $2,000) INTEREST RATE PERIOD AND OPTIONAL RETURN OF PREMIUM: Please select one interest rate period and one Return of Premium option. 1 Year Interest Rate Period 2 Year Interest Rate Period YES, I elect the Return of Premium Option 4 Year Interest Rate Period 6 Year Interest Rate Period NO, I decline the Return of Premium Option TAX QUALIFIED STATUS: Non-Qualified ROTH IRA (Conversion Year, if applicable) 1035 Exchange Traditional IRA Other - REMARKS: $ CONTRIBUTION FOR TAX YEAR $ TRUSTEE TRANSFER $ ROLLOVER FROM An annuity contract is not a deposit or obligation of, or guaranteed by any bank or financial institution. It is not insured by the Federal Deposit Insurance Corporation or any other government agency. Original Representative First Copy Owner P-1405 Secure II Fixed Annuity with Optional Return of Premium AS 6/17

2 Warnings, Notices and Statements Arkansas, District of Columbia, Kentucky, Louisiana, Maine, New Mexico, Ohio, Pennsylvania, Rhode Island and Tennessee Fraud Warning - Any person who knowingly and with intent to defraud any insurance company or other person, files an 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. Colorado Fraud Warning - It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory agencies. FLORIDA FRAUD WARNING - 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. Maryland Fraud Warning - Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Michigan Fraud Warning - Any person who submits an application or files a claim with intent to defraud or helps commit a fraud against an insurer, as determined by a court of competent jurisdiction, is guilty of a crime. New Jersey Fraud Warning - Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Oklahoma Fraud Warning - WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. Washington Fraud Warning - It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. Will any existing annuity contract or life insurance policy be replaced or will values from another annuity contract or life insurance policy (through loans, surrenders or otherwise) be used to make purchase payments for the contract applied for? NO YES Do you have any existing annuity contracts or life insurance policies? NO YES If Yes, Company Name: NOT INSURED BY ANY GOVERNMENT AGENCY NO BANK GUARANTEE NOT A DEPOSIT I/We understand this application will be part of the annuity contract. I/We have read, agree to and affirm the information above and on the reverse side to be true and correct to the best of my/our knowledge and belief. The Company will treat my/our statements as representations, not warranties. The Company may accept instructions from any Owner on behalf of all Owners. Signed at CITY STATE DATE OWNER SIGNATURE JOINT OWNER SIGNATURE (if applicable) ANNUITANT SIGNATURE (if other than Owner) Federal law requires the following notice: We may request or obtain additional information to establish or verify your identity. SELLING AGENT REPORT: To the best of your knowledge, will any existing annuity contract or life insurance policy be replaced or will values from another annuity contract or life insurance policy (through loans, surrenders, or otherwise) be used to make purchase payments for the contract applied for? NO YES Does the applicant have any existing annuity contracts or life insurance policies? NO YES If Yes, Company Name: Type of unexpired government-issued photo I.D. used to verify the applicant's identity? # I certify that the information provided by the owner has been accurately recorded; no written sales materials other than those approved by the Company were used; and I have reasonable grounds to believe the purchase of the contract applied for is suitable for the owner. AGENT SIGNATURE AGENT NAME PRINTED AGENT TELEPHONE NUMBER DATE AGENCY NAME FLORIDA LICENSE# (FLORIDA CONTRACTS ONLY) AGENT STANDARD ID# Select Commission Option: A B C P-1405 Secure II Fixed Annuity with Optional Return of Premium AS 6/17

3 Life and Annuity Division Protective Life Insurance Company 1 West Coast Life Insurance Company 1 Protective Life and Annuity Insurance Company Beneficiary Information Request Post Office Box 1928 / Birmingham, AL Use this form for initial beneficiary designations. Toll Free: / Fax: Owner s Name: Annuitant s Name: Contract Number: Owner s SSN/TIN: PLEASE NOTE: If multiple beneficiaries are named, proceeds will be paid equally to all primary beneficiaries surviving the owner (or annuitant if non-material owner) unless instructed otherwise. If all primary beneficiaries have predeceased the owner, proceeds will be paid to the named contingent beneficiaries equally unless instructed otherwise. If there are no surviving beneficiaries, proceeds will be paid to the owner s estate. BENEFICIARY INFORMATION: Beneficiary Type: (select one) Primary Name: Social Security Number: Address: Date of Birth: Telephone Number: Contingent Relationship to Owner: (select one) Spouse Non-spouse Percentage: % Beneficiary Type: Name: Social Security Number: (select one) Address: Primary Date of Birth: Telephone Number: Contingent Relationship to Owner: (select one) Spouse Non-spouse Percentage: % Beneficiary Type: Name: Social Security Number: (select one) Address: Primary Date of Birth: Telephone Number: Contingent Relationship to Owner: (select one) Spouse Non-spouse Percentage: % Beneficiary Type: Name: Social Security Number: (select one) Address: Primary Date of Birth: Telephone Number: Contingent Relationship to Owner: (select one) Spouse Non-spouse Percentage: % Beneficiary Type: Name: Social Security Number: (select one) Address: Primary Date of Birth: Telephone Number: Contingent Relationship to Owner: (select one) Spouse Non-spouse Percentage: % Beneficiary Type: Name: Social Security Number: (select one) Address: Primary Date of Birth: Telephone Number: Contingent Relationship to Owner: (select one) Spouse Non-spouse Percentage: % SPECIAL INSTRUCTIONS: SIGNATURES: Owner s Name (please print) Owner s Signature Date Joint Owner s Name (please print) Joint Owner s Signature Date 1 Not authorized in New York Page 1 of 1 LAD-1225 R:7/13

4 Protective Life Insurance Company 1707 N. Randall Road Elgin, Illinois Annuity Disclosure Statement for Form Series P-3270 Limited Flexible Premium Fixed Deferred Annuity Contract Description and Benefits The annuity contract you are applying for is a fixed deferred annuity contract that provides for the accumulation of funds to a specified maturity date. A deferred annuity provides a series of income payments that start after an accumulation period. It is important to remember than an annuity contract is a long term investment and you should not buy it for short term purposes. The contract may result in loss if kept for only a few years. Please see the Value Reductions description that follows. Guaranteed and Non-Guaranteed Elements A minimum guarantee applies to the interest rate credited to a purchase payment. The current interest rate credited to a purchase payment may not be less than this minimum guarantee. Guaranteed Interest The contract guaranteed minimum interest rate will never be less than 1% and will never be greater than 3%. Current Interest (Not Guaranteed) The initial crediting rate on a contract will be the rate we are then crediting on a specific date for contracts of that type. We monitor and adjust our interest rates. We declare current interest rates for certain time periods. The applicable current rate in effect when a Purchase Payment is received is guaranteed for the length of the interest rate period indicated on the application. Periodic Income Options The contract offers a choice of income payment methods (called annuity options), including certain periods and life (with or without a certain period). Guaranteed annuity option rates are provided in the contract, based on a guaranteed minimum interest rate of 1.5% Value Reductions We will deduct a withdrawal charge if during certain contract years you surrender the contract for cash or take a partial withdrawal in excess of the free withdrawal allowance. Free withdrawal allowance is contract value that may be withdrawn with no withdrawal charge. The withdrawal charges in years one through seven are the following percentages of the amount withdrawn in excess of the free withdrawal allowance: 8%, 8%, 7%, 6.5%, 5.5%, 4.5%, and 3%, respectively. 10% of the contract value may be withdrawn with no withdrawal charges in each contract year. If your contract includes a return of premium money-back guarantee, withdrawal charges will not be applied to the extent that they would cause the amount paid upon a full withdrawal to be less than the greater of: 1) 100% of Purchase Payments less prior partial withdrawals and premium taxes, and 2) 90% of Purchase Payments less prior partial withdrawals accumulated at the contract guaranteed minimum interest rate. (Continued on reverse side) P-3270 Disclosure Page 1 of 2 ProSaver Secure II 6/12

5 Charges and Fees There are no fees or administrative charges for this contract other than the surrender adjustments outlined above. How Values Can Be Accessed Values can be accessed by taking a full surrender of your contract, taking a partial withdrawal or by taking the value of your contract in the form of an annuity payout. The Death Benefit The contract provides that if the Owner dies prior to the maturity date, the death benefit is the contract value. Summary of Federal Tax Status (You should consult your own tax advisor for your particular situation) Because annuities provide retirement income funding, income tax on interest accumulated in annuities is deferred. Annuities used to fund certain employee pension benefit plans defer taxes on plan contributions as well as on interest or investment income. You are required to pay taxes on the deferred amount when you withdraw the money. You may incur a tax penalty if you withdraw the accumulation before your age 59 ½. The advantage of tax deferral is that you may be in a lower tax bracket in retirement than when you were employed. Additionally, you will be earning interest on the amount you would otherwise be paying in taxes during the accumulation period. Under the 1997 Tax Reform Act, an annuity purchased with after tax dollars can be used to fund a Roth IRA and the earnings will accumulate tax free under certain circumstances. This could provide a tax free lifetime income after retirement. The ProSaver Secure II Fixed Annuity, policy form series P-3270, is issued by Protective Life Insurance Company, Birmingham, Alabama. Product features and availability may vary by state. All benefits, payments and guarantees are subject to the claims paying ability of Protective Life Insurance Company. P-3270 Disclosure Page 2 of 2 ProSaver Secure II 6/12

6 PROTECTIVE LIFE INSURANCE COMPANY POST OFFICE BOX BIRMINGHAM, ALABAMA TELEPHONE: (800) NOTICE TO APPLICANTS REGARDING REPLACEMENT OF LIFE INSURANCE OR AN ANNUITY. THIS NOTICE IS FOR YOUR BENEFIT AND IS REQUIRED BY LAW. 1. If you are urged to purchase life insurance and to surrender, lapse, or in any other way change the status of existing life insurance, the agent is required to give you this notice. 2. It may not be advantageous to drop or change existing life insurance in favor of new life insurance, whether issued by the same or a different insurance company. Some of the disadvantages are: a. The amount of the annual premium under an existing policy may be lower than that under a new policy having the same or similar benefits. b. Generally, the initial costs of life insurance policies are charged against the cash value increases in the earlier policy years, the replacement of an old policy could result in the policyholder sustaining the burden of these costs twice. c. The incontestable and suicide clauses begin anew in a new policy. This could result in a claim under a new policy being denied by the company which would have been paid under the old policy. d. Existing policies may have favorable provisions than new policies in such areas as settlement options and disability benefits. e. An existing policy may have a reserve value in addition to any cash value which may be of some benefit to the insured. f. The insurance company carrying your current insurance policy can often make a desired change on terms which would be more favorable than if existing insurance is replaced with new insurance. 3. It may not be advantageous to change an existing policy to reduced paid-up or extended term insurance or to borrow against its loan value beyond your expected ability or intention to repay in order to obtain funds for premiums on a new policy. 4. There may be a situation in which a replacement policy is advantageous. You may want to receive the comments of the present insurance company before deciding this important financial matter. I hereby acknowledge that I received the above Notice to Applicants Regarding Replacement of Life Insurance or an Annuity before I signed the application for the proposed new insurance. Date Signature of Applicant A-1128-OK 1/84 ORIGINAL HOME OFFICE COPY APPLICANT Page 1 of 2

7 Definitions Premiums: Premiums are the payments you make on the life insurance or annuity contract. They are unlike deposits in a savings or investment program because if you drop the policy you might get back less than you paid in. Cash Surrender Value: This is the amount of money you can get if you surrender your life insurance policy or annuity. If there is a policy loan, the cash surrender value is the difference between the cash value printed in the 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 your policy 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. If a policy has a cash surrender value, you can receive such value in cash if you return the policy to the company with a written request. Place on Extended Term: This means you use your cash surrender value to change your insurance to term insurance with the same insurer. In this case, the net death benefits will be the same as before but you will only be covered for a specified period of time. Borrow Policy Loan Values: If your life insurance policy has a cash surrender value, you can usually borrow all or part of said amount from the insurer. Interest will be charged according to the terms of the policy, and if the loan and unpaid interest ever exceeds the cash surrender value the policy will be terminated. If you die, the amount of the loan and any unpaid interest due will be subtracted from the death benefits. Evidence of Insurability: This means proof that you are an acceptable risk. You have to meet the standards of the insurer regarding age, health, occupation, and such other standards as the insurer feels necessary to be eligible for coverage. Incontestable Clause: This says that after one (1) or two (2) years, according to the provisions of the contract, the insurer shall not resist a claim because you made a false or incomplete statement when you applied for the policy. During the first two (2) years if there are false or incomplete answers on the application and the insurer discovers them, the insurer can deny a claim as if the policy has never existed. Suicide Clause: This says that if you commit suicide after being insured for less than two (2) years, your beneficiaries will receive only a refund of the premiums that were paid. A-1128-OK 1/84 Page 2 of 2

8 PROTECTIVE LIFE INSURANCE COMPANY STATEMENT BY APPLICANT REGARDING NOTIFICATION OF REPLACEMENT TO THE REPLACED INSURER I have read the "NOTICE TO APPLICANTS REGARDING REPLACEMENT OF LIFE INSURANCE OR AN ANNUITY" which was furnished to me by the agent taking the application for this policy. (Applicant: Please Sign one of the following statements.) 1. Please notify my present insurer(s) regarding this transaction. Date Signature of Applicant 2. Please do not notify my present insurer(s) regarding this transaction. Date Signature of Applicant The signature of the applicant shall be that of the insured unless someone other than the insured is the owner of the policy. If someone other than the insured is the owner of the policy, the owner must sign. If the insured is under eighteen (18) years of age, the parent is deemed to be the owner of the policy. Certification by the agent: I hereby certify that nothing was said or done during the sales presentation to influence the decision of the applicant regarding this statement. Date Signature of Agent Insurance Agency or Agent License Number A-1128b-OK 3/02 ORIGINAL - HOME OFFICE COPY - APPLICANT

9 Life and Annuity Division Protective Life Insurance Company 1 West Coast Life Insurance Company 1 Request for Transfer or Protective Life and Annuity Insurance Company Exchange of Assets Post Office Box / Birmingham, AL Toll Free: / Fax: Existing Protective Contract Number: (for additional payments only) Check here and complete Box 4 if this is being submitted for a Rate Lock only. (If Rate Lock request is for a CD, you must include proof of maturity from the Financial Institution.) Please do not select this option for the Protective Indexed Annuity, because the interest crediting elements for that product are determined as of the date the contract is purchased. Complete this form to transfer assets to Protective Life Insurance Company, West Coast Life Insurance Company or Protective Life and Annuity Insurance Company (each, the Company ) for the issuance of a new annuity contract. EXISTING ACCOUNT, CONTRACT OR POLICY TO BE TRANSFERRED Company Name Telephone Number Company (Overnight) Address Contract/Account Owner s Name Contract/Account Number Owner s SSN/Tax ID The contract is: attached lost or destroyed Please check this box if the existing contract being surrendered is a Fixed Annuity. (If box is checked, and your new Protective Life annuity is being issued in the state of Nevada, please complete form A-1128-NEV-Annuity.) EXISTING ACCOUNT, CONTRACT OR POLICY TO BE TRANSFERRED Non-Qualified: Qualified: 1035 Exchange 1. Plan Type: 2. Transfer Type: Non-1035 Exchange IRA CD Trustee Transfer Mutual Fund 401(k) Roth IRA Direct Rollover Bank CD Mutual Fund 403(b)/TSA Other Non-1035 Exchanges Other Proposed Plan Type: Non-Qual IRA Roth IRA Other TRANSFER INSTRUCTIONS 1. Amount to be transferred: Complete: Liquidate and transfer all assets in my account, contract or policy Partial: Liquidate and transfer assets totaling $ 2. When should transfer occur: Immediately Upon maturity date of / / (mm/dd/yy) 3. Current estimated value of the assets to be transferred are $ 4. RATE LOCK I wish to lock in the interest rate that is in effect when this signed form is received by the Company. If this box is not checked, you will receive the interest rate in effect on the day we receive the transferred amounts. (Please do not select this option for the Protective Indexed Annuity, because the interest crediting elements for that product are determined as of the date the contract is purchased.) 1 Not authorized in New York Page 1 of 2 LAD-1120 R:08/14

10 Complete 1035 Exchange: I hereby make a complete and absolute assignment and transfer all rights, title and interest of every nature in the above contract to the accepting insurance company indicated below. Partial 1035 Exchange: I hereby direct the issuer of the above-referenced existing annuity contract to process a partial 1035 exchange to the accepting insurance company indicated below. I intend for this transaction to qualify as a tax-free exchange for Federal income tax purposes. Based on our understanding of IRS guidance in Rev. Proc , if a contract is involved in a tax-free partial exchange under Internal Revenue Code section 1035 that is completed on or after October 24, 2011, and an amount is withdrawn from or received in surrender of either contract within 180 days of the exchange, the IRS will apply general tax principles to determine the substance, and hence the treatment of the partial exchange and the subsequent withdrawal or surrender. Such a withdrawal or surrender could affect how the partial exchange and the withdrawal or surrender is reported to you and the IRS. For Other Transfers: Unless it is noted above to hold for a future date, I request the surrendering company to immediately complete the transfer or rollover. Do not withhold any amount for taxes from the proceeds. SIGNATURES: Owner s Signature Date Joint Owner s Signature Date Annuitant s Signature Date FOR HOME OFFICE USE ONLY NOTICE OF ACCEPTANCE: The Company will accept the assets and credit them to an annuity contract as described above. The Company has received an application from the Owner to establish an annuity contract for this transaction. Authorized Signature Title Date SETTLEMENT: Please make check payable for the proceeds and mail to: Protective Life Insurance Company Protective Life and Annuity Insurance Company (New York Only) West Coast Life Insurance Company Mailing Address: PO Box Overnight Address: 2801 Highway 280 South Attn: 3-1 Annuity New Business Attn: 3-1 Annuity New Business Birmingham, AL Birmingham, AL Page 2 of 2 LAD-1120 R:08/14

11

12

13

14

15

16

17

18

19