Annuity Processing Procedures

Transcription

1 GREAT SOUTHERN FINANCIAL SERVICES 2609-B East Sunshine, Springfield, MO (417) Annuity Processing Procedures Please contact the following with product info, rate questions, or insurance rate quotes. Marketing Financial (417) or (800) Please contact the following with annuity processing questions. Great Southern Investment Dept ~ Laura Smith (417) or Tabatha Wynn (417) BEFORE YOU WRITE NEW BUSINESS: If you are unsure if you are appointed with a particular company, you may not be. Most companies require pre-appointment & product training prior to presenting their products. Anti-Money Laundering Training is a requirement. Please contact Tabatha Wynn Please call Laura, Tabatha or Marketing Financial prior to dating any annuity company forms if you're unsure. REQUIREMENTS: Please use the Investment Dept address/phone # for all agent/bc contact info. NEW BUSINESS FORM GSB doc CUSTOMER INVESTMENT & SUITABILITY CONFIRMATION WORKSHEET GSB doc ANNUITY COMPANY FORMS when in doubt fill it out or contact one of us. OFAC printed the day of the application OFAC signed & dated by agent. Owner(s) IDs -- 2 current forms of 1 primary/1secondary owner(s) must be provided to GSB Investment Dept. with all applications (please follow GSB identification guidelines). ANNUITY COMPANY TRANSFER FORM Provide a copy to Great Southern CD/IRA Dept (if funds are from a GSB CD/IRA). SPRINGFIELD, MO LOCATIONS: Dispatch all required documents to the Investment Dept. Attn: New Business. ALL OTHER LOCATIONS: PLEASE DO NOTUSEWHITE OUT ON ANY COMPANY FORMS. HAVE OWNER S INITIALS & DATE ALL CORRECTIONS. Dispatch all required documents to Investments for business written the day of your dispatch pick up. Mail all required documents via overnight UPS or FedEx to Investments. Please drop in the nearest UPS or FedEx store or drop box if possible. UPS Account # 8W4W69 Shipping account numbers are to be used for investment dept new annuity business only. Please contact Tabatha or Laura for pre-printed labels & all other shipping questions. Please note: pre-printed UPS labels with barcodes may be associated to the wrong UPS account. Please review regularly for rate changes, etc. REV March 2015

2 2609-B East Sunshine, Springfield, MO (417) New Business Form Client Name(s): Owner's age(s): BC #/State: / Writing Agent Name: Split Commission with: (if applicable): Referred by: Commission Split %: Funds Info: Internal Funds (GSB) External Funds Check Enclosed: $ Qualified (CD/IRA, 401K, etc) Non-Qualified (Checking, CD, etc) Transfer(s) Approx: $ Qualified (CD/IRA, 401K, etc) Non-Qualified (Checking, CD, etc) Company Name ex: Sagicor Product Name ex: Sage Choice SPDA Surrender Charge Period (years) 1035 Exchange (NQ life/annuity) Approx: $ Agent Check List: New Business Non-Qualified - Life/Annuity to Life/Annuity Application 1035 Exchange Form Disclosures State Replacement Form Owner's ID Original Policy or Lost Policy Affidavit Owner's OFAC Cashier's/Personal Check Payable to Company IRA Annuity to IRA Annuity IRA Trsf Form IRA Trsf/Rollover Replacement Form IRA Trsf Form Original Policy or Lost Policy Affidavit Company Specific Forms (401K) W-9 (funds coming from Lincoln Benefit Life ) Agent's Report - Source of Funds: (MUST BE COMPLETED) 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 (Laura M. Smith): Date: Date: REV

3 Great Southern Bank doing business as Great Southern Financial Services 2609-B East Sunshine Springfield MO Date Owner Name Joint Owner Name Company/Product owner(s) Initials Disclosures Not FDIC Insured. Not a deposit or other obligation of Great Southern Bank. It is understood that if the contract is prematurely ended by the client, surrender charges will apply for the first years. Any money taken out of this contract in excess of the penalty free withdrawal amount provided in the contract during the surrender charge period will incur a penalty. The minimum guaranteed interest rate for the contract is %. The first year rate is % which includes a bonus of %. (Does not apply to indexed annuities.) If there are any surrender charges or penalties of any kind associated with the money used to purchase this annuity please list the amount of penalty: $. This contract was purchased with Qualified or Non-Qualified funds (Please circle which applies.) signatures Owner Joint Owner Agent Not FDIC insured Not a deposit May lose value No bank guarantee Not insured by any federal agency 06-15

4 Application for Annuity Issued by American National Insurance Company One Moody Plaza, Galveston, TX ANNUITANT Name: Last First M.I. Gender U.S. Citizen M F Yes No Date 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 Date of birth Age SSN TIN EIN Daytime telephone ( ) Address City State ZIP *APP* page 1 of 4 Overnight Address: American National Insurance Company, Mail Processing Center, Attn: Annuity 10427, 1949 E. Sunshine St., Springfield, MO Mailing Address: P.O. Box 10427, Springfield, MO Phone Number: 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 Date 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 Date 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 Date 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 Date 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-AR AMERICAN NATIONAL INSURANCE COMPANY RV 09-13

5 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 PLUS Use Supplemental Application Form for this section 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 Date 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 Date 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 presents a false or fraudulent claim for payment of a loss of benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. 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. Dated 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-AR AMERICAN NATIONAL INSURANCE COMPANY RV 09-13

6 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 ASIA Plus 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. For ASIA Plus, Complete Form Supplemental Application Strategy Plus Index Annuity and submit with application. Form R10039-AR AMERICAN NATIONAL INSURANCE COMPANY RV 09-13

7 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-AR AMERICAN NATIONAL INSURANCE COMPANY RV 09-13

8 Disclosure Statement for Lifetime Income Riders ANICO Strategy Plus 7 and Plus 10 Indexed Annuity Issued by American National Insurance Company One Moody Plaza, Galveston, TX page 1 of 6 There are two Lifetime Income Riders that can be added to the ANICO Strategy Plus 7 Indexed Annuity or the ANICO Strategy Plus 10 Indexed Annuity at issue. We want to make sure you understand the benefit a Lifetime Income Rider provides. The following is a brief summary of the Lifetime Income Riders. The exact provisions, limitations, terms and conditions are detailed in the Rider. You may apply for either Lifetime Income Rider, or no Rider at the time you apply for your annuity contract. You cannot apply for either Lifetime Income Rider once your annuity contract has been issued. Please note that there is a cost associated with each Rider. The maximum rider issue age is 80. If you have questions about the Lifetime Income Riders, please contact your agent, broker or advisor, or contact a company representative at For more information, please visit our website: LIFETIME INCOME RIDERS The Lifetime Income Riders guarantee to pay the contract owner an income equal to a percentage of the Income Base. The Lifetime Income Riders further guarantee that an income will be payable for life, even if the Annuity Value declines to zero. The Lifetime Income Riders available are: Lifetime Income Rider with a Fixed Rate Lifetime Income Rider with a Fixed Rate Plus Index Credit The income percentage depends upon the attained age at which the owner elects to begin receiving income. Once the owner elects to begin receiving income, the income percentage will remain the same in all years until the Rider terminates. The owner can elect to begin receiving income after the Income Benefit Waiting Period, as shown in the Rider Data Section, and the owner has attained the Minimum Age for Income Withdrawal (in cases of joint spousal owners, the younger owner.) Joint owners must be spouses. If you are a single owner, you may elect whether your income percentage will be based on a single life age or a joint life age. If you elect a joint life age, the joint life must be your spouse. If you and your spouse are joint owners, then your income percentage will be based on a joint life age. A chart detailing the single life age income percentages and the joint life age income percentages follows: Continued on reverse side Please retain this page for your records. Form AMERICAN NATIONAL INSURANCE COMPANY RV 03-15

9 page 2 of 6 Single Life Income Joint Life Income Age (when Percentage Age (when Percentage income begins) income begins) % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % Continued on next page Please retain this page for your records. Form AMERICAN NATIONAL INSURANCE COMPANY RV 03-15

10 page 3 of 6 Here s how the Lifetime Income Riders work: You, as owner of the contract, decide when income payments start, but they cannot start until after the Income Benefit Waiting Period, and the owner has attained the Minimum Age for Income Withdrawal (in cases of joint spousal owners, the younger owner.) On the issue date of a Lifetime Income Rider, the Income Base is equal to the Premium received plus any Rider Premium Enhancement. The Income Base will be credited an Income Base Growth Rate during the Income Base Growth Period, and index credit if applicable, until the owner starts to take income. The Income Base Growth Rate is and is shown in the data section of your contract. The Income Base Growth Period is years and is shown in the data section of your contract. If you take any excess withdrawals during the Income Base Growth Period the Income Base will be reduced. The accumulation of interest at the Income Base Growth Rate and any applicable index credit will stop once the owner starts to take income under a Lifetime Income Rider. A Lifetime Income Rider guarantees income payments for the life of the contract. All income payments received under the Rider reduce the Annuity Value, Surrender Value, Death Benefit, and the 10% Surrender Charge Free Withdrawal Privilege. Income payments received do NOT reduce the Income Base. Income payments will continue even if the Annuity Value is zero. If you have taken excess withdrawals during the year that exceed the Rider income amount, then the Income Base, and all future income payments, will be reduced downward. The reduction is calculated using a pro rata method in proportion to the Annuity Value. You can elect to receive less than the income amount in any year. However, any income amounts not taken cannot be added to the income payment amount in future years. The Income Base cannot be withdrawn in a lump sum. When you elect to start income payments, if the Annuity Value is greater than the Income Base, the Income Base will be increased to the Annuity Value. Hypothetical Examples for Income Base These Hypothetical Examples are for illustrative purposes only and are not a guarantee of any specific results. The values used are hypothetical and not based upon historical performance of the S&P 500. These Hypothetical Examples assume no excess withdrawals were made from the Annuity Value during the Income Base Growth Period, and that no income payments have begun under a Lifetime Income Rider. Lifetime Income Rider with a Fixed Rate Hypothetical Example Income Base = Premium x (1+Rider Premium Enhancement) ^ (Minimum of number of years since annuity contract was issued and Income Base Growth Period) Assumptions: Premium Received: $100, Rider Premium Enhancement: None Income Base Growth Rate: 7% Income Base Growth Period: 10 years Income Base at Issue: $ 100, ($100, x (1.00)) Income Base at End of Contract Year 1: $ 107, ($100, x (1.00) x (1.07) ^ 1)) Income Base at End of Contract Year 5: $ 140, ($100, x (1.00) x (1.07) ^ 5)) Income Base at End of Contract Year 12: $ 196, ($100, x (1.00) x (1.07) ^ 10)) Income Base at End of Contract Year 15: $ 196, ($100, x (1.00) x (1.07) ^ 10)) Continued on reverse side Please retain this page for your records. Form AMERICAN NATIONAL INSURANCE COMPANY RV 03-15

11 page 4 of 6 Lifetime Income Rider with a Fixed Rate Plus Index Credit Hypothetical Example Assumptions: Annuity Issue Date: Premium: $150, $50,000 to the Declared Rate Strategy $50,000 to an indexed strategy with a one-year Segment Term $50,000 to an indexed strategy with a three-year Segment Term Rider Premium Enhancement: None Income Base Growth Rate: 4% Income Base Growth Period: 10 years Interest credited on the portion in the Declared Rate Strategy: $ 1, Segment Earnings for indexed strategy with a one-year term on : $ 2, Segment Earnings for indexed strategy with a three-year term on : $ 0.00 Annuity Value on : $154, Income Base on before Index Credit: $156, Rider Index Credit = Income Base x (Sum of Segment Earnings for indexed strategies/sum of Annuity Value allocated to indexed strategies) =$156, x ($2,500.00/$100,000.00) =$156, x 2.50% =$3, Income Base on after Index Credit: $159, Impact of Excess Withdrawals on Income Base Hypothetical Example Assumptions: Declared Interest Rate: 2.25% Income Base Growth Rate: 7.00% Income Percentage: 4.00% This hypothetical example is for illustrative purposes only. This hypothetical example assumes an election to begin receiving income payments under a Lifetime Income Rider was made after the Income Benefit Waiting Period; and that an excess withdrawal above the income payment amount was made between the first Contract Anniversary and the second Contract Anniversary. Contract Year Annuity Value before Withdrawal Excess Withdrawal Income Base Income Withdrawal Annuity Value after Withdrawal Income Base Remaining 0 $ 100, $ 0.00 $ 150, $ 0.00 $ 100, $ 150, $ 102, $ 0.00 $ 160, $ 6, $ 95, $ 143, $ 96, $ 23, $ 121, $ 0.00 $ 73, $ 108, $ 74, $ 0.00 $ 121, $ 4, $ 69, $ 103, Continued on next page Please retain this page for your records. Form AMERICAN NATIONAL INSURANCE COMPANY RV 03-15

12 page 5 of 6 There is a premium charge for a Lifetime Income Rider. The charge is taken directly from the Annuity Value each year. The Lifetime Income Rider with a Fixed Rate charge is guaranteed to be 0.60% of the Income Base each year, and it is payable from the date the annuity contract is issued until the Rider terminates. The Lifetime Income Rider with a Fixed Rate Plus Index Credit charge is guaranteed to be 0.30% of the Income Base each year, and it is payable from the date the annuity contract is issued until the Rider terminates. The Rider charge is deducted up to the interest earnings from the Annuity Value, or if any amount is outstanding, upon surrender. If the contract is surrendered, we will deduct the prorated annual rider premium, as well as any deficiency remaining, from the surrender value. The annual rider premium will not reduce the minimum guaranteed surrender value. You can only apply for a Lifetime Income Rider at the same time you apply for the ANICO Strategy Plus 7 Indexed Annuity contract or the ANICO Strategy Plus 10 Indexed Annuity. You can drop a Lifetime Income Rider at any time and the cost will be prorated. Either Lifetime Income Rider will terminate when there is a change in the ownership of the annuity contract. Otherwise, either Lifetime Income Rider will terminate when the annuity contract terminates. If there are joint spousal owners and the joint spousal owners divorce after the issue date, we will treat a request to reduce or divide benefits under a Lifetime Income Rider as a request for a surrender which will be subject to any applicable taxes, and surrender charges may apply. If joint spousal owners divorce after income payments begin under a Rider, the surrender will be considered an excess withdrawal above the income payment due under a Rider. An excess withdrawal will reduce the Income Base, and all future income payments will be reduced. The reduction is calculated using a pro rata method in proportion to the Annuity Value. If joint spousal owners divorce prior to income payments beginning under a Lifetime Income Rider, the remaining owner will be considered a single owner for rider election purposes. If joint spousal owners divorce after income payments begin under a Lifetime Income Rider, the income payments will continue to the spouse granted ownership of the contract, as long as that spouse lives. Spousal Continuation - If the Lifetime Income Rider is issued to joint spousal owners, and one of the owners subsequently dies, the surviving spousal owner may elect to continue the contract including receiving Lifetime Income Rider Income Withdrawals. If the surviving spouse continues this Rider, the Income Base and Income Withdrawal Amount will remain the same. If the Lifetime Income Rider is issued to single owner, and the owner subsequently dies, the surviving spouse may elect to continue the contract including receiving Lifetime Income Rider Income Withdrawals. If the death of the single owner occurs after income payments begin based on an election of joint life age income percentages under a Lifetime Income Rider, the same income payments will continue to the spouse, as long as that spouse lives. If an election of single life age income percentages or no election, the new Income Base and the income payments will be recalculated using the surviving spouse s attained age and the single life age lifetime income percentage from the chart on page 2 of this disclosure statement. The S&P 500 Index is a product of S&P Dow Jones Indices LLC ( SPDJI ), and has been licensed for use by American National Insurance Company. S&P and S&P 500 are registered trademarks of Standard & Poor s Financial Services LLC ( S&P ); Dow Jones is a registered trademark of Dow Jones Trademark Holdings LLC ( Dow Jones ); and these trademarks have been licensed for use by SPDJI and sublicensed for certain purposes by American National Insurance Company. American National Insurance Company s products are not sponsored, endorsed, sold or promoted by SPDJI, Dow Jones, S&P, their respective affiliates, and none of such parties make any representation regarding the advisability of investing in such product(s) nor do they have any liability for any errors, omissions, or interruptions of the S&P 500 Index. Continued on next page Please retain this page for your records. Form AMERICAN NATIONAL INSURANCE COMPANY RV 03-15

13 Disclosure Statement for Lifetime Income Riders ANICO Strategy Plus 7 and Plus 10 Indexed Annuity Issued by American National Insurance Company One Moody Plaza, Galveston, TX page 6 of 6 *RIDER* Owner/Annuitant s Rider Disclosure Statement I confirm that I am purchasing an ANICO Strategy Plus 7 Indexed Annuity or an ANICO Strategy Plus 10 Indexed Annuity from American National Insurance Company and that I have read and signed the contract Disclosure Statement and retained a copy for my records. I also confirm that I am purchasing the following Lifetime Income Rider as part of my purchase of the ANICO Strategy 7 Indexed Annuity or an ANICO Strategy Plus 10 Indexed Annuity: Lifetime Income Rider with a Fixed Rate Lifetime Income Rider with a Fixed Rate Plus Index Credit I understand that: There is a cost associated with the Lifetime Income Rider that I have selected The Lifetime Income Rider can only be added at the time my annuity contract is issued The Lifetime Income Rider can be dropped any time after issue Name of Annuitant Signature of Owner Signature of Joint Owner Date Date I certify that the Lifetime Income Rider insert and disclosure material have 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 the Lifetime Income Rider. 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. This Rider Disclosure is intended to be used with Form Series LIR14. Form AMERICAN NATIONAL INSURANCE COMPANY RV 03-15

14 Strategy Plus Index Annuity Election Form Issued by American National Insurance Company One Moody Plaza, Galveston, TX page 1 *SUP* Annuitant s Name Owner s Name Owner s (Please Contact American National Insurance Company For Available Allocation Options) POINT TO POINT ALLOCATIONS - (MINIMUM $5,000 PER ALLOCATION) Segment Term Participation Rate Cap Rate Percentage MONTHLY SUM ALLOCATION - (MINIMUM $5,000 PER ALLOCATION) Monthly Cap Rate Percentage FIXED ANNUAL ALLOCATIONS - (MINIMUM $5,000 PER ALLOCATION) One Year Declared Rate One Year Specified Rate OPTIONAL RIDERS - (AVAILABLE AT ISSUE ONLY) q Lifetime Income Rider - Fixed Rate Only q Lifetime Income Rider - Fixed Rate Plus Index Credits SUPPLEMENTAL APPLICATION SIGNATURES Interest Rate Percentage When you buy this annuity, you are not buying an ownership interest in any stock or index. Interest earnings are paid at a rate that is related to the performance of the Published Index. The Published Index does not reflect dividends paid on the stocks underlying the index. Past performance of the index is no guarantee of future results. Dated at this day of,. (State) (Day) (Month) (Year) Signature of Annuitant Signature of Owner, if other than Annuitant Signature of Agent Signature of Joint Owner, if other than Annuitant Printed Agent s Name Agent s Phone Number Agent s Form AMERICAN NATIONAL INSURANCE COMPANY 01-13

15 Disclosure Statement for the ANICO Strategy Indexed Annuity PLUS 7 Issued by American National Insurance Company One Moody Plaza, Galveston, TX page 1 of 8 This document reviews important points to think about before you buy this American National Insurance Company (American National) 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 guaranteed interest for premium that is placed in the Declared Rate Strategy; or interest that depends on how the S&P 500 Index performs for premium that is placed in one or more of the multiple Indexed Strategies available through this annuity. You get to choose the way interest is earned by your selection(s) among the multiple strategies available through this annuity. 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 ask your agent, broker, advisor, or contact a company representative at THE ANNUITY CONTRACT How will the value of my annuity grow? When you purchase an ANICO Strategy Indexed Annuity Plus 7, you can choose from different interest crediting strategies. Each strategy credits interest differently. You can choose between a Declared Rate Strategy and several Indexed Strategies. Premium placed in the Declared Rate Strategy earns interest at a declared interest rate. Interest is credited daily in the Declared Rate Strategy. When you choose to place a portion of the Annuity Value in an indexed strategy, a Segment is created. A minimum of $5000 must be placed in any Segment for Indexed Strategies. Segment Terms in this annuity may be 1 year, 3 years or 5 years depending on the strategy(ies) you choose. When a Segment matures at the end of a Segment Term, interest, if any, will be credited. At least seven days prior to the start of the next Segment Term you will be required to choose what strategy(ies) you want the Segment Value placed in. If you do not choose where to place a maturing Segment Value, the maturing Segment Value will remain in the strategy if the strategy is still available. If you do not choose where to place a maturing Segment Value, and the strategy is no longer available, American National will place the maturing Segment Value in the strategy most similar, in American National s opinion, to the maturing Segment. If a Segment matures and has less than $5000, the Segment Value can remain in the strategy if the strategy is still available, or you can instruct us to transfer the maturing Segment Value to the Declared Rate Strategy. If a Segment matures and has less than $5000 and the strategy is no longer available, the Segment Value will be placed in the strategy most similar, in American National s opinion, to the maturing Segment, or you can instruct us to transfer the maturing Segment Value to the Declared Rate Strategy. Indexed strategies earn interest related to the performance of the S&P 500 Index. Whether an indexed strategy earns interest or not and how much interest is earned is dependent on a number of factors: index performance, participation rate, cap and segment term. The performance of the index cannot be predicted over any given period of time. Past history of the Index is no guarantee of future performance. There is not one particular interest crediting strategy that will deliver the most interest under all economic conditions. American National Insurance Company and its agents do not make any recommendations regarding the selection of indexed strategies. American National Insurance Company and its agents do not guarantee the performance of any indexed strategies. Below is a brief description of the interest crediting strategies available in the ANICO Strategy Indexed Annuity Plus 7: Declared Rate Strategy Premium placed in this strategy earns interest at a declared interest rate. This rate is declared at the beginning of each Contract Year and guaranteed for one year. The interest is credited daily. The initial Declared Rate will be shown in the Data Section of your Contract. A Declared Rate for future Segment Terms will be shown on your Annual Report. Continued on reverse side Please retain this page for your records. Form AMERICAN NATIONAL INSURANCE COMPANY RV 12-14

16 page 2 of 8 One Year Total Sum Performance with Monthly Cap Strategy Premium placed in this strategy earns interest on an annual basis by comparing the monthly changes in the S&P 500 Index. The indexing term for this strategy is one-year. The first Monthly Segment begins on the Segment Start Date and ends on the same date in the next calendar month. If a Monthly Segment falls on the 29 th, 30 th, or 31 st and a month does not have this date, then the Monthly Segment will end on the last day of that month. Each month, American National will calculate the change in Index Value compared to the previous month. Monthly increases in the Index Value are subject to a Cap. There is not a Floor of zero applied to the calculation of the change in Index Value monthly. The 12 values are summed to determine your interest rate for the Segment Term, subject to a Floor of zero. This strategy tends to perform better when the index is rising in an up market. This strategy does not tend to perform well in a down market. The Cap is the maximum rate of interest credited to values under this indexed strategy. The Monthly Cap for the initial Segment Term is shown in the Data Section of your Contract. The Floor is the minimum rate of interest credited to values under this indexed strategy and is applied at the Segment Maturity Date. The Cap and Floor for the initial Segment Term are shown in the Data Section of your Contract. The Cap and Floor will not change during your Segment Term. Cap and Floor rates for future Segment Terms will be shown on your Annual Report. Hypothetical Examples for One Year Total Sum Performance with Monthly Cap Strategy* These examples assume a 2% Monthly Cap and a 0% Floor. Example 1 Example 2 Month Change in Index Value Change in Index Value 1 2% Cap (4%) 2% 2 2% 2% 3-3% -3% 4 1% -4% 5-1% -1% 6 0% 0% 7 2% Cap (3%) 2% 8-2% -2% 9 2% Cap (4%) -2% % 1.5% 11-1% -1% 12 2% 2% Total 5.5% -3.5% Interest Rate to be credited 5.5% 0% Annuity Value at beginning of Segment $5000 $5000 Interest Credited at end of Segment $ 275 $ 0 Annuity Value at end of Segment after interest is credited $5275 $5000 *Hypothetical Examples are for illustrative purposes only and are not a guarantee of any specific results. These Hypothetical Examples assume no withdrawals were made from the Segment during the Segment Term. Continued on next page Please retain this page for your records. Form AMERICAN NATIONAL INSURANCE COMPANY RV 12-14

17 page 3 of 8 One Year Performance with Specified Rate Strategy Premium placed in this indexed strategy can earn a specified rate of interest during a one-year Segment Term by comparing the S&P 500 Index Value at the on the Segment Start Date to the Index Value on the Segment Maturity Date. If the Index Value on the Segment Maturity Date is greater than or equal of the Index Value on the Segment Start Date then the Interest Rate Credited will be the Specified Rate. If the Index Value on the Segment Maturity Date is less than the Index Value on the Segment Start Date, no interest earnings will be credited for that Segment Term. Hypothetical Examples for One Year Performance with Specified Rate Strategy*: These examples assume a 0% Floor. Hypothetical Example 1: S&P 500 Index Value on Segment Start Date: S&P 500 Index Value on Segment Maturity Date: Specified Rate:... 3% Annuity Value at beginning of Segment:... $5,000 Interest Credited at end of Segment Term:... $ 150 Annuity Value at end of Segment after Interest is credited:... $5,150 Hypothetical Example 2: S&P 500 Index Value on Segment Start Date: S&P 500 Index Value on Segment Maturity Date: Specified Rate:...3% Annuity Value at beginning of Segment:...$5,000 Interest Credited at end of Segment Term:...$ 0 Annuity Value at end of Segment after Interest is credited:...$5,000 *Hypothetical Examples are for illustrative purposes only and are not a guarantee of any specific results. These Hypothetical Examples assume no withdrawals were made from the Segment during the Segment Term. Point-to-Point Performance with Cap Strategy Premium placed in this strategy earns interest at a rate determined by the Participation Rate being multiplied by (The S&P 500 Index Value on the Segment Maturity Date minus the S&P 500 Index Value on the Segment Start Date) divided by the Index Value on the Segment Start Date, up to the Cap and no less than the Floor. The Participation Rate decides how much of the increase in the S&P 500 Index will be used to calculate index-related interest. The Cap is the maximum rate of interest credited to values under this indexed strategy. The Floor is the minimum rate of interest credited to values under this indexed strategy and is applied at the Segment Maturity Date. The Participation Rate, Cap and Floor for the initial Segment Term are shown in the Data Section of your Contract. The Participation Rate, Cap and Floor will not change during your Segment Term. The Participation, Rate, Cap and Floor for future Segment Terms will be shown on your Annual Report. Continued on reverse side Please retain this page for your records. Form AMERICAN NATIONAL INSURANCE COMPANY RV 12-14

18 page 4 of 8 This strategy allows you to choose between different Segment Terms (one, three or five years), and different Participation Rates (100%, 75% and 50%). Each Segment Term and Participation Rate combination has a different Cap. The different Segment Terms and Participation Rates are as follows: One-Year Point-to-Point Performance with Cap with 100% Participation Rate One-Year Point-to-Point Performance with Cap with 75% Participation Rate One-Year Point-to-Point Performance with Cap with 50% Participation Rate Three-Year Point-to-Point Performance with Cap with 100% Participation Rate Three-Year Point-to-Point Performance with Cap with 75% Participation Rate Three-Year Point-to-Point Performance with Cap with 50% Participation Rate Five-Year Point-to-Point Performance with Cap with 100% Participation Rate Five-Year Point-to-Point Performance with Cap with 75% Participation Rate Five-Year Point-to-Point Performance with Cap with 50% Participation Rate All variations of the Segment Terms and Participation Rates may not be available at all times, depending on economic conditions. A point-to-point strategy may be beneficial when the index is rising, but may reduce the amount of interest you would receive if the S&P 500 declines just before the end of a Segment Term. Interest will not be credited until the end of the Segment Term. You assume the risk of earning 0% interest on that portion of your Annuity Value for the Segment Term. If you choose a longer indexing term, make sure you can risk earning 0% interest for the entire term. Hypothetical Examples for One Year Point-to-Point Performance with Cap with 100% Participation Rate*: These examples assume a 0% Floor. Hypothetical Example 1: S&P 500 Index Value on Segment Start Date: S&P 500 Index Value on Segment Maturity Date: Index Change:... 7% Cap:... 3% Annuity Value at beginning of Segment:...$5,000 Interest Credited at end of Segment Term:...$ 150 Annuity Value at end of Segment after Interest is credited:...$5,150 Hypothetical Example 2: S&P 500 Index Value on Segment Start Date: S&P 500 Index Value on Segment Maturity Date: Index Change:... -5% Cap:... 3% Annuity Value at beginning of Segment:...$5,000 Interest Credited at end of Segment Term:... $ 0 Annuity Value at end of Segment after Interest is credited:...$5,000 Continued on next page Please retain this page for your records. Form AMERICAN NATIONAL INSURANCE COMPANY RV 12-14

19 page 5 of 8 Hypothetical Examples for Three Year Point-to-Point Performance with Cap with 75% Participation Rate*: These examples assume a 0% Floor. Hypothetical Example 1: S&P 500 Index Value on Segment Start Date: S&P 500 Index Value on Segment Maturity Date: Index Change:... 7% Cap:... 15% Annuity Value at beginning of Segment:...$5,000 Interest Credited at end of Segment Term:... $ 263 Annuity Value at end of Segment after Interest is credited:... $5,263 Hypothetical Example 2: S&P 500 Index Value on Segment Start Date: S&P 500 Index Value on Segment Maturity Date: Index Change:... -5% Cap:... 15% Annuity Value at beginning of Segment:...$5,000 Interest Credited at end of Segment Term:... $ 0 Annuity Value at end of Segment after Interest is credited:...$5,000 Hypothetical Examples for Five Year Point-to-Point Performance with Cap with 50% Participation Rate*: These examples assume a 0% Floor. Hypothetical Example 1: S&P 500 Index Value on Segment Start Date: S&P 500 Index Value on Segment Maturity Date: Index Change:... 40% Cap:... 55% Annuity Value at beginning of Segment:...$5,000 Interest Credited at end of Segment Term:...$1,000 Annuity Value at end of Segment after Interest is credited:...$6,000 Hypothetical Example 2: S&P 500 Index Value on Segment Start Date: S&P 500 Index Value on Segment Maturity Date: Index Change: % Cap:... 55% Annuity Value at beginning of Segment:...$5,000 Interest Credited at end of Segment Term:... $ 0 Annuity Value at end of Segment after Interest is credited:...$5,000 *Hypothetical Examples are for illustrative purposes only and are not a guarantee of any specific results. These Hypothetical Examples assume no withdrawals were made from the Segment during the Segment Term. Your Annuity s Value depends on: the amount of your premium; how you allocate the premium between the interest crediting strategies; whether withdrawals have been taken; and whether any riders were purchased. Continued on reverse side Please retain this page for your records. Form AMERICAN NATIONAL INSURANCE COMPANY RV 12-14

20 page 6 of 8 BENEFITS How do I get income (payouts) from my annuity? After the surrender charge period (7 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 Annuity 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 Contract is issued, you can withdraw up to 10% of your Annuity Value, as of the beginning of your contract year, without any surrender charges. Any amount in excess of 10% is subject to a surrender charge. If IRS Minimum Required Distributions are greater than the 10% limit, then we will increase the limit to equal the IRS Minimum Required Distributions so you can withdraw them without incurring any surrender charges. What happens after I die? If you die before we start to pay you income from your annuity, your named beneficiary will be paid the death benefit. If you die after payouts start under an Annuity Option you selected, and there are any remaining guaranteed payments under the selected Annuity Option, the remaining payments will be paid to the person you have named. What other benefits can I choose? There are two Lifetime Income Riders available. You can select one of the Life Income Riders to be added to your Contract: There is a cost associated with each Rider. The Lifetime Income Riders may not be available in all states. Please see separate disclosure for Riders (Form Series 10662). FEES, EXPENSES & OTHER CHARGES What happens if I take out some or all of the money from my annuity? You have access to the funds in your annuity contract through a number of methods including partial withdrawals or even full surrender of your contract. If you make any withdrawals from an indexed interest crediting strategy during the Segment Term, the amount withdrawn will not be credited with any interest related to an increase in the Index during the Segment Term. Unless you specify in writing which interest crediting strategy you want a withdrawal made from, the withdrawal will be taken pro rata from each interest crediting strategy. Surrender Charges Surrender charges would apply to your contract if you decided to surrender your contract in the first seven years, or take a withdrawal in excess of your 10% Surrender Charge Free Withdrawal as explained above. These surrender charges, which are expressed as a percentage of the amount withdrawn in excess of the Surrender Charge Free Withdrawal amount, are as follows: Contract Year Surrender Charge 7% 6% 5% 4% 3% 2% 1% 0 Surrender charges may be waived in the event of disability or confinement to a licensed treatment facility. Check your contract for specific details of these waivers. The disability and confinement waivers may not be available in all states. The disability and confinement waivers are not available in the state of California. When you make a withdrawal or surrender your contract, we also may increase or decrease the amount you receive based on a Market Value Adjustment (MVA). If interest rates went up after you bought your annuity, the MVA likely will decrease the amount you receive. If interest rates went down, the MVA likely will increase the amount you receive. Any applicable MVA does not apply to withdrawals equal to or less than the Surrender Charge Free Withdrawal amount, Required Minimum Distributions or to payments received under the disability and confinement waivers. You may surrender your annuity for its total Surrender Value at any time. The Surrender Value is the greater of the Annuity Value, less any applicable surrender charge, modified by any applicable MVA, less any outstanding Rider premiums, and less any applicable federal or state premium taxes which have been deducted; or the Minimum Guaranteed Surrender Value. If you have funds allocated to an indexed interest crediting strategy and surrender during the Segment Term, you will not earn interest related to an increase in the Index on the funds withdrawn. Continued on next page Please retain this page for your records. Form AMERICAN NATIONAL INSURANCE COMPANY RV 12-14

21 page 7 of 8 The Minimum Guaranteed Surrender Value is equal to 87.5% of your premium, accumulated at the minimum guaranteed rates required by law for the indexed interest crediting strategies and the Declared Rate Strategy, less any withdrawals and Rider charges. There are separate minimum guaranteed interest rates for the Declared Rate Strategy and the indexed interest crediting strategies. The guaranteed rates will be established at issue and will be guaranteed for the life of your annuity. You may receive less than the premium paid if you surrender during the early years of your annuity due to surrender charges. Do I pay any other fees or charges? No. There aren t any other fees or charges on this annuity, unless you purchase a rider. TAXES How will payouts and withdrawals from my annuity be taxed? This annuity is tax-deferred, which means you don t pay taxes on the interest it earns until the money is paid to you. When you take an Annuity Option or make a withdrawal, you pay ordinary income taxes on the earned interest. You also pay a 10% IRS penalty on earnings you withdraw before age 59 ½. If your state imposes a premium tax, it may be deducted from the money you receive. Income received under an Annuity Option is treated as part income (taxable) and part return of basis (not taxed). Additional rules apply to qualified annuities. Consult your tax advisor or tax attorney for your specific circumstances. Does buying an annuity in a retirement plan provide extra tax benefits? Buying an annuity within an IRA, 401(k), or other tax-deferred retirement plan doesn t give you any extra tax benefits. Choose your annuity based on its other features and benefits as well as its risks and costs, not its tax benefits. 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 7 years. This annuity does not participate directly in any stock or equity investments. You aren t buying shares of a 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. If you did not have a face to face meeting with your agent when purchasing this annuity, you can obtain general information regarding annuities from a free Annuity Buyer s Guide you can request from American National at 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 is not intended to be a complete explanation of your Contract. Please read your Contract carefully for more complete details. The ANICO Strategy Indexed Annuity Plus 7 (Policy Form Series IA13) may not be available in all states. Contact your agent or American National Insurance Company with any questions. The S&P 500 Index is a product of S&P Dow Jones Indices LLC ( SPDJI ), and has been licensed for use by American National Insurance Company. S&P and S&P 500 are registered trademarks of Standard & Poor s Financial Services LLC ( S&P ); Dow Jones is a registered trademark of Dow Jones Trademark Holdings LLC ( Dow Jones ); and these trademarks have been licensed for use by SPDJI and sublicensed for certain purposes by American National Insurance Company. American National Insurance Company s products are not sponsored, endorsed, sold or promoted by SPDJI, Dow Jones, S&P, their respective affiliates, and none of such parties make any representation regarding the advisability of investing in such product(s) nor do they have any liability for any errors, omissions, or interruptions of the S&P 500 Index. Continued on next page Please retain this page for your records. Form AMERICAN NATIONAL INSURANCE COMPANY RV 12-14

22 Disclosure Statement for the ANICO Strategy Indexed Annuity PLUS 7 Issued by American National Insurance Company One Moody Plaza, Galveston, TX page 8 of 8 *DSC* Owner/Annuitant s Statement I confirm that: I am purchasing an ANICO Strategy Indexed Annuity Plus 7 from American National Insurance Company I have read the ANICO Strategy Indexed Annuity Plus 7 Product Brochure I have read the ANICO Strategy Indexed Annuity Plus 7 Disclosure Statement and have kept a copy I choose to allocate my premium of $ as indicated on the Strategy Index Annuity Election Form I understand that all premium must be received at American National before the annuity contract can be issued, and that the declared rate applied to any premium allocated to the Declared Rate Strategy will be the declared rate for the Declared Rate Strategy in effect on the date my contract is issued. I understand that: Purchasing the ANICO Strategy Indexed Annuity Plus 7 does not give me ownership in any stock or index The index used in calculating an increase in the index and crediting interest on this annuity is the S&P 500 Index and that the S&P 500 Index does not reflect dividends paid on the stocks underlying the 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 Strategy Indexed Annuity Plus 7 has surrender charges for early surrenders prior to the end of 7 Contract years Name of Annuitant Signature of Owner Signature of Joint Owner Date Date I certify receipt of $ given to purchase an an ASIA Plus 7 Indexed Annuity Exchange Transfer of Funds 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. This disclosure is intended to be used with Form Series IA13. Not FDIC/NCUA insured Not a deposit Not insured by any federal government agency May lose value Form AMERICAN NATIONAL INSURANCE COMPANY RV 12-14

23 Annuity Suitability Analysis / USA PATRIOT Act Form Issued by American National Insurance Company One Moody Plaza, Galveston, TX page 1 of 4 *SUIT* SECTION 1 INFORMATION A Personal Information This form is designed to assist the agent in determining the suitability of an annuity sale. Owner Full Name SS#/Tax ID # Date of Birth Age Marital Status: q Married q Single List Number of Dependents Occupation Dependent ages B Financial Information 1. (Financial Experience) Have you had experience with any of the following investments and insurance products, and if so how long? q Mutual Funds # of yrs. q 401(k) Plans # of yrs. q Stocks # of yrs. q Bonds # of yrs. q CDs # of yrs. q Savings Accounts # of yrs. q Life Insurance # of yrs. q Annuities # of yrs. q Other # of yrs. If so, please explain your experience: 2. (Risk Tolerance) In considering this product, what is your risk tolerance? q Conservative (Low Risk) q Moderately Conservative q Moderate q Moderately Aggressive q Aggressive (High Risk) 3. Annual Gross Income: q $0 29,999 q $30,000 49,999 q $50,000 74,999 q $75,000 99,999 q $100, ,999 q $150, ,999 q $250, ,999 q $400,000 Over 4. Source of Income (Check all that apply) q Salary (W-2) q Investments q Social Security q Pension Plans q Reverse Mortgage q Other 5. What type of investments and insurance products do you own? q Mutual Funds q Stocks q Bonds q CDs q Savings Accounts q Life Insurance q 401(k) Plans q Annuities q Other 6. What type of life insurance or other annuities do you own? 7. Estimated Net Worth (Exclude primary residence, furnishings, automobiles, or funds from a reverse mortgage.) q $0 74,999 q $75, ,999 q $150, ,999 q $250, ,999 q $500, ,999 q $1,000,000 Over 8. Liquid Net Worth (These are assets that can be easily converted to cash without incurring penalty charges after purchasing this annuity. Do not include funds from a reverse mortgage.) q Under $25,000 q $25,000 50,000 q $50, ,000 q $100, ,000 q Over $250, (Financial Objectives) Why are you purchasing this annuity? (Check all that apply): q Income q Stable Growth q Tax Deferral q Estate Planning q Death Benefit q Safety of Principal q Retirement q Other 10. After the purchase of this annuity, will your income and liquid net worth be enough for living expenses and emergencies? q Yes q 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. 11. (Financial Time Horizon) 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? q Yes q No If Yes, please explain. 12. (Tax Status) What is your Federal Income Tax Bracket: q15% q 28% q 33% q 38% 13. What source of funds will you use to buy this annuity? Form 4465 AMERICAN NATIONAL INSURANCE COMPANY RV 01-12

24 page 2 of 4 C Exchanges/Replacements If you are exchanging one annuity for another, compare the benefits, features, and costs of the two annuities. (Agent must complete this section and any appropriate state replacement form.) Policy Comparison Replaced Proposed Policy Comparison Replaced Proposed Surrender Charge Amount Remaining (in dollars) $ N/A Market Value Adjustment q Yes q No q Yes q No Premium Enhancement (Bonus) Amount $ $ Premium Enhancement (Bonus) Recapture Charge Minimum Guaranteed Non-Forfeiture Interest Rate % % Guaranteed Declared/Fixed Interest Rate % % Remaining Surrender Charge Period (# of years) Confinement Waiver/Benefit q Yes q No q Yes q No Qualified Contract q Yes q No q Yes q No Terminal Illness Waiver/Benefit q Yes q No q Yes q No Annual Surrender Charge Free Withdrawal Privilege q Yes q No q Yes q No Optional Rider Benefits Available q Yes q No q Yes q No Percentage Rate Available When (i.e. during 1st contract year or beginning in 2nd contract year)? % % Optional Rider Benefit Fees (Amount) $ $ List or compare any other fees, features, benefits or factors that explain the reason(s) for this exchange: Besides this exchange, have you exchanged an annuity within the last 36 months? q Yes q No If so, please list the product name and company of the prior exchanged annuity: *** IMPORTANT NOTICE *** If I am exchanging my current annuity, I understand that with this exchange: I am subject to the commencement of a new surrender charge period with the new annuity. I will lose the existing contractual benefits of the annuity I currently own, including any benefits provided through optional riders. I will generally not receive all the benefits of the new annuity contract unless I hold the contract for the entire surrender charge period. Form 4465 AMERICAN NATIONAL INSURANCE COMPANY RV 01-12

25 page 3 of 4 NOTE TO AGENT/PRODUCER You should maintain any other information you used or considered 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. A Do Not Complete if You Completed Box B I acknowledge that the annuity product I am applying for is a long-term contract with substantial penalties for early withdrawal. I believe that this product meets my financial needs and objectives. Signature Of Owner (or Trustee if owner is Trust) Date Agent s Acknowledgement: Based on information collected, I believe the purchase of this annuity is suitable. Signature of Agent/Producer Date Do Not Complete if You Completed Box A B I elect not to provide the information in Sections 1B & C and/or I elect not to provide answers to certain questions in Sections 1B & C. I acknowledge that I have decided to purchase this 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 financial needs and objectives. Signature Of Owner (or Trustee if owner is Trust) Date Agent s Acknowledgement: The Owner(s) has not provided complete information and has decided to purchase this annuity without my recommendation. Signature of Agent/Producer Date Form 4465 AMERICAN NATIONAL INSURANCE COMPANY RV 01-12

26 page 4 of 4 USA PATRIOT Act Notice to be read by or to customer. 1. 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 of our contracts, and collect documents and information sufficient to provide such verification. Failure to provide the requested identification 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 the Owner/Trustee/Partner associated with a contract. Information on such identification must be recorded below. If the Owner is a minor or non-legal entity, review the identification of the individual who submits an application on behalf of the minor or non-legal entity. We may use third party sources to verify the information provided. a. Identification Verified Owner/Trustee/Partner Check one form of ID: Driver s license Resident Alien ID (Green Card) Passport Other: (Describe) The following information should be recorded exactly as it appears on the identification reviewed Owner Date of Birth Street Address (not PO Box) City State Zip Number on ID State or Country Identification Expiration Date b. Entity Verification: Check the appropriate entity as listed below and submit copies of documentation viewed to gain first-hand knowledge of the existence of a legitimate business. Corporation, LLC, professional association, or professional corporation: Articles of Incorporation, Organization or Association or similar document filed in the state in which the entity is formed Limited Partnership: Certificate of Limited Partnership or similar document filed 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 2. I certify that I personally met with the proposed Owner/Trustee/Partners and reviewed the above identification document. To the best of my knowledge, it accurately reflects the identity of the proposed Owner/Trustee/Partners. I was unable to personally review the identification documents for the reason stated below. I certify that, to the best of my knowledge, the information provided by the Owner/Trustee/Partners is true and accurate. Reason for not reviewing documents Note: Failure to personally review the identification documents will result in processing delays in order to verify customer identity and may result in a decision not to accept the business. Representative Signature Date Form 4465 AMERICAN NATIONAL INSURANCE COMPANY RV 01-12

27 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-Qualified Accounts Only 1. FUNDS COMING FROM: CHECK ONE: q NEW SALE, APPLICATION ATTACHED q ADDITIONAL DEPOSIT TO EXISTING POLICY NUMBER TRANSFER COMPANY NAME AND ADDRESS: TRANSFER COMPANY PHONE NUMBER: NAME OF INSURED/ANNUITANT*: NAME OF OWNER: NAME OF JOINT OWNER: SSN: SSN: POLICY/ACCOUNT NUMBER WITH TRANSFER COMPANY: *JOINT ANNUITANTS ARE ONLY ACCEPTED ON SPIA s* 2. TYPE OF TRANSACTION: I/We direct the Institution named above to liquidate and transfer the assets to American National in order to set up a Non-Qualified account: (MUST SPECIFY:) q Immediately q Upon Maturity / / q 1035 Exchange, Non-Qualified Policy SSN: q Non-1035 Exchange, Non-Qualified Funds From: Mutual Fund, Bank CD, or Other Non-Qualified Asset. q Full 1035 Exchange The Assignor hereby designates American National Insurance Company as beneficiary of the above policy/contract. Immediately following the above beneficiary designation, Assignor does hereby assign and transfer without exceptions, limitations or reservation to American National Insurance Company all assignable benefits, 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. $ q 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. q $ q % 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 07-13

28 page 2 of 2 3. CONTRACT STATEMENT: q CONTRACT INCLUDED If contract is not lost, please submit with this form. q 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 specific 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, firm, 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 benefit of: Date at this day of, (City, State) Owner Joint Owner Annuitant Agent Guarantee (if required) Witness Witness 6. ACCEPTANCE: TO BE COMPLETED BY AMERICAN NATIONAL The authorized signature below certifies 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: q ANNUITY SERVICES DEPARTMENT q VARIABLE CONTRACTS DEPARTMENT q LIFE NEW BUSINESS American National Insurance Company American National Insurance Company American National Insurance Company P.O. Box P.O. Box 9001 P.O. Box 3297 Springfield, MO League City Tx Springfield, MO 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 Family of Companies Mail Processing Center Variable Contracts Dept. Mail Processing Center Attn: Annuity South Shore Blvd., Suite 300 Attn: LNB E. Sunshine St. League City Tx E. Sunshine St. Springfield, MO Springfield, MO 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 Date

29 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 Qualified Accounts Only 1. FUNDS COMING FROM: CHECK ONE: q NEW SALE, APPLICATION ATTACHED q ADDITIONAL DEPOSIT TO EXISTING POLICY NUMBER TRANSFER COMPANY NAME AND ADDRESS: TRANSFER COMPANY PHONE NUMBER: NAME OF INSURED/ANNUITANT*: NAME OF OWNER*: SSN: POLICY/ACCOUNT NUMBER WITH TRANSFER COMPANY: *ANNUITANTS AND OWNER MUST BE THE SAME* SSN: 2. COMPLETE THIS SECTION FOR TRANSFER REQUESTS AND DIRECT ROLLOVER REQUESTS: q Total, Full Liquidation $ q Partial, % or $ q Annuitization, Term: Frequency of Payments: Please send these funds to American National Insurance Company q Immediately q Upon Maturity / / 3. COMPLETE THIS SECTION FOR TRANSFER REQUESTS: IRA/TSA Transfer into an annuity contract of the same qualification 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: q Tax-Sheltered Annuity (IRC Section 403(b)) q ROTH I.R.A. or Annuity (IRC Section 408) q Individual Retirement Account or Annuity (IRC Section 408) q SEP IRA q 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 Date Witness Signature Date Agent s Signature Date Form 4394-Q AMERICAN NATIONAL INSURANCE COMPANY RV 07-13

30 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 qualified plan. As owner of the account or policy indicated in Section 1, I hereby request a direct rollover of my: q Individual Retirement Annuity (IRC Section 408) q Tax-Sheltered Annuity (IRC Section 403(b)) q Governmental 457 Deferred Compensation Plan q Qualified Employer Plan (IRC Section 401) q SEP IRA q ROTH IRA into an q Individual Retirement Annuity (IRC Section 408) q Tax-Sheltered Annuity (IRC Section 403(b)) q Governmental 457 Deferred Compensation Plan q SEP IRA q 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 qualified 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 Date Witness Signature Date Agent s Signature Date 5. CONTRACT STATEMENT: q CONTRACT INCLUDED If contract is not lost, please submit with this form. q 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 qualified account(s). If this rollover is being made during or after the first 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 qualified annuity. Please do not withhold any taxes from the amount being transferred. q ANNUITY SERVICES DEPARTMENT q VARIABLE CONTRACTS DEPARTMENT q LIFE NEW BUSINESS American National Insurance Company American National Insurance Company American National Insurance Company P.O. Box P.O. Box 9001 P.O. Box 3297 Springfield, MO League City Tx Springfield, MO 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 Family of Companies Mail Processing Center Variable Contracts Dept. Mail Processing Center Attn: Annuity South Shore Blvd., Suite 300 Attn: LNB E. Sunshine St. League City Tx E. Sunshine St. Springfield, MO Springfield, MO PLEASE MAKE CHECK PAYABLE TO: AMERICAN NATIONAL By (Signature/Title) Form 4394-Q AMERICAN NATIONAL INSURANCE COMPANY RV Date

31 page 3 of 3 DEFINITIONS QUALIFIED RETIREMENT PLANS Tax-qualified retirement plans may include pension, profit-sharing plan, 401(k), 403(b) Tax Sheltered Annuity (TSA), Simplified 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 Qualified Retirement Plan to another Qualified Retirement Plan. A DIRECT ROLLOVER is the movement of funds from and Employer s Qualified 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-qualified employee retirement benefit 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-qualified employee retirement benefit plan funds. 60-DAY ROLLOVERS A tax-qualified 60-day rollover is the tax-free transfer of funds from one Qualified Retirement Plan to another Qualified 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 Qualified 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-qualified 60-day rollover from a tax-qualified plan could be subject to mandatory tax withholding by the plan. Policy may be referred to as contract or certificate in some states. Form 4394-Q AMERICAN NATIONAL INSURANCE COMPANY RV 07-13

32 Annuity Commission Selection AMERICAN NATIONAL INSURANCE COMPANY, ONE MOODY PLAZA, GALVESTON, TX *COMM* Application For: (Proposed Annuitant/Owner) This form must accompany any application submitted for the products listed below. Please select the product being applied for and the desired commission option. If this Commission Selection form does not accompany the application, or if no option is selected, the default option will be Option A. ANICO Strategy Indexed Annuity PLUS 10 ANICO Strategy Indexed Annuity PLUS 7 Option A Level Commissions (See commission schedule for percentage paid) Option B Asset-based Trail Commissions Trail commissions begin in policy year two and continue for as long as the policy is in force. Trail commissions are based upon a percentage of the policy account value. (See commission schedule for percentage paid) Palladium Century Annuity Palladium Century I Annuity Palladium Century III Annuity Palladium Century V Annuity Palladium Century VII Annuity Option A Level Commissions (See commission schedule for percentage paid) Option B Asset-based Trail Commissions Trail commissions begin in policy year two and continue for as long as the policy is in force. Trail commissions are based upon a percentage of the policy account value. (See commission schedule for percentage paid) Signature of Agent PC Code Date Form AMERICAN NATIONAL INSURANCE COMPANY 07.15

33 Buyer s Guide to: Fixed Deferred Annuity with Appendix for Equity Indexed Annuities Issued by American National Insurance Company One Moody Plaza, Galveston, TX Toll Free: (800) Website: page 1 of 10 Prepared by the NAIC National Association of Insurance Commissioners The National Association of Insurance Commissioners is an association of state insurance regulatory officials. This association helps the various insurance departments to coordinate insurance laws for the benefit of all consumers. This guide does not endorse any company or policy. Reprinted By: Form 4571 AMERICAN NATIONAL INSURANCE COMPANY 04-12