Page 1 of 6 Client Name: Joint Client Name: Variable Product Company & Product Name: Account Information: Qualified (Type) : Non-Qualified (Type): Traditional IRA Roth IRA Individual Joint With Rights of Survivorship Joint - Tenants in Common Client Information: Does the client own other investments (excluding Insurance)? Yes (If Yes, please indicate type & approximate dollar amount) No Stocks: $ Mutual Funds: $ Private Placement/LP s: $ Bonds: $ Variable Annuities: $ Other: (Type) Options: $ Fixed Annuities: $ Other: $ Does the client own current insurance products? Yes (If Yes, please complete the table below) No Term Face Amount: $ Term Length (Yrs): Years Owned: Whole Life Face Amount: $ ----------------- Years Owned: Universal/VUL Face Amount: $ ----------------- Years Owned: How many years do you expect until retirement? Year(s) Does the client live on fixed income, or anticipate doing so in the next 5-7 years? Yes No Monthly discretionary income (after tax monthly income minus monthly expenses): $ Does the client anticipate any significant increase in living expenses or decrease in income during the new contract s surrender charge period or prior to age 59 ½? Yes No If Yes, please explain:
Page 2 of 6 Does the client intend to make subsequent contributions to the contract: Yes No If Yes, please provide source, amount and time frame: When does the client anticipate taking distributions from this annuity: Immediately Within 1 st year 1 to 5 years 6 to 10 years More than 10 years Never Will the client rely on income from this annuity to meet anticipated: Living expenses: Yes No Health care expenses: Yes No Other expenses: Yes No What is the intended use(s) and/or purpose(s) of the annuity: Savings Vehicle Retirement Income Death Benefits Tax-Deferred Growth Other Source of Funds Please check the source(s) of funds used in purchasing this proposed annuity: Salary/Current Income Insurance Surrender/Withdrawal Legal/Insurance Settlement Asset Appreciation Business Revenue Mutual Fund Redemption Sale of Assets Transfer of Assets Stock Redemption Annuity Surrender/Withdrawal Savings Inheritance Describe how this transaction will benefit this customer:
Page 3 of 6 Product Information Surrender Schedule: In Year 1 2 3 4 5 6 7 8 9 Surrender % % % % % % % % % Charge The Mortality & Expense Fee associated with this product (excluding fees associated with any riders) is: % per year. Does M&E or other charges decrease or drop off at a stated future date for this product? Yes No If Yes, please describe: The administration charge associated with this product is: % per year. The distribution charge associated with this product is % per year. The Sub-Account Expense Range of this proposed annuity is: % to %. Average fee for all Sub-Accounts chosen is % Does the initial allocation of funds to the sub-accounts match the client s stated investment objectives and risk tolerance? Yes No If No, please describe: Please list any riders selected for this product, along with the corresponding charge for that rider and describe how and when the client expects to utilize the rider. Name of Rider/Description/Purpose Charge If a Mutual Fund, CD or Variable Life Insurance Policy was redeemed to purchase this Annuity, please complete (if a Variable or Fixed Annuity was redeemed, complete the Replacement Information on the next page of this form): Policy/Contract/Account #(s) Policy/Contract/Account Value ($ Amounts)
Page 4 of 6 Replacement Information Is this transaction a replacement of an existing Variable Annuity? Yes (If Yes, then complete the next section) No What is the product name and account number of the annuity being exchanged? Replacement Justification Please provide the specific benefits of the replacement that cannot be found on the existing policy/contract (check all that apply): Increased Death Benefit Increased Investment Options (Please specify) Guarantees (Please specify) Bonus, Lower Premiums, Riders (Please specify) Lower Fees Other (Please specify) Could riders be added to the existing contract? Yes No If Yes, please describe why such riders cannot meet the client s objectives: What is the current death benefit on the contract being exchanged? If there is an income rider on the current contract? Yes No what is the income base? Has the client exchanged any other policy/contract within the past 36 months? Yes No If yes, was there a surrender charge incurred? Yes No $ of penalty Is the registered representative the writing agent on the policy/contract being replaced? Yes No If yes, when was that policy/contract written? (Month/Year) Please provide the specific disadvantages of the replacement (check all that apply) Surrender Charge Increased Fees Tax Liability New Surrender Schedule Decreased Investment Options Interest Rate Decrease Decreased Death Benefit Loss of Guarantees (Please specify) Loss of Riders (Please specify) Other (Please specify) Any additional information that would be helpful in reviewing the application:
Page 5 of 6 Replacement Comparison Chart Existing Policy/Contract Fixed Insurance Fixed Annuity Variable Life Insurance Variable Annuity Age at Issue Proposed Policy/Contract Fixed Insurance Fixed Annuity Variable Life Insurance Variable Annuity Current $ At Issue $ Remaining Surrender Period (Years) Surrender Penalty Incurred $ Mortality & Expense Risk Charge Length of surrender Charge Period Annual Maintenance Fee Administration Fee Distribution Fee (if applicable) Average of Annual Fund Expenses Other Riders (list and tally total fees) Total Of All Fees From Above If the proposed annuity has an initial death benefit less than the existing contract, please describe why this aspect is suitable: Please note that if the death benefit or living benefit rider under the proposed annuity contract is less than or equal to the current surrender value of the existing contract, then the client must be made aware of the disadvantages associated with this replacement transaction. For more information on the annuities and the risks associated with replacements and exchanges, please go to www.finra.org, select Investors, select Annuities and Resources from the column labeled Investment Choices and select the document Should You Exchange Your Variable Annuity?. You may also obtain this document from your IPI Registered Representative.
Page 6 of 6 Please check one of the boxes: In review of the information provided in the prior pages of this Disclosure, the total annual expenses on the proposed product to be purchased are MORE LESS than the total annual charges on the product being exchanged/transferred. 1. I understand the value of the account will fluctuate and may be worth more or less than the original amount when liquidated. The guarantee features apply only in case of death or, in certain contracts, as a living benefit by a cash payment or a series of payments. 2. I understand a withdrawal prior to age 59 ½ may result in a 10% IRS penalty on any gains plus ordinary tax. 3. I understand any living benefits paid will be deducted from my account and that any deduction over chosen levels may result in a significant decline in the living benefit payment from the date of the excess withdrawal forward. 4. I understand that the separate accounts chosen will differ in risk and volatility, that the choices are mine to make, and that changes made will be effective as of the close of the market. There is no assurance that guidance received from my IPI advisor (if any) will result in gains. 5. I understand under current tax code upon death a stepped-up cost basis is not available and the gains are subject to ordinary income tax. 6. I understand by purchasing this product in my IRA or qualified account (including 403b & 457B) there are no additional tax advantages from which I will benefit. 7. I understand that if there is a guaranteed fixed interest account available under this contract, that the transfer of funds between the fixed and variable subaccounts may be limited by time and/or amount. 8. I understand that there may be a Market Value Adjustment on this policy, which may reduce the amount received in the case of early liquidation. This reduction would be in addition to any surrender charges. 9. I understand that in times of low interest the return on money market subaccounts may be lower than the annual fees charged, resulting in a total return that is negative. 10. I understand if purchasing a bonus annuity it may have higher internal charges, reduced crediting, or benefits and longer surrender periods. 11. I understand my IPI advisor also offers other investment choices, e.g. mutual funds with potentially lower fees. I have considered these alternatives and after discussion and due consideration, I consider this variable annuity policy a suitable product for my financial needs and objectives. 12. I understand there is a free look period after the delivery of the contract (length of time varies by state). 13. Based on my current financial status, investment objectives, age, risk tolerance, lack of need for income or liquidity, and investment knowledge, I do verify that a variable annuity is suitable for the portion of money invested in this contract, and it is understood that this is a long term investment. 14. I understand the items listed in this disclosure may not include all features of the variable annuity selected. I acknowledge that I have made an informed decision to purchase this variable product and, if applicable, have reviewed the differences between this product and my original product. This product fits my investment needs and objectives, liquidity needs, time horizon, risk tolerance and my general financial situation and with the signature(s) below indicates my consent to the transaction(s). Signature of Client: Date: Signature Joint Client: Date: Signature of IPI Advisor: Date: