ANNUITY AGENT CONTRACT TRANSMITTAL FORM

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1 ANNUITY AGENT CONTRACT TRANSMITTAL FORM This form should be completed for: Any new agents being contracted by you, or Any changes you are requesting to an existing agent s commission level. Agents requesting a transfer to a new Marketing Organization This form must be included with each new agent contract or to request change of existing level. NEW AGENT/PRODUCER Full Name of Agent being contracted: Business Name (if different than Producer): Contract Level (e.g. MGA, GA, A10): Reports to: Agent # TRANSFER / CHANGE IN CONTRACT LEVEL Full Name of Agent: Agent # Business Name (if different than Producer): Agent # New Contract Level (e.g. MGA, GA, A10): Reports to: Agent s Signature (Required for Transfers) Agent # Date Marketing Organization Name (Please Print) Authorized Signature Date Mail to: EQUITRUST LIFE INSURANCE COMPANY ATTN: Agency Administration P.O. Box Des Moines, IA Fax to: FOR INTERNAL HOME OFFICE USE ONLY EquiTrust Life Insurance Company P.O. Box Des Moines, IA ET-3102 (11-14)

2 APPOINTMENT APPLICATION 1. Name: Date of Birth: Sex: M F (as it appears on your license) 2. Business Name: Please check box to indicate mailing address 3. Business Address: Street City County State Zip 4. Residence Address: Street City County State Zip Previous Residence: (if less than 5 years at present address) Street City County State Zip 5. Residence Phone: Business Phone: Fax: 6. Social Security Number: Taxpayer Identification Number: 7. CRD Number (if securities licensed): Broker/Dealer Name : 8. For which states do you wish non-resident appointment? (Attach copy of current license. Fees required for non-resident appointments) 9. Do you currently have a debit balance with any insurance company? Yes No (if yes give a company name and explanation below) Balance: $ 10. If you answer Yes to any of the questions below, please write details on a separate sheet of paper and attach to this application. a. Have you ever had your insurance license suspended or revoked?... Yes No b. Have you ever had a complaint filed against you with an insurance department?... Yes No c. Has any claim ever been made against you, your surety company, or errors and omissions insurer arising out of insurance sales, or have you been refused surety bonding?... Yes No d. Have you ever been convicted of a felony?... Yes No e. Have you ever been convicted of a misdemeanor, including but not limited to crimes involving dishonesty, breach of trust, or a violation of a federal law?... Yes No f. Have you ever been party to any litigation?... Yes No g. Are there any unsatisfied judgments outstanding against you?... Yes No 11. Errors and Omissions Coverage REQUIRED (Must provide a copy of the declaration page). AGENT S DECLARATION AND AUTHORIZATION 1) I hereby certify that all my answers to the above questions are true. I understand that this application will form a part of my Agent s Contract with EquiTrust Life Insurance Company (the Company) and the information is to the best of my knowledge an accurate statement of fact. I further understand that if any material information given in this application is found to be incorrect or incomplete, it will be grounds for contract termination for cause at the sole discretion of the Company. 2) Certification Under penalty of perjury, I certify that: a) The Social Security Number or Taxpayer Identification Number shown on this form is correct (or I am waiting for a number to be issued to me); b) 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 Service 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. Signature of Applicant: Date: ET-3200 (01-15) EquiTrust Life Insurance Company P.O. Box Des Moines, IA Page 1 of 2 Incomplete without all pages

3 AUTHORIZATION FOR DISCLOSURE OF PERSONAL INFORMATION AND CONSENT TO INVESTIGATIVE CONSUMER REPORT I have applied for appointment with EquiTrust Life Insurance Company (the Company ). To enable the Company to properly verify and evaluate my qualifications, I understand that the Company needs access to certain personal information about me. I hereby authorize any employer or former employer, any school, any police department or other law enforcement organization, any financial institution, any consumer reporting agency, or any other person or organization having information about me to furnish any insurance company affiliated with EquiTrust Life Insurance Company with any and all information that such person or organization has in its possession, including credit information. I further acknowledge that one or more investigative consumer reports may be made in which information about my character, general reputation, personal characteristics, and/or mode of living is obtained through personal interviews with individuals such as neighbors, friends, or associates of mine. I hereby acknowledge and consent to the Company obtaining and utilizing such reports in its decision to contract with me. I understand that I have the right to make a written request to the Company within a reasonable period of time for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation, and that I may obtain a summary of consumer rights upon request. I further authorize the Company to obtain a Vector One report in connection with this application. Vector One is a service that provides member insurance companies with information about debit balances. I certify that I have received from the Company all disclosures required by the Fair Credit Reporting Act. APPOINTMENT APPLICATION For Minnesota and Oklahoma Residents Only: If a consumer credit report is obtained, I understand that I am entitled to receive a copy. I have checked the box if I would like to receive a copy of a consumer report if one is obtained by the Companies. For California Residents Only: By signing below, I acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW. I have checked the box if I would like to receive a copy of an investigative consumer report or consumer credit report if one is obtained by Companies at no charge whenever I have a right to receive such a copy under California law. A photocopy of this authorization is as valid as an original. I specifically waive any written notice from any present or former employer who may provide information based on this authorization. I understand this authorization will become a part of a written appointment application. I acknowledge and agree that should I become associated with the Company in the position of agent, this Authorization shall remain valid and in effect and will allow Company to obtain such reports as Company deem necessary on an ongoing basis without any additional notice or consent during the term of such association. Signed: Print Name: Date of birth (for identification purposes only): Social Security Number (for identification purposes only): Please list all other names used in the past: Address: ET-3200 (01-15) EquiTrust Life Insurance Company P.O. Box Des Moines, IA Page 2 of 2 Incomplete without all pages

4 NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW EquiTrust Life Insurance Company (the Company ) intend to obtain information about you from an investigative consumer reporting agency for appointment purposes. Thus, you can expect to be the subject of investigative consumer reports and consumer credit reports obtained for purposes of your application for appointment. Such reports may include information about your character, general reputation, personal characteristics and mode of living. With respect to any investigative consumer report from an investigative consumer reporting agency ( ICRA ), the Company may investigate the information contained in your appointment application and other background information about you, including but not limited to obtaining a criminal record report, verifying driving record, and other information about you, and interviewing people who are knowledgeable about you. The results of this report may be used as a factor in making appointment decisions. The source of any investigative consumer report (as that term is defined under California law) or consumer report will be General Information Services, 917 Chapin Road, Post Office Box 353, Chapin SC 29036; ; The Company agree to provide you with a copy of an investigative consumer report when required to do so under California law. Under California Civil Code section , you are entitled to find out from an ICRA what is in the ICRA s file on you with proper identification as follows: In person, by visual inspection of your file during normal business hours and on reasonable notice. You also may request a copy of the information in person. The ICRA may not charge you more than the actual copying costs for providing you with a copy of your file. A summary of all information contained in the ICRA s file on you that is required to be provided by the California Civil Code will be provided to you via telephone, if you have made a written request, with proper identification, for telephone disclosure, and the toll charge, if any, for the telephone call is prepaid by or charged directly to you. By requesting a copy be sent to a specified addressee by certified mail. ICRAs complying with requests for certified mailings shall not be liable for disclosures to third parties caused by mishandling of mail after such mailings leave the ICRAs. Proper Identification includes documents such as a valid driver s license, social security account number, military identification card, and credit cards. Only if you cannot identify yourself with such information may the ICRA require additional information concerning your employment and personal or family history in order to verify your identity. The ICRA will provide trained personnel to explain any information furnished to you and will provide a written explanation of any coded information contained in files maintained on you. This written explanation will be provided whenever a file is provided to you for visual inspection. You may be accompanied by one other person of your choosing, who must furnish reasonable identification. An ICRA may require you to furnish a written statement granting permission to the ICRA to discuss your file in such person s presence.

5 FAIR CREDIT REPORTING ACT DISCLOSURE This is to notify you that in connection with your application for appointment as an agent with EquiTrust Life Insurance Company ( the Company ), you have authorized the Company to obtain a consumer report on you as part of the process of considering your agent appointment application. If information from the report is utilized in whole or in part in making an adverse decision, before making the adverse decision, the Company will provide you with a copy of the consumer report and a description in writing of your rights under the Fair Credit Reporting Act. The Company may also obtain an investigative consumer report including information as to your character, criminal history, creditworthiness, general reputation, personal characteristics and mode of living. You have the right to request, in writing, within a reasonable time, that the Company make a complete and accurate disclosure of the nature and scope of the information requested. The Company reserves the right to obtain an investigative consumer report now and at any time while you are contracted with the Company. PLEASE RETAIN FOR YOUR FILES EquiTrust Life Insurance Company Please Retain for your Files

11 ENTITY INFORMATION FORM CERTIFICATION AND INDEMNIFICATION AGREEMENT FOR AGENT/AGENCY USE Agent: Agent Number: Agency: Agency Number: ENTITY INFORMATION Please provide the following information regarding the entity: 1. Legal name of the entity: 2. Type of Entity: Sole Proprietorship General Partnership Limited Partnership Limited Liability Partnership Limited Liability Company Corporation S Corporation Other 3. Date of Formation: 4. Taxpayer Identification Number for the entity: 5. State of domicile: 6. Is the entity registered with a governmental body such as the Secretary of State, County Recorder, etc.? Yes No If so, where registered? 7. List individuals authorized to act on behalf of the entity: (Attach additional page if necessary) Name Title Address 8. Are there any limitations on the authority of the above-listed individuals to act with regard to products and services offered through EquiTrust Life Insurance Company. and its affiliated companies ( EquiTrust Life Companies )? Yes No If Yes, describe the limitations: If No is marked or if the boxes are left blank, EquiTrust Life Companies are authorized to act upon instructions from any of the individuals listed in #7. EquiTrust Life Insurance Company P.O. Box Des Moines, IA Phone Fax ET-AGT ENTITY-3503 (12-15) Page 1 of 2 Incomplete without all pages

12 REQUIRED: ATTACH THE FOLLOWING DOCUMENTATION FOR THE APPROPRIATE ENTITY TYPE Corporation (either C or S): Limited Liability Company: Limited Liability Partnership: Limited Partnership: Partnership: Other entities: Copy of filed Articles of Incorporation and any amendments Copy of filed Articles of Organization and any amendments Copy of filed Partnership Registration and any amendments Copy of filed Certificate of Limited Partnership and any amendments Copy of Partnership Document and any amendments Copy of Governing Documents and any amendments CERTIFICATION AND INDEMNIFICATION AGREEMENT The undersigned hereby certifies that the information provided in the Entity Information section above is true and correct, and that the entity has not been dissolved, modified, or amended in any manner which would cause above representations to be incorrect. EquiTrust Life Insurance Company and its affiliated companies 1 and each of their officers, directors, employees and agents, or the successors and assigns of any of them (collectively, the EquiTrust Life Companies ) are authorized to rely on the information set forth in this document until the EquiTrust Life Companies are notified of any change to said information in writing. Any changes are to be delivered to the EquiTrust Life Companies main office and will become effective as soon as the EquiTrust Life Companies have had a reasonable amount of time to act upon the changes. No change will affect any transactions initiated by the EquiTrust Life Companies before the change has become effective. The undersigned hereby agrees to personally indemnify and hold harmless the EquiTrust Life Companies from any and all liability, including attorneys fees, the EquiTrust Life Companies incur by acting upon instructions reasonably believed by any of them to be valid instructions originating from authorized individuals with respect to any policy, account, fund or similar instrument in which the entity listed above has an interest. Signed: Print Name: Title: Date: Signed: Print Name: Title: Date: 1 "Affiliated companies" shall include any company now in existence or that comes into existence that controls, is controlled by or is under common control with EquiTrust Life Insurance Company. "Controls" means the power to direct or cause to be directed the management or affairs of the applicable company. Affiliated companies shall also include any investment company which is managed by or advised by another affiliated company. ET-AGT ENTITY-3503 (12-13) EquiTrust Life Insurance Company P.O. Box Des Moines, IA Phone Fax Page 2 of 2 Incomplete without all pages

15 Avoid Commission Delays: Tips for Good-Order Applications ET-2510 (11-12) All Forms Never use whiteout on any of the forms Any correction to Agent Only information needs to be crossed out, initialed & dated by the agent Any correction to Client Only information needs to be crossed out, initialed, & dated by the client. Annuity Application Page 2 Section G May need Replacement form if required by your state Financial Needs Analysis Disclosure & Comparison Form Trust Certification Forms & When Trust is Owner Power of Attorney Signing as Owner Specific Forms for Florida, Clients 65 or Older Page 3 Section I & J Agent s signature in both sections Page 3 Section J If replacement Reason must be given Agent cannot write-in N/A in any location of this form. Page 1 Source of Funds if Other, must give location (i.e. Gift from Father, inheritance, savings, etc.) An IRA is not a source of funds Page 1 Section 1 Questions 2a & 2b Must be answered if yes to other replacements in question 2. Page 2 Section 2 Questions 4 Must complete for all Deferred Annuities If the answer to Question 4 is yes, Question 5 & 5a must be answered Page 2 Section 2 Question 10 Years of experience must be given Client needs to initial page 1 of the FNA form Surrender Charge Schedule Entire complete schedule must be given for Column A & Column B Do not write in dollar amount for What is Paid at Death Agent cannot write-in N/A in any location of this form Do not write in a dollar amount for question 3 Current Surrender Charge Trustee Certification Form Required All signatures of owner must include Ttee /trustee behind signatures Form must be notarized POA Certification Form Required All signatures of owner must include POA behind signatures Form must be notarized In addition to EquiTrust s Financial Needs Analysis form, clients 65 or older must complete Florida specific Annuity Suitability Questionnaire Clients 65 or older must use Florida specific Disclosure & Comparison for replacements Clients 64 or younger must use EquiTrust Disclosure & Comparison form for replacements EquiTrust Life Insurance Company 7100 Westown Pkwy Suite 200 West Des Moines, IA

LIFE IMC CONTRACT TRANSMITTAL. If Business is submitted with or prior to a contracting application or contract change please indicate below:

LIFE IMC CONTRACT TRANSMITTAL. If Business is submitted with or prior to a contracting application or contract change please indicate below: LIFE IMC CONTRACT TRANSMITTAL *O2681IMCC* *O2681IMCC* Agent : Agent Code (if known): If Business is submitted with or prior to a contracting application or contract change please indicate below: c Pending