Immediate Annuity New York Regulation 60 Annuity Replacement Packet Submitting New York ( Reg 60 ) Annuity Replacement Business with Step 1 To start off, complete and mail these forms to (addresses below): Disclosure Information Request Definition of Replacement (Replacement Packet) (Replacement Packet) Information Release Authorization For each carrier proposed to be replaced. (Replacement Packet) A copy of a recent statement for each policy/contract to be replaced (Obtain from applicant.) As soon as Nationwide receives your submission, it goes into action, preparing the Disclosure Statement(s) and other necessary forms. They will then fax or mail these to you, so you can proceed to Step 2. Step 2 When you receive your Disclosure Statement(s) and other documents from Nationwide, return to the applicant, fill out the forms below (with signatures) and submit them to. You re done! Application for Annuity (New Business Enrollment Packet) Transfer of Assets form (New Business Enrollment Packet) Disclosure Statement(s) (Faxed/Mailed from Nationwide) Additional forms as required (New Business Enrollment Packet) List of Sales Literature Used (Replacement Packet) Important Notice Regarding Replacement (Replacement Packet) All New York replacement business or inquiries should be sent to: Regular Address: Overnight Address: PO Box 182021 RR1-04-F4 (NY REG60) Columbus, OH 43218-2021 5100 Rings Rd. Dublin, OH 43017-1522 For questions or more information, contact: Nationwide s Reg 60 Specialists Team Phone: 1-877-624-0385 Fax: 1-888-637-3460 FAF-0103NY.10 06/2013 *FAF-0103NY.10*
Step 1 What is New York Regulation 60? New York Regulation 60, effective November A copy of any sales literature used in making 10, 1998, places specific requirements on the sale must be provided to the replaced replacement transactions conducted in the carrier(s). state of New York. The law is designed to give The replacing carrier must provide a 60 day New York consumers an apples-to-apples free look period for the new policy or comparison of carriers, so they can make contract. informed choices about their carrier. The replaced carrier must be allowed New York Regulation 60 requires that: reinstatement at the replacing carrier s Illustrative disclosure information must be contract value during the free look period. obtained from the carrier(s) to be replaced Please note: New York Regulation 60 does and the replacing carrier prior to securing not necessarily replace a carrier s current the customer s signature on the new conservation policy or conservation period. policy application. Carrier(s) being replaced have 20 calendar days to provide their information, potentially adding approximately 25 days to transfers. Signed Disclosure Statement, Important Notice Regarding Replacement, and Definition of Replacement forms must be submitted with each new policy application. A copy of the Definition of Replacement signed by the agent/broker and the applicant be left with the applicant for his/her records. Nationwide s Commitment to Helping Agents or Brokers Nationwide remains committed to meeting your sales and service needs in every way possible. We know Regulation 60 provisions can be time-consuming, but we will help facilitate the process for you by obtaining the appropriate information and preparing the required forms for signatures. Once you send in the requested information in step 1, Nationwide s Reg 60 Specialists Team will: Request illustration and disclosure information from relinquishing carrier(s) every 5 days, so their response can be obtained within the required 20 days. Complete Disclosure Statement(s) up to Agent Statement section. Good faith approximations will be used to provide disclosure information for any carrier that does not comply within 20 days. Return all appropriate Disclosure Statement(s) to you promptly for review and signatures so you can complete the sale. APO-4159-F 06/2013 *APO-4159-F*
Disclosure Information Request for proposed policy(s) replacement under New York Regulation 60! Agent or Broker must complete this section! Please provide a copy of the applicant s account statement(s) whenever possible. Step 1 Agent or Broker who is requesting the information Name: Phone: ( ) Company: Fax: ( ) Applicant Name: SSN: / / (Optional) Address: Phone: ( ) City: State: ZIP: Nationwide Immediate Annuity Please provide specific information about the proposed product. Income Option: Annuitant Date of Birth: / / Annuitant Gender: Survivor Date of Birth: / / Survivor Gender: Cost Basis (If Non-Qualifed): $ Payment Frequency: Monthly Quarterly Semi-Annual Annual Income Start / / Plan Type: Non-qualified IRA ROLLOVER Roth tax year established: Investment Amount (surrender value of existing policies): $ Relinquishing Carrier(s) Please provide a copy of the customer s account statement(s) whenever possible. If funds are coming from more than three carriers, please make additional copies of this form and attach as needed. 1 Company: Address: City: State: ZIP: Phone: ( ) Policy Number: Approx. Surrender Value: $ Type of policy: Variable annuity Fixed annuity Life insurance 2 Company: Address: City: State: ZIP: Phone: ( ) Policy Number: Approx. Surrender Value: $ Type of policy: Variable annuity Fixed annuity Life insurance 3 Company: Address: City: State: ZIP: Phone: ( ) Policy Number: Approx. Surrender Value: $ Type of policy: Variable annuity Fixed annuity Life insurance APO-4158-18D 06/2013 *APO-4158-18D*
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Step 1 Information Release Authorization for proposed annuity / life insurance replacement in accordance with New York Regulation 60 Attention Broker or Agent: A separate copy of this form must be filled out and signed for each relinquishing carrier. Before filling out this form, make additional copies as needed. To (Relinquishing Carrier): Re: Contract/Policy Number(s): (Please check all that apply.) Full Surrender Amount $ Partial Surrender Amount $ Penalty Free Amount $ Not Known/Not Available With this letter of intent, I hereby authorize the release of requested information regarding the above contract(s)/policy(s) to. In accordance with New York Regulation 60, please complete the enclosed Disclosure Information Request regarding my above contract(s)/policy(s) within twenty (20) days. Send the requested information by overnight mail or via fax to Nationwide Life Insurance Company (and to the agent/broker below) at: By overnight mail: By fax: RR1-04-F4 (NY REG60) OR Attention: NY REG60 5100 Rings Rd. Fax: 1-888-637-3460 Dublin, OH 43017-1522 If you have any questions, please call the Regulation 60 Team at 1-877-624-0385. Associates are available from 8:30 a.m. to 5:00 p.m. Eastern time, Monday through Friday. Applicant Print Name: Signature: X Joint Applicant (if applicable) Print Name: Signature: X SSN: (Optional.) Date of Birth: (Optional.) SSN: (Optional.) Date of Birth: (Optional.) / / / / Broker or Agent Name: Address: City: State: ZIP: APO-4160-S 06/2013 *APO-4160-S*
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Step 1 Department of Financial Services 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 or broker 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 the Department of Financial Services of the State of New York Regulation No. 60 has occurred or is likely to occur and your agent or broker 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. Print Name of Applicant: Signature of Applicant: X Print Name of Joint Applicant (if applicable): Signature of Joint Applicant (if applicable): X To the best of my knowledge, a replacement is involved in this transaction: Yes Print Agent or Broker Name: No Signature of Agent or Broker: X APO-3381-K 06/2013 *APO-3881-K.P1*
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Applicant Step 2 List of Sales Literature Used for proposed annuity / life insurance replacement in accordance with New York Regulation 60 Name: Broker or Agent Name: Company: Sales Literature Used SSN: (Optional.) / / Most Nationwide form numbers are located in the lower left corner on the cover or back page. Any client analysis tools not related to a specific product are not considered sales literature for purposes of New York Regulation 60. Please write in the form number and title for each piece of sales literature (including proposals) used in this sale. If sales literature used does not contain a form number, please provide the title and attach a copy of the piece to this form. Prospectuses Brochures Miscellaneous Form Number Title Return This Form Return this form to Nationwide with the Application, 1035 form or Transfer of Assets form (if applicable), Disclosure Statement, Important Notice Regarding Replacement, and any additional required paperwork. Please note: If there is any sales material listed on this form, Part D of the Disclosure Statement (Agent or Broker s Statement) must be marked that The attached proposal, including sales material, was used for this sale. APO-4161-J 06/2013 *APO-4161-J*
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Step 2 Department of Financial Services of the State of New York IMPORTANT Notice Regarding Replacement or Change of Life Insurance Policies or Annuity Contracts This Notice Is For Your Benefit and Required By Regulation No. 60 You are contemplating the purchase of a life insurance policy or annuity contract in connection with the surrender, lapse or change of existing life insurance policies or annuity contracts. The agent or broker is required to give you this notice together with a signed disclosure statement containing the summary result comparison for the new life insurance policy or annuity contract and any life insurance policies or annuity contracts to be changed that sets forth the facts of the transaction and its advantages and disadvantages to you. Your decision could be a good one or a mistake so make sure you understand the facts. You should: 1. Carefully study the disclosure statement, which includes a summary result comparison, until you are sure you understand fully the effect of the transaction. 2. Ask the company or agent or broker from whom you bought your existing life insurance policies or annuity contracts to review with you the transaction and the disclosure statement. You may be able to effect the changes you desire more advantageously with them. Their customer service telephone number is contained in the disclosure statement. 3. Consult your tax advisor. There may be unfavorable tax implications associated with the contemplated changes to your existing life insurance policies or annuity contracts. As a general rule, it is often not advantageous to drop or change existing coverage in favor of new coverage, whether issued by the same or a different company. Some of the reasons it may be disadvantageous are: 1. The amount of the annual premium under an existing life insurance policy may be lower than that called for by a new life insurance policy having the same or similar benefits. Any replacement of the same type of policy will normally be at a higher premium rate based upon the insured s then attained age. 2. Since the initial costs of a life insurance policy are charged against the cash value increases in the earlier life insurance policy years, the replacement of an old life insurance policy by a new one results in the policyholder sustaining the burden of these costs twice. Annuity contracts usually contain provision for surrender charges, therefore a replacement involving annuity contracts may result in the imposition of surrender charges. 3. The incontestable and suicide clauses begin anew in a new life insurance policy. This could result in a claim being denied under the new life insurance policy that would have been paid under the life insurance policy that was replaced. 4. An existing life insurance policy or annuity contract often has more favorable provisions than a new life insurance policy or annuity contract in areas such as loan interest rate, settlement options, disability benefits and tax treatment. 5. There may have been changes in your health since the purchase of the existing coverage. LIFE-4359-J 06/2013 *LIFE-4359-J.P1*
Step 2 6. The insurance company with which you have existing coverage can often make a desired change on terms that would be more favorable than if you replaced existing coverage with new coverage. You have the right, within 60 days from the date of delivery of a new life insurance policy or annuity contract, to return it to the insurer and receive an unconditional full refund of all premiums or considerations paid on it, or in the case of a variable or market value adjustment policy or contract, a payment of the cash surrender benefits provided under the policy or contract, plus the amount of all fees and other charges deducted from gross considerations or imposed under the life insurance policy or annuity contract, and MAY have the right to reinstate or restore any life insurance policies and annuity contracts that were surrendered, lapsed or changed in the transaction to their former status to the extent possible and in accordance with the insurer s published reinstatement rules to the extent such rules are not inconsistent with the provisions of this part. IMPORTANT: This right should NOT be viewed as reinstating or restoring your life insurance policy or annuity contract to the same condition as if it had never been replaced. There may be consequences in reinstating or restoring your life insurance policy or annuity contract, including but not limited to: The right to reinstate or restore your life insurance policy or annuity contract applies only to companies subject to New York insurance laws; Your life insurance policy or annuity contract is subject to your specific company s reinstatement rules, which may vary from company to company. These rules may require payment of both premium and interest; however, you will not be subject to evidence of insurability, or a new contestable or suicide period; You may not receive the interest or investment performance during the period the life insurance policy or annuity contract was replaced; and There may be unfavorable federal income tax consequences as a result of the reinstatement of your life insurance policy or annuity contract. IMPORTANT: In the case of a variable or market value adjustment policy or contract, the value of the policy or contract may increase or decrease during the 60 day period depending on the performance of the underlying investments, which may effect the value of the refund you receive. I hereby acknowledge that I read the above IMPORTANT NOTICE and have received a copy of same. Signature of Applicant: X Signature of Joint Applicant (if applicable): X LIFE-4359-J 06/2013 *LIFE-4359-J.P2*