Please contact the following with annuity processing questions. Tabatha Wynn (417) or Laura Smith (417)

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1 Please view regularly for updates - Great Southern Bank Annuity Processing Procedures Please contact the following with product or rate questions. Marketing Financial Stacey Douglas, Alan Lockhart, & other Associates (417) or (800) Please contact the following with annuity processing questions. Tabatha Wynn (417) or Laura Smith (417) REQUIRMENTS: AGENT and GSB contact info on all annuity paperwork must be entered as the investment department address and phone number. OMIT ALL S Great Southern Bank Phone: (417) B E. Sunshine Fax: (417) Springfield, MO NEW BUSINESS FORM CUSTOMER INVESTMENT & SUITABILITY CONFIRMATION WORKSHEET ANNUITY COMPANY FORMS OFAC printed the day of application OFAC signed & dated by agent. TWO current forms of Owner(s) ID: 1 primary/1secondary owner(s) must be provided to GSB Investment Dept. with all applications. Agent Anti-Money Laundering annual training - LIMRA site: SPRINGFIELD METRO REGION: Dispatch all required documents to the Investment Dept. Attn: New Business. ALL OTHER LOCATIONS: Dispatch all required documents to the Investment Dept. Attn: New Business for business written the day of your dispatch pick up. Mail all required documents via overnight UPS or FedEx to the Investment Dept drop in the nearest drop box if possible. UPS Account # 97V7R3 FedEx Account # Shipping account numbers are to be used for investment dept new annuity business only. Please contact Tabatha or Laura for pre-printed labels, etc. Rev 11/2010

2 New Business Form Client Name(s): Owner's age: BC #: Agent Name: Referred by: Funds Info: Internal Funds External Funds Check Enclosed: $ Company Name Transfer(s) Approx: $ Qualified Non-Qualified 1035 Exchange Approx: $ Product Name Rate Lock Selected Agent Check List: New Business Non-Qualified Annuity to Annuity IRA Trsf/Rollover Application 1035 Exchange Form IRA Trsf Form Disclosures MO Replacement Form Company Specific Forms ID & OFAC Original Policy or Lost (401K Only) Check Payable to CO Policy Affidavit IRA Annuity to IRA Annuity IRA Trsf Form Replacement Form Original Policy or Lost Policy Affidavit Bankers Report-Source of Funds: This section is required for All transactions. 1. Provide your detailed explanation regarding how this purchase meets the client's stated investment goal. Attach additional sheet if necessary. Agent Signature: Approver Signature: : : REV 1009

3 Customer Investment & Suitability Confirmation Worksheet Owner Information Joint Owner Information 1. Name: 3. Name: 2. Occupation: 4. Occupation: 5. U.S. Citizen: Yes No 6. U.S. Citizen: Yes No 7. Approximate Annual Income: [ ] Under $25,000 [ ] $25,000 - $50,000 [ ] $50,000 - $100,000 [ ] $100,000 - $250,000 [ ] Over $250, Approximate Net Worth: Net Worth= Total Assets (not including home & auto) less total debts [ ] Under $50,000 [ ] $50,000 - $100,000 [ ] $100,000 - $250,000 [ ] $250,000 - $500,000 [ ] Over $500, Source of Income: Current Wages Pension Plan Social Security Investment Income Required Minimum Distribution or 72-t distributions Other 10. Federal Income Tax Bracket: 0% 10% 15% 20% 25% 28% 33% 35% Other 11. What is your financial objective in purchasing this product? Check all that apply: Income Now Flexibility Tax Deferral Provides Guarantees Potential Growth Followed by Income Pass Assets on to Beneficiaries Lifetime Income Payout Other: 12. What is your risk tolerance? Aggressive Moderate Conservative 13. What is your investment time frame? 0-5 yrs 5-10 yrs Over 10 yrs 14. Do you have sufficient liquid assets available for monthly living expenses and emergencies other than the money you plan to use to purchase this annuity? Yes, please list dollar amount(s): CD's $ Money Markets $ Stocks $ Bonds $ DDA $ Mutual Funds $ Annuities $ Other $ No 15. What is the source of premium for this annuity? Check all that apply: Annuity Life Insurance Certificates of Deposit Other Investments Other 15a. Yes No Are there any settlement fees, surrender charges or penalties of any kind associated with any source(s) of the annuity premium checked above? 15b. If 15a is yes please list amount of penalty: $ 16. Do you now own, or have you previously owned, any of the following financial products? (check all that apply) Certificates of Deposit Fixed Annuity Variable Annuity Stock/Bond/Mutual Funds Life Insurance 17. With the exception of any surrender charge free withdrawals, required minimum distribution, etc. do you expect to take any money out of this product before the end of the withdrawal charge period? Yes No If Yes, please explain:

4 Owner(s) please initial Yes No Did the agent explain that if you take money out of this product in excess of the surrender charge free withdrawal amount provided in the contract during the withdrawal window charge period you will incur a penalty? 19. Yes No I understand that my annuity has: (NOT APPLICABLE TO FIXED INDEXED ANNUITIES) % current base rate for year(s) only % bonus rate for the first year only (if applicable) % minimum base rate for renewals after year(s) 20. Yes No I understand that Great Southern is not obligated to provide benefits under any annuity contract and does not guarantee performance by the issuer. 21. Yes No I understand that any withdrawals prior to the age of 591/2 may be subject to a 10% tax penalty. 22. To the extent you are willing, please provide any other information you considered material to your decision to purchase this annuity: Owners Confirmation Yes No Was your decision to purchase this annuity based on your agent's recommendation? By signing below, I acknowledge the information I provided above, regarding my financial status, tax status, investment objectives, and any other information requested by my agent is complete and accurate to the best of my knowledge. I further acknowledge that neither Great Southern nor its representatives offer legal or tax advice and that I have been advised to consult my own personal attorney or tax advisor on an tax matters. I acknowledge that the fixed annuity I am applying for is a long term contract with penalties for early withdrawal; additionally I am aware that any withdrawals taken from the annuity may result in a taxable event. I believe the annuity I am applying for is suitable according to my insurance needs and/or financial objectives. Owner's Signature Owner's Signature Agent's Confirmation Yes No Was the owner's decision to purchase this annuity based on your recommendation? By signing below, I acknowledge that I have made a reasonable effort to obtain information from the Owner concerning the Owner(s)' financial status, tax status, investment objectives and other information considered reasonable. It is my belief that based on the information the Owner provided and based on all the circumstances know to me at the time the recommendation was made, the annuity being applied for, based on my recommendation is suitable for the Owner(s)' insurance needs and/or financial objectives. Agent's Signature Under Federal law the extension of credit for which you have applied may not be conditioned upon your purchase of an insurance product or annuity from the bank or its affiliates or agreement not to obtain, or prohibition of obtaining, an insurance product or annuity from an unaffiliated entity. Investment Products are: Not FDIC Insured May Lose Value No Bank Guarantee REV 0509

5 Application for Annuity Issued by American National Insurance Company One Moody Plaza, Galveston, TX *APP* page 1 of 4 Overnight Address: 4500 Lockhill-Selma Road, San Antonio, TX Mailing Address: PO Box , San Antonio, TX Phone Number: ANNUITANT Name: Last First M.I. Gender U.S. Citizen M F Yes No of birth Age SSN TIN Daytime telephone ( ) Address City State ZIP 2. OWNER (If other than Annuitant. If IRA or TSA, the Owner and Annuitant must be the same person.) Name: Last First M.I. Gender U.S. Citizen M F Yes No of birth Age SSN TIN EIN Daytime telephone ( ) Address City State ZIP Note: If a Trust, Corporation, or Charity is named as Owner, copy of Trust Agreement or Corporate Resolution must be provided. 3. JOINT OWNER (Not available with Qualified plans) Name: Last First M.I. Relationship to Owner Gender M F of birth Age SSN TIN EIN U.S. Citizen Daytime telephone Yes No ( ) Address City State ZIP Note: If a Trust, Corporation, or Charity is named as Owner, copy of Trust Agreement or Corporate Resolution must be provided. 4. PRIMARY BENEFICIARY (A of Birth and SSN is required for each beneficiary. Complete Additional Beneficiary Page if additional space is needed.) A. Name: Last First M.I. Percent Payable Relationship Gender M F of birth Age SSN TIN EIN U.S. Citizen Daytime telephone Yes No ( ) Address City State ZIP Note: If a Trust is named as Beneficiary, provide date trust was created. Month Day Year B. Name: Last First M.I. Percent Payable Relationship Gender M F of birth Age SSN TIN EIN U.S. Citizen Daytime telephone Yes No ( ) Address City State ZIP Note: If a Trust is named as Beneficiary, provide date trust was created. Month Day Year 5. NAME OF ANNUITY PRODUCT APPLIED FOR (A signed copy of the product disclosure form given to owner must be submitted.) 6. APPLIED FOR ANNUITY TYPE NON-QUALIFIED QUALIFIED If Qualified, check the type of plan. CASH WITH APPLICATION ROLLOVER IRA SEP PENSION PLAN 1035 Exchange TRANSFER Roth IRA TSA-403b (Profit Sharing or Defined Benefit) CASH WITH APPLICATION Other (ANICO does not offer SIMPLE IRA s) Amount paid with application $ (Check must be payable to American National Insurance Company.) If a 1035 Exchange, Rollover, or Transfer is occurring, the expected premium amount is $. Form R10039 AMERICAN NATIONAL INSURANCE COMPANY RV 04-10

6 page 2 of 4 7. BILLING DATA FOR FLEXIBLE ANNUITY USE ONLY. (Minimum additional premium $100 EFT) MODE: Annual Semiannual Quarterly Monthly Amount $ METHOD: Direct EFT (attach voided check) Government Allotment Salary Deduction* *Complete for salary deduction selection: Franchise Name Franchise Number 8. RIDER SELECTION AND INITIAL PREMIUM ALLOCATION Only complete for applicable index annuity products when appropriate. Not all products may be available in all states. Check product availability for your state. ANICO Strategy Indexed Annuity Riders may only be added at issue Lifetime Income Rider Enhanced Death Benefit Rider Initial Premium Allocation Declared Interest Option % Indexed Interest Option % Total 100 % 9. INCOME OPTIONS - FOR IMMEDIATE ANNUITIES ONLY Complete a W-4P for withholdings Single Life Payout Options Joint Life Payout Options With Cost of Living Adjustment With Cost of Living Adjustment Life Only Joint to Survivor Life with Certain Period years (5-20) Joint to Spouse Certain Period years (5-30) Payments to be made for a Certain Period Fixed Amount for years or $ of years (5-20) Joint Annuitant Name: Single Life Payout Options - Cost of Living Adjustment not available: SSN TIN Gender M F Life Cash Refund of Birth U.S. Citizen Y N Life Installment Refund Payments will be % upon death of 1st life If you have elected a Cost of Living Adjustment, please complete the following: Simple Interest at % (1-5) Compound Interest at % (1-5) Frequency of Payments: Monthly Quarterly Semiannual Annual Payments to Start Method: EFT (Attach Voided Check) 10. TOTAL INSURANCE/ANNUITIES IN FORCE ON PROPOSED ANNUITANT Yes No Do you have existing life insurance or annuity coverage? Yes No Will the annuity applied for replace or use cash values of any existing life insurance or annuity issued by any company? If Yes, agent must provide and complete the appropriate replacement form. FRAUD WARNING Any person who knowingly intends to defraud or facilitates a fraud against an insurer by submitting an application or filing a false claim, or makes an incomplete or deceptive statement of a material fact, may be guilty of insurance fraud. APPLICATION SIGNATURES To the best of my knowledge and belief, the statements and answers in this application are true and complete. Under penalty 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), 2.) I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Services (IRS) that I am subject to backup withholding as a result of failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and 3.) I am a U.S. person (including a U.S. resident alien). You must cross out item 2 if you have been notified by the IRS that you are currently subject to backup withholding. The IRS does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. d at this day of,. (State) (Day) (Month) (Year) Signature of Annuitant Signature of Joint Annuitant (For Immediate Annuities) Signature of Owner, if other than Annuitant Signature of Joint Owner, if other than Annuitant Signature of Agent Form R10039 AMERICAN NATIONAL INSURANCE COMPANY RV 04-10

7 page 3 of 4 *AGR* AGENT S REPORT THESE QUESTIONS MUST BE ANSWERED IN EVERY CASE: Yes No Does the applicant have existing life insurance policies or annuity contracts? Yes No As Agent, do you have knowledge or reason to believe that replacement of existing Insurance/Annuities may be involved? If Yes, agent must provide and complete the appropriate replacement form. Print Agent s Name Agent s Signature Agent PC Number, SSN, or TIN Telephone Number Address List name and Personal Code of all agents, besides yourself, entitled to any commission with appropriate percentage. Agent Personal Code % Agent Personal Code % ADDITIONAL REQUIRED FORMS For Systematic Withdrawals, complete Form Annuity Service Request Form and submit with application. For Required Minimum Distribution Requests, complete Form IRA/TSA Required Minimum Distribution Election Request and submit with application. For Lifetime Income Rider withdrawals, complete Form Lifetime Income Rider Request Form and submit with application. (For ANICO Strategy Index Annuity only) For TSA-403(b) plans, an Information Sharing Agreement must be submitted with application. For additional beneficiary designations, complete Form Additional Beneficiary Page and submit with application. For Non-Qualified 1035 Exchanges, complete Form 4394-NQ - Non-Qualified 1035 Exchange Request and submit with application. For Qualified Transfers or Rollovers, complete Form 4394-Q - Qualified Transfer or Rollover Request and submit with application. Form R10039 AMERICAN NATIONAL INSURANCE COMPANY RV 04-10

8 page 4 of 4 *PRCT* Premium Receipt American National Insurance Company One Moody Plaza, Galveston, Texas Valid only for an annuity and for the premium amount shown in the application paid for an annuity. Received from this day of year the sum of ($ ) in cash as premium on an annuity on the life of for which an application has been made to this company, bearing the same number and date as this receipt. Signature of soliciting agent Print agent s name The company accepts payment by check, draft, or money order subject to its being honored upon presentation. Checks, drafts, or money orders must be made payable to American National Insurance Company. Do not leave payee blank or make payable to agent. Form R10039 AMERICAN NATIONAL INSURANCE COMPANY RV 04-10

9 American National Insurance Company One Moody Plaza, Galveston, TX Disclosure Statement for the ANICO Equity Index Annuity This document reviews important points to think about before you buy this American National Insurance Company annuity. It is a single premium deferred annuity which means you buy it with one premium. This annuity is tax-deferred, which means you don t pay taxes on the interest it earns until the money is paid to you. This annuity can earn interest that depends on how the S&P 500 Index performs. You can use this annuity to save 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 questions about this annuity, please contact your agent, broker or advisor, or contact a company representative at THE ANNUITY CONTRACT How will the value of my annuity grow? The value in your annuity contract is called its annuity value. When your contract is issued, the amount of your annuity value is your initial premium. On the date your ANICO Equity Index Annuity is issued, your contract will receive a specified rate, which will be effective for the initial six-year term of the contract. At the end of your first contract year, a comparison will be made of the S&P 500 Index as of the issue date of your contract to the S&P 500 Index at the end of that first year. If the S&P 500 Index has increased or remains the same, i.e., zero gain, the specified rate is credited to your contract. If the S&P 500 Index is down, your annuity value remains the same. This comparison occurs at the end of each contract year of the initial six-year term. There will never be a negative index charge to the annuity, although you could earn 0% interest. A new non-indexed interest rate will be declared for each contract year after the initial six-year term. After the first contract year, your annuity value equals the initial premium, plus any index credits and interest credits, minus any partial surrenders and their applicable surrender charges. Past performance of the Index is no guarantee of future results. BENEFITS How do I get income (payments) from my annuity? After the surrender charge period (6 years) you may elect to receive the proceeds of your annuity in a lump sum or in a series of payments. We offer a variety of income payment options, including options that will pay you an income guaranteed for life. Your financial advisor can help you make the right choice for your needs at the time you elect to receive your annuity proceeds. After your first contract year, you can withdraw up to 10% of your Annuity Value, as of the beginning of your second contract year, without any surrender charges. You may want to seriously consider other options before exercising this privilege. Any amount withdrawn in excess of 10% is subject to a surrender charge. Continued on reverse side... Please retain this page for your records Form 9321 Page 1 of 4 Rev. 10/09

10 What happens after I die? This annuity provides a benefit upon the death of the owner (if prior to distribution) of the annuity to the beneficiary named in the contract. The Company will pay the greater of the Annuity Value or the Surrender Value upon receipt of proof of death. If death occurs before the end of the Initial Term, an Index Credit will be added to the Annuity Value as of the date of death if there has been an Index Gain between the beginning of the contract year and the date of death. If the Annuitant is not the Owner and dies before the Maturity, this contract will terminate. We will pay the Death Benefit to the Beneficiary. If the Annuitant dies after distribution under a Settlement Option has begun and before the guaranteed payments, if any, have been paid, any remaining payments will continue at least as rapidly as under the method of distribution in effect at the Annuitant s death. Such payments will be paid to the Beneficiary. FEES, EXPENSES & OTHER CHARGES What happens if I take out some or all of the money from my annuity? Surrender Charges If you should decide to surrender your contract in the first 6 years. These surrender charges, which are expressed as a percentage of your annuity value, are as follows: Contract Year 1st 2nd 3rd 4th 5th 6th 7th Surrender Charge 8% 8% 7% 6% 4% 2% 0% Surrender charges may be waived in the event of disability or confinement to a licensed treatment facility. See Waiver of Surrender Charges (Form 10256) or the contract (Form REIA-NQ,PQ; GREIA-NQC,PQC; ROP-EIA) for complete details about these waivers. TAXES How will payments and withdrawals from my annuity be taxed? Federal income tax on annuity earnings is deferred until distributions are taken. Distributions taken before age 59½ are subject to a 10% penalty tax unless an exception applies. If your state imposes a premium tax, it may be deducted from the money you receive. Income received under a settlement option is treated as part income (taxable) and part return of basis (not taxed). Additional rules apply Continued on next page... Please retain this page for your records Form 9321 Page 2 of 4 Rev. 10/09

11 to qualified annuities. Consult your tax advisor or tax attorney for your specific circumstances. Also, if you place your annuity in a tax-qualified retirement plan such as an IRA, you will receive no additional tax advantage from the annuity. Therefore, before purchasing an annuity for a taxqualified plan, you should carefully consider the annuity s other features before making your decision. OTHER INFORMATION What else do I need to know? This annuity is designed for people who are willing to let their assets build for at least 6 years. This annuity does not participate directly in any stock or equity investments. You aren t buying shares of stock or an index. Dividends paid on the stocks on which the indexes are based don t increase your annuity earnings. We may change your annuity contract from time to time to follow federal or state laws and regulations. If we do, we ll tell you about the changes in writing. We pay the agent, broker, or firm for selling the annuity to you. After you receive your contract, you have a number of days to review your annuity contract. During that period, if you decide against the purchase, you can return the contract and receive a complete refund of your premium. What should I know about the insurance company? Established in 1905, American National Insurance Company has been a consistent source of financial strength and long term planning which has earned the respect of its policyowners. American National s financial strength and operating integrity have positioned it as a leader in the insurance industry. American National offers innovative insurance and related financial products, customer-focused service, and ranks among the larger life insurance companies in the United States. For more information, please visit our website: This Disclosure Statement is not intended to be a complete explanation of your contract. Please read your contract carefully for more complete details. The ANICO Equity Index Annuity may not be available in all states. Contact your agent or American National Insurance Company with any questions. Continued on next page... Please retain this page for your records Form 9321 Page 3 of 4 Rev. 10/09

12 American National Insurance Company One Moody Plaza, Galveston, TX Disclosure Statement for the ANICO Equity Index Annuity Owner/Annuitant s Statement I confirm that: I am purchasing an ANICO Equity Index Annuity from American National Insurance Company I have read the ANICO Equity Index Annuity Product Brochure I have read the ANICO Equity Index Annuity Disclosure statement and have kept a copy I understand that: Purchasing the ANICO Equity Index Annuity does not give me ownership in a stock or index Past performance of the Index is no guarantee of future results. The Index may lose value, and I may receive only the Minimum Guaranteed Surrender Value Minimum Guaranteed Surrender Values are not related to the Index The ANICO Equity Index Annuity has surrender charges for early surrenders prior to the end of the 6 year initial term. Name of Annuitant Signature of Owner Signature of Joint Owner For the agent: I certify receipt of $ 1035 Exchange Transfer of Funds given to purchase an ANICO Equity Index Annuity contract. I certify that the product brochure and disclosure material has been presented and explained to the Annuitant/ Owner and a copy provided to the Annuitant/Owner. I have not made any statements that differ from this material, nor have I made any promises about the expected future values of this contract. Signature of Agent Agent PC Number, SSN, or TIN (you must provide one) Information provided is not intended to be legal or tax advice. You should consult with your attorney or tax advisor for your specific circumstances. Standard & Poor s, S&P, S&P 500, and Standard & Poor s 500 TM are trademarks of Standard & Poor s Financial Services LLC ( Standard & Poor s ) and have been licensed for use by American National Insurance Company. The ANICO Equity Index Annuity is not sponsored, endorsed, sold or promoted by Standard & Poor s and Standard & Poor s makes no representation regarding the advisability of purchasing the ANICO Equity Index Annuity. This disclosure is intended to be used with Form REIA-NQ,PQ; GREIA-NQC,PQC; ROP-EIA Not FDIC/NCUA insured Not a deposit Not insured by any federal government agency No bank/cu guarantee May lose value White - Home Office Copy Pink - Client Copy Yellow - Agent Copy Form 9321 Page 4 of 4 Rev. 10/09

13 Non-Qualified 1035 Exchange Request Issued by American National Insurance Company One Moody Plaza, Galveston, TX page 1 of 2 *1035* Complete this form for Non-Qualifi ed Accounts Only 1. FUNDS COMING FROM: CHECK ONE: NEW SALE, APPLICATION ATTACHED ADDITIONAL DEPOSIT TO EXISTING POLICY NUMBER TRANSFER COMPANY NAME AND ADDRESS: TRANSFER COMPANY PHONE NUMBER: NAME OF INSURED/ANNUITANT*: SSN: NAME OF OWNER: SSN: NAME OF JOINT OWNER: SSN: POLICY/ACCOUNT NUMBER WITH TRANSFER COMPANY: 2. TYPE OF TRANSACTION: *JOINT ANNUITANTS ARE ONLY ACCEPTED ON SPIA s* I/We direct the Institution named above to liquidate and transfer the assets to American National in order to set up a Non-Qualifi ed account: (MUST SPECIFY:) Immediately Upon Maturity / / 1035 Exchange, Non-Qualifi ed Policy Non-1035 Exchange, Non-Qualifi ed Funds From: Mutual Fund, Bank CD, or Other Non-Qualifi ed Asset. Full 1035 Exchange The Assignor hereby designates American National Insurance Company as benefi ciary of the above policy/contract. Immediately following the above benefi ciary designation, Assignor does hereby assign and transfer without exceptions, limitations or reservation to American National Insurance Company all assignable benefi ts, interest, property, rights, claims, options, privileges, obligations and title in the policy/contract in exchange for a new policy/contract as described in Assignor s application to American National Insurance Company for such policy/contract. Assignor and American National Insurance Company expressly represent and recognize that the sole purpose of this assignment is to affect an exchange of insurance policies/contracts. Assignor represents and agrees that Assignor has consulted his/her own tax advisor regarding the tax consequences of this transaction. Assignor represents and agrees that American National Insurance Company has made no representations concerning Assignor s tax treatment under Internal Revenue Code Section 1035 or otherwise as a result of this transaction. American National Insurance Company assumes no responsibility or liability for the assignor s tax treatment under Internal Revenue Code Section 1035(a) or otherwise as a result of this transaction. $ Partial 1035 Exchange I understand the Internal Revenue Service may take the position that an exchange of a portion of an existing life insurance policy/ contract for a new life insurance policy or an annuity contract, or the exchange of a portion of an existing life insurance or annuity contract for a new annuity contract, does not qualify as a valid exchange under Section 1035 of the Internal Revenue Code. I understand, acknowledge, and agree that American National assumes no liability or responsibility for any tax consequences associated with the proposed partial exchange. $ % Please complete the information below if 1035 Exchange includes loan value: $ Amount of 1035 Exchange $ Amount of loan included in 1035 Exchange (Not available with all products) Appropriate loan form must be submitted with the application if transferring loan value. Form 4394-NQ AMERICAN NATIONAL INSURANCE COMPANY RV 12-09

14 page 2 of 2 3. CONTRACT STATEMENT: CONTRACT INCLUDED If contract is not lost, please submit with this form. CERTIFICATE OF LOST CONTRACT I/We certify that the above numbered contract has been lost or destroyed and to the best of my/our knowledge and belief, is not in anyone s possession. 4. SPECIAL INSTRUCTIONS: 5. SIGNATURES: I/We agree that (1) American National is participating in this transaction at my specifi c request and as an accommodation to me: (2) American National and its representatives make no representation concerning treatment under IRC Section 1035(a) or otherwise; (3) American National assumes no responsibility nor any liability for the validity of this transaction or for the tax treatment under IRC Section 1035(a) and assumes that I/We consulted a tax advisor; (4) No person, fi rm, or corporation has a legal or equitable interest under the above referenced contract, except the undersigned, and no proceedings of either a legal or equitable nature have been instituted or are pending against the undersigned or involving the above referenced contract; and (5) the full-partial distribution from my existing contact may be subject to surrender charges. I/We authorize the transaction described above. For the benefi t of: at this day of, (City, State) Owner Witness Joint Owner Annuitant Agent Guarantee (if required) Witness 6. ACCEPTANCE: TO BE COMPLETED BY AMERICAN NATIONAL The authorized signature below certifi es acceptance of the assignment and surrender or transfer of funds as instructed in this request. After deducting any sums as are permitted under the plan, please complete this transaction and send a check with a copy of this form to: ANNUITY SERVICES DEPARTMENT VARIABLE CONTRACTS DEPARTMENT LIFE NEW BUSINESS American National Insurance Company American National Insurance Company American National Insurance Company P O Box P O Box P.O. Box San Antonio Tx San Antonio Tx San Antonio Tx If shipping via overnight service: If shipping via overnight service: If shipping via overnight service: American National Insurance Company American National Insurance Company American National Insurance Company Annuity Services Dept Variable Contracts Dept Life New Business 4500 Lockhill-Selma Road 4500 Lockhill-Selma Road 4500 Lockhill-Selma Road San Antonio Tx San Antonio Tx San Antonio Tx PLEASE MAKE CHECK PAYABLE TO: AMERICAN NATIONAL By (Signature/Title) FOR ALL 1035 EXCHANGES, PLEASE PROVIDE THE COST BASIS INFORMATION FOR THE CURRENT POLICY. Form 4394-NQ AMERICAN NATIONAL INSURANCE COMPANY RV 12-09

15 Qualified Transfer or Rollover Request Issued by American National Insurance Company One Moody Plaza, Galveston, TX page 1 of 3 *1035* Complete this form for Qualifi ed Accounts Only 1. FUNDS COMING FROM: CHECK ONE: NEW SALE, APPLICATION ATTACHED ADDITIONAL DEPOSIT TO EXISTING POLICY NUMBER TRANSFER COMPANY NAME AND ADDRESS: TRANSFER COMPANY PHONE NUMBER: NAME OF INSURED/ANNUITANT*: SSN: NAME OF OWNER*: SSN: POLICY/ACCOUNT NUMBER WITH TRANSFER COMPANY: *ANNUITANTS AND OWNER MUST BE THE SAME* 2. COMPLETE THIS SECTION FOR TRANSFER REQUESTS AND DIRECT ROLLOVER REQUESTS: Total, Full Liquidation $ Partial, % or $ Annuitization, Term: Frequency of Payments: Please send these funds to American National Insurance Company Immediately Upon Maturity / / 3. COMPLETE THIS SECTION FOR TRANSFER REQUESTS: IRA/TSA Transfer into an annuity contract of the same qualifi cation type (i.e. TSA, IRA, or both ROTH IRA) As owner of the account or policy indicated in Section 1, I hereby request transfer of: Tax-Sheltered Annuity (IRC Section 403(b)) ROTH I.R.A. or Annuity (IRC Section 408) Individual Retirement Account or Annuity (IRC Section 408) SEP IRA Governmental 457 Deferred Compensation Plan By signing below, I authorize the transfer of the IRA assets in the manner described above and certify that all of the information provided by me is correct and may be relied upon by the Trustee or Custodian. I understand that I am responsible for determining my eligibility to transfer within the limits set forth by tax laws, related regulations, and plan agreements. I assume responsibility for any tax consequences or penalties that may apply to the transfer of my assets. Owner s Signature Witness Signature Agent s Signature Form 4394-Q AMERICAN NATIONAL INSURANCE COMPANY RV 12-09

16 page 2 of 3 4. COMPLETE THIS SECTION FOR DIRECT ROLLOVER REQUESTS: Direct Rollover into a Traditional IRA, 403(b) Plan, 457(b) Plan, or other qualifi ed plan. As owner of the account or policy indicated in Section 1, I hereby request a direct rollover of my: Individual Retirement Annuity (IRC Section 408) Tax-Sheltered Annuity (IRC Section 403(b)) Governmental 457 Deferred Compensation Plan Qualifi ed Employer Plan (IRC Section 401) SEP IRA ROTH IRA into an Individual Retirement Annuity (IRC Section 408) Tax-Sheltered Annuity (IRC Section 403(b)) Governmental 457 Deferred Compensation Plan SEP IRA ROTH IRA I understand the rules and conditions applicable to direct rollovers and certify that I qualify for a direct rollover of the funds or assets listed above. Due to the important tax consequences of rolling funds over to an IRA or other qualifi ed plan, I have been advised to see a tax advisor. I hereby request payment from the plan designated above in the form of a direct rollover. I assume full responsibility for this direct rollover transaction and will not hold the Plan Administrator, Trustee, or Custodian of either the distributing or receiving plans liable for any adverse consequences that may result. I hereby irrevocably designate this contribution of funds and/or property indicated above as a direct rollover contribution. Owner s Signature Witness Signature Agent s Signature 5. CONTRACT STATEMENT: CONTRACT INCLUDED If contract is not lost, please submit with this form. CERTIFICATE OF LOST CONTRACT I certify that the above numbered contract has been lost or destroyed and to the best of my knowledge and belief, is not in anyone s possession. 6. REQUIRED MINIMUM DISTRIBUTION (RMD) INFORMATION: If you have attained age 70½, the IRS requires annual minimum distribution from your qualifi ed account(s). If this rollover is being made during or after the fi rst year for which you must take a required minimum distribution, you may not roll over any distribution, which would constitute a required minimum distribution from the distributing plan. 7. SPECIAL INSTRUCTIONS: 8. ACCEPTANCE OF FUNDS: TO BE COMPLETED BY AMERICAN NATIONAL This is to certify that American National Insurance Company will accept the funds to establish a qualifi ed annuity. Please do not withhold any taxes from the amount being transferred. ANNUITY SERVICES DEPARTMENT VARIABLE CONTRACTS DEPARTMENT LIFE NEW BUSINESS American National Insurance Company American National Insurance Company American National Insurance Company P O Box P O Box P.O. Box San Antonio Tx San Antonio Tx San Antonio Tx If shipping via overnight service: If shipping via overnight service: If shipping via overnight service: American National Insurance Company American National Insurance Company American National Insurance Company Annuity Service Dept Variable Contracts Dept Life New Business 4500 Lockhill-Selma Road 4500 Lockhill-Selma Road 4500 Lockhill-Selma Road San Antonio Tx San Antonio Tx San Antonio Tx PLEASE MAKE CHECK PAYABLE TO: AMERICAN NATIONAL By (Signature/Title) Form 4394-Q AMERICAN NATIONAL INSURANCE COMPANY RV 12-09

17 page 3 of 3 DEFINITIONS QUALIFIED RETIREMENT PLANS Tax-qualifi ed retirement plans may include pension, profi t-sharing plan, 401(k), 403(b) Tax Sheltered Annuity (TSA), Simplifi ed Employee Pension (SEP) Plan, Keogh, Traditional or Roth Individual Retirement Account (IRA). TRUSTEE-TO-TRUSTEE/DIRECT ROLLOVER TRANSFERS The TRUSTEE-TO-TRUSTEE transfer is the transfer of funds from one Qualifi ed Retirement Plan to another Qualifi ed Retirement Plan. A DIRECT ROLLOVER is the movement of funds from and Employer s Qualifi ed Retirement Plan directly to an IRA with a new trustee. In both instances, the plan participant does not take actual or constructive receipt of the funds, and the check is made payable and sent to the new trustee. Trustee-to-trustee transfers are non-reportable events. Direct rollovers are reported to the IRS by the employee plan trustee and coded as a direct rollover. Both the trustee-to-trustee transfers and the direct rollovers are different than 60-day rollovers in that the IRS allows more than one transfer/direct rollover within a year. Direct rollovers are not subject to mandatory tax withholding. NOTE If a lump-sum distribution of funds is taken from a tax-qualifi ed employee retirement benefi t plan and the plan participant does not choose to use a direct rollover, the employer could be required to withhold 20 percent (20%) for taxes. For this reason, direct rollovers are the preferred method of moving tax-qualifi ed employee retirement benefi t plan funds. 60-DAY ROLLOVERS A tax-qualifi ed 60-day rollover is the tax-free transfer of funds from one Qualifi ed Retirement Plan to another Qualifi ed Retirement Plan with the participant taking actual or constructive receipt of the funds. The check is made payable to the plan participant. The plan participant has 60 days to deposit these funds into another Qualifi ed Retirement Plan or the distribution will be taxable. Plan participants can make one 60-day rollover of funds within a 12-month period. A tax-qualifi ed 60-day rollover from a tax-qualifi ed plan could be subject to mandatory tax withholding by the plan. Policy may be referred to as contract or certifi cate in some states. Form 4394-Q AMERICAN NATIONAL INSURANCE COMPANY RV 12-09

18 USA Patriot Act Notification and Customer Identification Verification Issued by American National Insurance Company One Moody Plaza, Galveston, TX page 1 of 1 *USA* 1. Client Name Application or Policy Number Source of Funds W-2 Wages Investments Social Security or Pension Savings another insurance contract Other (please explain) USA PATRIOT Act Notice to be read by or to customer. 2. The USA PATRIOT Act requires that we establish an Anti-Money Laundering ( AML ) Program, notify customers that we must verify the identity of the owner(s) of our contracts, and collect documents and information suffi cient to provide such verifi cation. You should know that failure to provide the requested identifi cation will result in delays in the issuance of the requested coverage and may result in a decision not to accept your business. Customer Identification Verification In order to satisfy such obligations, we require our representative to review and verify a current government issued photo ID for each Owner/Trustee/Partner associated with a contract. Information on such identifi cation must be recorded below. We may use third party sources to verify the information provided. a. Identification Verified (One for each Owner/Trustee/Partner. Use additional forms if necessary.) Owner/Trustee/Partner Joint Owner/Trustee/Partner Check one form of ID: Check one form of ID: Driver s license Driver s license Resident Alien ID (Green Card) Resident Alien ID (Green Card) Passport Passport Other: (Describe) Other: (Describe) The following information should be recorded exactly as it appears on the identification reviewed Name of Birth Name of Birth Street Address (not PO Box) Street Address (not PO Box) City, State, Zip City, State, Zip Number on ID State or Country Number on ID State or Country Identifi cation Expiration Identifi cation Expiration b. Entity Verification: Check the appropriate entity as listed below and submit copies of documentation viewed to gain fi rst-hand knowledge of the existence of a legitimate business. If the Owner is a minor or non-legal entity, review the identifi cation of the individual who submits an application on behalf of the minor or non-legal entity. Corporation, LLC, professional association, or professional corporation: Articles of Incorporation, Organization or Association or similar document fi led in the state in which the entity is formed Limited Partnership: Certifi cate of Limited Partnership or similar document fi led in the state where the partnership is formed General Partnership or Joint Venture: Agreement, Joint Venture Agreement or similar agreement governing the formation and operation of the partnership Trust and All Other Entities: Document governing the formation and operation of the entity 3. I certify that I personally met with the proposed Owner(s)/Trustee(s)/Partners and reviewed the above identifi cation document. To the best of my knowledge, it accurately refl ects the identity of the proposed Owner(s)/Trustee(s)/Partners. I was unable to personally review the identifi cation documents for the reason stated below. I certify that, to the best of my knowledge, the information provided by the Owner(s)/Trustee(s)/Partners is true and accurate. Reason for not reviewing documents Note: Failure to personally review the identifi cation documents will result in processing delays in order to verify customer identity and may result in a decision not to accept the business. Representative Name Personal Code Representative Signature Form 4439 AMERICAN NATIONAL INSURANCE COMPANY RV 05-07

19 Suitability Acknowledgement Issued by American National Insurance Company P O Box 1763, Galveston, TX page 1 of 1 *SUIT* This form must be completed for each Consumer who is purchasing a fixed annuity. This form must be submitted to American National Insurance Company prior to the annuity being issued. 1 Owner/Applicant Information Owner/Applicant Name (please print) Social Security Number of Birth Joint Owner/Applicant Name (please print) Social Security Number of Birth COMPLETE EITHER SECTION 2 OR 3 If Section 2 and 3 are both signed the annuity will not be issued and a new form must be submitted. Complete only one section. Provide the appropriate information and return the completed form to the insurer at the address shown above. DO NOT COMPLETE IF SECTION 3 IS COMPLETED 2 Suitability Acknowledgement Acknowledgement of Responsibility for Suitability Recommendation to Consumers I have reasonable grounds for believing that the recommendation for this Consumer to purchase/exchange an annuity is suitable on the basis of the facts disclosed by the Consumer as to their investments and other insurance products and their financial situation and needs. I have made reasonable efforts to obtain information concerning the Consumer s financial status, tax status, investment objectives and such other information I considered reasonable in making the recommendation. Also, I agree to maintain and make available upon request to the insurer or the insurance commissioner records of the information collected and other information used as the basis for this insurance recommendation for a minimum of 5 years in most states and up to 10 years in certain other states, after the insurer completes the recommended transaction. Any process that accurately reproduces the actual document may be used to maintain these records. Agent Name (please print) Telephone # Agent/Producer Signature DO NOT COMPLETE IF SECTION 2 IS COMPLETED 3 Consumer s Acknowledgement of Responsibility I elect not to provide information my agent has requested related to the purchase or exchange of an annuity and/or; I have decided to enter into the purchase of a fixed annuity without a recommendation from my agent. Owner/Applicant Signature (or Trustee if owner is Trust) Joint Owner Signature (if any) Agent/Producer Signature Form 4466 AMERICAN NATIONAL INSURANCE COMPANY RV 02-08

20 Fixed Annuity Suitability Analysis Form Issued by American National Insurance Company One Moody Plaza, Galveston, TX page 1 of 2 *SUIT* This form must be completed for persons that are purchasing a fixed annuity. This form is designed to assist the agent and client in gathering information to determine whether the purchase of an annuity is suitable for the client. This form or other documentation that contains substantially the same information that the agent used in evaluating suitability and making a recommendation must be maintained in the agent s client file for a minimum of 5 years in most states and up to 10 years in certain other states, after the insurer completes the recommended transaction. Section 1 To be completed with your agent to determine if the proposed fi xed annuity purchase meets your fi nancial needs and objectives. A - Personal Identification Owner Full Name SS#/Tax ID # of Birth Age Joint Owner (if any) Full Name SS#/Tax ID # of Birth Age Marital Status: Married Single Occupation List Number of Dependents Dependent ages B - Financial Profile (For Joint Owners, information may be combined.) 1. Annual Gross Income $0-29,999 $30,000-49,999 $ 50,000-74,999 $75,000-99,999 $100, ,999 $150, ,999 $250, ,999 $400,000 - Over 2. Source of Income (Check all that apply) Salary (W 2) Investments Social Security Pension Plans Other 3. What type of investments and insurance products do you own? Mutual Funds Stocks Bonds CDs Savings Account(s) Life Insurance Other Annuities 4. What type of life insurance or other annuities do you own? 5. Estimated Net Worth (Exclude primary residence, furnishings, automobiles.) $0-74,999 $75, ,999 $150, ,999 $250, ,999 $500, ,999 $1,000,000 - Over 6. Liquid Net Worth (After purchasing this annuity - These are assets that can be easily converted to cash without incurring penalty charges.) Under $10,000 $10,000-25,000 $25,000-50,000 $50, ,000 Over $100, Why are you purchasing this annuity? (Check all that apply): Income Stable Growth Tax Deferral Estate Planning Safety of Principal Retirement Other Form 4467 AMERICAN NATIONAL INSURANCE COMPANY RV 07-09

21 page 2 of 2 8. After the purchase of the annuity, will your income and liquid net worth be enough for living expenses and emergencies? Yes No (Many financial planners recommend that a person maintain an amount of liquid net worth equal to 3 to 6 months of a person s monthly living expenses in case of emergencies.) 9. With the exception of any surrender charge free withdrawal, do you expect to withdraw any money from this annuity before the end of the surrender charge period? Yes No If Yes, please explain. 10. What is your Federal Income Tax Bracket: 15% 28% 33% 38% 11. The agent has discussed with me whether an existing life insurance or annuity will be replaced in connection with the proposed sale of this annuity and whether surrender charges apply. Yes No 12. What source of funds will you use to buy this fixed annuity? Note to Producer: You should maintain in your files any other information you used or considered, not listed above, in making your recommendation. Section 2 - Representations and Signatures Complete Either A or B If Box A and B are both signed the annuity will not be issued and a new form must be submitted. Complete only one box. Do Not Complete if You Completed Box B A. I acknowledge that the fi xed annuity product I am applying for is a long-term contract with substantial penalties for early withdrawal. I believe that this product meets my fi nancial needs and objectives. Owner/Applicant Signature (or Trustee if owner is Trust) Joint-Owner Signature (if any) Agent s Acknowledgement: Based on information collected, I believe the purchase of this annuity is suitable. Agent/Producer Signature Do Not Complete if You Completed Box A B. I elect not to provide information in Section 1 B or answers to certain questions in Section 1 B and/or I have decided to purchase this fi xed annuity without a recommendation from my agent or the Company. I understand that the annuity is a long-term contract with substantial penalties for early withdrawal. I believe that this product meets my fi nancial needs and objectives. Owner/Applicant Signature (or Trustee if owner is Trust) Joint-Owner Signature (if any) Agent s Acknowledgement: The Owner(s) has not provided complete information and has decided to purchase this fi xed annuity without my recommendation. Agent/Producer Signature Form 4467 AMERICAN NATIONAL INSURANCE COMPANY RV 07-09

22 Important Notice Regarding Replacement of Life Insurance Issued by American National Insurance Company One Moody Plaza, Galveston, TX page 1 of 1 American National Insurance Company (ANICO) American National Life Insurance Company of Texas (ANTEX) *IRF* Our agent is recommending that you purchase a life insurance policy from us. In connection with this purchase, you have indicated either as a result of his recommendation or at your own initiative, that you may terminate or change your existing policy issued by our company or that you may obtain a loan from our company against your existing policy to pay premiums on the proposed policy. Any of these actions is a replacement of life insurance. This notice must be given to you, along with a Comparative Information Form which includes preliminary information comparing the proposed policy with your existing policy to be replaced. Please read this notice and the Comparative Information Form carefully. Whether it is to your advantage to replace your existing insurance coverage, only you can decide. It is in your best interest, however, to have adequate information before a decision to replace your present coverage becomes final so that you may understand the essential features of the proposed policy and of your existing insurance coverage. To this end, we are required to give you a Policy Summary including complete information on the proposed policy no later than when the policy is delivered to you. In addition, we will, at your request, furnish you additional information concerning your existing policy. You may want to discuss your purchase with other advisors. The information you receive will be of value to you in reaching a final decision. If either the proposed policy or the existing insurance you intend to replace is a participating policy you should be aware that dividends may materially reduce the cost of insurance and are an important factor to consider. Dividends, however, are not guaranteed. You should also recognize that a policy which has been in existence for a period of time may have certain advantages to you over a new policy. If the policy coverages are basically similar, the premiums for a new policy may be higher because rates increase as your age increases. Under your existing policy, the period of time during which our company could contest the policy because of a material misstatement or omission on your application, or deny coverage for death caused by suicide, my have expired or may expire earlier than it will under the proposed policy. You existing policy may have options which are not available under the policy being proposed to you or may not come into effect under the proposed policy until a later time during your life. Also, your proposed policy s cash values and dividends, if any, may grow slower initially because the company will incur the cost of issuing your new policy. On the other hand, the proposed policy may offer advantages which are more important to you. If you are considering borrowing against your existing policy to pay the premiums on the proposed policy, you should understand that in the event of your death, the amount of any unpaid loan, including unpaid interest, will be deducted from the benefits of your existing policy thereby reducing your total insurance coverage. After we have issued your policy, you will have twenty days from the date the new policy is delivered to you to cancel the policy issued on your application and receive back all payments you made to us. CAUTION If, after studying the information made available to you, you do decide to replace the existing life insurance with our company with a new life insurance policy issued by our company, you are urged not to take action to terminate or alter your existing life insurance coverage until after you have been issued the new policy, examined it and have found it acceptable to you. If you should terminate or otherwise materially alter your existing coverage and fail to qualify for the life insurance for which you have applied, you may find yourself unable to purchase other life insurance or able to purchase it only at substantially higher rates. I have received and read a copy of this Replacement Notice. (Signed) Form AMERICAN NATIONAL INSURANCE COMPANY RV 03-07