INSTRUCTIONS FOR REPLACEMENT REGULATIONS

Transcription

1 Please check appropriate underwriting company: Jefferson-Pilot Life Insurance Company, PO Box 21008, Greensboro, NC Jefferson Pilot Financial Insurance Company, PO Box 515, Concord, NH INSTRUCTIONS FOR REPLACEMENT REGULATIONS New replacement regulations have been adopted in a number of states. Copies of the regulations are available on JPF Net. The following steps are necessary to comply with the new regulations. 1. Existing Insurance For each application, a producer is required to ask an applicant if he or she has any existing life insurance policies* or annuity contracts*. The producer and the applicant must complete and sign the statement regarding existing policies* or contracts*, Form BJ-01135NJ. This form must accompany the application whether or not a replacement is proposed. 2. Replacement Notice If there are existing policies* or contracts*, the producer and the applicant must also complete and sign Important Notice: Replacement of Life Insurance and Annuities, Form BJ-01134NJ. This form must accompany the application whether or not a replacement is proposed. A copy must be provided to the applicant If there is a replacement, all policies* and contracts* to be replaced must be listed on the form in detail, including the reason for replacement. The producer is required to read the form aloud to the applicant or the applicant must initial the form to indicate that the reading was waived. 3. Sales Material We require that only approved sales material be used. The regulations define sales material as a sales illustration and any other written, printed or electronically presented information created, completed or provided by the producer that is used in the presentation to the applicant. (A printed hard copy of any electronically presented sales material must be given to the applicant no later than the time of contact delivery.) If there is a replacement, a producer must complete and sign item 3, certifying that only company approved sales material was used and that copies were left with the applicant. The producer must maintain documentation of all sales materials used. The replacement regulations require that we contact the applicant after the contract* is issued to affirm that you left copies of all sales materials used with the applicant. We make this contact via a letter. If the contract* is mailed to you for delivery, it is your responsibility to provide this letter to the applicant with the contract*. The regulations require this letter to be provided to the applicant within 10 days of the issue date. *Note: Certificate will replace policy or contract in some states. Page 1 of 1 BJ-01136NJ 11/04

2 Jefferson Pilot Financial Insurance Company (JPFIC) Jefferson-Pilot Life Insurance Company (JPL) Jefferson Pilot LifeAmerica Insurance Company (JPLA) AUTHORIZATION TO TRANSFER NON-QUALIFIED ASSETS Please complete form and send to the To be used for transferring non-qualified funds from a financial institution or mutual fund to JPFIC/JPL/JPLA. This form is not to be used for 1035 Exchanges of insurance or annuity policies. appropriate service center, (check one): Fixed Annuity Service Center: Dept. 5168, PO Box 26074, Greensboro, NC EIA/VA Service Center: One Granite Place, PO Box 515, Concord, NH ext.5394 Check One New Sale, Application attached. Additional deposit to existing policy* number Note: Funds will be placed in your policy according to your existing allocation, unless stated otherwise. Type of Existing Account Mutual Fund Certificate of Deposit of Non-Qualified Other Account Owner s Information Name: Address: City/State/Zip: Telephone: Social Security Number: Current Joint Owner (if applicable) Current Trustee/Custodian Company: Address: City/State/Zip: Telephone: Account Number: Account Owner Election Please liquidate the above-named account plan as follows (check one option in a and b): a. Immediately b. Entire amount $ Upon maturity Specified amount of $ % (less fees/expenses) To the extent there are early withdrawal penalties, I understand and I am aware of these changes. Multiple Transfer Request This transaction is part of a multiple transfer request. Please issue the contract when the last requested payment is received. This transaction is part of a multiple transfer request. Please issue the contract with the following instructions: Required Signatures: Signature of Account Owner Signature of Joint Owner (if applicable) Signature Guarantee (if required) Name of Financial Institution if required for Signature Guarantee Acceptance of Funds The company hereby agrees to accept the transferred funds and to apply them to a non-qualified annuity as established by the applicant. Your check should be made payable to Jefferson Pilot Financial Insurance Company Jefferson-Pilot Life Insurance Company Jefferson Pilot LifeAmerica Insurance Company (fbo:owner). Mail to the appropriate service center as checked above. By: * Policy may be referred to as contract or certificate in certain states. Secretary FA /02 Rev

3 Please check appropriate underwriting company: Jefferson-Pilot Life Insurance Company, PO Box 21008, Greensboro, NC Jefferson Pilot Financial Insurance Company, PO Box 515, Concord, NH EXISTING POLICY* OR CONTRACT* STATEMENT 1. Does the applicant have any existing life insurance policies* or annuity contracts*? Yes No Applicant s Signature and Printed Name Producer s Signature and Printed Name 2. If there are existing policies* or contracts*, complete the Important Notice: Replacement of Life Insurance or Annuity, Form BJ-01134NJ. 3. If a replacement is involved, the following statement must be completed. I certify that only company approved sales materials were used in this sale and that copies of all sales materials were left with the applicant. *Note: Certificate will replace policy or contract in some states. Producer s Signature and Printed Name Page 1 of 1 BJ-01135NJ 11/04

4 Qualified Transfer or Rollover Transmittal (for movement of tax-qualified funds only) Check One Jefferson Pilot Financial Insurance Company (JPFIC) Jefferson-Pilot Life Insurance Company (JPL) Jefferson Pilot LifeAmerica Insurance Company (JPLA) Please complete form and send to the appropriate service center, (check one): Fixed Annuity Service Center: Dept. 5168, PO Box 26074, Greensboro, NC EIA/VA Service Center: One Granite Place, PO Box 515, Concord, NH ext.5394 New Sale, Application attached. Additional deposit to existing policy* number Note: Funds will be placed in your policy according to your existing allocation, unless stated otherwise. Type of Transaction complete one Trustee-to-Trustee/Direct Rollover Transfer $ 60-Day Rollover $ Individual Plan Participant Information Name: Address: City/State/Zip: Telephone: ( ) Social Security Number: Current Trustee/Custodian Company: Address: City/State/Zip: Telephone: ( ) Account Number: Participant Election Please liquidate the above-named tax-qualified plan as follows (check one option in a and b): a. Immediately b. Entire amount $ Upon maturity Specified amount of $ Not applicable (60-day rollover) % (less fees/expenses) Prior Distribution Information (Participant age 70 and over only) If you have attained age 70 1/2, the IRS requires annual minimum distributions from your qualified account(s). The IRS requires this distribution prior to transferring funds to a new account. If you have not taken your current year s distribution, check here to request the current trustee or custodian to distribute before transferring funds to JPFIC/JPL/JPLA. a. Was your last distribution based on single or joint life expectancy? Single life Joint life and based on other life of Birth: / / Sex: M F Mo. Day Yr. b. What method was used to calculate your last distribution? Recalculation Nonrecalculation (factor used ) Note: Annual recalculation based on life expectancy. Non-spouse beneficiary life expectancy cannot be recalculated. Participant Signatures I agree that I am responsible for determining whether a transfer made using this form meets IRS requirements relating to nontaxable transfers. I have read the definitions on the back of the form and I understand them. Plan Participant: : Signature Guarantee (if required): Name of Financial Institution (if signature guarantee is required): Acceptance of Funds This is to certify that JPFIC/JPL/JPLA will accept the funds to establish a qualified annuity. Please do not withhold any taxes from the amount being transferred. Please make the check payable to Jefferson Pilot Financial Insurance Company Jefferson- Pilot Life Insurance Company Jefferson Pilot LifeAmerica Company (fbo: Owner). Mail to the appropriate service center By: as checked above. FA-0028 Secretary Page 1 of 2 1/02 Rev

5 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 an 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 to the new trustee 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 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 plan 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. If you have any questions regarding this form, please contact the appropriate service center as checked on page 1. * Policy may be referred to as contract or certificate in certain states. FA-0028 Page 2 of 2 1/02 Rev

6 Form W-4P What Is Form W-4P? This form is for recipients of income from annuity, pension, and certain other deferred compensation plans to tell payers whether income tax is to be withheld and on what basis. Your options depend on whether the payment is periodic or nonperiodic (including an eligible rollover distribution) as explained on page 3. You can use this form to choose to have no income tax withheld from the payment (except for eligible rollover distributions or payments to U.S. citizens delivered outside the United States or its possessions) or to have an additional amount of tax withheld. What Do I Need To Do? If you want no tax to be withheld, you can skip the worksheet below and go directly to the form at the bottom of this page. Otherwise, complete lines A through F of the worksheet. Many recipients can stop at line F. Other Income? If you have a large amount of income from other sources not subject to withholding (such as interest, dividends, or taxable social security), you should consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Call for copies of Form 1040-ES, and Pub. 505, Tax Withholding and Estimated Tax. Department of the Treasury Internal Revenue Service When Should I File? File as soon as possible to avoid underwithholding problems. Multiple Pensions? More Than One income? To figure the number of allowances you may claim, combine allowances and income subject to withholding from all sources on one worksheet. You can file a Form W-4P with each pension payer, but do not claim the same allowances more than once. Your withholding will usually be more accurate if you claim all allowances on the Form W4-P for the largest source of income subject to withholding. Personal Allowances Worksheet A Enter 1 for yourself if no one else can claim you as a dependent... A You are single and have only one pension; or You are married, have only one pension, and your spouse has no B Enter 1 if: income subject to withholding; or... B Your income from a second pension or a job, or your spouse s pension or wages (or the total of all) is $1,000 or less. C Enter 1 for your spouse. You may choose to enter if you are married and have either a spouse who has income subject to withholding or you have more than one source of income subject to withholding. (This may help you avoid having too little tax withheld.)... C D Enter number of dependents (other than your spouse or yourself) you will claim on your return... D E Enter 1 if you will file as a head of household on your tax return... E F Add lines A through E and enter total here.... F { } If you plan to itemize or claim other deductions and want to reduce your withholding, use For the Deductions and Adjustments Worksheet on page 2. accuracy, do all If you have more than one source of income subject to withholding or a spouse with income worksheets subject to withholding AND your combined earnings from all sources exceed $30,000, that apply. ($50,000 if married filing jointly), use the Multiple Pensions/More Than One Income Worksheet on page 2 if you want to avoid having too little tax withheld. If neither situation applies, stop here and enter the number from line F above on line 2 of Form W-4P below. D193 For Paperwork Reduction Act Notice, see instr. CS1 Form W-4P Cut here and give the certificate to the payer of your pension or annuity. Keep the top portion for your records Form W-4P Department of the Treasury Internal Revenue Service Withholding Certificate for Pension or Annuity Payments OMB No Your social security number Claim or identification number (if any) of your pension or annuity contract Complete the following applicable lines: 1 I elect not to have income tax withheld from my pension or annuity. (Do not complete lines 2 or 3.)... 2 I want my withholding from each periodic pension or annuity payment to be figured using the number of allowances and marital status shown. (You may also designate a dollar amount on line 3.)... Marital status: Single Married Married, but withhold at higher Single rate (Enter number 3 I want the following additional amount withheld from each pension or annuity payment. Note: For periodic payments,.. of allowances.) you cannot enter an amount here without entering the number (including zero) of allowances on line $ Your signature D193 For Paperwork Reduction Act Notice, see instr. CS1 Form W-4P BJ-7880

7 Please check appropriate underwriting company: Jefferson-Pilot Life Insurance Company, PO Box 21008, Greensboro, NC Jefferson Pilot Financial Insurance Company, PO Box 515, Concord, NH IMPORTANT NOTICE: REPLACEMENT OF LIFE INSURANCE OR ANNUITIES This document must be signed by the applicant and the producer, if there is one, and a copy left with the applicant. You are contemplating the purchase of a life insurance policy* or annuity contract*. In some cases this purchase may involve discontinuing or changing an existing policy* or contract*. If so, a replacement is occurring. Financed purchases are also considered replacements. A replacement occurs when a new policy* or contract* is purchased and, in connection with the sale, you discontinue making premium payments on the existing policy* or contract*, or an existing policy* or contract* is surrendered, forfeited, assigned to the replacing insurer, or otherwise terminated or used in a financed purchase. A financed purchase occurs when the purchase of a new life insurance policy* involves the use of funds obtained by the withdrawal or surrender of or by borrowing some or all of the policy* values, including accumulated dividends, of an existing policy*, to pay all or part of any premium or payment due on the new policy*. A financed purchase is a replacement. You should carefully consider whether a replacement is in your best interest. You will pay acquisition costs and there may be surrender costs deducted from your policy* or contract*. You may be able to make changes to your existing policy* or contract* to meet your insurance needs at less cost. A financed purchase will reduce the value of your existing policy* and may reduce the amount paid upon the death of the insured. We want you to understand the effects of replacements before you make your purchase decision and ask that you answer the following questions and consider the questions on the back of this form. 1. Are you considering discontinuing making premium payments, surrendering, forfeiting, assigning to the insurer, or otherwise terminating your existing policy* or contract*? YES NO 2. Are you considering using funds from your existing policies* or contracts* to pay premiums due on the new policy* or contract*? YES NO If you answered yes to either of the above questions, list each existing policy* or contract* you are contemplating replacing (include the name of the insurer, the insured or annuitant, and the policy* or contract* number if available) and whether each policy* will be replaced or used as a source of financing: INSURER CONTRACT* OR INSURED REPLACED (R) OR NAME POLICY* # OR ANNUITANT FINANCING (F) Make sure you know the facts. Contact your existing company or its agent for information about the old policy* or contract*. [If you request one, an in-force illustration, policy* summary or available disclosure document must be sent to you by the existing insurer.] Ask for and retain all sales material used by the agent in the sales presentation. Be sure that you are making an informed decision. The existing policy* or contract* is being replaced because. I certify that the responses herein are, to the best of my knowledge, accurate. *Note: Certificate will replace policy or contract in some states. Applicant s Signature and Printed Name Producer s Signature and Printed Name Page 1 of 2 BJ-01134NJ 11/04

8 I do not want this notice read aloud to me, (Applicants must initial only if they do not want the notice read aloud.) A replacement may not be in your best interest, or your decision could be a good one. You should make a careful comparison of the costs and benefits of your existing policy* or contract* and the proposed policy* or contract*. One way to do this is to ask the company or agent that sold you your existing policy* or contract* to provide you with information concerning your existing policy* or contract*. This may include an illustration of how your existing policy* or contract* is working now and how it would perform in the future based on certain assumptions. Illustrations should not, however, be used as a sole basis to compare policies* or contracts*. You should discuss the following with your agent to determine whether replacement or financing your purchase makes sense. PREMIUMS: POLICY* VALUES: INSURABILITY: Are they affordable? Could they change? You re older are premiums higher for the proposed new policy*? How long will you have to pay premiums on the new policy*? On the old policy*? New policies* usually take longer to build cash values and to pay dividends. Acquisition costs for the old policy* may have been paid; you will incur costs for the new one. What surrender charges do the policies* have? What expense and sales charges will you pay on the new policy*? Does the new policy* provide more insurance coverage? If your health has changed since you bought your old policy*, the new one could cost you more, or you could be turned down. You may need a medical exam for a new policy*. [Claims on most new policies* for up to the first two years can be denied based on inaccurate statements. Suicide limitations may begin anew on the new coverage.) IF YOU ARE KEEPING THE OLD POLICY* AS WELL AS THE NEW POLICY*: How are premiums for both policies* being paid? How will the premiums on your existing policy* be affected? Will a loan be deducted from death benefits? What values from the old policy* are being used to pay premiums? IF YOU ARE SURRENDERING AN ANNUITY OR INTEREST SENSITIVE LIFE PRODUCT: Will you pay surrender charges on your old contract*? What are the interest rate guarantees for the new contract*? Have you compared the contract* charges or other policy* expenses? OTHER ISSUES TO CONSIDER FOR ALL TRANSACTIONS: What are the tax consequences of buying the new policy*? Is this a tax-free exchange? (See your tax advisor.) Is there a benefit from favorable grandfathered treatment of the old policy* under the federal tax code? Will the existing insurer be willing to modify the old policy*? How does the quality and financial stability of the new company compare with your existing company? If you choose to replace your existing policy* or contract* you will have 30 days to review your new policy* and return it for cancellation. If you choose to return it, it will be deemed void from the beginning and any premiums paid, including any policy* fees or charges, will be refunded. *Note: Certificate will replace policy or contract in some states. Page 2 of 2 BJ-01134NJ 11/04

9 Annuity Application Send Application & Check to: Jefferson-Pilot Life Insurance Company Jefferson-Pilot Life Insurance Company (For EIA products, check box to the right.) EIA Service Center (800) , ext 5394 Fixed Annuity Service Center (800) One Granite Place, Concord, NH 03302; or 100 N Greene St, Greensboro, NC 27401; or PO Box 515, Concord, NH PO Box 26074, Greensboro, NC Owner Male Female Full Name: 4. Annuitant (if other than Owner) Male Female Full Name: Address: City: State: Zip: S.S.N.: D.O.B.: Phone # ( ) 2. Joint Owner, if any (Non-Qualified Only) Male Female Full Name: Address: City: State: Zip: S.S.N.: Relationship to Owner: 3. Annuity Product Applied For: Deferred Annuity: Product Name Immediate Annuity: Payment Option Payment Mode: M Q SA A Payment Amount: $ First Payment : 8. Special Instructions: D.O.B.: Address: City: State: Zip: S.S.N.: D.O.B.: 5. Primary Beneficiary Full Name S.S.N. (Required) Relationship Contingent Beneficiary Full Name S.S.N. (Required) Relationship Premium Premium Remitted with Application: $ 1035 Exchange*, Approx. Premium: $ Premium Tax Status: Non-Qualified Qualified: IRA IRA Rollover** Other * Attach 1035 exchange form(s). ** Attach qualified funds transfer form. 9. Owner s Statement: The Owner(s) understands and agrees that: 1. The above statements and answers are true, complete, and correct to the best of his or her knowledge and belief. 2. The statements made shall form the exclusive basis of any annuity issued hereon. 3. Checks must be made payable to the life insurance company, not to the agent. The canceled check is your receipt. 4. Only a Company officer can make, modify, discharge, or waive any of the Company s rights. 5. Under penalties of perjury, the Owner(s) certifies that: (1) the Social Security Number(s) or Federal Tax Identification Number(s) reported above for the Owner(s) is the correct number (or the Owner(s) is waiting for a number to be issued); and (2) the Owner(s) is not subject to backup withholding either because (a) the Owner(s) has not been notified by the Internal Revenue Service (IRS) that the Owner(s) is subject to backup withholding as a result of a failure to report all interest or dividends, or (b) the IRS has notified the Owner(s) he or she is no longer subject to backup withholding. 6. Placing an annuity in a tax qualified retirement plan (e.g., an IRA) will result in no additional tax advantage from the annuity. 7. Any person who includes any false or misleading information on an application or insurance policy is subject to criminal and civil penalties. 10. Do you have any existing life insurance or annuities? Yes No Is the annuity applied for intended to replace or change existing life insurance or annuities? Yes No 11. Application Signed in: City State Signature of Owner Signature of Joint Owner, if any 12. Writing Agent s Statement Yes Signature of Annuitant No To the best of your knowledge, the annuity applied for is intended to replace or change existing life insurance or annuities. If replacement or change is involved, I have attached copies of Comparison and Notice Statements and a list of companies involved, as required. Signature of Writing Agent State License # (if required) Writing Agent (print name) Writing Agent Social Security Number or Agent Number ( ) Agency Name Agent Phone # BJ New Jersey 11/04 Rev