Spousal Signature (if required for Community Property State)

Transcription

1 Special Instructions to Transferring Company for Qualified Plans: If the Owner is of RMD age please process the Required Minimum Distribution for the current year prior to transferring the funds. C. QUALIFIED ACCOUNT TRANSFER I wish to liquidate and transfer the: Full Value Partial Value in the amount of $ or % (Certain restrictions may apply). From: IRA SIMPLE IRA Roth IRA SEP IRA Stretch IRA Other To: IRA SIMPLE IRA Roth IRA SEP IRA Stretch IRA NOTE: For IRA transfers, if we are issuing a Roth IRA at EquiTrust Life you are responsible for issuing a 1099R for the conversion at the time of surrender. D. QUALIFIED ACCOUNT ROLLOVER I wish to liquidate and rollover the: Full Value Partial Value in the amount of $ or % (Certain restrictions may apply). From: IRA Qualified Retirement Plan SEP IRA TSA 401(k) Plan 457 Plan Other To: IRA SEP IRA This amount represents all or part of my eligible rollover distribution. I understand there will be no mandatory 20% withholding from this distribution because it is a direct rollover to an eligible retirement plan as defined under applicable tax laws. TSA/401(k)/457 Plan/ 401(a) to IRA Qualifying event: Separated from service Age 59 ½ Termination of plan Disability Death If this is a transfer into an existing contract, please provide the existing Contract Number. Without this contract number, the transfer must be made into a new contract. 4. SIGNATURES AND AUTHORIZATIONS Please make check(s) payable and mail to: EquiTrust Life Insurance Company (overnight) or EquiTrust Life Insurance Company (regular mail) Attn: Annuity New Business Attn: Annuity New Business 7100 Westown Pkwy Suite 200 P.O. Box West Des Moines, IA Des Moines, IA I understand that the Company is providing this form for my convenience and makes no representations concerning my tax treatment. I agree to execute any additional documents required to complete this transaction. If this is an exchange, I acknowledge that this qualifies under Section 1035 of the Internal Revenue Code as a like-tolike exchange. Signature of Owner (Note: A signature guarantee may be required) Signature of Joint Owner (if applicable) Signature Guarantee by: Name of Bank/Firm Spousal Signature (if required for Community Property State) Signature of Officer and Title Place Signature Guarantee Stamp here: 5. ACCEPTANCE FOR TRANSFER/1035 EXCHANGE (Home Office Use Only) The Company requests this liquidation and transfer of the assets listed above. By its signature below, the Company represents that the above described receiving Annuity Contract is or is intended to be an Annuity Contract of the type indicated and that the Company will accept the Section 1035 Exchange/Transfer on behalf of the person(s) named on this form. Please provide us with a report of the pre-and post-tefra cost basis in the current contract, if applicable. Authorized Signature Title New Contract Number EquiTrust Life Insurance Company PO Box Des Moines, Iowa ET-TRN/ (10-14)

2 OTHER NOTES Any examples of historical performance of the S&P 500 should not be considered a representation of future performance of the S&P 500. Future performance of the S&P 500 may be greater or less than any index performance shown in connection with the sale and issue of your annuity Contract. Your Index Credits are based not only on the index, but also the Index Cap or the Participation Rate. The MARKETPOWER BONUS INDEX Annuity is backed by the financial strength of the Company. It is not guaranteed by any bank and is not insured by the Federal Deposit Insurance Corporation (FDIC) or any other agency of the federal government. Funded plans under the Employee Retirement Income Security Act of 1974 (ERISA) may not be used with this annuity. The Company can be contacted toll-free at (866) for further clarification if, for any reason, your understanding of your annuity is different from this explanation. S&P 500 is a trademark of The McGraw-Hill Companies, Inc., and has been licensed for use by the Company. The Product is not sponsored, endorsed, sold or promoted by Standard & Poor s, and Standard & Poor s makes no representation regarding the advisability of purchasing the Product. The S&P 500 Index does not reflect dividends paid on the underlying stocks. INITIAL PREMIUM ALLOCATION 1-Year Interest Account 1-Year Point-to-Point Cap Index Account 1-Year Average Cap Index Account 1-Year Average Participation Index Account 1-Year Monthly Cap Index Account 2-Year Monthly Average Cap Index Account Total 100% Minimum Allocations allocation must equal of 100%. $2,000 Percentages in an account. must be whole Percentages percentages. must be whole percentages. If this annuity is replacing an existing annuity, it is important that you compare the two, taking into account whatever charges you may incur on the surrender of the existing annuity and your need to access your funds. For information about your existing annuity, contact the issuing company. The insurance producer is appointed to represent the Company and is approved to provide services to you on our behalf. The insurance producer will be compensated by us in connection with any business placed with our Company. Applicant Statement: By signing below, I acknowledge that I have read, or have been read, this document and understand I am applying for an indexed annuity. I also acknowledge that the annuity meets my financial objectives. I have received a copy of this document, as well as any advertisement that was used in connection with the sale of this annuity. I understand this is not a registered security and that while the values of the policy may be affected by an external index, the policy does not directly participate in any stock or equity investments. Other than the minimum guaranteed values, there are no guarantees, promises, or warranties. I have read the Important Notice Regarding Sales to Military Personnel, if applicable. Signature of Owner(s)/Applicant(s) Name of Owner(s)/Applicant(s) (please print) Social Security # Daytime Telephone Number Agent Statement: By signing below, I acknowledge I have reviewed this document with the applicant. I certify that a copy of this document, as well as any advertisement used in connection with the sales of this annuity, has been provided to the applicant. I have not made statements that differ in any significant manner from this material. I have not made any promises or guarantees about the future value of any non-guaranteed elements. I have provided the client the Important Notice Regarding Sales to Military Personnel, if applicable. Signature of Agent Agent Name & Number (please print) ET-MPP-1101 (01-13) EquiTrust Life Insurance Company Westown Pkwy Ste 200 West Des Moines, Iowa Mailing Address PO Box Des Moines, Iowa COMPANY COPY Page 3 of 3 incomplete without all pages

3 OTHER NOTES Any examples of historical performance of the S&P 500 should not be considered a representation of future performance of the S&P 500. Future performance of the S&P 500 may be greater or less than any index performance shown in connection with the sale and issue of your annuity Contract. Your Index Credits are based not only on the index, but also the Index Cap or the Participation Rate. The MARKETPOWER BONUS INDEX Annuity is backed by the financial strength of the Company. It is not guaranteed by any bank and is not insured by the Federal Deposit Insurance Corporation (FDIC) or any other agency of the federal government. Funded plans under the Employee Retirement Income Security Act of 1974 (ERISA) may not be used with this annuity. The Company can be contacted toll-free at (866) for further clarification if, for any reason, your understanding of your annuity is different from this explanation. S&P 500 is a trademark of The McGraw-Hill Companies, Inc., and has been licensed for use by the Company. The Product is not sponsored, endorsed, sold or promoted by Standard & Poor s, and Standard & Poor s makes no representation regarding the advisability of purchasing the Product. The S&P 500 Index does not reflect dividends paid on the underlying stocks. INITIAL PREMIUM ALLOCATION 1-Year Interest Account 1-Year Point-to-Point Cap Index Account 1-Year Average Cap Index Account 1-Year Average Participation Index Account 1-Year Monthly Cap Index Account 2-Year Monthly Average Cap Index Account Total 100% Minimum Allocations allocation must equal of 100%. $2,000 Percentages in an account. must be whole Percentages percentages. must be whole percentages. If this annuity is replacing an existing annuity, it is important that you compare the two, taking into account whatever charges you may incur on the surrender of the existing annuity and your need to access your funds. For information about your existing annuity, contact the issuing company. The insurance producer is appointed to represent the Company and is approved to provide services to you on our behalf. The insurance producer will be compensated by us in connection with any business placed with our Company. Applicant Statement: By signing below, I acknowledge that I have read, or have been read, this document and understand I am applying for an indexed annuity. I also acknowledge that the annuity meets my financial objectives. I have received a copy of this document, as well as any advertisement that was used in connection with the sale of this annuity. I understand this is not a registered security and that while the values of the policy may be affected by an external index, the policy does not directly participate in any stock or equity investments. Other than the minimum guaranteed values, there are no guarantees, promises, or warranties. I have read the Important Notice Regarding Sales to Military Personnel, if applicable. Signature of Owner(s)/Applicant(s) Name of Owner(s)/Applicant(s) (please print) Social Security # Daytime Telephone Number Agent Statement: By signing below, I acknowledge I have reviewed this document with the applicant. I certify that a copy of this document, as well as any advertisement used in connection with the sales of this annuity, has been provided to the applicant. I have not made statements that differ in any significant manner from this material. I have not made any promises or guarantees about the future value of any non-guaranteed elements. I have provided the client the Important Notice Regarding Sales to Military Personnel, if applicable. Signature of Agent Agent Name & Number (please print) ET-MPP-1101 (01-13) EquiTrust Life Insurance Company Westown Pkwy Ste 200 West Des Moines, Iowa Mailing Address PO Box Des Moines, Iowa APPLICANT COPY Page 3 of 3 incomplete without all pages

4 3. Are you aware that the fixed annuity contract for which you are applying may be a long-term contract with substantial penalties for early withdrawal? Yes No N/A Confidence Income Immediate Annuity 4. Do you have a reverse mortgage on your primary residence? 5. Do you have an emergency fund for unexpected expenses? Yes Yes No No 6. Considering your financial and tax status, why are you considering purchasing this annuity? (Check all that apply) Estate Planning Potential Growth Tax Deferral Flexible Income Options Other: 7. Indicate your willingness to accept financial risk: Conservative Moderate Aggressive 8. What is your financial experience? 0-5 years 6-10 years years Over 20 years 9. Types of current assets (Check all that apply) Stocks/Bonds CDs/Money Market Funds Real Estate Mutual Funds Life Insurance/Annuities 401k/Pension 10 Combined state and federal tax bracket: Other (provide details): 10-20% 21-30% 31-40% 41-50% 11. Do you anticipate material changes in your annual income, financial situation and needs, existing assets, liquidity needs, or liquid net worth? Yes No If yes, please explain If purchasing Confidence Income Immediate Annuity, do not answer items 12, 13 or 14, and go to Section 3: Signatures. For all other products, continue to item Will you need access to these funds during your lifetime? Yes No If you answered No to item 12, skip items 13 and 14, and go to Section 3: Signatures. 13. When will you need access to these funds? Less than 1 year 1 to 5 years 6 to 10 years Over 10 years 14. How do you anticipate accessing funds from this annuity? (Check all that apply) Penalty-free withdrawals Required minimum distributions (qualified only) Other, please explain: Annuitize SECTION 3: SIGNATURES By signing below, I acknowledge that I have read and reviewed the product specific Disclosure Statement with my agent, in addition to the financial factors listed above, and have determined that the product meets my needs and objectives. Signature of Owner/Applicant Printed Name of Owner/Applicant Signature of Joint Owner/Applicant Printed Name of Joint Owner/Applicant By signing below I acknowledge that I have made a reasonable effort to obtain information concerning the financial and tax status, investment objectives and other information considered reasonable for this purchase. It is my belief that based on this information and all circumstances known to me at this time, the annuity being applied for meets the financial needs and objectives provided by my clients. In addition, I have verified identity, believe the information provided to me is true and accurate and I understand the Company may contact my client directly for additional information, if necessary. Signature of Agent Printed Name of Agent and Agent Number ET-2506 (1-14) EquiTrust Life Insurance Company PO Box Des Moines, Iowa Page 2 of 2 Incomplete without all pages

5 Supplement to Disclosure and Comparison of Products For California Residents Age 65 and Older Note: For California residents age 65 and older, this form must be completed for each product being replaced, in addition to any state-required replacement forms. When explaining the substantial financial benefit, please provide specific reasons. Examples of specific reasons may include the addition of new riders or features; greater flexibility in premium payments or pay-out options; or the desire to move away from market risk inherent in an existing variable product. Attach additional forms, if needed. 1. Name of company being replaced Contract Number 2. Please explain the reason(s) this transaction will provide you with a substantial financial benefit, over the life of the contract, including full details: Owner s Printed Name Owner s Signature Joint Owner s Printed Name Joint Owner s Signature Signature of Agent EquiTrust Life Insurance Company PO Box Des Moines, Iowa ET-2506SPIA-CA (01-13)

6 DISCLOSURE & COMPARISON OF PRODUCTS CONFIDENCE INCOME ANNUITY (SPIA) - CALIFORNIA This form must be submitted for each product being replaced, in addition to any state-required replacement forms. For California residents age 65 & older, the second page of this form must also be completed. IMPORTANT: Do not leave any blanks. Any missing, incomplete or incorrect information will require a new SIGNATURE and DATE by the owner prior to issuing the proposed annuity contract. 1. Name of company being replaced Contract Number 2. Contract Effective (mm/dd/yyyy): 3. Current Surrender Charge (excluding MVA) _ 4. Please explain why you have chosen to replace your existing life insurance or annuity contract. (Give specific reasons use additional pages, if needed.) 5. Is the agent assisting you with this annuity purchase the same agent on the product being replaced? Yes No 6. Are you aware that the annuity that you are purchasing cannot be surrendered and therefore will have no surrender value? Yes No 7. EquiTrust Contract Number (if known) If the replaced product is an annuity, please complete the following information: Generic Contract Type Column A * Annuity Being Replaced Product Name Qualified Contract Yes No Yes No Contract Benefits What is paid at death? (i.e. full accumulated value, surrender charges Column B * EquiTrust Annuity Single Premium Immediate Annuity Confidence Income Annuity See Product Disclosure Form apply, etc?) Penalty Free Withdrawal-After 1 st Year % Not Available Minimum Guaranteed Interest % See Product Disclosure Premium Bonus (percentage) % Not Available Charges Surrender Charge Period in Years Entire Surrender Charge Schedule (%) Does Not Apply Does Not Apply Administrative or Rider Fees Yes No Does Not Apply Asset Fees Yes No Does Not Apply Do the Products listed above include the following features? Return of Premium Yes No Does Not Apply Market Value Adjustment Yes No Does Not Apply Nursing Home Rider Yes No Not Available Terminal Illness Rider Yes No Not Available Income Benefit Rider Elected Yes No Not Available Living Benefit Rider Yes No Not Available Loan Options Yes No Not Available Owner s Printed Name Owner s Signature Joint Owner s Printed Name Joint Owner s Signature Signature of Agent ET-2506SPIA-CA (01-13) EquiTrust Life Insurance Company PO Box Des Moines, Iowa

7 AUTOMATIC DEPOSIT AUTHORIZATION AGREEMENT Owner/Joint Owner: Contract Number (if known): Contract type: Deferred Annuity Contract Single Premium Immediate Annuity AGREEMENT I hereby authorize EquiTrust Life Insurance Company to make deposits to my account and for the Financial Institution named below to accept these deposits. I also authorize EquiTrust Life Insurance Company to make withdrawals from my account if necessary to correct an incorrect deposit amount and for the Financial Institution to accept such withdrawals. EquiTrust Life Insurance Company will complete the ABA Transit Number and Account Numbers from the voided check attached below. This authority is to remain in full force until EquiTrust Life Insurance Company has written notification from me of its termination in such time and in such manner as to afford EquiTrust Life Insurance Company a reasonable opportunity to act on it. Bank Account Owner Name: Joint Bank Account Owner Name Owner Social Security Number: Joint Social Security Number: Bank Account Owner Signature: Joint Bank Account Owner Signature: : : EquiTrust Life Contract Owner Signature: EquiTrust Life Contract Joint Owner Signature: THE ACCOUNT MUST BE A REGULAR CHECKING OR SAVINGS ACCOUNT NOTE: Money Market and Brokerage Accounts are not acceptable. Account Information: Checking Saving Financial Institution Name: Address: City, State, Zip: Financial Institution ABA Transit Number: Account Number: Note: The electronic transfer of funds may take 2-3 business days to reach your account once funds are released from our office. This processing time is dependent on your bank. IF USING A CHECKING ACCOUNT, ATTACH A VOIDED CHECK HERE DEPOSIT SLIPS ARE NOT ACCEPTABLE NOTE: Amounts greater than $50,000 must be distributed via check. ET-2513 (10-13) EquiTrust Life Insurance Company P.O. Box Des Moines, IA Phone Fax

8 Special Instructions to Transferring Company for Qualified Plans: If the Owner is of RMD age please process the Required Minimum Distribution for the current year prior to transferring the funds. C. QUALIFIED ACCOUNT TRANSFER I wish to liquidate and transfer the: Full Value Partial Value in the amount of $ or % (Certain restrictions may apply). From: IRA SIMPLE IRA Roth IRA SEP IRA Stretch IRA Other To: IRA SIMPLE IRA Roth IRA SEP IRA Stretch IRA NOTE: For IRA transfers, if we are issuing a Roth IRA at EquiTrust Life you are responsible for issuing a 1099R for the conversion at the time of surrender. D. QUALIFIED ACCOUNT ROLLOVER I wish to liquidate and rollover the: Full Value Partial Value in the amount of $ or % (Certain restrictions may apply). From: IRA Qualified Retirement Plan SEP IRA TSA 401(k) Plan 457 Plan Other To: IRA SEP IRA This amount represents all or part of my eligible rollover distribution. I understand there will be no mandatory 20% withholding from this distribution because it is a direct rollover to an eligible retirement plan as defined under applicable tax laws. TSA/401(k)/457 Plan/ 401(a) to IRA Qualifying event: Separated from service Age 59 ½ Termination of plan Disability Death If this is a transfer into an existing contract, please provide the existing Contract Number. Without this contract number, the transfer must be made into a new contract. 4. SIGNATURES AND AUTHORIZATIONS Please make check(s) payable and mail to: EquiTrust Life Insurance Company (overnight) or EquiTrust Life Insurance Company (regular mail) Attn: Annuity New Business Attn: Annuity New Business 7100 Westown Pkwy Suite 200 P.O. Box West Des Moines, IA Des Moines, IA I understand that the Company is providing this form for my convenience and makes no representations concerning my tax treatment. I agree to execute any additional documents required to complete this transaction. If this is an exchange, I acknowledge that this qualifies under Section 1035 of the Internal Revenue Code as a like-tolike exchange. Signature of Owner (Note: A signature guarantee may be required) Signature of Joint Owner (if applicable) Signature Guarantee by: Name of Bank/Firm Signature of Officer and Title Place Signature Guarantee Stamp here: 5. ACCEPTANCE FOR TRANSFER/1035 EXCHANGE (Home Office Use Only) The Company requests this liquidation and transfer of the assets listed above. By its signature below, the Company represents that the above described receiving Annuity Contract is or is intended to be an Annuity Contract of the type indicated and that the Company will accept the Section 1035 Exchange/Transfer on behalf of the person(s) named on this form. Please provide us with a report of the pre-and post-tefra cost basis in the current contract, if applicable. Authorized Signature Title New Contract Number EquiTrust Life Insurance Company PO Box Des Moines, Iowa ET-TRN/ (12-12)

9 NOTICE TO CALIFORNIA RESIDENTS AGE 65 OR OLDER This notice is required to be given in connection with your purchase of a life insurance or annuity product. You are advised that the sale or liquidation of the following to fund this purchase may have tax consequences, penalties or other costs: stocks; bonds; individual retirement accounts; certificates of deposit; mutual funds; annuities; or other assets. You may want to consult an independent legal or financial expert for further information. EquiTrust Life annuities have not been filed for exemption under the Medi-Cal Program and assets from this annuity will be counted when determining eligibility for Medi-Cal. I have received a copy of this disclosure and I understand its contents. Owner s Signature Joint Owner s Signature This form must be delivered to the Applicant at the point of sale when the Applicant is age 65 or older. ET-4903CA (9-06) APPLICANT COPY EquiTrust Life Insurance Company P.O. Box Des Moines, Iowa /

10 NOTICE REGARDING REPLACEMENT CALIFORNIA REPLACING YOUR LIFE INSURANCE POLICY OR ANNUITY? Are you thinking about buying a new life insurance policy or annuity and discontinuing or changing an existing one? If you are, your decision could be a good one -- or a mistake. You will not know for sure unless you make a careful comparison of your existing benefits and the proposed benefits. Make sure you understand the facts. You should ask the company or agent that sold you your existing policy to give you information about it. Hear both sides before you decide. This way you can be sure you are making a decision that is in your best interest. We are required by law to notify your existing company that you may be replacing their policy. EXISTING INSURANCE WHICH MAY BE REPLACED OR CHANGED: Full name of Insurance Company Including Home Office Location Policy or Contract Number Insured Applicant s Signature Producer s Signature AGENT INFORMATION: THREE COPIES NEEDED PRODUCER INFORMATION: THREE COPIES NEEDED Send the signed original to the Home Office, leave a signed copy with the applicant and retain a permanent copy in your producer file. EquiTrust Life Insurance Company PO Box Des Moines, Iowa CA(04-03) ET-RPL-4900CA (9-05)

11 NOTICE TO CALIFORNIA RESIDENTS AGE 65 OR OLDER This notice is required to be given in connection with your purchase of a life insurance or annuity product. You are advised that the sale or liquidation of the following to fund this purchase may have tax consequences, penalties or other costs: stocks; bonds; individual retirement accounts; certificates of deposit; mutual funds; annuities; or other assets. You may want to consult an independent legal or financial expert for further information. EquiTrust Life annuities have not been filed for exemption under the Medi-Cal Program and assets from this annuity will be counted when determining eligibility for Medi-Cal. I have received a copy of this disclosure and I understand its contents. Owner s Signature Joint Owner s Signature This form must be delivered to the Applicant at the point of sale when the Applicant is age 65 or older. ET-4903CA (9-06) COMPANY COPY EquiTrust Life Insurance Company P.O. Box Des Moines, Iowa /

12 SECTION I SIGNATURES CERTIFICATION 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 due to failure to report interest and dividend income, and 3. I am a U.S. person (including a U.S. resident alien). Certification instructions. You must cross out Item 2 above if you have been notified by the IRS that you are currently subject to backup withholding I/We declare that all statements in this Application are true to the best of my/our knowledge and belief, and agree that this Application shall be a part of the Annuity Contract issued by the Company. Acceptance of any Annuity Contract issued on this Application shall constitute ratification of any corrections, additions, or changes made by the Company and recorded in the space Special Requests, Remarks, Corrections or Endorsements except that no change shall be made as to amount, classification, plan or benefits, unless agreed to in writing. It is understood that no producer or other unauthorized person except an Executive Officer or an Assistant Secretary of the Company is authorized to waive forfeitures, to make or alter contracts, or to waive any of the Company s rights or requirements. The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. If the contract applied for contains a Market Value Adjustment provision, payments and values are subject to a Market Value Adjustment which may result in upward or downward adjustments in amounts withdrawn or surrendered. 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. Signed at: City and State Signature of Owner Signature of Joint Owner SECTION J PRODUCER CERTIFICATE FOR PRODUCER USE ONLY Will this plan replace any existing life insurance or annuity? Yes No If Yes, please explain the reason for replacement: For any replacement, indicate the source of funds to be replaced: Term Life Whole Life Variable Life Fixed Annuity Variable Annuity Other be specific Producer Certifications: I certify that I used only insurer-approved sales material with this Application and that an original or a copy of all sales material was left with the Owner. I certify that a printed copy of any electronically presented sales material was/will be presented to the Owner no later than the date the Contract is delivered. I certify that this Application is in accordance with the Company s written statement of the Company s position with respect to the acceptability of replacements. Signature of Producer ANN-APP(05-13) Page 3 of 3 Incomplete without all pages

13 Special Instructions to Transferring Company for Qualified Plans: If the Owner is of RMD age please process the Required Minimum Distribution for the current year prior to transferring the funds. C. QUALIFIED ACCOUNT TRANSFER I wish to liquidate and transfer the: Full Value Partial Value in the amount of $ or % (Certain restrictions may apply). From: IRA SIMPLE IRA Roth IRA SEP IRA Stretch IRA Other To: IRA SIMPLE IRA Roth IRA SEP IRA Stretch IRA NOTE: For IRA transfers, if we are issuing a Roth IRA at EquiTrust Life you are responsible for issuing a 1099R for the conversion at the time of surrender. D. QUALIFIED ACCOUNT ROLLOVER I wish to liquidate and rollover the: Full Value Partial Value in the amount of $ or % (Certain restrictions may apply). From: IRA Qualified Retirement Plan SEP IRA TSA 401(k) Plan 457 Plan Other To: IRA SEP IRA This amount represents all or part of my eligible rollover distribution. I understand there will be no mandatory 20% withholding from this distribution because it is a direct rollover to an eligible retirement plan as defined under applicable tax laws. TSA/401(k)/457 Plan/ 401(a) to IRA Qualifying event: Separated from service Age 59 ½ Termination of plan Disability Death If this is a transfer into an existing contract, please provide the existing Contract Number. Without this contract number, the transfer must be made into a new contract. 4. SIGNATURES AND AUTHORIZATIONS Please make check(s) payable and mail to: EquiTrust Life Insurance Company (overnight) or EquiTrust Life Insurance Company (regular mail) Attn: Annuity New Business Attn: Annuity New Business 7100 Westown Pkwy Suite 200 P.O. Box West Des Moines, IA Des Moines, IA I understand that the Company is providing this form for my convenience and makes no representations concerning my tax treatment. I agree to execute any additional documents required to complete this transaction. If this is an exchange, I acknowledge that this qualifies under Section 1035 of the Internal Revenue Code as a like-tolike exchange. Signature of Owner (Note: A signature guarantee may be required) Signature of Joint Owner (if applicable) Signature Guarantee by: Name of Bank/Firm Signature of Officer and Title Place Signature Guarantee Stamp here: 5. ACCEPTANCE FOR TRANSFER/1035 EXCHANGE (Home Office Use Only) The Company requests this liquidation and transfer of the assets listed above. By its signature below, the Company represents that the above described receiving Annuity Contract is or is intended to be an Annuity Contract of the type indicated and that the Company will accept the Section 1035 Exchange/Transfer on behalf of the person(s) named on this form. Please provide us with a report of the pre-and post-tefra cost basis in the current contract, if applicable. Authorized Signature Title New Contract Number EquiTrust Life Insurance Company PO Box Des Moines, Iowa ET-TRN/ (12-12)

14 Authorization to Hold Issue For Multiple Premiums TO BE USED FOR FLEXIBLE PREMIUM INDEX PRODUCTS Contract Owner Name (please print): Joint Owner Name (please print): I/we understand this is a Flexible Premium product, and that while the initial premium is allocated as specified on the application, subsequent premiums after policy issue are directed to the fixed account for the remainder of the policy year. I/we want all premiums related to the initial issue allocated in like fashion. I/we authorize EquiTrust Life Insurance Company to hold issuing the contract until all funds specified on the application have been received. I/we also understand that the starting index value will not be set and/or interest will not begin until the date funds are received. Contract Owner s Signature: : Joint Owner s Signature: : Writing Agent s Signature: Agent #: Writing Agent s Signature: Agent #: EquiTrust Life Insurance Company P.O. Box Des Moines, IA ET-2504 (02-12)

15 MEDICAL AUTHORIZATION FORM HIPAA COMPLIANT Print Name of Proposed Insured: of Birth: / / SS#: - - Driver s License#: State: The purpose of this Authorization is to permit I. Santos Insurance & Assoc. Inc. to obtain and release nonpublic personal information about me, the Proposed Insured named above, for the purposes of determining my eligibility for, and obtaining insurance products and services from, one or more of the insurers or other institutions listed below. I authorize any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy, medical facility, Pharmacy Benefit Manager or other health care provider that has provided treatment or services to me or on my behalf within the past 10 years ( my Providers ) to disclose my entire medical record and any other information that may be considered protected health information under the Health Insurance Portability and Accountability Act of 1996 ( HIPAA ) concerning me to I. Santos Insurance & Assoc. Inc. and its staff, affiliated companies and/or entities, insurance companies and their re-insurers. This includes information on the diagnosis or treatment of Human Immunodeficiency Virus (HIV) infection and sexually transmitted diseases. This also includes information on the diagnosis and treatment of mental illness and the use of alcohol, drugs, and tobacco, but excludes psychotherapy notes. By my signature below, I acknowledge that any agreements I have made with my Providers that restrict disclosure of my medical records and any associated HIPAA protected health information do not apply for purposes of this authorization and I instruct my Providers to release and disclose my entire medical record without restriction. I understand that the information contained in these records may be used only for the purpose of the procurement, or the evaluation or underwriting for the possible procurement, or life, health, long term care, or other insurance products. In connection therewith, I specifically authorize the companies listed below to receive information from, and to release information to, I. Santos Insurance & Assoc. Inc. I also specifically authorize I. Santos Insurance & Assoc. Inc. and the companies listed below to release information about me to their reinsurers, underwriters or other persons or organizations performing business, professional or insurance functions for them. This Authorization shall be effective for twelve months after the date signed below. I understand that I am entitled to receive a copy of this authorization. I understand that I can revoke this authorization by sending written notice of the revocation to I. Santos Insurance & Assoc. Inc., 2372 Morse Avenue, Irvine, CA and that the revocation will take effect when received by I. Santos Insurance & Assoc. Inc.. Any action taken in reliance on this authorization prior to the notice of the revocation shall be valid. I understand that any information that is used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by certain state and federal rules governing privacy and confidentiality of health information. I acknowledge that I have read and understand the above authorization. I also understand and acknowledge that each of the insurers listed on this form or to which I may formally apply, may require me to sign a similar authorization used exclusively by such insurer before they will process my application or offer insurance coverage.. I further agree that a copy of this authorization, whether a photocopy, carbon copy, or otherwise, shall have equal standing as if it were an original and can be relied upon by I. Santos Insurance & Assoc. Inc. and/or any third party designated herein. X Proposed Insured s Signature/Guardian or Custodian/Authorized Representative X Broker/Agent/Agency/Firm Signature American General AVIVA AXA Equitable Banner Genworth ING Life Group John Hancock Lincoln Benefit Lincoln Financial MetLife Mutual of Omaha North American Principal Protective Prudential Reliastar Security Life Transamerica

16 PRIVACY POLICY At I. Santos Insurance & Assoc. Inc., protecting your privacy is very important to us. We are strongly committed to safeguarding the information you provide us and to using it responsibly. Because of our commitment to you, we have adopted and adhere to the following policy regarding the privacy of your personal information. Collection of Information We may collect nonpublic personal financial information about you from some or all of the following sources: Information we received from you on applications, new account forms and fact-finding questionnaires; Your transactions with us, our affiliates, and those product sponsors with whom we have vendor agreements or other arrangements for the provision of services to you; Information we receive from non-affiliated third parties, including, but not limited to consumer reporting agencies; and Affiliated and unaffiliated product sponsors with whom we have selling relationships and whose products you own. Disclosure of Information We will not share nonpublic personal information concerning our potential, current, or former customers with affiliated or unaffiliated third parties, except as permitted by law. Nor will we share this information for marketing purposes, except as permitted by law. Generally, we may disclose customer nonpublic personal information to affiliates and non-affiliated third partiers that provide services to us or have contracts with us to supply the products or services that you have requested through us. Examples of third parties with whom we may share your information include: Insurance companies, mutual fund companies, insurance support organizations, and other product sponsors to effect purchases and sales and allow for the servicing of your account; Your agent or broker/dealer; Clearing agencies through whom we clear and settle securities transactions; Third party investment advisory firms with whom we have relationships for the management of customer advisory accounts; Businesses, such as banks and other financial institutions with whom we have an agreement for the marketing and sale of products and services; Regulatory or law-enforcement authorities; and Record keeping companies Where we share your nonpublic personal information with third parties for the purposes noted above, we ensure that there are contractual restrictions on their use and disclosure of that information Protection of Information We have security practices and procedures in place to prevent unauthorized use or access to your nonpublic personal information. Within Financial Professionals Group Corporation, your information is only available to those individuals requiring access to process or service your transactions with us, and those fulfilling compliance, legal or audit functions on our behalf. We maintain physical, electronic, and procedural safeguards to ensure the protection of your nonpublic personal information in accordance with state and federal privacy regulations.