APPLICATION FOR ANNUITY

Transcription

1 APPLICATION FOR ANNUITY 850 East Anderson Lane Austin, Texas ANNUITANT: Birth Soc. Sec. Name Sex Date Age No. Address City State Zip Employer Annual Salary $ OWNER: This section must be left blank on IRA, SEP AND TSA plans. Soc. Sec. Full Name (if other than annuitant) No. Address City State Zip Soc. Sec. Joint Owner No. Soc. Sec. Contingent Owner (if other than annuitant) No BENEFICIARY OF ANNUITANT: Relationship Primary Beneficiary to Annuitant Relationship Contingent Beneficiary to Annuitant PLAN: Plan Name Tax Status: Non-Qualified IRA HR-10(Keogh) 403b(TSA) SEP/IRA 401k Other Will this annuity replace any existing insurance or annuities in this or any other company? Yes No (If yes, complete applicable replacement forms in states where required.) PREMIUMS: Premiums: Submitted with application $ SPECIAL REQUESTS: Amount to be billed $ If IRA, premium submitted applies to tax year Expected first yearly premium $ Anticipated amount on policy exchanges or transfers $ (If any, attach Transfer Form No. SA-8600, the policy/document that is to be exchanged, and any applicable replacement form.) Mode: Single Premium Annual Semi-annual Monthly Other 9 pay per year 10 pay per year Circle months not to bill: J F M A M J J A S O N D Date for 1st premium billing: Month Day Year Billing Type: Bank Draft Direct Bill List Bill Government Allotment Special Billing Instructions: Billing Name Address City State Zip I have read the statements above and to the best of my knowledge and belief they are true and correct. Any statement made by either the agent of this application or by any other person shall not be binding on the Company unless such statement is reduced to writing by the Company and made a part of the annuity contract. I have received and read a copy of the annuity information brochure and understand the features of the plan of insurance applied for. Signed in (City) (State) on (date) AGENT: If signed in Florida, my Florida State Insurance License number is my Agent Name is (printed) Annuitant Signature Agent Signature (agent must complete reverse side) Owner Signature Joint Owner Signature Page 1 of 2

2 AGENT S SECTION: Do you have any reason to believe that replacement of existing insurance or annuity will be involved? Yes No If yes, give details below and attach applicable replacement forms. Agent Signature Agent Number Agent Name (printed) Agent Phone Commission Splits: Agent Number Agent Name Commission Split % % % % ***ALL CHECKS MUST BE PAYABLE TO NATIONAL WESTERN LIFE INSURANCE COMPANY*** Print Annuitant s Name Date Page 2 of 2

3 (Please attach additional sheets as necessary) DM-1081.Rev.7.08

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5 MINIMUM DISTRIBUTION REQUIREMENTS DISCLOSURE For all annuitants age 70 and older Dear Annuity Contract Owner: We want to be sure you are aware of the Internal Revenue Code Regulation Section 1.401(a)(9), minimum distribution requirements that may affect your annuity contract. Please read this form carefully, sign, and send a copy with your application. If you attain(ed) age during the current calendar year and have a qualified retirement plan or IRA, the Internal Revenue Code normally requires that you take your first distribution between January 1 of this year and April 1 of the next calendar year (a later date may apply for governmental or church plans). Subsequent annual distributions are required to be taken no later than December 31 of each year, which means that your second minimum distribution must be taken no later than December 31 of the year following the year in which you attain age If you attained age prior to the current calendar year and have a qualified retirement plan or IRA, your minimum distribution must be taken no later than December 31 of this year. Depending upon your personal tax situation, it may be necessary for you to begin taking the required minimum distribution from your annuity contract. If this is the case, your agent can furnish the forms necessary to set up your minimum distribution. Please be aware that once you begin taking this distribution, you cannot change your selection. You should be aware that your annuity may have surrender charges or market value adjustments which will apply to your required minimum distribution. Additionally, you may not be permitted by certain annuity contracts to take any withdrawals without incurring a withdrawal charge during the first policy year. AS WITH ALL PERSONAL TAX MATTERS, WE STRONGLY SUGGEST THAT YOU CONSULT YOUR TAX ADVISOR BEFORE MAKING A DECISION ABOUT YOUR MINIMUM DISTRIBUTION. If you fail to take the required distribution by the appropriate deadline, you may be subject to an excise tax equal to 50% of the amount which should have been withdrawn but was not. Remember, unless you elect a minimum distribution, we must assume that you have met your minimum distribution requirements for this year and do not wish to elect to set up automatic distributions. National Western Life Insurance Company does not provide tax advice. If you have any tax questions, please consult with your tax advisor. I understand that it is my sole responsibility to comply with the Internal Revenue Code requirements concerning minimum distributions. Owner Date SA-8714.Rev.6.05 NATIONAL WESTERN LIFE INSURANCE COMPANY 850 EAST ANDERSON LANE AUSTIN, TEXAS

6 NWL PROTECTOR ONE CONSUMER INFORMATION DISCLOSURE BROCHURE A Flexible Premium Deferred Annuity Group Policy Form and State Variations Certificate Form C-03 and State Variations The NWL Protector One Annuity is a long term contract designed as an appropriate planning vehicle for retirement security with a terminal illness benefit National Western Life Insurance Company 850 East Anderson Lane, Austin, TX SA-9750.Rev.7.06 Page 1 of 5

7 NWL PROTECTOR ONE The NWL Protector One Annuity is a flexible premium deferred annuity. It is a long-term contract intended as a secure planning vehicle for retirement accumulation and income with a terminal illness benefit. The NWL Protector One Annuity provides the important benefits of any tax deferred annuity: interest accumulation, safety, tax-deferral, and liquidity. The NWL Protector One Annuity is an excellent combination of performance and flexibility. the Accumulation Account multiplied by the Market Value Adjustment Factor, less a withdrawal charge, if any. The Accumulation Account multiplied by the Market Value Adjustment Factor will never be less than the premiums paid less any partial withdrawals, accumulated at 2.0%. National Western Life reserves the right to credit a different interest rate, not less than the Minimum Guaranteed Interest Rate, to the Accumulation Account while the Accumulation Account is less than $10,000. INSTRUCTIONS The Agent MUST REVIEW this Consumer Information Disclosure Brochure with the Applicant and both MUST SIGN and date the original, which is REQUIRED to be submitted with the annuity application. This Consumer Information Disclosure Brochure is not part of the Certificate and does not modify it in any way. See the Certificate for all terms, benefits, guarantees, and limitations. INTEREST RATE AND ADDITIONAL INTEREST Premium payments into the NWL Protector One Annuity earn the first-year base interest rate, which is increased by first-year only additional interest of 1%. The first-year base rate and first-year additional interest are guaranteed for the first twelve months and are shown on page three of the Certificate. Including this additional interest, the total rate of interest credited in the first year will be higher than the thirteenth month and after. After the first Certificate Year, renewal rates will be declared from time to time and are subject to change, but are guaranteed to never be less than 2.0% compounded annually during the deferred period. National Western Life offers a wide variety of annuity products with various interest rates and features. Please ask your agent for more information. ACCUMULATION ACCOUNT AND CASH SURRENDER VALUE The Accumulation Account is equal to 100% of premiums, less partial withdrawals and withdrawal charges on such partial withdrawals, plus or minus any Market Value Adjustments on such partial withdrawals, with interest. The Cash Surrender Value is EARLY WITHDRAWAL CHARGE An early withdrawal charge will apply during the first ten Certificate Years on withdrawn amounts exceeding any Free Withdrawal amounts. Any partial withdrawal taken without charge within the 12 months prior to the date of a full surrender will be subject to the full early withdrawal charge on that amount at the time of full surrender. Withdrawal charges are calculated by multiplying the Accumulation Account, plus any Free Withdrawal amounts taken in the 12 months prior to the full surrender of the Cash Surrender Value, by the Withdrawal Charge Rate shown on the schedule below. National Western Life reserves the right to defer payment for up to 6 months after we receive your request for cash. Certificate Year Withdrawal Charge Rate 10% 10% 9% 9% 7% 5% 5% 5% 5% 5% 0% MARKET VALUE ADJUSTMENT This is a long-term accumulation annuity. If withdrawals are made during the first 10 Certificate Years, National Western Life makes a Market Value Adjustment to the Accumulation Account. The Cash Surrender Value is reduced if the Market Value Interest Rate at the time of withdrawal is greater than the Market Value Interest Rate at issue Page 2 of 5

8 less 0.5%; the Cash Surrender Value is increased if the Market Value Interest Rate at the time of withdrawal is greater than 0.5% less than the Market Value Interest Rate at issue. This adjustment reflects changes in the interest rate environment since the Certificate was issued. The Market Value Interest Rate shown on the Certificate is compared to the Market Value Interest Rate on a similar Certificate being issued at the time of withdrawal. The amount payable for a partial withdrawal or a full withdrawal of the Cash Surrender Value may be adjusted up or down based on the difference between the two rates and also the time remaining in the 10 year Market Value Adjustment Period. While the Market Value Adjustment is made to the Accumulation Account, it is calculated only on the amount of the withdrawal. The Market Value Adjustment Factor multiplied by the Accumulation Account will never be less than premiums paid less partial withdrawals, accumulated at 2.0% interest. THE MARKET VALUE ADJUSTMENT DOES NOT APPLY TO: 1) any systematic withdrawal of interest earnings; 2) other Free Withdrawals; 3) Income Settlement Options; 4) any Death Benefit; or 5) under any circumstances after 10 years from the date of issue. FREE WITHDRAWALS OR SYSTEMATIC INTEREST EARNINGS Each Certificate Year, including the first, one withdrawal of up to 10% of the Accumulation Account may be withdrawn without withdrawal charge. This 10% feature is cumulative up to 50% for years in which no withdrawal is made. Withdrawals may be subject to federal income tax. Any unused Free Withdrawals of less than 10% may not be accumulated each year. No portion of a full surrender during the surrender charge period can be free of a withdrawal charge. Any Free Withdrawal taken within the prior 12 months from the date of a full surrender will be subject to the full withdrawal charge on that amount at the time of surrender. Alternatively, systematic withdrawal of interest earnings can be made without withdrawal charge. If each payment is at least $100 and the principal is not invaded, a specific amount may be withdrawn. The systematic payments may be paid monthly, quarterly, semi-annually, or annually. Generally, there is a 10% income tax penalty on withdrawals of interest earned prior to age TERMINAL ILLNESS BENEFIT Upon receiving satisfactory documentation, withdrawal charges and any Market Value Adjustment will be waived for full surrender or partial withdrawal if the Annuitant is first diagnosed after the Certificate Date with an illness from which the Annuitant is not expected to recover and from which the Annuitant is expected to die within twelve (12) months. National Western Life reserves the right to obtain a second medical opinion at the Company s expense. See Certificate for complete details and requirements. SETTLEMENT OPTIONS AT ANNUITY DATE Settlement Options are based on the Accumulation Account and are available on the Annuity Date. The Settlement Options that may be elected by the Owner include: 1. Income for Life 2. Life Income with a Guaranteed Period 3. Life Income with Installment Refund 4. Survivorship Annuity 5. Monthly Income for a fixed period not less than 5 years, nor more than 30 years. 6. Annual Income for a fixed period not less than 5 years, nor more than 30 years. 7. Proceeds Held at Interest Only for a period not less than 5 Years Page 3 of 5

9 A guaranteed interest rate of 1.5% is used in calculating payments. National Western Life may, at its option, use an interest rate that is higher than the guaranteed rate. Consult the Certificate for complete details of these options. BENEFIT AT DEATH OF ANNUITANT At the death of the Annuitant before the Annuity Date, the Beneficiary will receive the Accumulation Account as a single sum or a guaranteed income option with no Market Value Adjustment applied. At the death of the Annuitant after the Annuity Date, the Beneficiary will receive any unpaid guaranteed amounts under the Settlement Option in force on the date of death. No other death benefits will be paid. Spousal Continuation Benefit: Where the surviving spouse is the named Beneficiary and the Annuitant spouse dies, the surviving spouse may become the Annuitant and continue the annuity and the income tax-deferral. PREMIUM PAYMENTS AND ISSUE AGES A minimum initial premium payment of $5,000 is required. Additional premium payments of at least $100 can be made. The maximum premium payment without prior Company approval is $500, % of the premium deposits earn interest from the date funds are received at the Company. If applicable, Federal, State, or Municipal taxes, or any fees or assessments related to the Certificate, payment of which is required or authorized by law, will be deducted from the benefits under the Certificate. National Western Life will not issue this annuity if the age of the Annuitant exceeds the maximum issue age, which is published from time to time. The maximum Owner age at issue is 85. STATEMENT OF ACCOUNT Each calendar year the Owner will receive a detailed statement of the Cash Surrender Value and Accumulation Account. FREE LOOK PERIOD Your satisfaction is important to us! If you change your mind about whether this annuity fits your needs after you receive your Certificate, or if you are dissatisfied for any reason, you have at least twenty days* after receipt of the Certificate during which you can return it without incurring charges (referred to as a free look period). *This time period may be longer; please see your Certificate for details. QUALIFIED PLAN WITHDRAWAL DISCLOSURE Plan the distribution of tax-qualified retirement funds carefully. The distribution of IRAs and other qualified funds usually must begin when age is reached. National Western Life will not waive any early withdrawal penalty for any distribution to the extent it exceeds the annual 10% Free Withdrawal amount. If this is a concern, taking a distribution from other sources of qualified funds may be the solution. LEGAL AND TAX ADVICE National Western Life does not authorize its agents or employees to give legal or tax advice. Representations made in this brochure are based on the Company s understanding of current tax law. For an explanation of how those laws apply to you, consult with an attorney, accountant, or other tax advisor. All withdrawals from the NWL PROTECTOR ONE are subject to federal income tax and withdrawals made before age may be subject to a 10% income tax penalty. Some or all of a non-qualified withdrawal will be reported as taxable income depending on the withdrawal amount and the amount of accrued interest earned in the Certificate. This is so because interest on non-qualified annuities is assumed withdrawn first. Page 4 of 5

10 The NWL PROTECTOR ONE is underwritten by National Western Life Insurance Company, 850 East Anderson Lane, Austin, Texas, Group Policy Form has been issued to the group policyholder, Consumers Nationwide Trust, as Group Policy No. F Non-Qualified, Group Policy No. F0653 IRA, Group Policy No. F0654 ROTH IRA, Group Policy No. F0655 Other Qualified. Not approved in all states. NWL PROTECTOR ONE ANNUITY NATIONAL WESTERN LIFE INSURANCE COMPANY Consumer Disclosure Signature Thank you for choosing to purchase the NWL Protector One Annuity. If you have any questions after you receive your annuity Certificate, please contact your agent or call National Western s Customer Service Department at We want to be sure that you read all of this Disclosure and are aware of the benefits and features explained herein. Please initial and sign where indicated with an asterisk (*), acknowledging that you understand the following: This is a deferred annuity, and it is a long-term savings vehicle. This annuity has a free look period, during which you can surrender the annuity Certificate after receiving it without incurring withdrawal charges (described more fully in your annuity Certificate). Any results shown, other than guaranteed minimum values, are not guarantees, promises, or warranties. Withdrawal charges and/ora Market Value Adjustment may be deducted from your Accumulation Account. For any Certificate issued as a tax-qualified plan, you may have to make withdrawals to meet minimum distribution requirements, and those withdrawals may incur withdrawal charges. *initial The above-stated features have been fully explained to me. I have received a copy of this Disclosure, and I have reviewed it with my agent. I fully understand the Disclosure and the specific points outlined above. The Disclosure is not a part of the annuity Certificate and does not modify it in any way. The annuity Certificate itself contains all terms, benefits, guarantees, limitations, restrictions, and exclusions. Applicant s Signature Date I certify that I reviewed this Disclosure with the applicant Agent s Signature & Agent No. Date SA-9750.Rev.7.06 Page 5 of 5

11 NOTICE REGARDING REPLACEMENT OF LIFE INSURANCE OR ANNUITY Replacing Your Life Insurance or Annuity? Are you thinking about buying a new life insurance policy or annuity and discontinuing or changing an existing one? If you are, your decision could be a good one or a mistake. You will not know for sure unless you make a careful comparison of your existing benefits and the proposed benefits. Make sure you understand the facts. You should ask the insurance producer or company that sold you your existing policy to give you information about it. Hear both sides before you decide. This way you can be sure you are making a decision that is in your best interest. If you choose to purchase the new policy or annuity, you will have the right to an unconditional refund of all premiums provided that you exercise your right within the 20-day period commencing on the date of delivery of the new policy. We are required by law to notify your existing company that you may be replacing their policy. List below the identification of policies which are involved in the replacement transaction. Insurance Producer s Signature Date SA-8086-IL.Rev.2.03 NATIONAL WESTERN LIFE INSURANCE COMPANY 850 EAST ANDERSON LANE AUSTIN, TEXAS White - Applicant Yellow - Company

12 NOTICE REGARDING PROPOSED REPLACEMENT OF LIFE INSURANCE OR ANNUITY Name of Existing Insurer Address City, State, Zip Code Salutation You are herewith given notice that we are in receipt of application(s) for life insurance or annuity(ies) for an individual presently insured with your company. IDENTIFICATION Name of Insured Address This notice is given pursuant to 50 III. Adm. Code (c). Insurance Producer s Signature SA-8087-IL.Rev.4.06 NATIONAL WESTERN LIFE INSURANCE COMPANY 850 EAST ANDERSON LANE AUSTIN, TEXAS White Company Yellow Existing Insurer

13 850 East Anderson Lane, Austin, TX Proposed Insured/Annuitant: Name SSN: xxx-xx- (last 4 digits) Funds Coming From: Existing Company Name Street Address City State Zip Existing Company Phone Number ( ) Area Code Policy / Account to be Transferred: Policy/Account No. (Attach recent statement) Type of policy/account: Annuity Life Ins Brokerage Acct Certificate of Deposit TSA/403(b) Other Policy/Account Owner(s) Name(s) The undersigned hereby requests and directs that the following action be taken in order to transfer the policy/account fund identified above: Entire Account Liquidation/Transfer/Rollover Partial $ or % QUALIFIED ACCOUNT(S) Minimum Required Distribution Instructions **Must complete if applicant is age 70 or older** Calculate and withhold the Minimum Required Distribution for Tax Year and send to the policyholder prior to transferring funds. I have already satisfied my current year Minimum Required Distribution. I will satisfy my current year distribution from another qualified account. Employer Owned/Sponsored Retirement Plan Distribution/Rollovers 401k and/or other Employer owned retirement plans will require the applicant to do phone liquidation/transfer or will require plan distribution paperwork (they will not accept this form). Direct Transfer/ Rollover of a Qualified Account Surrender of an established qualified contract(s) under the Internal Revenue Code for reinvestment in a new qualified contract as follows: IRA ROTH IRA SEP IRA Other: TSA/403(b) to IRA (a direct rollover which requires a qualifying event ) Qualifying events: Age 59 ½ Terminated from Service (Date of Termination ) 1035 EXCHANGE OF A NON-QUALIFIED ANNUITY OR LIFE INSURANCE POLICY 1035 Tax-Free Exchange (for 1035 exchange of partial and entire accounts) The undersigned intends the execution of this document to be part of a tax-free exchange of policies or contracts under Section 1035 of the Internal Revenue Code, and understands that if National Western Life underwrites and issues a new policy or contract on the above insured, then National Western Life intends to surrender the above policy or contract for its cash value and that the above policy or contract will no longer be in force or effect as of the coverage termination date. National Western Life is hereby directed to apply the surrender proceeds upon receipt to the purchase of a policy or contract according to the written instructions it has received. Absolute Assignment (1035 exchange of an entire account only) For value received, the undersigned owner hereby assigns and transfers all rights, title and interest in the above described policy or contract to National Western Life Insurance Company, hereafter known as National Western Life. National Western Life shall be entitled to all ownership rights, privileges, options and powers under said policy or contract. **In accordance with the Tax Equity and Fiscal Responsibility Act of 1982, furnish a statement to National Western Life and to the former contract holder of the cost basis in the contract.** SA-8600.Rev.5.09 Page 1 of 2

14 CERTIFICATE OF DEPOSIT (MATURITY DATE MUST BE WITHIN 60 DAYS OF TRANSFER) Liquidate Certificate of Deposit on the maturity date of / /. Liquidate Certificate of Deposit upon receipt of this request. I am aware of any penalty that may be imposed from an early withdrawal. Please Initial Qualified Non-Qualified BROKERAGE ACCOUNT/MONEY MARKET ACCOUNT **MEDALLION SIGNATURE GUARANTEE MAY BE REQUIRED** Qualified Non-Qualified TAX WITHHOLDING ELECTION FOR PAYEES OF SURRENDERS Even if the undersigned elects not to have federal income tax withheld, the undersigned acknowledges that he/she is liable for payment of federal income tax on the taxable portion of the surrender. The undersigned also may be subject to tax penalties under estimated tax payment rules if the payments of estimated tax and withholding, if any are not adequate. It is further agreed that National Western Life has made no representations and that it has no responsibility or liability concerning the undersigned s tax treatment under the Internal Revenue Code. I want to have federal income tax withheld from my surrender. Please withhold $ or % I do not want to have federal income tax withheld from my surrender. LOST POLICY/ CONTRACT STATEMENT If the policy/contract is not attached, I/We hereby certify that the above numbered contract has been lost or destroyed and, to the best of my/our knowledge and belief, is not in anyone s possession. AUTHORIZATION TO RELEASE INFORMATION I/We hereby grant permission to release all information pertaining to this requested transaction to National Western Life Insurance Company as long as this transaction is pending. The undersigned is aware of any surrender/withdrawal penalties that may apply and the undersigned authorizes the transaction described above. The undersigned also understands and is aware that there may be lost interest and/or market value changes that may occur during and after this transaction. The undersigned represents and agrees that National Western Life is participating in this transaction at the undersigned s specific request and as an accommodation to the undersigned, and as such the undersigned does not hold National Western Life responsible for any surrender/withdrawal penalties, lost interest, market value changes, and/or any and all other decreases in value to the above accounts as a result of this transaction. Dated at: this day of, 20 (City, State) Signature: Insured/Annuitant Signature: Owner Signature: Joint Owner Signature: Spouse Medallion Signature Guarantee (if applicable) If you reside in one of the following community property states, your spouse must also sign: AZ, CA, ID, LA, NM, NV, TX, WA and WI. FOR HOME OFFICE USE ONLY ACCEPTANCE: This is to certify that the above individual has established a: Tax-qualified annuity (IRA) Roth IRA Non-Qualified Annuity Life Contract Other The authorized signature below certifies acceptance of the assignment and surrender or transfer of funds. Please make check payable to: ISSUER/ASSIGNEE National Western Life Insurance Company 850 East Anderson Lane Austin, TX By: Date: Authorized National Western Life signature **IMPORTANT INCOMPLETE FORMS WILL BE RETURNED TO AGENT** SA-8600.Rev.5.09 Page 2 of 2

15 Re: Policy/Contract # Home Office Use Only Owner Name This policy/contract was solicited and applied for in the state of and will be delivered in the state of. Date Owner (NOTE: Utah residents cannot use this form.) Date Agent SA-9988 NATIONAL WESTERN LIFE INSURANCE COMPANY 850 EAST ANDERSON LANE AUSTIN, TEXAS