Contents. New Business Transmittal Form NB Transmittal ANN CBLA-3,5,7 Annuity Application ICC17A-SPDACD APP 0517

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1 CBLA-3, -5, -7 Application Package (Compact Only) Compact States Include: Alabama, Alaska, Arizona, Arkansas, Colorado, Connecticut, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, Wyoming Contents Form Form ID New Business Transmittal Form NB Transmittal ANN 3-18 CBLA-3,5,7 Annuity Application ICC17A-SPDACD APP 0517 Agent Certification AgentCert MYGA 11-1 Suitability Questionnaire AnnSuit Generic Understanding Your SPDA DISC-SPDA CBL 357_rvsd B NAIC Buyers Guide NAICAnnBuyersGuide (3-2014) 1035 Exchange/Transfer or Rollover Authorization TransRollover Form Trust Certification TrustCert 1-17 Payment Authorization Payment Authorization Supplemental Beneficiaries SupplBenef 1-17 Important Notice The Replacement form is required and not included in this Application Package. Please be sure to submit either the Multi-State ( MST ) approved Replacement Form OR a State Specific Replacement Form for those states not covered by the Multi-State version Englert Drive Durham, NC Toll Free: Fax: CBLife.com Products and services are underwritten and/or provided by Colorado Bankers Life Insurance Company (Durham, NC), licensed in 49 states (excluding New York), the District of Columbia, and Puerto Rico. Products and services may not be available in all states. CBLA 3, 5, 7 AppPkg Cover ICC 3-18

2 Colorado Bankers Life Insurance Company 2327 Englert Dr., Durham, NC New Business Transmittal Form Please complete and submit the New Business Transmittal form on top of each policy application sent to Colorado Bankers Life Insurance Company. This sheet must accompany all new business applications. Please Print or Type Please mail the policy to: (check one) Agent Policyholder Agent Name Date Agent Writing Code (Provided to you by Colorado Bankers) Bank, Broker Dealer, or Agency Name For help, please contact us at or NB Transmittal ANN 3 18

3 CBLA-3,5,7 Individual Single Premium Deferred Annuity Application Underwritten by COLORADO BANKERS LIFE INSURANCE COMPANY Administrative Office: 2327 Englert Drive. Durham, North Carolina, TYPE OF APPLICATION: Individual Custodial (UGMA/UTMA) Non-Natural Person (Trust/Corp/Non-Corp Entity) OWNER and / or ANNUITANT First Name MI Last Name Male Female Residence Address (Cannot be a P.O. Box) City State Zip Mailing Address (If different than residence address) City State Zip Phone Address Date of Birth (MM/DD/YYYY) Social Security # Marital Status Single Married If not US Citizen, please provide the following information Country of Citizenship Type of Visa Visa Exp. Date (MM/DD/YYYY) If Custodian, please provide the following information First Name MI Last Name Joint Owner (Non-Qualified Only - Must be the spouse of the Owner/Annuitant) First Name MI Last Name Male Female Phone Address Date of Birth (MM/DD/YYYY) Social Security # Mailing Address (If different than Owner/Annuitant s mailing address) City State Zip If not US Citizen, Please provide the following information Country of Citizenship Type of Visa Visa Exp. Date (MM/DD/YYYY) Name TRUST/CORPORATE/NON-CORPORATE ENTITY Tax ID State ICC17 A-SPDACD APP 0517 PAGE 1 of 4

4 3 BENEFICIARY INFORMATION (Include additional beneficiaries on the Supplemental Beneficiaries form) Percentages must be in whole numbers. Both Primary and Contingent Beneficiary percentages must each add up to 100%. Primary Beneficiary First Name MI Last Name Benefit (%) (Enter non-natural entity name if applicable) Address (Street name & number required) City State Zip Social Security # / TIN Relationship to Owner Date of Birth (MM/DD/YYYY) Primary Contingent First Name MI Last Name Benefit (%) (Enter non-natural entity name if applicable) Address (Street name & number required) City State Zip Social Security # / TIN Relationship to Owner Date of Birth (MM/DD/YYYY) Primary Contingent First Name MI Last Name Benefit (%) (Enter non-natural entity name if applicable) Address (Street name & number required) City State Zip Social Security # / TIN Relationship to Owner Date of Birth (MM/DD/YYYY) Primary Contingent First Name MI Last Name Benefit (%) (Enter non-natural entity name if applicable) Address (Street name & number required) City State Zip Social Security # / TIN Relationship to Owner Date of Birth (MM/DD/YYYY) ICC17 A-SPDACD APP 0517 PAGE 2 of 4

5 4 POLICY & PREMIUM DETAILS Annuity Type (Select one) Non-Qualified Qualified: IRA Roth IRA Roth Conversion Inherited IRA Contribution: Current Year $ Prior Year $ Initial Premium Method & Amount (Select all that apply) Check Amount $ EFT Amount $ (Must complete Payment Authorization form) 1035 Exchange/Rollover /Transfer Amount $ (Must complete Annuity Rollover/1035 Exchange form) Plan: CBLA-3,5,7 Single Premium Amount * * [ ] check if amount is estimated or a transfer is requested (Please select one) CBLA 3 Year CBLA 5 Year CBLA 7 Year EXISTING COVERAGE / REPLACEMENTS Does the Proposed Annuitant or Owner have any other life or annuity policies? If yes, complete replacement notice if required by your state. Is the Policy applied for replacing or likely to replace any existing life or annuity policy? If yes, complete replacement notice if required by your state. Yes Yes No No SPECIAL INSTRUCTIONS ICC17 A-SPDACD APP 0517 PAGE 3 of 4

6 7 ACKNOWLEDGEMENTS & SIGNATURES Electronic Document Delivery Authorization Yes No I (we) (Owner(s)) authorize Colorado Bankers Life Insurance Company ( CBL ) to provide all present and future notices concerning this annuity, and any other CBL annuities or policies that I (we) may own, via at the address provided above. I (we) acknowledge that I (we) have the ability to access the Internet and view documents in the Adobe PDF format. I (we) understand that I (we) am (are) responsible for any subscription or access fees of my Internet service provider. I (we) acknowledge that I (we) may request specific documents in paper form at any time without revoking this consent and, or I (we) can revoke this consent at any time, by contacting CBL in writing at the address at the top of this document. I (we) acknowledge that CBL has the right to deliver notices and policy and contract documents via , but is not obligated to do so. Agreements and Signatures Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law. State insurance law may prohibit the owner of an annuity contract from entering into any agreement to sell, transfer or assign an annuity contract prior to the date the contract was issued, or within a period of time specified by state law after the date the contract was issued. You should consult with legal advisors if you have any questions about these matters. By signing below, I acknowledge the statements above and understand and agree to the following: All statements, information and answers given in this application are true and correct to the best of my knowledge; I certify that the Social Security or Taxpayer Identification number shown above is correct; and This application is subject to acceptance by the Company. If this application is rejected for any reason, the Company will be liable only for return of the purchase payment paid, without interest; I may return my contract within the right-to-examine period (shown on the first page of my contract) if I am dissatisfied for any reason; Signature of Owner, Annuitant or Custodian Date (MM/DD/YYYY) Signed in City / State SIGN Signature of Joint Owner Date (MM/DD/YYYY) Signed in City / State SIGN Signature of Trustee Date (MM/DD/YYYY) Signed in City / State SIGN Signature of Agent Date (MM/DD/YYYY) Signed in City / State NOTE: If Owner is married and lives in a community property state (AZ, CA, ID, LA, MN, NV, TX, WA, & WI), the spouse must be named as the sole primary beneficiary or the spouse must sign here. Signature of Spouse Date (MM/DD/YYYY) Signed in City / State All checks must be made payable to COLORADO BANKERS LIFE INSURANCE COMPANY. Do not make checks payable to any producer, agent, or agency. ICC17 A-SPDACD APP 0517 PAGE 4 of 4

7 Individual Single Premium Deferred Annuity Agent Certification Underwritten by COLORADO BANKERS LIFE INSURANCE COMPANY Administrative Office: 2327 Englert Drive Durham, North Carolina COMPLETE ALL SECTIONS OF THE AGENT CERTIFICATION CLEARLY AND LEGIBLY, AS INDICATED: Name of Applicant: Nature of relationship with applicant (s)? Friend/Relative Referred Lead Cold Call Business Acquaintance Other (explain) How long have you known applicant (s)? Number of: Years Months How well acquainted are you with applicant(s)? First Contact Well Known Casually Self Relative List other annuity/insurance products you sold to this applicant: What are your reasons for recommending this product? I certify that to the best of my knowledge: Yes No 1. Does the applicant have any existing life insurance or annuities? Yes No Yes No 2a. Will the annuity applied for in this application change or replace any existing insurance or annuity? 2b. Must answer 2b if 2a is Yes I gave the applicant a copy of all sales materials used in the sale of the insurance applied for, as required by applicable law. Yes No 3. I have made a reasonable effort to obtain information from applicant(s) concerning his/her/their financial status, investment objectives and other information considered pertinent. Yes No 4. It is my belief that based on the information the applicant(s) provided and all the circumstances known to me at the time the annuity being applied for, is suitable for the applicant(s) insurance needs and/or financial objectives. Yes No 5. It is my belief that the applicant(s) do not have any diminished capacity with regards to making financial decisions on his/her/their own behalf. Agent Signature: Agent Name: Date: Agent Signature Month Day Year First Name MI Last Name Agency Name: Agent Address: Fax# AgentCert MYGA 11-17

8 Annuity Owner Profile and Suitability Questionnaire Underwritten by COLORADO BANKERS LIFE INSURANCE COMPANY Administrative Office: 2327 Englert Drive Durham, North Carolina TYPE OF APPLICATION: Individual Custodial (UGMA/UTMA) Trust (Annuitant must be the Trust Grantor) TYPE OF ANNUITY: Non-Qualified Qualified 1 OWNER INFORMATION: Section 1a. Complete this section for Individual Ownership and Trust Ownership Owner Name/Trust/Trust Grantor Date of Birth/Date of Trust (MM/DD/YYYY) Section 1b. Complete this section for Individual Ownership Only Citizenship Status Is the Owner actively employed? US Citizen Resident Alien Non-resident Alien Yes No Retired Occupation (Or source of income if not employed) Does Owner reside in a nursing home? Yes No Joint Owner Name Date of Birth (MM/DD/YYYY) Citizenship Status Is the Joint Owner actively employed? US Citizen Resident Alien Non-resident Alien Yes No Retired Occupation (Or source of income if not employed) Does Joint Owner reside in a nursing home? Yes No Section 1c. Complete this section for Trust Ownership Only Annuitant Date of Birth (MM/DD/YYYY) Citizenship Status Is the Annuitant actively employed? US Citizen Resident Alien Non-resident Alien Yes No Retired Relationship of Annuitant to Trust Grantor 2 FINANCIAL OBJECTIVES/RISK ANALYSIS (COMPLETE FOR INDIVIDUAL OWNER OR TRUST ANNUITANT) Current Financial Objective Market Growth Income Tax Advantage Growth (SELECT ALL THAT APPLY) Conservation Growth Capital Preservation Page 1 of 3 AnnSuit Generic 11-17

9 3 HOUSEHOLD FINANCIAL INFORMATION (COMPLETE FOR INDIVIDUAL OWNER OR TRUST ANNUITANT) (A) Average Monthly Income (B) Average Monthly Living Expenses (Rent, Mortgage, Utilities, Taxes. Assessments, Food, Transportation Costs, Other) Average Net Monthly Income (Subtract A - B) Tax Bracket 0-15% 16-25% 26-35% Over - 35 % Source of Income (CHECK ALL THAT APPLY) Employment Investments Reverse Mortgage Pension / Social Security Other Do you anticipate significant changes to your income or living expenses? Yes No If Yes, please describe below (ex. Pension income, social security, mortgage paid, balloon note due, rent increase, etc.) 4 HOLDINGS (COMPLETE FOR INDIVIDUAL OWNER OR TRUST ANNUITANT) Net Worth (EXCLUDING RESIDENCE) Liquid Assets CDs Checking Savings Total Liquid Assets Proposed Annuity % of Net Worth Please check which financial product(s) you have prior experience with and for how many years? CDs Fixed Annuities Life Insurance Mutual Funds Indexed Annuities Variable Annuities Stocks/Bonds Reverse Mortgage None Check One: Periodic Payments Monthly Quarterly Semi-annually Annually Expected Amount Source of Funds for Annuity Purchase Current Amount Amount to be used for Annuity CD Life Insurance Cash Value Savings / Checking / Money Market Existing Fixed Annuity Stocks / Bonds / Mutual Funds Existing Variable Annuity Reverse Mortgage Other (describe) Page 2 of 3 AnnSuit Generic 11-17

10 4 HOLDINGS (cont.) What are your reasons for purchasing this annuity? (CHECK ALL THAT APPLY) Funding Retirement Future Income Safety of Principal Minimum Guarantees Tax Deferral Other What do you consider your Risk Tolerance? (SELECT ONE) Speculative Aggressive Moderate Conservative Very Conservative Do you plan to withdraw funds from this annuity within the next 7 years? Yes No Will this annuity replace a current annuity or life insurance policy? If Yes, what, if any, surrender charges remain on the current policy? % Yes No How long do you expect to keep this annuity? Less than 2 yrs 2-4 yrs 4-7 yrs 8-12 yrs 13+ yrs FOR CALIFORNIA APPLICANTS ONLY: Do you intend to apply for means-tested government benefits, including, but not limited to, Medi-Cal or the veterans aid and attendance benefit? Yes No 5 DISCLOSURES/OWNER STATEMENT FOR MASSACHUSETTS APPLICANTS ONLY: List existing policies or contracts previously sold by this producer to the annuity owner or annuitant if a trust. Product Carrier Date of Issue Product Carrier Date of Issue Product Carrier Date of Issue Product Carrier Date of Issue FOR NEW JERSEY APPLICANTS ONLY: I acknowledge that I have reviewed the information below, on the date signed below. 1) The solicitation, negotiation, and sale of the annuity I applied for, and its suitability are subject to the regulatory oversight of the New Jersey Department of Banking and Insurance; and 2) For inquiries or assistance, I may contact the New Jersey Department of Banking and Insurance, Consumer Inquiry and Response Center as follows: CONSUMER INQUIRY AND RESPONSE CENTER (CIRC) Phone: (609) NJDOBI, P.O. BOX 471, TRENTON, NJ, Phone: (800) WEB: Fax: (609) I (we) have been given, have read, and understand the Understanding Your Flexible Premium Deferred Annuity form for this annuity, which informs me (us) of various features of the annuity, such as potential surrender period and surrender charge, potential tax penalty if I (we) sell, exchange, surrender or annuitize the annuity, and how purchase payments, interest, and renewals are handled. I (we) have discussed with my (our) producer my (our) anticipated financial needs and my (our) risk tolerance, and I (we) have determined that buying this annuity product will help me (us) in meeting my (our) insurance needs and/or financial objectives. I (we) have reviewed the information supplied about me (us) in this suitability form and acknowledge its accuracy. Further, I (we) understand that CBLife will be using this information to review the recommendation made by my (our) producer as to the suitability of the annuity being applied for. / / Signature of Owner Date Signature of Joint Owner Date Signature of Annuitant if Trust Owner / Date Page 3 of 3 AnnSuit Generic 11-17

11 CBLA Understanding Your Single Premium Deferred Annuity Please sign and date below, acknowledging that you have read and understand all the following: This form is not intended to be a complete explanation of the annuity. Only the annuity contract contains all the details. If there is a conflict between this disclosure and that contract, the annuity contract shall take precedence. Terms, Definitions and Understanding the Basics of the Annuity Administrative Office: 2327 Englert Drive Durham, North Carolina What is an annuity? An annuity is a long-term contract between the contract owner ( you or Owner ) and an insurance company, in which you give Colorado Bankers Life Insurance Company ( CBL or we ) a sum of money (called a premium). This premium accumulates over time on a tax-deferred basis until you withdraw it from the annuity or begin taking a set of payments from the annuity contract. You can use an annuity to save money for retirement and to receive retirement income for life. It is not meant to be used to meet short-term financial goals. This Annuity This annuity (Form Series ICC17C- SPDACD POL 0517 or C-SPDACD POL 0517) is a single premium annuity, which means you may make only one premium payment to the contract. It also is a fixed annuity, which means it earns a specified interest rate during each rate period. This annuity also is deferred, which means payouts begin at a future date and you do not pay taxes on the interest it earns until the money in it is paid to you. Free-Look Period Within 21 days after the annuity contract is first received (30 days if replacing another contract), you may cancel it for any reason by delivering or mailing it to the agent through whom it was purchased or to the administrative office of CBL shown above. Upon cancellation, CBL will return any premium paid and the annuity contract will be void from the contract date. Who is the Annuitant? The Annuitant is the Natural Person on whose life Annuity Payout Options (see below) are based and who receives the payments made under that option. The initial Annuitant is shown on the contract data page of the annuity contract. Annuitization Applying the annuity's Account Value to an Annuity Payout Option is called "annuitization". When you annuitize, you can choose one of several Annuity Payout Options stated in the annuity contract. Once you have chosen to apply all the Account Value to annuitize the annuity, you may not change the Annuity Payout Option or surrender the annuity or have access to any value of the annuity, other than the payments being made under the Annuity Payout Option. Account Value The Account Value of the annuity contract equals the single premium paid into the annuity, plus all interest credited, minus any withdrawal amounts including any charges and fees, minus any Account Value applied to an Annuity Payout Option, and minus any applicable taxes. Amounts surrendered may include withdrawal charges and fees and applicable taxes. Minimum Guaranteed Interest Rate The interest rate declared by CBL for the annuity will never be less than this rate. It is shown on the contract data page in the annuity contract. This rate is set at the time you purchase the annuity and is guaranteed never to change for the life of the contract. Cash Surrender Value The Cash Surrender Value is the amount you will receive if you surrender the entire contract (a Full Surrender ). The Cash Surrender Value is the Account Value minus withdrawal charges and taxes. Full Surrender A Full Surrender occurs when you request we pay out, as a lump sum, the full value available under the annuity contract. That value is the Cash Surrender Value, and is specifically defined in the annuity contract. A Full Surrender terminates the annuity contract. Death of the Owner The phrase Death of the Owner has a very specific meaning under the annuity contract because the death of different persons can trigger the payment of a death benefit or other benefits under the contract depending on the circumstances. Specifically, under the annuity contract the Death of an Owner means: (a) the death of the Owner if, at the time in question, there is only an Owner who is a natural person, and no Joint Owner; or (b) the death of the first to die of the Owner and Joint Owner, if, at the time in question, there is both an Owner and Joint Owner; or (c) the death of the Annuitant under the contract, if, at the time in question, the Owner is not a Natural Person. The annuity contract contains additional limitations. Please contact your agent for additional details about the annuity. This disclosure is not meant to replace any required state replacement forms. It is designed to assist you in understanding the nature of the annuity purchase. DISC-SPDA CBL 357_rvsd B Page 1 of 4

12 Benefits and Features of the Annuity Interest Crediting Interest is earned and credited daily on the Account Value in the annuity. The initial interest rate will be guaranteed from the contract date of the annuity up to the end of the initial rate period. The initial interest rate and the initial rate period are shown on the contract data page of the annuity contract. For each succeeding rate period after the initial rate period, CBL will credit interest at a rate equal to or in excess of the Minimum Guaranteed Interest Rate. CBL will declare the interest rate for each new rate period on or before the start of that rate period. Annuity Payout Options These are the choices you have as to how your Account Value will be paid out as a set of payments. You can choose from several Annuity Payout Options that provide a stream of payments for life and/or for a specific period of years. These options are listed in the annuity contract. Death Benefit A death benefit will be provided upon the Death of the Owner prior to the Maturity Date (which is shown on the contract data page of the annuity contract). If the owner is not a natural person, the death of the annuitant will be treated as the death of the owner. The amount of the death benefit will be the Cash Surrender Value, which may be less than the Account Value. The death benefit payable may not be subject to a Withdrawal Charge, please review your contract carefully. Full, Partial Surrender (Withdrawal) Withdrawal Charge Waiver Features - Accumulated Interest After the contract has been in force for 30 days the Owner may request a withdrawal of the interest credited to the Account Value. Payments can be paid in three, six or twelve month options; with a minimum payment of $ Required Minimum Distribution (RMD) After the contract has been in force for six months, an RMD may be made and the Withdrawal Charges may be waived subject to the requirements of the contract. Free Withdrawal After the contract has been in force for one year, the Owner may request to withdraw, once per contract year, up to 10% of the Account Value subject to a minimum withdrawal of $200. Nursing Home Withdrawal After the contract has been in force for one year, the withdrawal charge will be waived on a withdrawal equal to 50% of the Account Value, subject to the requirements of the Nursing Home Withdrawal provision being satisfied. Full Surrenders and Partial Surrenders (also known as Withdrawals) You may access the value in the annuity contract by taking all the Account Value available for surrender, a Full Surrender, or less than all that value as a Partial Surrender (Withdrawal). No more than four (4) Partial Surrenders may be taken each Contract Year unless Systematic Withdrawals are being made. Partial Surrenders and Systematic Withdrawals are subject to a minimum withdrawal amount and the contract must retain a minimum account value. See the annuity contract for details. Partial Surrenders may be assessed withdrawal charges for each occurrence that a Partial Surrenders is made, unless those charges are waived. All minimum values and withdrawal charges are specified on the contract data page of the annuity contract. Partial Surrenders (Withdrawals) or Full Surrenders may be subject to tax and/or tax penalties in addition to any charges imposed under the contract. withdrawal charges may not apply to certain features. Please refer to the annuity contract and tax advisor for full details. Partial Surrenders and Withdrawals are the same. The annuity contract contains additional limitations. Please contact your agent for additional details about the annuity. This disclosure is not meant to replace any required state replacement forms. It is designed to assist you in understanding the nature of the annuity purchase. DISC-SPDA CBL 357_rvsd B Page 2 of 4

13 Charges and Fees of the Annuity Withdrawal Charges Withdrawal charges are assessed upon a Full or Partial Surrender of the annuity contract. Withdrawal Charges are equal to a percentage multiplied by the Account Value being surrendered according to the Withdrawal Charge Schedule of your contract. The full schedule is shown here. Contract Year Thereafter CBLA 3 Year 9% 8% 7% 0% 0% 0% 0% 0% Withdrawal Charge CBLA 5 Year 9% 8% 7% 6% 5% 0% 0% 0% Withdrawal Charge CBLA 7 Year Withdrawal Charge 9% 8% 7% 6% 5% 4% 3% 0% Tax Guidelines Applicable to the Annuity Tax Treatment When you make any Partial Surrender (including Systemic Withdrawals) or a Full Surrender under the annuity, you may be subject to federal income tax on the amount withdrawn. Federal law requires that withdrawals be taken first from interest earnings. In addition, you may be subject to a 10% federal penalty tax on any amount withdrawn if you make withdrawals or surrender the annuity before age 59 1/2, unless another statutory exemption applies. Withdrawals and surrenders may also be subject to state income tax. If this is a qualified annuity, all withdrawals and surrenders may be taxable. Please consult your tax advisor as to the tax impact of any withdrawal or surrender on your own situation. Other Matters You Should Be Aware of Concerning the Annuity Other Notes - If you are purchasing this annuity contract for use in an IRA or other qualified plan, you should consider other features of the annuity besides tax deferral as reasons for it being appropriate for your needs, because IRAs and qualified plans already receive tax-deferred treatment under the IRS Code. Neither CBL nor its agents or representatives give legal, tax or accounting advice. Please consult an attorney or independent tax advisor as to the applicability of this information to your own situation. If this annuity is replacing an existing annuity, it is important that you compare the two, taking into account whatever surrender charges or withdrawal charges you may incur on the surrender of your existing annuity and your need to access your funds. For information about your existing annuity, contact the issuing company. Agent Compensation The agent is appointed to represent CBL and to provide services to you on our behalf. The agent will earn a commission for each annuity contract sold. The actual percentage or amount of compensation paid to the agent will vary based on specific circumstances. Changes to the annuity The owner will be notified in writing of any changes to the annuity contract. Regulation of the annuity in New Jersey In New Jersey, the sale and suitability of annuities is regulated by the New Jersey Department of Banking and Insurance. You may obtain assistance from the Department by contacting or , or by visiting the Department s website at The annuity contract contains additional limitations. Please contact your agent for additional details about the annuity. This disclosure is not meant to replace any required state replacement forms. It is designed to assist you in understanding the nature of the annuity purchase. DISC-SPDA CBL 357_rvsd B Page 3 of 4

14 Applicant Disclosure Statement and USA Patriot ACT Customer Information: I (we) acknowledge that this document has been read to me (us), or that I (we) have read this document, and I (we) fully understand the information contained in this document and that all information provided below is accurate to the best of my (our) knowledge. 1. I (we) understand that this annuity is a long term contract with penalties for withdrawals and early surrender. 2. I (we) understand that this annuity is not FDIC, NCUA or NCUSIF insured, is not guaranteed by any Bank or Credit Union, is not a deposit, nor insured by any Federal Government Agency. 3. I (we) acknowledge that the annuity meets my current financial needs and objectives and is suitable for me. To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. What this means for you is that when you apply for an annuity, we will ask for your name, address, date of birth and other information that will allow us to identify you. Please list your current driver s license, valid passport or other official identifying documents and their numbers on the appropriate line below to verify your identity; and show that (or those) document(s) to the annuity representative, if one is involved in taking your application. Owner: Identifying Document: Document Name (Driver s License, Passport, Visa) Document Identifying Number Owner Signature Date Joint Owner: Identifying Document: Document Name (Driver s License, Passport, Visa) Document Identifying Number Joint Owner Signature Date Agent Statement: By signing, I certify that: (1) I have reviewed this document with the applicant(s); (2) I have provided a copy of this document to the applicant(s); (3) I have made no statements that differ in any significant manner from this document; (4) I have made no promises or guarantees about the future value of any non-guaranteed elements of this annuity; and (5) I have verified the identity of the applicant(s). Agent Signature Date Print Name of Agent The annuity contract contains additional limitations. Please contact your agent for additional details about the annuity. This disclosure is not meant to replace any required state replacement forms. It is designed to assist you in understanding the nature of the annuity purchase. DISC-SPDA CBL 357_rvsd B Page 4 of 4

15 Buyer s Guide for Deferred Annuities Fixed Table of Contents What Is an Annuity?...1 When Annuities Start to Make Income Payments...1 How Deferred Annuities Are Alike...1 How Deferred Annuities Are Different... 2 How Does the Value of a Deferred Annuity Change?... 3 Fixed Annuities... 3 Fixed Indexed Annuities... 4 What Other Information Should You Consider?...4 Fees, Charges, and Adjustments... 4 How Annuities Make Payments... 5 How Annuities Are Taxed...6 Finding an Annuity That s Right for You... 6 Questions You Should Ask...7 When You Receive Your Annuity Contract National Association of Insurance Commissioners NAICAnnBuyersGuide (3-2014)

16 What Is an Annuity? An annuity is a contract with an insurance company. All annuities have one feature in common, and it makes annuities different from other financial products. With an annuity, the insurance company promises to pay you income on a regular basis for a period of time you choose including the rest of your life. When Annuities Start to Make Income Payments Some annuities begin paying income to you soon after you buy it (an immediate annuity). Others begin at some later date you choose (a deferred annuity). How Deferred Annuities Are Alike There are ways that most deferred annuities are alike. They have an accumulation period and a payout period. During the accumulation period, the value of your annuity changes based on the type of annuity. During the payout period, the annuity makes income payments to you. They offer a basic death benefit. If you die during the accumulation period, a deferred annuity with a basic death benefit pays some or all of the annuity s value to your survivors (called beneficiaries) either in one payment or multiple payments over time. The amount is usually the greater of the annuity account value or the minimum guaranteed surrender value. If you die after you begin to receive income payments (annuitize), your chosen survivors may not receive anything unless: 1) your annuity guarantees to pay out at least as much as you paid into the annuity, or 2) you chose a payout option that continues to make payments after your death. For an extra cost, you may be able to choose enhanced death benefits that increase the value of the basic death benefit. You usually have to pay a charge (called a surrender or withdrawal charge) if you take some or all of your money out too early (usually before a set time period ends). Some annuities may not charge if you withdraw small amounts (for example, 10% or less of the account value) each year. Any money your annuity earns is tax deferred. That means you won t pay income tax on earnings until you take them out of the annuity. You can add features (called riders) to many annuities, usually at an extra cost. An annuity salesperson must be licensed by your state insurance department. A person selling a variable annuity also must be registered with FINRA 1.as a representative of a broker/dealer that s a FINRA member. In some states, the state securities department also must license a person selling a variable annuity. 1 Insurance companies sell annuities. You want to buy from an insurance company that s financially sound. There are various ways you can research an insurance company s financial strength. You can visit the insurance company s website or ask your annuity salesperson for more information. You also can review an insurance company s rating from an independent rating agency. Four main firms currently rate insurance companies. They are A.M. Best Company, Standard and Poor s Corporation, Moody s Investors Service, and Fitch Ratings. Your insurance department may have more information about insurance companies. An easy way to find contact information for your insurance department is to visit and click on States and Jurisdictions Map. 1. FINRA (Financial Industry Regulatory Authority) regulates the companies and salespeople who sell variable annuities National Association of Insurance Commissioners 1 NAICAnnBuyersGuide (3-2014)

17 Insurance companies usually pay the annuity salesperson after the sale, but the payment doesn t reduce the amount you pay into the annuity. You can ask your salesperson how they earn money from the sale. Sources of Information Contract: The legal document between you and the insurance company that binds both of you to the terms of the agreement. Disclosure: A document that describes the key features of your annuity, including what is guaranteed and what isn t, and your annuity s fees and charges. If you buy a variable annuity, you ll receive a prospectus that includes detailed information about investment objectives, risks, charges, and expenses. Illustration: A personalized document that shows how your annuity features might work. Ask what is guaranteed and what isn t and what assumptions were made to create the illustration. How Deferred Annuities Are Different There are differences among deferred annuities. Some of the differences are: Whether you pay for the annuity with one or more than one payment (called a premium). The types and amounts of the fees, charges, and adjustments. While almost all annuities have some fees and charges that could reduce your account value, the types and amounts can be different among annuities. Read the Fees, Charges, and Adjustments section in this Buyer s Guide for more information. Whether the annuity is a fixed annuity or a variable annuity. How the value of an annuity changes is different depending on whether the annuity is fixed or variable. Fixed annuities guarantee your money will earn at least a minimum interest rate. Fixed annuities may earn interest at a rate higher than the minimum but only the minimum rate is guaranteed. The insurance company sets the rates. Fixed indexed annuities are a type of fixed annuity that earns interest based on changes in a market index, which measures how the market or part of the market performs. The interest rate is guaranteed to never be less than zero, even if the market goes down. Variable annuities earn investment returns based on the performance of the investment portfolios, known as subaccounts, where you choose to put your money. The return earned in a variable annuity isn t guaranteed. The value of the subaccounts you choose could go up or down. If they go up, you could make money. But, if the value of these subaccounts goes down, you could lose money. Also, income payments to you could be less than you expected. Some annuities offer a premium bonus, which usually is a lump sum amount the insurance company adds to your annuity when you buy it or when you add money. It s usually a set percentage of the amount you put into the annuity. Other annuities offer an interest bonus, which is an amount the insurance company adds to your annuity when you earn interest. It s usually a set percentage of the interest earned. You may not be able to withdraw some or all of your premium bonus for a set period of time. Also, you could lose the bonus if you take some or all of the money out of your annuity within a set period of time National Association of Insurance Commissioners 2 NAICAnnBuyersGuide (3-2014)

18 How Does the Value of a Deferred Annuity Change? Fixed Annuities Money in a fixed deferred annuity earns interest at a rate the insurer sets. The rate is fixed (won t change) for some period, usually a year. After that rate period ends, the insurance company will set another fixed interest rate for the next rate period. That rate could be higher or lower than the earlier rate. Fixed deferred annuities do have a guaranteed minimum interest rate the lowest rate the annuity can earn. It s stated in your contract and disclosure and can t change as long as you own the annuity. Ask about: The initial interest rate What is the rate? How long until it will change? The renewal interest rate When will it be announced? How will the insurance company tell you what the new rate will be? Fixed Deferred Indexed Formulas Annual Point-to-Point Change in index calculated using two dates one year apart. Multi-Year Point-to-Point Change in index calculated using two dates more than one year apart. Monthly or Daily Averaging Change in index calculated using multiple dates (one day of every month for monthly averaging, every day the market is open for daily averaging). The average of these values is compared with the index value at the start of the index term. Monthly Point-to-Point Change in index calculated for each month during the index term. Each monthly change is limited to the cap rate for positive changes, but not when the change is negative. At the end of the index term, all monthly changes (positive and negative) are added. If the result is positive, interest is added to the annuity. If the result is negative or zero, no interest (0%) is added. Fixed Indexed Annuities Money in a fixed indexed annuity earns interest based on changes in an index. Some indexes are measures of how the overall financial markets perform (such as the S&P 500 Index or Dow Jones Industrial Average) during a set period of time (called the index term). Others measure how a specific financial market performs (such as the Nasdaq) during the term. The insurance company uses a formula to determine how a change in the index affects the amount of interest to add to your annuity at the end of each index term. Once interest is added to your annuity for an index term, those earnings usually are locked in and changes in the index in the next index term don t affect them. If you take money from an indexed annuity before an index term ends, the annuity may not add all of the index-linked interest for that term to your account.. Insurance companies use different formulas to calculate the interest to add to your annuity. They look at changes in the index over a period of time. See the box Fixed Deferred Indexed Formulas that describes how changes in an index are used to calculate interest. The formulas insurance companies use often mean that interest added to your annuity is based on only part of a change in an index over a set period of time. Participation rates, cap rates, and spread rates (sometimes called margin or asset fees) all are terms that describe ways the amount of interest added to your annuity may not reflect the full change in the index. But if the index goes down over that period, zero interest is added to your annuity. Then your annuity value won t go down as long as you don t withdraw the money National Association of Insurance Commissioners 3 NAICAnnBuyersGuide (3-2014)

19 When you buy an indexed annuity, you aren t investing directly in the market or the index. Some indexed annuities offer you more than one index choice. Many indexed annuities also offer the choice to put part of your money in a fixed interest rate account, with a rate that won t change for a set period. How Insurers Determine Indexed Interest Participation Rate Determines how much of the increase in the index is used to calculate index-linked interest. A participation rate usually is for a set period. The period can be from one year to the entire term. Some companies guarantee the rate can never be lower (higher) than a set minimum (maximum). Participation rates are often less than 100%, particularly when there s no cap rate. Cap Rate Typically, the maximum rate of interest the annuity will earn during the index term. Some annuities guarantee that the cap rate will never be lower (higher) than a set minimum (maximum). Companies often use a cap rate, especially if the participation rate is 100%. Spread Rate A set percentage the insurer subtracts from any change in the index. Also called a margin or asset fee. Companies may use this instead of or in addition to a participation or cap rate. What Other Information Should You Consider? Fees, Charges, and Adjustments Fees and charges reduce the value of your annuity. They help cover the insurer s costs to sell and manage the annuity and pay benefits. The insurer may subtract these costs directly from your annuity s value. Most annuities have fees and charges but they can be different for different annuities. Read the contract and disclosure or prospectus carefully and ask the annuity salesperson to describe these costs. A surrender or withdrawal charge is a charge if you take part or all of the money out of your annuity during a set period of time. The charge is a percentage of the amount you take out of the annuity. The percentage usually goes down each year until the surrender charge period ends. Look at the contract and the disclosure or prospectus for details about the charge. Also look for any waivers for events (such as a death) or the right to take out a small amount (usually up to 10%) each year without paying the charge. If you take all of your money out of an annuity, you ve surrendered it and no longer have any right to future income payments. Some annuities have a Market Value Adjustment (MVA). An MVA could increase or decrease your annuity s account value, cash surrender value, and/or death benefit value if you withdraw money from your account. In general, if interest rates are lower when you withdraw money than they were when you bought the annuity, the MVA could increase the amount you could take from your annuity. If interest rates are higher than when you bought the annuity, the MVA could reduce the amount you could take from your annuity. Every MVA calculation is different. Check your contract and disclosure or prospectus for details National Association of Insurance Commissioners 4 NAICAnnBuyersGuide (3-2014)

20 Annuity Fees and Charges Contract fee A flat dollar amount or percentage charged once or annually. Percentage of purchase payment A front-end sales load or other charge deducted from each premium paid. The percentage may vary over time. Premium tax A tax some states charge on annuities. The insurer may subtract the amount of the tax when you pay your premium, when you withdraw your contract value, when you start to receive income payments, or when it pays a death benefit to your beneficiary. Transaction fee A charge for certain transactions, such as transfers or withdrawals. How Annuities Make Payments Annuitize At some future time, you can choose to annuitize your annuity and start to receive guaranteed fixed income payments for life or a period of time you choose. After payments begin, you can t take any other money out of the annuity. You also usually can t change the amount of your payments. For more information, see Payout Options in this Buyer s Guide. If you die before the payment period ends, your survivors may not receive any payments, depending on the payout option you choose. Full Withdrawal You can withdraw the cash surrender value of the annuity in a lump sum payment and end your annuity. You ll likely pay a charge to do this if it s during the surrender charge period. If you withdraw your annuity s cash surrender value, your annuity is cancelled. Once that happens, you can t start or continue to receive regular income payments from the annuity. Partial Withdrawal You may be able to withdraw some of the money from the annuity s cash surrender value without ending the annuity. Most annuities with surrender charges let you take out a certain amount (usually up to 10%) each year without paying surrender charges on that amount. Check your contract and disclosure or prospectus. Ask your annuity salesperson about other ways you can take money from the annuity without paying charges. Living Benefits for Fixed Annuities Some fixed annuities, especially fixed indexed annuities, offer a guaranteed living benefits rider, usually at an extra cost. A common type is called a guaranteed lifetime withdrawal benefit that guarantees to make income payments you can t outlive. While you get payments, the money still in your annuity continues to earn interest. You can choose to stop and restart the payments or you might be able to take extra money from your annuity. Even if the payments reduce the annuity s value to zero at some point, you ll continue to get payments for the rest of your life. If you die while receiving payments, your survivors may get some or all of the money left in your annuity National Association of Insurance Commissioners 5 NAICAnnBuyersGuide (3-2014)

21 Payout Options You ll have a choice about how to receive income payments. These choices usually include: For your lifetime For the longer of your lifetime or your spouse s lifetime For a set time period For the longer of your lifetime or a set time period How Annuities Are Taxed Ask a tax professional about your individual situation. The information below is general and should not be considered tax advice. Current federal law gives annuities special tax treatment. Income tax on annuities is deferred. That means you aren t taxed on any interest or investment returns while your money is in the annuity. This isn t the same as tax-free. You ll pay ordinary income tax when you take a withdrawal, receive an income stream, or receive each annuity payment. When you die, your survivors will typically owe income taxes on any death benefit they receive from an annuity. There are other ways to save that offer tax advantages, including Individual Retirement Accounts (IRAs). You can buy an annuity to fund an IRA, but you also can fund your IRA other ways and get the same tax advantages. When you take a withdrawal or receive payments, you ll pay ordinary income tax on all of the money you receive (not just the interest or the investment return). You also may have to pay a 10% tax penalty if you withdraw money before you re age 59½. Finding an Annuity That s Right for You An annuity salesperson who suggests an annuity must choose one that they think is right for you, based on information from you. They need complete information about your life and financial situation to make a suitable recommendation. Expect a salesperson to ask about your age; your financial situation (assets, debts, income, tax status, how you plan to pay for the annuity); your tolerance for risk; your financial objectives and experience; your family circumstances; and how you plan to use the annuity. If you aren t comfortable with the annuity, ask your annuity salesperson to explain why they recommended it. Don t buy an annuity you don t understand or that doesn t seem right for you. Within each annuity, the insurer may guarantee some values but not others. Some guarantees may be only for a year or less while others could be longer. Ask about risks and decide if you can accept them. For example, it s possible you won t get all of your money back or the return on your annuity may be lower than you expected. It s also possible you won t be able to withdraw money you need from your annuity without paying fees or the annuity payments may not be as much as you need to reach your goals. These risks vary with the type of annuity you buy. All product guarantees depend on the insurance company s financial strength and claims-paying ability National Association of Insurance Commissioners 6 NAICAnnBuyersGuide (3-2014)

22 Questions You Should Ask Do I understand the risks of an annuity? Am I comfortable with them? How will this annuity help me meet my overall financial objectives and time horizon? Will I use the annuity for a long-term goal such as retirement? If so, how could I achieve that goal if the income from the annuity isn t as much as I expected it to be? What features and benefits in the annuity, other than tax deferral, make it appropriate for me? Does my annuity offer a guaranteed minimum interest rate? If so, what is it? If the annuity includes riders, do I understand how they work? Am I taking full advantage of all of my other tax-deferred opportunities, such as 401(k)s, 403(b)s, and IRAs? Do I understand all of the annuity s fees, charges, and adjustments? Is there a limit on how much I can take out of my annuity each year without paying a surrender charge? Is there a limit on the total amount I can withdraw during the surrender charge period? Do I intend to keep my money in the annuity long enough to avoid paying any surrender charges? Have I consulted a tax advisor and/or considered how buying an annuity will affect my tax liability? How do I make sure my chosen survivors (beneficiaries) will receive any payment from my annuity if I die? If you don t know the answers or have other questions, ask your annuity salesperson for help. When You Receive Your Annuity Contract When you receive your annuity contract, carefully review it. Be sure it matches your understanding. Also, read the disclosure or prospectus and other materials from the insurance company. Ask your annuity salesperson to explain anything you don t understand. In many states, a law gives you a set number of days (usually 10 to 30 days) to change your mind about buying an annuity after you receive it. This often is called a free look or right to return period. Your contract and disclosure or prospectus should prominently state your free look period. If you decide during that time that you don t want the annuity, you can contact the insurance company and return the contract. Depending on the state, you ll either get back all of your money or your current account value National Association of Insurance Commissioners 7 NAICAnnBuyersGuide (3-2014)

23 1035 Exchange/Transfer or Rollover Authorization Underwritten by COLORADO BANKERS LIFE INSURANCE COMPANY Administrative Office: 2327 Englert Drive Durham, North Carolina This form can be used: (1) to accomplish a FULL or a PARTIAL Exchange of policies/contracts pursuant to Internal Revenue Code (IRC) Section 1035; (2) to Transfer funds from an existing account into a life policy or annuity issued by Colorado Bankers Life Insurance Company ( CBLife ); or (3) to make a Direct Rollover into an annuity issued by CBLife. Complete the requested information, check the appropriate boxes, and date and sign this form. CBLife POLICY/CONTRACT INFORMATION Is this a new or existing account? New Existing - Policy/Contract # Check One: Life Insurance Annuity OWNER (individual or trust) JOINT OWNER INSURED/ANNUITANT First Name MI Last Name / Trust Name First Name MI Last Name First Name MI Last Name SSN/TIN SSN SSN Exchange (Non-Qualified Annuity/Life Insurance) Owner Initials SURRENDERING COMPANY INFORMATION (FUNDS TO BE MOVED TO CBLife) Name Contract/Policy Number Original Date of Issue Surrender Charge $ Current Rate % Address City State Zip OWNER First Name MI Last Name / Trust Name SSN/TIN JOINT OWNER First Name MI Last Name SSN INSURED/ANNUITANT First Name MI Last Name SSN JOINT INSURED First Name MI Last Name SSN Full or Partial (Check One) All (Full) Transfer Partial Transfer Transfer Details Dollar Amount or Percent $ or % Transfer Date (WHEN TO PROCESS TRANSFER) Immediately upon receipt On or after specific date Page 1 of 5 TransRollover Form 12-17

24 2 Transfers (Non-Qualified Only) Owner Initials SURRENDERING FINANCIAL INSTITUTION INFORMATION (SOURCE OF FUNDS TO BE MOVED TO CBLife) Name Account Number Address City State Zip Product(s) CD (Select one below): Immediately OR Liquidation Date (Liquidations prior to maturity may incur a penalty.) Mutual Fund Other (please specify) Full or Partial (Check One) All (Full) Transfer Partial Transfer Transfer Details Dollar Amount or Percent $ or % Transfer Date (WHEN TO PROCESS TRANSFER) Immediately upon receipt On or after specific date Receipt of Funds Included with application To follow application 3 Rollovers (Trustee to Trustee Transfers) Owner Initials SURRENDERING COMPANY INFORMATION (FUNDS TO BE MOVED TO CBLife) Existing Company Information Name Account Number Address City State Zip Plan Type (SELECT ONE) Traditional IRA 401(k) Roth IRA 403(b) SEP IRA 457(b) Inherited IRA Other Surrender Charge $ Current Rate % Full or Partial (Check One) (Check One) All (Full) Transfer Direct Partial Transfer Transfer Details Dollar Amount or Percent $ or % Transfer Date (WHEN TO PROCESS TRANSFER) Immediately upon receipt On or after specific date Receipt of Funds Included with application To follow application Page 2 of 5 TransRollover Form 12-17

25 4 Taxpayer Certification By executing this form, I (we) authorize the full or partial liquidation of my (our) existing contract, policy or account in accordance with the relevant section(s) completed above. I (we) hereby instruct the relevant financial institution to process my (our) requested liquidation based on the timeframe selected above. I (we) understand that it is my (our) responsibility to confirm the processing guidelines of the financial institution from which any funds are coming with respect to selecting a specific transfer date. Under penalties of perjury, I (we) certify that: 1. The number on this form is my (our) correct taxpayer identification number (or I (we) am (are) waiting for a number to be issued to me (us)); and 2. I (we) am (are) not subject to backup withholding because (a) I (we) am (are) exempt from backup withholding, or (b) I (we) have not been notified by the Internal Revenue Service (IRS) that I (we) am (are) subject to backup withholding as a result of failure to report all interest or dividends, or (c) The IRS has notified me (us) that I (we) am (are) no longer subject to backup withholding; and 3. I (we) am (are) a U.S. person (including a U.S. resident alien). This space intentionally left blank Page 3 of 5 TransRollover Form 12-17

26 5 Acknowledgements and Agreements By signing below, I (we) acknowledge the statements above and understand and agree to the following: All statements and answers given in this form are true and correct to the best of my (our) knowledge; This form is subject to acceptance by the Colorado Bankers Life Insurance Company (CBLife). If this form is rejected for any reason, CBLife will be liable only for return of purchase payment paid; I (we) may return my (our) policy or contract within the right-to-examine period (shown on the first page of my policy or contract) if I (we) am (are) dissatisfied for any reason. Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law. State insurance law may prohibit the owner of an annuity contract from entering into any agreement to sell, transfer or assign an annuity contract prior to the date the contract was issued, or within a period of time specified by state law after the date the contract was issued. You should consult with legal advisors if you have any questions about these matters. FOR 1035 Exchanges - AUTHORIZATION FOR 1035 TAX-FREE EXCHANGE I (we) fully assign and transfer to Colorado Bankers Life Insurance Company (CBLife) all claims, options, privileges, rights, title and interest to either all of the life insurance policy, all of the annuity contract, or part of the annuity contract value identified in the CBLife Policy/Contract Information section on page 1( Assigned Contract ) of this form. The sole purpose of this assignment/transfer is to affect a tax-free exchange under Section 1035(a) of the Internal Revenue Code. All the powers, elections, appointments, options and rights I (we) have as owner of the Assigned Contract, including the right to surrender, are now exercisable by CBLife. Simultaneous with this full assignment, I (we) also revoke all existing beneficiary designations under the Assigned Contract. Other than to me (us), no person, firm or corporation other than myself (ourselves) and the insurer that issued the Assigned Contract, has an interest in the Assigned Contract. No proceedings in insolvency or bankruptcy have been instituted by or against me (us). I (we) understand that CBLife intends to surrender the Assigned Contract for its cash value, and to apply the proceeds to the new contract to be issued by CBLife. I (we) authorize the surrendering company to send the proceeds directly to CBLife, and I (we) understand that fees and surrender charges may apply. This exchange is subject to acceptance by CBLife. CBLife is not liable for changes in market value of the Assigned Contract that may occur before the proceeds are received by it in good order and allocated to the new contract. Prior to the date of receipt of the proceeds by CBLife, no value will accrue or be earned on the new CBLife contract. In accordance with the Tax Equity and Fiscal Responsibility Act of 1982, I (we) direct and authorize the surrendering company to furnish a statement to CBLife and to the former policy or contract holder of my (our) cost basis in the Assigned Contract. I (we) authorize CBLife to rely upon the cost basis information provided by the surrendering company, but agree that CBLife will assume no responsibility for determining or verifying cost basis. If cost basis is not provided, I (we) acknowledge that more restrictive or less beneficial tax rules may apply to the amounts transferred. For Transfers - AUTHORIZATION TO LIQUIDATE AND TRANSFER By signing below, I (we) direct that the Surrendering Financial Institution named above in Section 2 ( Distributing Company ) liquidate and transfer the full value or the partial value of the Distributing Company account identified above in Section 2. I (we) further direct CBLife to apply all the funds it receives from this directive to an annuity or life contract issued to me (us). I (we) further acknowledge and accept responsibility for any charges or fees that may be imposed by the Distributing Company as a result of this liquidation. For Rollovers - AUTHORIZATION TO TRANSFER QUALIFIED FUNDS By signing below, I (we) direct that the Surrendering Company named above in Section 3 ( Surrendering Company ) liquidate and transfer the value of the Surrendering Company account identified above in Section 3. I (we) further direct CBLife to apply all the funds it receives from this directive to an annuity issued to me (us). I (we) further acknowledge and accept responsibility for any charges or fees that may be imposed as a result of this transfer. Page 4 of 5 TransRollover Form 12-17

27 6 Signatures I (we) am (are) aware of and accept any surrender/withdrawal penalties which may apply; and I (we) authorize the transaction described above. The undersigned represents and agrees that CBLife is participating in this transaction at the undersigned's specific request and as an accommodation to the undersigned. It is further agreed that CBLife has made no representations regarding, and has no responsibility nor liability concerning, the undersigned's income, estate or inheritance tax treatment under the relevant tax laws. I (we) hereby authorize the above requested action, and agree to the terms stated in this form. Signature of Owner Signature of Joint Owner Signature of Spouse (Required in AZ, CA, ID, LA, NM, NV, TX, WA or WI only) Date Date Date Is there an Irrevocable Beneficiary? No Yes (must complete the information below) First Name MI Last Name Address First Name MI Last Name Address Signature of Irrevocable Beneficiary Signature of Irrevocable Beneficiary Date Date Signature Guarantee (if applicable) Date (A separate guarantee is needed for each signature) FOR INTERNAL USE ONLY Acceptance and Directive: The authorized signature below certifies acceptance of the assignment, surrender, or transfer of funds as instructed in this request. After deducting any sums as are permitted under the relevant policy, contract, account, or plan, please complete this transaction and send a check with a copy of this form to: Check to with Application: Colorado Bankers Life Insurance Company 2327 Englert Drive, Durham, NC Check to follow Application: Colorado Bankers Life Insurance Company Network Place, Chicago, IL FBO: Policy/Contract # To send funds electronically, use the following information: For ACH Transactions: Company: Colorado Bankers Life Insurance Company Routing number: Bank account number: Include in ACH notes: Policyholder Name & Last 4 of SSN For Wire Transactions: Company: Colorado Bankers Life Insurance Company Routing number: Bank account number: Include in wire notes: Policyholder Name & Last 4 of SSN Print Name of Authorized Officer Title of Authorized Officer Signature of Authorized Officer Date Page 5 of 5 TransRollover Form 12-17

28 Trust Certification Underwritten by COLORADO BANKERS LIFE INSURANCE COMPANY Administrative Office: 2327 Englert Drive Durham, North Carolina Name of Insured / Annuitant Contract / Policy # ( NEW FOR NEW APPLICANT) 1 TRUST INFORMATION Name of Trust Trust Tax ID Date of Trust State of Trust Type of Trust Inter Vivos/Revocable Living Trust Irrevocable Testamentary Trust Complete the following only for Inter Vivos/Revocable Living Trust: Name of Trust Grantor (First Name, MI, Last Name) Grantor Tax ID Address Phone Address 2 TRUSTEE INFORMATION (SUPPLY THE FOLLOWING INFORMATION FOR ALL CURRENT TRUSTEES OF THE TRUST) The first Trustee listed will be the primary point of correspondence from Colorado Bankers Life for all matters pertaining to the policy or contract referenced above. MI Address City State Zip Phone Address (ADDITIONAL SPACE FOR ENTRIES AVAILABLE ON NEXT PAGE) Page 1 of 2 TrustCert 1-17

29 MI Address City State Zip Phone Address MI Address City State Zip Phone Address Pursuant to the terms of the trust document and applicable law, action to be taken on behalf of the trust: Must be taken by all Trustees May be taken by one Trustee acting alone Must be taken by more than one Trustee (LIST TRUSTEE NAMES THAT MUST ACT TOGETHER FOR THE TRUST) Trustee designated to sign application 3 TRUSTEE CERTIFICATION AND INDEMNIFICATION AGREEMENT The undersigned trustees, constituting all of the currently acting trustees of the trust, hereby certify, as trustees and personally as individuals, that the information provided in the sections above is true and correct, and that the trust has not been revoked, modified, or amended in any manner which would cause the above representations to be incorrect. Colorado Bankers Life Insurance Company (CBL) and each of its officers, directors, employees and agents, or the successors and assigns of any of them are authorized to rely on the information set forth in this document until CBL is notified of any change to said information in writing. Any change(s) to the information contained in this form is to be delivered to the CBL administrative office and will become effective as soon as CBL has had a reasonable amount of time to act upon the changes. It is agreed that no such change will affect any transactions initiated by CBL before the later of: (1) the date the change became effective, or (2) the date CBL was properly informed of such change. The undersigned trustee(s) hereby agree, as trustees and personally as individuals, to personally indemnify, defend and hold harmless CBL from any and all liability, including attorneys fees, CBL may incur by acting upon instructions reasonably believed by CBL to be valid instructions originating from said trustee(s), and from any and all acts of said trustee(s) with respect to any policy, account, fund or similar instrument. TRUSTEE SIGNATURE PRINT NAME DATE TRUSTEE SIGNATURE PRINT NAME DATE TRUSTEE SIGNATURE PRINT NAME DATE Page 2 of 2 TrustCert 1-17

30 Payment Authorization Form For Annuity Initial Premiums Underwritten by COLORADO BANKERS LIFE INSURANCE COMPANY Administrative Office: 2327 Englert Drive Durham, North Carolina There are two options to pay your initial premium electronically utilizing the instructions below. If you have any questions, please contact our Customer Service department at (800) Send CBLife an Electronic Payment Note: Completion & submission of this form is not required if initiating electronic payment with Option 1. For ACH Transactions: Company: Colorado Bankers Life Insurance Company Routing number: Bank account number: Include in ACH Notes: Policyholder Name, Last 4 of SSN, and CBLife Policy No. (if available) For Wire Transactions: Company: Colorado Bankers Life Insurance Company Routing number: Bank account number: Include in Wire Notes: Policyholder Name, Last 4 of SSN, and CBLife Policy No. (if available) 2. Authorize CBLife to Make One-time EFT Debit OR ACCOUNT INFORMATION Account Type: Checking Savings Financial Institution Name: Please fill in your routing & account numbers in the boxes. ROUTING NUMBER ACCOUNT NUMBER Initial Premium Amount: eapplication ID (if available): I certify that I am the authorized account holder of record for the account ( My Account ) listed in the "EFT Authorization" section above, and that I have full authority to make purchases and authorize payments from that Account. I understand that Colorado Bankers Life Insurance Company ( CBLife ) underwrites and services the product listed above. I hereby authorize CBLife to initiate debit entries, and, if necessary, credit entries and adjustments for any debit entries made in error, to My Account as provided in this authorization. I also authorize CBLife and my Financial Institution to deduct from My Account the amount listed for a one time payment and to pay such premium deposit amounts to CBLife. Should this deduction be declined for any reason, My Account will be subject to normal credit procedures and fees. I understand this authorization is for a single transaction to pay for my Initial Premium of my annuity contract. NON-OWNER PAYORS: I also understand and confirm that I have no rights and may not be entitled to any benefits, including a refund of any payments made under this authorization, for the product listed above, for which payments will be made under this authorization, if I am not the owner of such product according to its terms. Account holder (Payor) Signature: Date (MM/DD/YY): Proposed Annuitant s Name: Social Security No.: Proposed Owner s Name: Social Security No.: Note: An incomplete authorization may cause a delay in processing. Products and services are underwritten and/or provided by Colorado Bankers Life Insurance Company (Home Office: Durham, NC), licensed in 49 states (excluding New York), the District of Columbia, and Puerto Rico. Products and services may not be available in all states. Payment Authorization 11-17

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