Application for FIXED DEFERRED ANNUITY

Transcription

1 Application for FIXED DEFERRED ANNUITY Protective Life and Annuity Insurance Company Overnight U. S. Postal Mail Birmingham, Alabama 2801 Hwy 280 South P. O. Box Birmingham, Alabama Birmingham, Alabama Contract # PRIMARY OWNER: NAME: DAY PHONE: ADDRESS: CITY: STATE: ZIP: SSN/Tax ID: DOB: AGE: SEX: M F CITIZENSHIP: U.S.; Resident Alien ( ); Non-Resident Alien ( ) Country Country JOINT OWNER: (Where Applicable) NAME: DAY PHONE: ADDRESS: CITY: STATE: ZIP: SSN/Tax ID: DOB: AGE: SEX: M F CITIZENSHIP: U.S.; Resident Alien ( ); Non-Resident Alien ( ) Country Country ANNUITANT: (If different from Primary Owner)(Must be a natural person) NAME: DAY PHONE: ADDRESS: CITY: STATE: ZIP: SSN/Tax ID: DOB: AGE: SEX: M F CITIZENSHIP: U.S.; Resident Alien ( ); Non-Resident Alien ( ) Country Country BENEFICIARY DESIGNATION (If there is no surviving Owner): PRIMARY CONTINGENT: PERCENTAGE: RELATIONSHIP (to Owner): Spouse Nonspouse SSN/Tax ID: DOB/Trust date: PRIMARY CONTINGENT: PERCENTAGE: RELATIONSHIP (to Owner): Spouse Nonspouse SSN/Tax ID: DOB/Trust date: ADDITIONAL BENEFICIARIES Use 'REMARKS' section, below. INITIAL PURCHASE PAYMENT (check payable to Protective Life Insurance Company): WITH FUNDS FUNDS WILL FOLLOW (minimum $2,000) INTEREST RATE PERIOD AND OPTIONAL RETURN OF PREMIUM: Please select one interest rate period and one Return of Premium option. 1 Year Interest Rate Period 2 Year Interest Rate Period YES, I elect the Return of Premium Option 4 Year Interest Rate Period 6 Year Interest Rate Period NO, I decline the Return of Premium Option TAX QUALIFIED STATUS: Non-Qualified ROTH IRA (Conversion Year, if applicable) 1035 Exchange Traditional IRA Other - REMARKS: $ CONTRIBUTION FOR TAX YEAR $ TRUSTEE TRANSFER $ ROLLOVER FROM An annuity contract is not a deposit or obligation of, or guaranteed by any bank or financial institution. It is not insured by the Federal Deposit Insurance Corporation or any other government agency. Original Representative First Copy Owner A-1405 Secure II Fixed Annuity with Optional Return of Premium AS 6/17

2 Will any existing annuity contract or life insurance policy be replaced or will values from another annuity contract or life insurance policy (through loans, surrenders or otherwise) be used to make purchase payments for the contract applied for? NO YES Do you have any existing annuity contracts or life insurance policies? NO YES If Yes, Company Name: NOT INSURED BY ANY GOVERNMENT AGENCY NO BANK GUARANTEE NOT A DEPOSIT I/We understand this application will be part of the annuity contract. I/We have read, agree to and affirm the information above and on the reverse side to be true and correct to the best of my/our knowledge and belief. The Company will treat my/our statements as representations, not warranties. The Company may accept instructions from any Owner on behalf of all Owners. The Contract for which you are applying may provide a bonus. The bonus will be credited by us in a nondiscriminatory manner and consistent with New York law. Signed at CITY STATE DATE OWNER SIGNATURE JOINT OWNER SIGNATURE (if applicable) ANNUITANT SIGNATURE (if other than Owner) Federal law requires the following notice: We may request or obtain additional information to establish or verify your identity. SELLING AGENT REPORT: To the best of your knowledge, will any existing annuity contract or life insurance policy be replaced or will values from another annuity contract or life insurance policy (through loans, surrenders, or otherwise) be used to make purchase payments for the contract applied for? NO YES Does the applicant have any existing annuity contracts or life insurance policies? NO YES If Yes, Company Name: Type of unexpired government-issued photo I.D. used to verify the applicant's identity? # I certify that the information provided by the owner has been accurately recorded; no written sales materials other than those approved by the Company were used; and I have reasonable grounds to believe the purchase of the contract applied for is suitable for the owner. AGENT SIGNATURE AGENT NAME PRINTED AGENT TELEPHONE NUMBER DATE AGENCY NAME AGENT STANDARD ID# Select Commission Option: A B C A-1405 Secure II Fixed Annuity with Optional Return of Premium AS 6/17

3 Life and Annuity Division Protective Life Insurance Company 1 West Coast Life Insurance Company 1 Protective Life and Annuity Insurance Company Beneficiary Information Request Post Office Box 1928 / Birmingham, AL Use this form for initial beneficiary designations. Toll Free: / Fax: Owner s Name: Annuitant s Name: Contract Number: Owner s SSN/TIN: PLEASE NOTE: If multiple beneficiaries are named, proceeds will be paid equally to all primary beneficiaries surviving the owner (or annuitant if non-material owner) unless instructed otherwise. If all primary beneficiaries have predeceased the owner, proceeds will be paid to the named contingent beneficiaries equally unless instructed otherwise. If there are no surviving beneficiaries, proceeds will be paid to the owner s estate. BENEFICIARY INFORMATION: Beneficiary Type: (select one) Primary Name: Social Security Number: Address: Date of Birth: Telephone Number: Contingent Relationship to Owner: (select one) Spouse Non-spouse Percentage: % Beneficiary Type: Name: Social Security Number: (select one) Address: Primary Date of Birth: Telephone Number: Contingent Relationship to Owner: (select one) Spouse Non-spouse Percentage: % Beneficiary Type: Name: Social Security Number: (select one) Address: Primary Date of Birth: Telephone Number: Contingent Relationship to Owner: (select one) Spouse Non-spouse Percentage: % Beneficiary Type: Name: Social Security Number: (select one) Address: Primary Date of Birth: Telephone Number: Contingent Relationship to Owner: (select one) Spouse Non-spouse Percentage: % Beneficiary Type: Name: Social Security Number: (select one) Address: Primary Date of Birth: Telephone Number: Contingent Relationship to Owner: (select one) Spouse Non-spouse Percentage: % Beneficiary Type: Name: Social Security Number: (select one) Address: Primary Date of Birth: Telephone Number: Contingent Relationship to Owner: (select one) Spouse Non-spouse Percentage: % SPECIAL INSTRUCTIONS: SIGNATURES: Owner s Name (please print) Owner s Signature Date Joint Owner s Name (please print) Joint Owner s Signature Date 1 Not authorized in New York Page 1 of 1 LAD-1225 R:7/13

4 ProSaver Secure II NY A Limited Flexible Premium Fixed Deferred Annuity Contract Protective Life and Annuity Insurance Company 1707 N. Randall Road, Elgin, IL or ANNUITY DISCLOSURE STATEMENT The ProSaver Secure II NY annuity is way to accumulate money for retirement on a tax-deferred basis and create a guaranteed stream of income for life. An annuity is a long term investment. It is not intended to meet short term financial needs or goals. The ProSaver Secure II NY annuity offers these features: It is a limited flexible premium annuity contract. This means that you may but are not required to make additional payments into the contract, but only during the first contract year. We do not charge a fee to issue a ProSaver Secure II NY contract, and we do not assess any ongoing or annual fee. However, withdrawals from the contract (in excess of the penalty-free amount) may be subject to a withdrawal charge. Please refer to section 4 of this Disclosure Statement ("Withdrawals and Withdrawal Charges") for a description of these charges. You may allocate your purchase payments to one interest guarantee period selected from among those we are offering when you purchase the contract. When you purchase the contract, you may add an optional money-back guarantee. If you select this option and liquidate your contract before you begin taking annuity income payments, the total amount you receive from the contract will not be less than the total amount you paid for it. That means, even if withdrawal charges would otherwise apply, we will waive those charges to the extent necessary to return the full amount you paid. However, if you choose this option, your contract will have a lower interest rate than a similar contract issued on the same day without the money-back guarantee. After a withdrawal charge period expires, you may apply the contract value to a new interest guarantee period to earn a competitive interest rate and continue income tax deferral without purchasing a new contract. This Disclosure Statement summarizes important information you should consider before buying a Secure II contract. Please read it carefully, along with the Buyer's Guide for Fixed and Equity Indexed Annuity Contracts, which was prepared by the National Association of Insurance Commissioners to help consumers understand the different types of annuity contracts available and the general features of each type. You may also receive other product information from your sales agent. We encourage you to read all this material carefully and discuss it with your sales agent to determine if a Secure II annuity is appropriate considering your financial needs and goals. The Secure II Annuity Contract Governs Your Rights Under The Contract. This disclosure statement and the other literature you receive provide only a summary description of the annuity. The Secure II contract itself governs your rights. After you receive your annuity contract, you will have a specified period of time to review it. If, during that period, you decide you do not want the contract, you may cancel it and receive a complete refund of the amount you paid for it. Purchasing and Managing Your Contract 1. Purchase Payments. The minimum initial purchase payment is $2,000. We will accept additional purchase payments of not less than $50 each, provided we receive them within one year from the date we issue the contract. The maximum total purchase payments we will accept is $1,000,000, unless we agree to accept a greater amount before you submit it. 2. Declared Interest Rates and Interest Guarantee Periods. When you purchase a contract, you select one interest guarantee period from among those we are offering at that time. That interest guarantee period applies to each purchase payment you make. We, in our sole discretion, declare the interest rate applicable to each interest guarantee period. Interest rates vary from time to time, so different interest rates may apply to each purchase payment you make. However, the interest rate in effect at the time you make a purchase payment will apply for the entire interest guarantee period. When an interest guarantee period expires, we will credit interest at the declared rate in effect for your contract at that time. Declared rates after an interest guarantee period expires remain in effect for one year. Interest is credited daily at a rate that, when compounded, yields an annual effective interest rate equal to the declared rate. 3. Guaranteed Minimum Interest Rate. We set a minimum interest rate when you purchase a contract. The minimum interest rate will be between 1% and 3%, and will remain in effect at least until the initial withdrawal charge period expires. (See, the "Withdrawals and Withdrawal Charges", below.) We will not declare an interest rate that is lower than the guaranteed minimum interest rate. Please ask your financial advisor for the current minimum and declared interest rates for the Secure II contract. LAD-1228NY Page 1 of 2 Secure II NY Disclosure Statement 12/12

5 4. Withdrawals and Withdrawal Charges. The ProSaver Secure II NY annuity is intended to be used as a long-term investment vehicle for retirement planning. However, you do have access to the contract value by requesting a withdrawal or surrender. Anytime before the annuity income payments begin, you may request a withdrawal or full surrender of the contract. The minimum withdrawal request we will process is $500. If, immediately after any withdrawal is processed, your contract value would be less than $2,000, we will terminate the contract and send you the entire surrender value in a lump sum. Generally, a withdrawal charge will be assessed for any withdrawal or surrender that exceeds the contract's penaltyfree amount. The withdrawal charge is a percentage of the amount withdrawn (in excess of the penalty-free amount) based on the number of complete years that have elapsed since the beginning of the withdrawal charge period, typically, the date the contract was issued. # OF YEARS ELAPSED SINCE BEGINNING THE WITHDRAWAL CHARGE PERIOD WITHDRAWAL CHARGE % 0 8.0% 1 8.0% 2 7.0% 3 6.5% 4 5.5% 5 4.5% 6 3.0% 7+ 0% You may withdraw up to the penalty-free amount each contract year without any withdrawal charge. The penalty-free amount is equal to 10% of the contract value as of the prior contract anniversary. During the first contract year, the penalty-free amount is 10% of your initial purchase payment. We will also waive withdrawal charges if you or your spouse meet the qualifying conditions and: a) enter a nursing home; b) are diagnosed with a terminal illness; or c) become unemployed. We will also waive withdrawal charges if you decide to surrender your contract after we declare a renewal interest rate that is more than 0.50% lower than the base interest rate. All withdrawals reduce interest earnings due to the interruption of compounding. More frequent withdrawals (such as monthly withdrawals) reduce interest earnings more than annual withdrawals. All withdrawals will reduce the death benefit, contract value and surrender value. Withdrawals of earnings are subject to income tax, and may be subject to a 10% IRS penalty tax if taken before age 59½. Under current tax law, any withdrawal from the contract will be deemed a withdrawal of earnings until all earnings attributable to the contract at the time of the withdrawal are withdrawn. Only then will a withdrawal reduce principal. If your contract is issued as a Traditional IRA or other tax qualified plan, you may be subject to required minimum distributions ("RMDs"). Generally, RMDs must begin by the end of the calendar year in which you reach the age of 70½. However, the rules are complex and exceptions may apply. You should consult with a qualified tax advisor to learn if your contract is subject to RMDs, and if so, how if the RMD rules apply to your particular situation. 5. Death Benefit. The contract provides a death benefit equal to the contract value if the owner dies before annuity income payments begin. 6. Annuity Options. Anytime after the first contract anniversary, you may apply the contract value to an annuity option and begin receiving income payments. Income payments must begin before the oldest owner's or annuitant's 96 th birthday. You may select an option that will make regular, fixed periodic payments for a specific period, for life, or for life with payments guaranteed for a specific period. Annuity options can be based on the life of one or two people. You may request the income payments be made monthly, quarterly or annually, provided each income payment is at least $100. The amount of each income payment depends upon the annuity option and payment mode you select, the amount that is applied to the annuity option, and the payment rates we are using for that annuity option at that time. The ProSaver Secure II NY Annuity, policy form number series A-3270 (and state variations), is issued by Protective Life and Annuity Insurance Company, Birmingham, Alabama. All benefits, payments and guarantees are subject to the claims paying ability of Protective Life and Annuity Insurance Company. LAD-1228NY Page 2 of 2 Secure II NY Disclosure Statement 12/12

6 Life and Annuity Division Protective Life Insurance Company 1 West Coast Life Insurance Company 1 Request for Transfer or Protective Life and Annuity Insurance Company Exchange of Assets Post Office Box / Birmingham, AL Toll Free: / Fax: Existing Protective Contract Number: (for additional payments only) Check here and complete Box 4 if this is being submitted for a Rate Lock only. (If Rate Lock request is for a CD, you must include proof of maturity from the Financial Institution.) Please do not select this option for the Protective Indexed Annuity, because the interest crediting elements for that product are determined as of the date the contract is purchased. Complete this form to transfer assets to Protective Life Insurance Company, West Coast Life Insurance Company or Protective Life and Annuity Insurance Company (each, the Company ) for the issuance of a new annuity contract. EXISTING ACCOUNT, CONTRACT OR POLICY TO BE TRANSFERRED Company Name Telephone Number Company (Overnight) Address Contract/Account Owner s Name Contract/Account Number Owner s SSN/Tax ID The contract is: attached lost or destroyed Please check this box if the existing contract being surrendered is a Fixed Annuity. (If box is checked, and your new Protective Life annuity is being issued in the state of Nevada, please complete form A-1128-NEV-Annuity.) EXISTING ACCOUNT, CONTRACT OR POLICY TO BE TRANSFERRED Non-Qualified: Qualified: 1035 Exchange 1. Plan Type: 2. Transfer Type: Non-1035 Exchange IRA CD Trustee Transfer Mutual Fund 401(k) Roth IRA Direct Rollover Bank CD Mutual Fund 403(b)/TSA Other Non-1035 Exchanges Other Proposed Plan Type: Non-Qual IRA Roth IRA Other TRANSFER INSTRUCTIONS 1. Amount to be transferred: Complete: Liquidate and transfer all assets in my account, contract or policy Partial: Liquidate and transfer assets totaling $ 2. When should transfer occur: Immediately Upon maturity date of / / (mm/dd/yy) 3. Current estimated value of the assets to be transferred are $ 4. RATE LOCK I wish to lock in the interest rate that is in effect when this signed form is received by the Company. If this box is not checked, you will receive the interest rate in effect on the day we receive the transferred amounts. (Please do not select this option for the Protective Indexed Annuity, because the interest crediting elements for that product are determined as of the date the contract is purchased.) 1 Not authorized in New York Page 1 of 2 LAD-1120 R:08/14

7 Complete 1035 Exchange: I hereby make a complete and absolute assignment and transfer all rights, title and interest of every nature in the above contract to the accepting insurance company indicated below. Partial 1035 Exchange: I hereby direct the issuer of the above-referenced existing annuity contract to process a partial 1035 exchange to the accepting insurance company indicated below. I intend for this transaction to qualify as a tax-free exchange for Federal income tax purposes. Based on our understanding of IRS guidance in Rev. Proc , if a contract is involved in a tax-free partial exchange under Internal Revenue Code section 1035 that is completed on or after October 24, 2011, and an amount is withdrawn from or received in surrender of either contract within 180 days of the exchange, the IRS will apply general tax principles to determine the substance, and hence the treatment of the partial exchange and the subsequent withdrawal or surrender. Such a withdrawal or surrender could affect how the partial exchange and the withdrawal or surrender is reported to you and the IRS. For Other Transfers: Unless it is noted above to hold for a future date, I request the surrendering company to immediately complete the transfer or rollover. Do not withhold any amount for taxes from the proceeds. SIGNATURES: Owner s Signature Date Joint Owner s Signature Date Annuitant s Signature Date FOR HOME OFFICE USE ONLY NOTICE OF ACCEPTANCE: The Company will accept the assets and credit them to an annuity contract as described above. The Company has received an application from the Owner to establish an annuity contract for this transaction. Authorized Signature Title Date SETTLEMENT: Please make check payable for the proceeds and mail to: Protective Life Insurance Company Protective Life and Annuity Insurance Company (New York Only) West Coast Life Insurance Company Mailing Address: PO Box Overnight Address: 2801 Highway 280 South Attn: 3-1 Annuity New Business Attn: 3-1 Annuity New Business Birmingham, AL Birmingham, AL Page 2 of 2 LAD-1120 R:08/14

8 Life and Annuity Division Protective Life and Annuity Insurance Company Post Office Box Birmingham, AL Highway 280 South / Birmingham, AL General Instructions for Toll Free: Regulation 60 Applications Fax: Step Process Regulation 60 sets forth the procedures and forms which are required for any annuity application being solicited in New York as a replacement of existing life insurance or annuity contract. The following provides you with the procedures, instructions and forms necessary to assure a correct application package and quality issuance of the contract. Once you meet with your client, if a REPLACEMENT exists, the following steps must be followed: 1. The DEFINITION OF REPLACEMENT form must be completed in all instances. If your client answers YES to any of these questions, a replacement condition now exists, and 2. All necessary forms (application, marketing checklist, DEFINITION OF REPLACEMENT, IMPORTANT NOTICE REGARDING REPLACEMENT, exchange and/or transfer paperwork, and any other appropriate forms) specifically including the AUTHORIZATION TO DISCLOSE POLICY INFORMATION form must be reviewed with, completed, and signed by the proposed policy owner. 3. Leave a copy of all forms, specifically including the DEFINITION OF REPLACEMENT with the client. Forward signed originals of all forms to either your firm s suitability review area or Protective Life and Annuity Insurance Company ( Protective ) in accordance with your firm s policies and procedures, as accepted by Protective 4. Protective will complete the DISCLOSURE STATEMENT information regarding the new proposed contract and will secure the comparative information from the company being replaced. 5. The completed DISCLOSURE STATEMENT will be sent to the applicant on your behalf with a letter advising the client to contact you with any questions. This step allows the applicant to review the appropriate comparison information before Phase II and issuance of the contract. The applicant is not required to sign or return the DISCLOSURE STATEMENT to us. 6. We will send you (by or other method agreed upon between Protective and your firm) the completed DISCLOSURE STATEMENT. Upon your receipt, make a copy for your records. Sign and return a copy of the completed DISCLOSURE STATEMENT to us. 7. Upon our receipt of the DISCLOSURE STATEMENT you signed and following a review of the completed forms and materials you submitted with the application, we will begin Phase II and continue processing the application and transfer request. 8. Upon receipt of funds from the replaced carrier, we will issue the contract and deliver it to you or your client, as prescribed by your firm and its agreement with us. LAD R:12/17

9 APPENDIX 11 INSURANCE DEPARTMENT OF THE STATE OF NEW YORK DEFINITION OF REPLACEMENT IN ORDER TO DETERMINE WHETHER YOU ARE REPLACING OR OTHERWISE CHANGING THE STATUS OF EXISTING LIFE INSURANCE POLICIES OR ANNUITY CONTRACTS, AND IN ORDER TO RECEIVE THE VALUABLE INFORMATION NECESSARY TO MAKE A CAREFUL COMPARISON IF YOU ARE CONTEMPLATING REPLACEMENT, THE AGENT IS REQUIRED TO ASK YOU THE FOLLOWING QUESTIONS AND EXPLAIN ANY ITEMS THAT YOU DO NOT UNDERSTAND. AS PART OF YOUR PURCHASE OF A NEW LIFE INSURANCE POLICY OR A NEW ANNUITY CONTRACT, HAS EXISTING COVERAGE BEEN, OR IS IT LIKELY TO BE: (1) LAPSED, SURRENDERED, PARTIALLY SURRENDERED, FORFEITED, ASSIGNED TO THE INSURER REPLACING THE LIFE INSURANCE POLICY OR ANNUITY CONTRACT, OR OTHERWISE TERMINATED? YES NO (2) CHANGED OR MODIFIED INTO PAID-UP INSURANCE; CONTINUED AS EXTENDED TERM INSURANCE OR UNDER ANOTHER FORM OF NONFORFEITURE BENEFIT; OR OTHERWISE REDUCED IN VALUE BY THE USE OF NONFORFEITURE BENEFITS, DIVIDEND ACCUMULATIONS, DIVIDEND CASH VALUES OR OTHER CASH VALUES? YES NO (3) CHANGED OR MODIFIED SO AS TO EFFECT A REDUCTION EITHER IN THE AMOUNT OF THE EXISTING LIFE INSURANCE OR ANNUITY BENEFIT OR IN THE PERIOD OF TIME THE EXISTING LIFE INSURANCE OR ANNUITY BENEFIT WILL CONTINUE IN FORCE? YES NO (4) REISSUED WITH A REDUCTION IN AMOUNT SUCH THAT ANY CASH VALUES ARE RELEASED, INCLUDING ALL TRANSACTIONS WHEREIN AN AMOUNT OF DIVIDEND ACCUMULATIONS OR PAID-UP ADDITIONS IS TO BE RELEASED ON ONE OR MORE OF THE EXISTING POLICIES? YES NO (5) ASSIGNED AS COLLATERAL FOR A LOAN OR MADE SUBJECT TO BORROWING OR WITHDRAWAL OF ANY PORTION OF THE LOAN VALUE, INCLUDING ALL TRANSACTIONS WHEREIN ANY AMOUNT OF DIVIDEND ACCUMULATIONS OR PAID-UP ADDITIONS IS TO BE BORROWED OR WITHDRAWN ON ONE OR MORE EXISTING POLICIES? YES NO (6) CONTINUED WITH A STOPPAGE OF PREMIUM PAYMENTS OR REDUCTION IN THE AMOUNT OF PREMIUM PAID? YES NO IF YOU HAVE ANSWERED YES TO ANY OF THE ABOVE QUESTIONS, A REPLACEMENT AS DEFINED BY NEW YORK INSURANCE DEPARTMENT REGULATION NO. 60 HAS OCCURRED OR IS LIKELY TO OCCUR AND YOUR AGENT IS REQUIRED TO PROVIDE YOU WITH A COMPLETED DISCLOSURE STATEMENT AND THE IMPORTANT NOTICE REGARDING REPLACEMENT OR CHANGE OF LIFE INSURANCE POLICIES OR ANNUITY CONTRACTS. Date: Signature of Applicant: Date: Signature of Applicant: TO THE BEST OF MY KNOWLEDGE, A REPLACEMENT IS INVOLVED IN THIS TRANSACTION: YES NO Date: Signature of Agent: LAD /17

10 Life and Annuity Division Protective Life and Annuity Insurance Company Post Office Box Birmingham, AL Toll Free: Request for Disclosure Fax: Date: Name: ANNUITANT INFORMATION: Address: Phone Number: Social Security Number/Tax ID: Date of Birth: PROPOSED ANNUITY: The following products may not be available for your firm. Please check with your firm for availability. Protective Variable Annuity II B Series NY ProSaver Secure II ROP ** Platinum Plus NY ** ProSaver Secure II Non-ROP ** ProPayer Income Annuity NY Protective Indexed Annuity NY ROP * * Protective Indexed Annuity NY Non-ROP * Please indicate Surrender Charge Duration: 5 Years 7 Years 10 Years * Please indicate Contract Allocation: (Must equal 100%) % Annual Point to Point % Annual Trigger Indexed Strategy % Fixed Interest Strategy ** Please indicate Guaranteed Period(s): % into the Year Guaranteed Period % into the Year Guaranteed Period % into the Year Guaranteed Period NOTE: All Guaranteed Periods and/or Surrender Charge Durations may not be available at all times. Yes, I wish to lock in the interest rate that is in effect when this signed form is received by the Company. (Not Applicable for Protective Indexed Annuity NY.) Agent s Printed Name Agent s Company Name Agent s Signature Agent s Phone Number Agent s Address Yes, I wish to have the completed disclosure form faxed to me at: Agent s Fax Number Yes, I wish to have the completed disclosure form ed to me at: Agent s Address LAD-1111 R:10/17

11 Life and Annuity Division Protective Life and Annuity Insurance Company Post Office Box Birmingham, AL Authorization to Disclose Toll Free: Policy Information Fax: Protective Identifying Number: Policy Owner(s) Policy(s): Life Insurance Life Insurance Life Insurance Annuity Annuity Annuity Company: Policy / Contract No.: (If additional space is required, please provide details on back of this form). In accordance with New York State Insurance Department Regulation No. 60, please furnish the information needed for completing the enclosed alternate New York State Disclosure Statement. This authorization is valid until revoked by the undersigned in writing. Policy Owner s Signature Print Policy Owner s Name Joint Policy Owner s Signature Print Joint Policy Owner s Name Street Address City, State and Zip Code Date PLEASE COMPLETE FORM AND RETURN TO THE COMPANY LAD-1110 R:8/17

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