FORM VA/VUL REQUEST TO PURCHASE VARIABLE OR INDEXED LIFE OR ANNUITY INSURANCE PRODUCT This Request must be submitted when purchasing, replacing or redeeming any and all types of Variable and/or Indexed Insurance products such as: Variable Life or Annuities, Indexed Life or Annuities, etc. Customer Name: Type of Account: Product Name: Management Company: Describe Any Riders, Added Benefits, Guarantees, etc.) Purchase Amount: $._ Is the Transaction being funded by new monies or a replacement? If replacement, has existing contract been in force at least 72 months? Yes No If No, please provide detailed explanation on reverse side. CHECK ONE: (If replacement, provide side by side comparison). New Purchase _ Replacement _ I will be transferring or exchanging securities to the above Account from an existing Account, and/or liquidating certain securities or financial instruments in order to fund said Account from: Existing Instrument: Describe exactly how you will transfer or liquidate the funds to purchase New Variable/Indexed Insurance Product: Has the Representative discussed withdrawal limitations and all other charges, fees and penalties? Yes No Has the Representative discussed Investment Strategies, Contract Structure, Tax Implications, Income & Withdrawal Options, Guarantees, Death Benefit, Annuitization and other features, it s nature as a Long Term Investment, the effect of the performance of the sub accounts as to the product guarantees and returns? Yes No I acknowledge and understand that my liabilities, charges and expenses for the New Product (name product) will be: Management Product Company Description: _ Charge: Surrender Charge: M&E Expenses: Rider & Benefit Charges: _ Other Fees:_ What, do you understand, are the distinct disadvantages of the Proposed Variable/Indexed Product: (Clients Handwriting) What, do you understand, are the major advantages of the New Proposed Variable/Indexed Product: (Clients Handwriting) Client Signature Date Joint (Spouse) Signature Date Page 1.
The objective of the original investment was to: The objective of the proposed investment (Variable Insurance Product) is to: Customer Confirmation of Terms and Conditions regarding the Purchase of a Variable Insurance Contract. Was this product solicited by the Representative or unsolicited. 1. Did you receive a current Prospectus regarding the specific Variable product you are applying for? Yes No 2. Did you receive the necessary information and warranties, if any, regarding the Riders and/or additional Benefits and policy terms that you have agreed to and which are included in your Variable Insurance Contract? Yes No 3. Were you informed of your right to conduct a Free Look during the initial allotted policy period and notified of your Waiting Period, during which time you may request a return of your deposits? Yes No 4. Were you given the option of waiting to invest the funds until the end of the Waiting Period? Yes No 5. Do you fully understand all of the charges and expenses described on the front of this Form? Yes No 6. Did you feel no pressure in applying for a Variable Insurance Product and no coerced influence? Yes No 7. If a senior citizen, were you given the opportunity or advance notice to have another person present during the presentation of the proposed new variable insurance product? Yes No 8. If a senior, did you complete a Senior Citizen Waiver Form for MFSI? Yes No 9. Did the comparison of your existing product and the proposed product include such notices and awareness as to the possible loss of certain attractive provisions that are not offered in the new proposed product? Yes No 10. Were you told of possible tax consequences (income tax exposure, capital gains tax, estate taxes, gift taxes, etc. regarding both your proposed transfer or exchange to a new financial insurance contract? Yes No 11. Are you aware of similar benefits made available to you from your present management company? Yes No 12. If you were offered a bonus interest rate, were you informed that addt l charges may apply? Yes No 13. Do you understand that the tax deferral features may not be necessary depending on the plan? Yes No 14. Do you understand, if switching between fixed to variable or indexed annuities or products, that you may be exchanging guaranteed rates of return for market risks and other risk based features? Yes No 15. Is this your only fixed/index/variable annuity exchange within the preceding 60 months? Yes No 16. If No, did you incur a surrender charge or other fee as part of the replacement/exchange? Yes No 17. If No, did you incur a loss of benefits as part of the replacement/exchange? Yes No 18. Do you understand that Annuties are long term financial products and that some annuities such as immediate annuities are permanent and cannot be surrendered? Yes No 19. Do you have enough liquidity to cover current and expected living and medical expenses for at a minimum, the duration of the contract s surrender charge period and that withdrawals are subject to other charges? Yes No If customer answered yes to all of the foregoing questions listed herein above, please initial here: (ini) If customer answered no to any of the questions listed herein above, please provide a very detailed explanation and provide as much information as possible to support your reasons for this purchase. (indicate Question #): Q#. REGISTERED REPRESENTATIVE S STATEMENTS: Explain any additional actions that may be required (i.e. review of benefits, added disclosures, Cognitive Awareness Test, follow up by Compliance, etc. to insure that Client understands the consequences of his/her proposed transaction. Page 2
FORM VA/VUL part 2 Customer Account #: _ Does the Client have more than thirty percent (30%) of their net worth invested in annuities? Yes No _ Client Wants/needs Tax Deferral Investment _ Client wants Death Benefit Features _ Client wants Living Benefit Features _ Client does not want traditional annuitization _ Client does not want to disclose net worth. If so, explain: Client understand Estate consequences of possible Income in respect of Decedent (IRD) _ Client understands M&E Charges may be higher than comparable mutual funds. _ Client understands the 30% net worth investment annuity policy is a matter of compliance with MFSI and not a standard in the Brokerage Business; and furthermore, serves as a guide in determining suitability for these products. Client understands that MFSI does not usually recommend more than 40% of liquid assets to be invested into Annuities. _ Client does not have an updated will or trust and wants to avoid Probate for their heirs (VUL). _ Client wants Nursing Home Riders/Benefits Primary Investment Objective: (check all that apply) _ Client wants guaranteed lifetime income. Tax Deferral Future Income Death Benefit Current Income Other Primary Reason for Exchange and/or Replacement: (select all that apply) Enhanced Death Benefits (explain): Locking in Market Gains Step Up Features: Living Benefits or Guaranteed Income Riders: Other Features: i.e Greater variety or number of funds, fund families, investment managers, allocation models, etc. For Review Purposes, Financial Information Required: Total Net Worth (incl. real estate) - $ _ Total Amount Invested in Annuities - $ Total Liquid Assets - $ _ Total Liabilities - $ Total Amount Invested (excluding annuities) - $ Current Annual Gross Income - $ _ Average Gross Income last 3 years - $ _ Tax Bracket I received a copy of an Illustration showing side by side comparisons of the existing and proposed insurance contracts and their respective premiums, contract costs and market values and benefits. I did not receive any comparison Illustration and am relying solely on the information contained in the Side by Side Comparison on Page 4 of this Document. Page 3.
_ ANNUITY REPLACEMENT DISCLOSURE FORM _ (Must be completed when replacing or effecting a 1035 Exchange) When replacing VUL, you must complete 10.a.b.c. and also 18.a.b.c. Side By Side Comparison Item# Description Existing Contract (A) Proposed Contract (B) 1 Company 2 Product Name and Type 3 Contract Number (if known) 4 Contract Issue Date 5 Owner 6 Annuitant 7 Beneficiaries 8 Surrender Charge (Time Period and Schedule) 9 Surrender Period Remaining 10 Current Market Value (date of evaluation) 10.a. Projected Cost & Market Value (Life Only - 2 yrs hence) 10.b. Projected Cost & Market Value (Life Only - 5 yrs hence) 10.c. Projected Cost & Market Value (Life Only - 10 yrs hence) 11 Surrender Charges,Year & % as result of Exchange 12 Market Value Adjustment Surrender Charge if any 13 Premiums Paid/Contributed or to be Paid/Contributed 14 Total Withdrawals since inception 15 Return Inception to Date 16 Mortality, Expense & Administration Fees 17 Death Benefit (Age provisions for step up, term, etc.) 18 Death Benefit and other Riders/Benefits 18.a. Death Benefit and Riders (Life Only - 2 years hence) 18.b. Death Benefit and Riders (Life Only - 5 years hence) 18.c. Death Benefit and Riders (Life Only - 10 years hence) 19 Bonus Amounts and bonus percentage (if applicable) 20 Riders/Benefit Enhancement(s) e.g. nursing home waiver 21 Costs of Riders/Benefits (percentage and dollar amounts) 22 Existing Riders/Benefits that will be lost (mark w/ L) or New Riders/Benefits not available with existing contracts (mark w/ N) or improved Riders (mark w/ I and explain) L- N-, I- Acknowledged and Agreed To: this day of _, 20, in city of, Client Signature Joint (Spouse) Signature RR Code/ Signature / rr First Line Supervisor_ COMPLIANCE REVIEW: [STAMPS] Chief Compliance Officer/Other Registered Principal COMMENTS: Title/Code: Rev. 11/10 Page 4.
SUITABILITY & CUSTOMER PROFILE The purpose of this section is to identify specific suitability for an Annuity or Life insurance product under Finra Rules and Regulations as well as Annuity Rules under California Insurance Code 1749.8 and NAIC Model Regulation 275. Customer Name: Note: Please circle either Life or Annuity when answering the following questions. INCOME: Annual Earned Income: $. Annual Unearned Income: $. Total Annual Income from all Sources (direct or indirect): $ _. EXPERIENCE: Financial Experience:Limited: Moderate: Advanced: Substantiate your level of experience: _ RISK TOLERANCE: What is your risk tolerance for the Funds in this Annuity or Life Insurance Contract? Conservative Moderate Less Moderate Aggressive Very Aggressive Protection of Principal Income Some Income & some Asset Growth Asset Appreciation TIME TOLERANCE: What do you expect this Life or Annuity insurance product to be in terms of financial security and how do you expect to be financially positioned in the years ahead (5, 10 and 20). 5 Years Hence: _ 10 Years Hence: 20 Years Hence: Federal Income Tax Bracket: _% State ( ) & Income Tax Bracket: _% Other Tax Bracket: %, Expl: Financial Objectives & Intended Use of this Life or Annuity Contract: Income Tax Deferral Principal Protection Tax Planning Death Benefit Estate Planning Accumulation Future Income Withdrawal Benefit Capital Preservation Wealth Transfer Guarantees: Type (Interest Rate, Income, etc.): Riders: Type (Nursing Home Waiver, Living Care, Unemployment, etc.): Other Benefits (Credits, Bonuses, Survivorship, etc.): _ What is/are your most important reason(s) for purchasing this Life or Annuity Insurance Contract? Annuitization Interest Rate Bonus Contract Benefits Contract Guarantees Rider Fees Policy Charges / M&E Other _ Page 5.
Did you review the financial solvency of the intended insurer for the Life/Annuity Product? Yes No Do you understand that the claims paying ability of the insurer is dependent on its financial solvency? Yes No Do you understand the guarantees offered are dependent on the insurer s financial solvency? Yes No Do you understand that some contract guarantees are conditional (i.e. recurring fees, etc.)? Yes No Please describe your NO answers: Do you have a reverse mortgage? Yes No Did you take out a new mortgage or equity line to fund this Insurance Contract? Yes No Are you replacing another life or annuity contract in order to purchase this one? Yes No Please describe your YES answers: If you are a Senior citizen (Age 60 and over), did you sign a Senior Consent Form? Yes No If you are a Senior citizen (Age 70 and over), did you consent to a Cognitive Awareness Exam? Yes No Please describe your NO answers: Financial resources used for funding of this life or annuity insurance contract: Earnings and Wages Cash Values from Life insurance contracts Mutual Funds CDs, Money Markets Stocks & Bonds Trust Proceeds Future Income Withdrawal Benefit Capital Preservation Inheritance Alimony/Child Support Gift from 3 rd Party Gambling Winnings Other _ Insurance Company DETAILS OF CONTRACTS BEING REPLACED OR EXCHANGED Contract #1 Contract #2 Contract #3 Insurer s Product Name Contract Number Surrender Type Full Partial Loan Full Partial Loan Full Partial Loan Surrender/Loan Amount Length of Time Held Charges and Other Fees Yes No Yes No Yes No Death Benefit Amount Do you plan on taking Distributions: Less than a year 1 or 2 years 3 through 7 years Over 7 years Do you plan on accessing these funds by: Penalty Free Withdrawals RMD (Qualified Plans) Lump Sum Immediate Annuity (Cannot be changed once implemented) Annuitization N/A (No intent to access funds) What percentage of your Liquid Net Worth does this Life or Annuity Contract represent? % What percentage of your Liquid Net Worth does the total of your Life and/or Annuity Contracts represent? % After making this purchase, I have adequate resources for unforeseen financial emergencies? Yes No Page 6.
Variable/Indexed/Fixed Life & Annuity Disclosure Form Variable Life/Indexed/Fixed Life & Annuity Explanation of Investments (EOI) Required for all new Variable/Indexed/Financed/Fixed Premium Life or Annuity Insurance Contract Purchases or 1035 Exchanges and must accompany either a Switch Letter or Form VA/VUL or both. Required whenever new purchases, transfers or exchanges are made involving Annuities or Life Insurance of any kind or type. Customer: Contract # (when assigned): The following elements of variable life insurance and variable annuities (collectively Variable Contracts ) have been explained to me. I have considered all relevant factors and understand and accept their applicability to my continued purchase in this contract. PROSPECTUS I ACKNOWLEDGE RECEIPT OF AND UNDERSTAND THE IMPORTANCE OF READING AND UNDERSTANDING THE PROSPECTUS FOR THE FOLLOWING: Name of Variable Product: Issuer: _ This product is (check one): Variable Life/AnnuityFinanced Premium Life Indexed Life/Annuity SEPARATE ACCOUNT INVESTMENT OBJECTIVES. I understand that this Variable Contract may have a number of Separate and Fixed accounts, among which I may allocate my purchase payments. I understand that each Separate Account has differing investment objectives and risk characteristics, as are fully described in the prospectus. I understand the investment objectives and risk characteristics of the Separate Accounts I have selected, as indicated on the application or enrollment form for the above referenced Variable Contract. FIXED ACCOUNT RATE GUARANTEE. I understand that any purchase payments allocated to the fixed account option will earn interest for the guarantee period(s) indicated on the application, at a rate in effect at the time the amounts are applied. I further understand the guaranteed rates are subject to change at the end of the respective guarantee period and are based on the claims paying ability of the issuing insurance company. LIFE INSURANCE COVERAGE. I understand that this product offers life insurance benefits and that a portion of the annual purchase payment will be allocated to cover insurance costs. The initial Death Benefit will be: $ Addt l DB/Coverage(s): _ The initial Total Premium(s) will be: $ Addt l Premium(s): $ Special Riders/Benefits and/ Premiums: Special Risk/Class Assessment: _ Initial Premium to be Paid before or at time of Contract Delivery: $. I understand that I have a FREE LOOK Period during which time I have the right to return the policy for absolutely no reason and to have any initial paid premium returned to me. I understand that if I choose to have the initial premium invested in any sub accounts, and the accounts should lose value during the FREE LOOK period, that should I decide to return said Variable contract, that I will bear such loss(es) as a result. I hereby choose to instruct the Issuer to: Hold Premiums Invest Premiums during the FREE LOOK period and at the end of the Free Look Period to apply the premiums as instructed. Page 7
CONTRACT VALUE. I understand my death benefit and policy value can vary depending on the investment performance of the account(s) allocated to the Separate Accounts I have selected. CONTRACT CHARGES. I understand my policy will be subject to ongoing charges and expenses described in the prospectus. I further understand that my policy will be subject to a surrender charge of _% in year one (1), declining to 0% at the end of year. Contract charges, Fees, Maintenance expenses, Mortality charges, rider fees and expense as well as any other miscellaneous expenses, as disclosed in the prospectus, may apply to additional premiums as well as to the initial premiums. I understand my total initial costs for mortality, fund expenses, contract maintenance and fees to be: $ I understand my total annual recurring costs for all contract charges and M&E to be approximately: $_ CONTRACT ILLUSTRATIONS I ACKNOWLEDGE RECEIPT OF AND UNDERSTAND THE ESTIMATED PROJECTION OF POLICY PREMIUMS, DEATH BENEFIT AND CASH VALUES FOR THE FOLLOWING: Name and Date of Illustration: Dtd: Issuer: WITHDRAWALS. I understand withdrawals are subject to limitations as described in the prospectus. I also understand that loans and withdrawals may decrease or negatively impact both the death benefit and any present and/or future policy values and benefits; and may incur certain tax consequences as well. INITIAL AND/OR SCHEDULED PREMIUMS. (Variable Life Insurance only) I understand that purchase of this contract may require additional premiums to be deposited on an annual basis or other regularly scheduled basis. I understand that the policy will lapse any time (1) outstanding loans exceed policy value less surrender charge or (2) if the policy value less outstanding loans and surrender charges is insufficient to pay certain monthly deductions, and (3) a grace period expires without a sufficient payment. I further authorize the Issuer to: borrow from the Cash Values to pay premiums when otherwise scheduled premiums have not been received by the due date. I prohibit the Issuer from engaging in any Automatic Loan Provision in the policy and will rely on any appropriate notification of unpaid premiums during the Grace Period by either USPS or electronic mail. VERIFICATION OF SOURCE OF FUNDS. Were other investments or equity products (i.e., mutual funds, structured notes, CDs, real property, stocks, bonds, etc.) liquidated to provide funding for the new insurance contracts? No Yes (If yes, a Switch letter must also be completed.) 1035 EXCHANGE OR LIFE INSURANCE REPLACEMENT. Is this VUL replacing an existing Life and/or Annuity Policy of whatever nature (Indexed, Fixed, Variable, etc.)? If Yes, complete Page 4 - Side by Side Comparisons Yes No Signed at, ; this day of, 200. Client Signature _ Joint (Spouse) Signature First Line Supervisor_/ Managing Principal COMPLIANCE REVIEW: [STAMPS] Chief Compliance Officer/Other Registered Principal COMMENTS: RR Code/ Signature / Title/Code: Revised 02/12 Page 8.