GREEK CATHOLIC UNION OF THE USA (Herein called GCU)

Transcription

1 GREEK CATHOLIC UNION OF THE USA (Herein called GCU) 5400 TUSCARAWAS ROAD, BEAVER, PENNSYLVANIA DEFERRED ANNUITY APPLICATION (Please print) Is the Proposed Annuitant a member of the GCU? Yes. No. If not, Proposed Annuitant must apply for membership Lodge Number 1. Full Name of Proposed Annuitant: 2. Address: City, State: Zip: Phone: 3. Date of Birth: Age: Sex: Social Security No.: Maiden Name of Female: 4. Beneficiary: (Give: full name(s); address; phone; SSN; share; and relationship to Proposed Annuitant) Primary: SS#: Contingent: 5a. Is the annuity applied for intended to replace or change existing insurance or annuity with any insurer? Yes. No b. Other Annuities in force? Yes No. If Yes, total amount $ c. Will existing value from another policy or annuity (through loans, surrenders, or otherwise) be used to pay premiums for the policy applied for? Yes No. If Yes to a or c, show name of insurer and contract numbers: 6. Type of Deferred Annuity: Plan: Billing Options: Annual Semi-Annual Quarterly Monthly Do Not Bill Amount paid with application: $ Benefits to commence on. (This date may be changed as provided in the contract.) Unless otherwise elected, benefits will be paid: (1) Monthly for the lifetime of Proposed Annuitant; and (2) Will be guaranteed for a period of 10 years. Qualified Annuity Plan. Check appropriate box. IRA SEP IRA TSA Keogh Roth Coverdell Other Please note, the appropriate Disclosure Statements must be included with the application. Form DefAnu-2010

2 FRAUD WARNINGS For your protection, various state laws, require the following statements to appear on this form For Residents of Arizona, Pennsylvania, West Virginia: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act which is a crime and subjects the person to criminal and civil penalties. For Residents of Ohio: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. For Residents of Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or 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. For Residents of Florida or Indiana: Any person who knowingly and with intent to defraud or deceive an insurer files a false statement of claim containing any false, incomplete or misleading information commits a felony. For Residents of Virginia: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. For Residents of New Jersey: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. For Residents of Connecticut: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against the insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud. The Proposed Annuitant shall be the Owner of any contract issued except when the Applicant is an entity other than a person, the Applicant will be the owner. The contract will be effective on the latter of: (1) the effective date requested in this Application; or (2) the date the full first premium is received by the GCU at its Home Office. I represent that the answers and statements in the Application are full, complete and true, to the best of my knowledge and belief. I agree that this Application shall be the basis for and a party of any contract issued. I understand that only an officer of GCU may, in writing: (1) make or modify contracts: or (2) waive any of GCU s rights or requirements. Dated at: this Day of, Agent Signature: Agent Name (Print): License No.: X Proposed Annuitant s Signature Parent or Guardian if Proposed Annuitant is Under Age 16 GCU Agent No.: Agent s Report 1. To the best of your knowledge, is life insurance or annuity replacement involved in this transaction? Yes No. 2. Did you ask each question exactly as set forth in the application? Yes No. 3. To the best of your knowledge, is the annuity now applied for intended to replace or change any existing insurance with any company? If yes, have you complied with any regulatory requirements regarding replacement? Yes No. 4. I have verified the Proposed Insured s identity by viewing the individual s photograph on a driver s license, passport or other official document. Yes No. Date: Authorized Agent: Form DefAnu-2010

3 Suitability Evaluation Worksheet for Fixed Annuities The GCU is committed to selling our members the appropriate products to meet their financial needs. These questions are designed to help determine if purchasing a fixed annuity product is suitable for your needs. All questions must be completed and your signature is required on this form. Owner/Applicant: Address: City, State, Zip: Phone: Date of Birth: Occupation; Occupation Status: Marital Status: No. of Dependents: Residence Information: Owner: At Home Assisted Living Facility Nursing Home Spouse: At Home Assisted Living Facility Nursing Home What percentage of your liquid assets would you feel comfortable allocating to the risk categories listed below? Low Risk Moderate Risk High Risk = 100% of Total liquid Assets Spouse s Name: Date of Birth; Occupation: Occupation Status: Are you a US Citizen? Yes No Is spouse? Yes No When do you plan to retire? When will your spouse retire? Have you ever owned a: (Check all that apply) Fixed Annuity Variable Annuity Variable Life Ins Money Market Acct Savings Account Certificate of Dep Mutual Fund Stock Bond Financial/investment Objectives: (Check all that apply) Options for lifetime Income Increase Return on Assets Preservation of Principal Pass Assets to Heirs Reduce the Effects of Inflation Increase Current Income Income Tax Deferral Other Current Insurance and Annuities Applicant Premium Face Amount Cash Value Death Benefit Circle One Life Insurance $ $ $ $ Non Qualified Qualified Life Insurance $ $ $ $ Non Qualified Qualified Life Insurance $ $ $ $ Non Qualified Qualified Annuity $ $ $ $ Non Qualified Qualified Annuity $ $ $ $ Non Qualified Qualified Annuity $ $ $ $ Non Qualified Qualified Approximate Annual Income $0 - $24,999 $25,000 - $49,999 $50,000 - $74,999 $75,000 - $99,999 $100,000 - $199,999 $200,000 and over Federal Income Tax Bracket 0% 10% 15% 25% 28% 33% 35% Other Approximate Net Worth (Fixed & Liquid Assets) $0-$49,999 $50,000 - $149,999 $150,000 - $249,999 $250,000 - $499,999 $500,000 - $999,999 $1,000,000 and over Sources of Income (check all that apply) Current Wages Investment Income Social Security Pension Plan Req. Minimum Distribution (RMD) or 72 (t)/(q) distributions Other What annual income do you require? GCUSuit (over)

4 Do you anticipate any major changes in your future income needs? Yes (please explain) No Do you anticipate any large expenses in the foreseeable future? Yes (please explain) No Do you have funds available in case of an emergency? Yes (if so where and how much) No Do you currently handle your finances? Yes No (please explain) Will there be any surrender charges or penalties to withdraw funds from your current financial product (i.e., the source of funds for this annuity purchase)? Yes No If yes, provide the name of company, product, year of purchase, account value prior to surrender, dollar amount of surrender charge or penalty, and percentage of surrender charge or penalty. Do not reduce amount or percentage by any bonus earned on the proposed annuity and do not reduce the penalty by offsets such as MVAs (market value adjustments). If applicable provide MVA amount separately and indicate positive or negative. Company/Product/Year of Purchase Account Value Prior to Surrender Charge of MVA Surrender Charge Amt. ($) Surrender Charge Amt. (%) MVA Amt ($) (+/-) Acknowledgements I understand an annuity is a long-term contract that I should not plan to fully surrender before completion of the surrender charge periods. I understand that my principal may be subject to a surrender charge if I surrender or partially surrender my contract before completion of the surrender charge period. I understand surrender charges may apply to withdrawals, that may be taxable, and when made before age 59-1/2, may result in tax penalties. (If replacement) I understand the benefits and costs of this replacement, including but not limited to surrender charges, possible loss of benefits, tax consequences, product features and enhancements, fees, and expenses. My agent has provided a comparison of the benefits and restrictions of both contracts. I understand that I should contact a tax professional or attorney for any tax or legal advice. PLEASE REVIEW THE FORM AND SIGN ATTESTING THAT THE INFORMATION IS TRUE AND CORRECT TO THE BEST OF YOUR KNOWLEDGE. THIS FORM SHOULD NOT BE SIGNED IF ANY REQUIRED ITEM IS LEFT BLANK. Applicant/Owner s Signature Date Agent s Statement I believe the purchase of this annuity contract is suitable after reviewing the information provided to me by the applicant/owner. If applicable, I have discussed the advantages and disadvantages of any replacement or exchange of another annuity contract or life policy. I have reasonably informed the applicant/owner of all-important features of the annuity and proposed transaction. To the best of my knowledge, the questions on this form have been answered truthfully and I have complied with GCU suitability requirements consistent with my contractual obligations. Agent Signature and Producer Number Date GCUSuit122118

5 Certificate No.: ELECTION OF SETTLEMENT OPTION Insured: Owner of the above number certificate do hereby request that the cash proceeds provided by the certificate be applied under the payment option elected below. The payee for the payments provided by the option elected shall be: I. Interest Income (Option A Annuities): Amount to be applied under this option: $ The GCU to hold the specified amount on deposit and pay interest on such amount to the payee: Monthly Quarterly Semi-annually Annually. (the payment may not be less than $50.00.) The rate of interest shall be: (1) % per year for a period of months from the date of this option; and (2) then as declared, from time to time, by the GCU but not less than % per year. The payee shall have the right to withdraw all or part of the amount then held under this option in amounts of not less than $100. The GCU will deduct a withdrawal charge of n/a % of the amount withdrawn from any withdrawal during a period of n/a months from the date of this option. II. III. Payments for a Specified Period or a Specified Amount. Amount to be applied under this option. $ Period: years. Specified Amount: $ Payment Frequency: Monthly Quarterly Semi-annually Annually. (The payment amount may not be less than $50.) The Period or Specified Amount must be such that payments do not extend beyond the life expectancy of the payee. The payment amount includes interest at a guaranteed rate of % per year. The payment amount may be increased by any additional interest credits declared, from time to time, by the GCU. The payee has the right to withdraw the present value of any remaining payments at any time. Present value will be determined using interest at the guaranteed rate. Payments for Life. Amount to be applied under this option: $ Guaranteed Period (may not exceed the life expectancy of the payee): None, payments stop at the death of the payee 10 Years 15 Years 20 Years Payment Frequency: Monthly Quarterly Semi-annually Annually. (The payment amount may not be less than $50.) Payments will be made for the lifetime of the payee. Any Guaranteed Period begins on the date of the first payment. The payment amount includes interest at a guaranteed rate of % per year. The payment amount may be increased by any additional interest credits declared, from time to time, by the GCU. The beneficiary for any remaining amount to be paid under the option elected at the death of the payee shall be: The payee may change the beneficiary at any time by written notice to the GCU at its National Headquarters. ( ) PRIMARY (Name) (Date of Birth) (Social Security No.) (Phone Number) ( ) CONTINGENT (Name) (Date of Birth) (Social Security No.) (Phone Number) ( ) CONTINGENT (Name) (Date of Birth) (Social Security No.) (Phone Number) PAYEE: (your signature) Birthdate Social Security Number: Phone Number: ( ) Date GCU Executive Vice President/COO

6 0123ÿ ÿ1ÿÿ22ÿ #ÿ!"#$ÿ&'()*+'ÿ) (ÿ.##/0ÿ,+01'#- 2ÿÿ2ÿ ABCBDEÿGEHEIJKLEMCNOÿ012ÿÿÿ1231ÿP1ÿÿ 2ÿQ13ÿ2Qÿ1ÿ0123ÿRS9TUÿÿÿV1ÿ Qÿ2ÿÿWÿPQUÿV1ÿ1ÿXXXYZ[\Y]^_à^[bcde6 fbdkjneoÿ0123ÿrs9tÿÿ12ÿg66ÿhuÿ2qÿuÿ12ÿ2ÿ 234ÿ516ÿ7898:;;<9 ÿw1ÿ2ÿ2ÿ1ÿ1uÿÿiqvÿ 1332ÿjUÿQÿ2ÿ12ÿQ2Qÿ 1316ÿgÿ0123ÿRS9Tÿ1ÿÿ2ÿÿ12ÿ 31ÿ1ÿQ2ÿ13ÿkÿ1ÿW1Qÿ213ÿ12ÿ3ij6ÿ l1ÿ1ÿ3ÿÿ0123ÿrs9tÿ1ÿ11ÿijÿ1ÿ1ÿÿÿ 3Vÿ1Wÿÿ6 Q2ÿ13ÿkÿWQÿ213ÿÿ3ÿikÿ12ÿ VPÿ2112ÿQ2P1ÿ12ÿ12ÿ3ÿ1ÿg66ÿhÿ1ÿ PÿQ2Qÿ1QÿÿgQÿÿ12ÿÿ11jÿ12ÿiPjÿ 1ÿÿÿQQ1ÿ31ÿ1ÿkÿWQ6 121QUÿ12ÿÿVPÿ2112ÿQ2P1UÿÿkQÿ1ÿ VÿmÿQÿn6ÿl12ÿ21ÿQÿ0123ÿRS9TÿWÿ23ÿÿ ÿÿ1ÿq1oÿÿÿ0123ÿrs9tÿ12ÿm;7p6 qemedriÿsmncdbtcujmn 1ÿÿ312ÿÿ1ÿ12ÿ1ÿ13ÿPŽÿ1ÿ Ž1PUÿ12ÿ1o2ÿ32QÿQÿ12ÿ1ÿÿW12wVjUÿ2Qÿÿ1ÿ 1ÿ22ÿ2ÿ1ÿÿ2ÿÿv1Q6ÿ l12ÿ11ÿqqÿ1ÿw2ÿÿ3ÿÿ21quÿ ÿ21uÿqvÿÿ21ÿ12ÿÿ3ÿ AuIEDNÿ uc~ÿlbicukieÿkemnujmnÿjdÿljdeÿc~rmÿjmeÿumtjleoÿÿ 0123ÿ7;9;S Uÿ 3Qÿkÿ12ÿQQ6ÿ22WUÿ1ÿ 3Vÿ1WÿQQ1ÿk6ÿÿTP6ÿ8;8UÿkÿR1QVÿQÿ 3QÿkUÿ12ÿ312ÿ12316ÿ ÿ0123ÿ7;9;s ÿqÿ W1QVÿ1Wÿ1ÿ1Qÿ3ÿ12ÿ1ÿ12ÿÿ 3ÿW1QVÿ12ÿm;7pÿQÿÿQQ1ÿ31ÿ1ÿkÿ 1ÿÿWQ6ÿv13ÿÿW12wijÿVÿÿkPÿ 31ÿ1ÿÿ36 ex[y^\z{ÿ22juÿ1ÿÿwÿÿw12wÿqÿv1ÿq2ÿ1ÿ ÿ0123ÿrs9tÿp1w6 0123ÿ Wÿÿ21ÿ1ÿQ23ÿÿ3P2ÿ1ÿ TP6ÿ8;8ÿÿXXXYZ[\Y]^_à^[b\ex \6ÿ22Uÿ1ÿÿÿÿ Vÿ8ÿ12ÿÿ12ÿÿXXXYZ[\Y]^_`cd yyÿ1ÿ3wÿ2ÿ u}mÿc~unÿjdloÿ0123ÿrs9tÿÿ1ÿqÿÿ1ÿvÿ6 Q23ÿ12ÿkÿW1QVÿ312ÿ26ÿv1Q2ÿVÿ ÿ12ÿÿ1ÿÿÿ312ÿ13qÿkÿ1uÿÿ ÿ1ÿq1oÿwÿÿq2ÿ13ÿkÿwqÿiÿ 1ÿ0123ÿRS9ÿ12ÿ0123ÿRS9T6 QPÿÿ136ÿÿ0123ÿRS9 Uÿ 12ÿR1QVÿ ÿÿ1ÿÿ312ÿÿ1ÿ1ÿ12ÿuÿÿw12wvÿ 1Uÿ12ÿÿ2Vÿ31ÿ1ÿ13ÿ1Qÿ1ÿ12ÿ16ÿ 2ÿ12ÿ0123ÿRS9TÿwÿUÿ1ÿÿ1ÿÿÿ12ÿ 1ÿÿ1Wÿÿ31ÿ1ÿkÿ1o2ÿVÿWQÿ132ÿ1ÿ 12ÿ21ŽQÿ1ÿkÿ12ÿm;7p6ÿÿ1ÿÿÿ12Uÿ1ÿ l1ÿÿ1ÿÿÿ12ÿÿ ƒ ˆ Š ŒŒÿ1ÿ Uÿ12ÿ1231ÿ1ÿ12ÿW1QVÿ213ÿÿ 36 šuc~~jigum}ÿadjlÿfemnujmnÿrmgÿ MMBuCuEN 2ÿ1ÿ3ÿ3Qÿ213ÿ1Uÿ21:2VUÿ1wÿ 2QÿWÿ1ÿÿ12ÿkÿ226ÿÿ1ÿÿ11ÿÿk Q1oÿQÿ1ÿ13ÿÿ1ÿÿW12wÿ12ÿ0123ÿRS9T6 51ÿÿÿ1ÿÿ11ÿ3ÿkÿWQUÿ1ÿWÿ2ÿÿ W2ÿÿ2ÿÿÿ12QÿÿQQUÿÿ 12QÿÿP2Uÿ12ÿÿ12Vÿ6ÿ Qÿ EKrDrCEÿ~EDEÿrMGÿ}uHEÿAJDLÿšžŸfÿCJÿC~EÿKr,'#- #ÿ!"#$ÿ&'()*+'ÿ) EDÿJÿ (ÿ.##/0ÿ,+01'#- JBDÿKEMNuJMÿJDÿrMMBuC ÿÿ1ÿ3ÿ1ÿpÿq2qÿ1qÿÿgqÿ ÿqÿ3ÿ1ÿ12vÿ216 Oÿ EEKÿC~Eÿ JD N~EEC N ÿjdÿ JBDÿDEtJDGNO 923ÿ1ÿÿ22ÿ 2ÿÿ2ÿ ÿajdÿfduhrt ÿ tcÿrmgÿfrked JD ÿ EGBtCuJMÿ tcÿ JCutE ÿneeÿkr}eÿ Oÿ 234ÿ516ÿ7898:;;<9 l12ÿ2ÿ3ÿqÿ3qqÿ 13ÿQQ2ÿi3P2ÿQÿ2ÿ12ÿ22ÿ21j vÿ12ÿ1wuÿuÿqÿ Tÿ1Q JLKIECEÿC~EÿJIJ um}ÿrkkiutr IEÿIuMENO ªÿ3 ±ÿ «JBDÿNu}MrCBDEÿ W1QVÿiÿÿ312ÿÿ1ÿ1ÿ12ÿÿ1ÿQÿÿ T1 312SS2S13ÿR12wUÿP12ÿPVV6 WQUÿ1ÿWÿ1WÿkÿWÿ1ÿÿ12ÿkÿ22UÿQÿ1ÿ C~EDÿuMtJLEOÿÿ1ÿÿÿ2Vÿ31ÿ1ÿ13ÿ213ÿ12ÿ 12ÿ1ÿPŽÿ1ÿW1QVÿiÿÿ2UÿQQQUÿ 12ÿÿVjUÿ1Q2ÿ3wVÿ3Qÿkÿ3ÿVÿ 9Q1Uÿ QŽ3UÿQÿ QQ1ÿ13ÿR12wÿ1ÿ 1ÿÿ1VÿkÿWQÿ213ÿ12ÿ36ÿÿ1ÿÿ 13ÿ213ÿWVUÿÿTP6ÿ8;8ÿ12ÿÿÿ12ÿÿXXXY Z[\Y]^_`cd yyÿ1ÿqÿ1ÿÿ1ÿ1qÿqžÿ12ÿw1qvÿ 2UÿQ2ÿ13ÿkÿW1QVÿÿ1ÿÿkPÿ JCE ÿ1ÿ2ÿqÿ221qÿ223ÿ3ÿ3ÿpÿ P1UÿUÿQÿ2ÿQ2Qÿ131ÿœÿ213ÿ QQÿ223ÿ2V3ÿi jœÿqÿ213ÿ1332ÿ 6ÿÿ31QÿQÿ2ÿ1ÿW1QVÿQQÿ1ÿijÿÿ wqÿ1ÿ3ÿ1ÿ2œÿipjÿw2ÿÿ3ÿ2ÿ1ÿpÿ Q2Qÿ1QÿÿgQÿÿ12ÿÿ11œÿQÿijÿ Q2P1ÿ213ÿÿ1ÿ ÿ2ÿ1kpÿquÿ212uÿ1ÿ PŽÿ1ÿW1QV6ÿÿVÿnÿ12ÿÿW1QVÿ2ÿ =>?@ «JBDÿNJturIÿNEtBDuC v3ÿ12ÿq1ÿ3p2ÿ iÿjÿ1ÿ12ÿ1ÿ12ÿ ÿ12 ÿmbl ED ³ÿ²rDuCrIÿNCrCBN V32Q ÿ QQ1ÿ31UÿÿUÿ1ÿWÿWQÿ213ÿÿ1ÿ12ÿÿ36ÿi JCE ÿ012ÿ21qÿ3uÿ vwÿ2ÿÿ1ÿgjÿmjcÿ rmcÿrm ÿ1ÿ3p2ÿ1ÿ1wÿqÿ32ÿÿ1o2ÿ3vÿ12ÿw1qvÿ213ÿÿkedujgutÿ1ÿ12ÿ 1ÿoÿ2ÿÿ31ÿ2ÿW1ÿ2Vÿÿ3P2ÿiQVÿh21jÿ1ÿ1Wÿ1ÿÿm6jÿ6666ÿ µ ÿ36ÿil1ÿ1ÿ3ÿqvÿÿqq1ÿq12ÿ31ÿ1ÿÿn6jÿ ÿ i 2ÿ3P2ÿ ÿq2ÿ13ÿkÿwqÿ213ÿ12ÿ1ÿ12ÿ6ÿi91oÿ13ÿÿmÿ12ÿn6jÿ 32QUÿPÿW1QÿÿV2ÿVÿ26 1ÿ1W6j v6ÿ516ÿ7;mm8 rceÿ 0123ÿšžŸfÿim;7pj

7 Authorization for Direct Deposit into a Checking Account (For transferring funds from your GCU account to your Financial Institution) New Request Change to Existing Cancel Existing First Name: Last Name: Address: (Is this a new address? Yes No) Address: Certificate Number(s): Last 4 Digits of SSN: Phone Number: ( ) Cell Phone: ( ) Date of Birth: / / Financial Institution s Name: Financial Institution s Phone: Please complete the following information: Desired Frequency of Direct Deposit: Monthly Quarterly Semi-Annually Annually FOR DIRECT DEPOSITS A Voided Check is Required. PLEASE ATTACH HERE WITH TAPE. I hereby authorize GCU to initiate electronic payment entries and to initiate, if necessary electronic deposit entries and adjustments for any electronic entry in error to my (our) account indicated below and the financial institution named below, hereinafter called DEPOSITORY, to credit and/or debit the same to such account. This authority is to remain in full force and effect until GCU has received written notification from me (or either of us) of its termination in such time and in such manner as to afford GCU and DEPOSITORY a reasonable opportunity to act on it. Owner s Signature Required Date GCUDirDep022013

8 Authorization for Direct Deposit into a Savings Account (For transferring funds from your GCU account to your Financial Institution Savings account) New Request Change to Existing Cancel Existing First Name: Certificate Number(s): Last Name: Address: Last 4 Digits of SSN: Phone Number: ( ) (Is this a new address? Yes No) Cell Phone: ( ) Address: Date of Birth: / / Please complete the following information: Desired Frequency of Direct Deposit: Monthly Quarterly Semi-Annually Annually Please have your financial institution complete the following information: Financial Institution Name: Financial Institution Phone Number: Financial Institution Routing Number: Account owner s name: Savings Account Number: Financial Institution Representative Name: Signature: Date: I hereby authorize GCU to initiate electronic payment entries and to initiate, if necessary electronic deposit entries and adjustments for any electronic entry in error to my (our) account indicated below and the financial institution named below, hereinafter called DEPOSITORY, to credit and/or debit the same to such account. This authority is to remain in full force and effect until GCU has received written notification from me (or either of us) of its termination in such time and in such manner as to afford GCU and DEPOSITORY a reasonable opportunity to act on it. Owner s Signature Required Date Please return completed form to: Greek Catholic Union, 5400 Tuscarawas Road, Beaver, PA GCUDDSave022513