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 P.O. Box Birmingham, AL Telephone: IMPORTANT NOTICE: REPLACEMENT OF LIFE INSURANCE OR ANNUITIES This document must be signed by the applicant and the insurance producer/agent, if there is one, and a copy left with the applicant. You are contemplating the purchase of a life insurance policy or annuity contract. In some cases this purchase may involve discontinuing or changing an existing policy or contract. If so, a replacement is occurring. Financed purchases are also considered replacements. A replacement occurs when a new life insurance policy or annuity contract is purchased and, in connection with the sale, you discontinue making premium payments on the existing life insurance policy or annuity contract, or an existing life insurance policy or annuity contract is surrendered, forfeited, assigned to the replacing insurer, or otherwise terminated or used in a financed purchase. A financed purchase occurs when the purchase of a new life insurance policy involves the use of funds obtained by the withdrawal or surrender of or by borrowing some or all of the life insurance policy values, including accumulated dividends, of an existing life insurance policy, to pay all or part of any premium or payment due on the new life insurance policy. A financed purchase is a replacement. You should carefully consider whether a replacement is in your best interests. You will pay acquisition costs and there may be surrender costs deducted from your life insurance policy or annuity contract. You may be able to make changes to your existing life insurance policy or annuity contract to meet your insurance needs at less cost. A financed purchase will reduce the value of your existing life insurance policy and may reduce the amount paid upon the death of the insured. We want you to understand the effects of replacements and ask that you answer the following questions and consider the questions on the back of this form. 1. Are you considering discontinuing making premium payments, surrendering, forfeiting, assigning to the insurer, or otherwise terminating your existing life insurance policy or annuity contract? Yes No 2. Are you considering using funds from your existing policies or annuity contracts to pay premiums due on the new life insurance policy or annuity contract? Yes No If you answered yes to either of the above questions, list each existing life insurance policy or annuity contract you are contemplating replacing (include the name of the insurer, the insured or annuitant, and the life insurance policy or annuity contract number if available) and whether each life insurance policy or annuity contract will be replaced or used as a source of financing: ANNUITY CONTRACT INSURED REPLACED (R) INSURER OR OR OR NAME LIFE INSURANCE POLICY # ANNUITANT FINANCING (F) Make sure you know the facts. Contact your existing company or its insurance producer/agent for information about the old life insurance policy or annuity contract. If you request one, an in-force illustration, life insurance policy summary or available disclosure documents must be sent to you by the existing insurer. Ask for and keep all sales material used by the insurance producer/agent in the sales presentation. Be sure that you make an informed decision. The existing life insurance policy or annuity contract is being replaced because. I certify that the responses herein are, to the best of my knowledge, accurate: Applicant s Signature and Printed Name Insurance Producer s/agent Signature and Printed Name Date Date IPD-1145

7 I do not want this notice read aloud to me. aloud.) (Applicants must initial only if they do not want the notice read A replacement may not be in your best interest, or your decision could be a good one. You should make a careful comparison of the costs and benefits of your existing life insurance policy or annuity contract and the proposed life insurance policy or annuity contract. One way to do this is to ask the company or insurance producer/agent that sold you your existing life insurance policy or annuity contract to provide you with information concerning your existing life insurance policy or annuity contract. This may include an illustration of how your existing life insurance policy or annuity contract is working now and how it would perform in the future based on certain assumptions. Illustrations should not, however, be used as a sole basis to compare policies or annuity contracts. You should discuss the following with your agent to determine whether replacement or financing your purchase makes sense: PREMIUMS: Are they affordable? Could they change? You re older are premiums higher for the proposed new life insurance policy? How long will you have to pay premiums on the new life insurance policy? On the old life insurance policy? POLICY VALUES: New policies usually take longer to build cash values and to pay dividends. Acquisition costs for the old life insurance policy may have been paid; you will incur costs for the new one. What surrender charges do the policies have? What expense and sales charges will you pay on the new life insurance policy? Does the new life insurance policy provide more insurance coverage? INSURABILITY: If your health has changed since you bought your old life insurance policy, the new one could cost you more, or you could be turned down. You may need a medical exam for a new life insurance policy. (Claims on most new policies for up to the first two years can be denied based on inaccurate statements. Suicide limitations may begin anew on the coverage.) IF YOU ARE KEEPING THE OLD LIFE INSURANCE POLICY AS WELL AS THE NEW LIFE INSURANCE POLICY: How are premiums for both policies being paid? How will the premiums on your existing life insurance policy be affected? Will a loan be deducted from death benefits? What values from the old life insurance policy are being used to pay premiums? IF YOU ARE SURRENDERING AN ANNUITY OR INTERST SENSITIVE LIFE PRODUCT: Will you pay surrender charges on your old annuity contract? What are the interest rate guarantees for the new annuity contract? Have you compared the annuity contract charges or other life insurance policy expenses? OTHER ISSUES TO CONSIDER FOR ALL TRANSACTIONS: What are the tax consequences of buying the new life insurance policy? Is this a tax-free exchange? (See your tax advisor.) Is there a benefit from favorable grandfathered treatment of the old life insurance policy under the Federal Internal Revenue Tax Code? Will the existing insurer be willing to modify the old life insurance policy? How does the quality and financial stability of the new company compare with your existing company? IPD-1145

8 PROTECTIVE LIFE INSURANCE COMPANY P.O. Box Birmingham, AL Telephone: SALES LITERATURE CERTIFICATION FORM I certify that I used only insurer-approved sales materials and copies of all sales materials used were left with the applicant. Producer s Signature, Printed Name & Date IPD-1150

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

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