About West Coast Life Representing a century of service to the insurance industry, West Coast Life boasts a colorful history of growth and industry “firsts.” West Coast Life was founded April 2, 1906, in San Francisco, just 16 days before the city’s devastating earthquake and fire. As an indication of the company’s enterprising spirit, West Coast Life was the first company to offer a loan to the city for reconstruction. Within a short period of time, West Coast Life began to grow and pioneered many “firsts” within the life insurance industry. • The first American life insurance company in Hawaii • The first American life insurance company in the Philippines and in China • The first to issue an unemployment compensation disability policy in America • The first to issue a group policy west of the Mississippi • The first to underwrite association business in the United States • The first to provide an automatic premium loan provision in a life insurance policy • And, the first to use the Check-O-Matic concept, the name of which we gave to the rest of the industry (at the request of LIAMA, now known as LIMRA).* As of February 2007, West Coast Life was rated A+ (Superior, 2nd highest of 15 ratings) for financial strength by A.M Best, an independent rating company. This financial strength rating is based on a variety of factors including operating performance, asset quality, financial flexibility and capitalization. For the most current rating information from A.M. Best and other independent ratings companies, visit our website at www.westcoastlife.com. *West Coast Life company archives. The Income Advantage Plus Annuity, policy form WCL-2112 and state variations thereof, is an immediate annuity contract and is issued by West Coast Life Insurance Company, 343 Sansome Street, San Francisco, CA 94104. Product features and availability may vary by state. Consult the contract for benefits, options, limitations, and exclusions. The tax treatment of annuities is subject to change. Neither West Coast Life nor its representatives offer legal or tax advice. Please consult your legal or tax advisor regarding your individual situation before making any tax-related decisions. All Income Advantage Plus Annuity payments and all guarantees are subject to the claims paying ability of West Coast Life Insurance Company.
WCLABD.1003.02.07 For Producer Information Only. Do not use with consumers.
West Coast Life Income Advantage Plus
Annuity Security and Flexibility… payments guaranteed for your client’s retirement needs now, and in the future • PAYPlusSM Annual Income Escalation Option • Commutable Value Option
An Immediate Income Annuity Issued by West Coast Life Insurance Company
• Wide Variety of Payment Options • Medical Underwriting
Producer Guide WCLABD.1003.02.07 (03/07) Producer information only. Do not use with consumers.
West Coast Life Income Advantage Plus Annuity Overview Saving for retirement is important and helping your clients make sure their resources can last throughout their retirement is equally important. We understand these challenges and want to lend a hand by providing the following valuable tools to help you discuss the features and benefits of income annuities with your clients: the Income Advantage Plus Annuity Product Guide (WCLAC.1045.02.07) and a Consumer’s Guide to Medical Underwriting for Annuities (WCLAC.1041.12.06). The Income Advantage Plus Annuity is a single premium immediate annuity that enables your clients to convert some of their assets to a reliable stream of payments. The scheduled payments and variety of payment options can help your clients more effectively prepare for and live comfortably through retirement. With the Income Advantage Plus Annuity, your clients have the security of knowing that their payments are guaranteed by West Coast Life Insurance Company, a highly rated insurance company. Tax Advantages The Income Advantage Plus Annuity provides certain tax advantages. If your clients purchase an annuity contract with pre-tax dollars (money that has not been subject to income taxes, such as an IRA or employer-sponsored plan), any income taxes will generally be deferred until the annuity payments are made. If your clients purchase an annuity contract with after-tax dollars (money that has already been subject to income taxes), a portion of each annuity payment will be considered a return of principal (until your entire original principal has been paid out) and will not be taxable. The tax treatment of annuities is subject to change. Neither West Coast Life nor its representatives offers legal or tax advice. Purchasers should consult their attorney or tax advisor regarding their individual situation.
Choices & Flexibility The Income Advantage Plus Annuity offers your clients the choice of: • payments for as long as they live • payments for a Certain Period, from five to 30 years • payments for as long as they live and for a Certain Period • payments for as long as they live with an Installment Refund • payments for as long as they live with a Cash Refund
Also, depending on the payment option selected, the Income Advantage Plus Annuity can provide payments for: • your client and their spouse, if they choose a Joint Annuity Option • your client’s beneficiary, should your client die prematurely
Product Specifications • Minimum Purchase Amount: • Maximum Purchase Amount: • Issue Ages: • Payment Modes: • Payment Date:
$10,000 $2,000,000 (over $2 million requires prior home office approval) For “Life only” and “Life with Cash Refund” payment schedules, the maximum issue age is 85. For “Certain Period,” “Life with Certain Period,” or “Life with Installment Refund” payment schedules, contracts may be issued to age 99. This contract is not available in New York. Monthly, Quarterly, Semi-Annually, or Annually Annuity payments will begin one payment mode after the contract is issued, unless otherwise specified. If your client would like their annuity payments to begin on another date, for example, the date used on an illustration, please specify that date in the Special Remarks section of the application. Annuity payments must begin within one year of the date the contract is issued.
Licensing The Income Advantage Plus Annuity is a non-registered insurance product. While appropriate state insurance licenses are required, a securities license is not needed to sell this product.
Annuity Parties • The owner is generally the person who buys the annuity contract and is entitled to exercise all rights and privileges provided in the contract. In other words, the owner makes all the decisions about the contract. • The annuitant is the person upon whose life all annuity payments are based. The annuitant makes no decisions about the contract, and has no rights to the contract. In most situations, the owner names himself or herself as the annuitant. • The beneficiary is the person named by the owner to receive any remaining benefits upon the death of the owner. The beneficiary will have the rights of the owner upon the owner’s death. • The payee is the person or persons the owner designates to receive the annuity payments. The owner may change the payee at any time, unless the owner made the designation irrevocable.
Additional Benefits In addition to the regular annuity payment schedules, the Income Advantage Plus Annuity offers these valuable benefit choices: • PAYPlusSM Option: this option provides annual payment increases that compound on the anniversary of your client’s first payment. Your client may choose from annual increases up to ten percent of the prior year’s payment. It may be selected only at the time of purchase, and may not be selected if the Commutable Value Option is selected. • Commutable Value Option: this option enables your client to fully surrender (“cash out”) their annuity and receive a percentage of their adjusted purchase payment (purchase payments less prior annuity payments they have received). The primary consideration in purchasing an immediate annuity should be to meet a need for an immediate and continuing stream of annuity payments. If your client uses the Commutable Value Option, their annuity payments will stop. Therefore, the Commutable Value Option generally should be used only in the event of emergency, or if your client’s financial situation has changed significantly since the purchase of the annuity. Please note that your client may receive less than their purchase payments when they exercise the Commutable Value Option. Your client’s Commutable Value is calculated based on the income year in which they exercise the option and the length of their certain period contract. The Commutable Value Option is available on “certain period” payment schedules only, and may be selected only at the time of purchase. It may not be selected if the PayPlusSM option is selected. The Commutable Value Option is not available in New Jersey or Oregon. Availability may vary in other states. The chart below shows how much adjusted purchase payment your client will receive if they exercise this option.
Portion of Adjusted Purchase Payment to be Returned
(adjusted for prior annuity payments that have been made)
Income Year in which Commutable Value Option is Exercised
5-12 Year Certain Period
13-16 Year Certain Period
17-30 Year Certain Period
1 to 3
6 or more
Please note the Certain Period is generally available from five to 30 years, but a four year Certain Period may also be available in some situations with prior West Coast Life home office approval.
• Medical Underwriting: some of your clients may benefit from optional medical underwriting available with the purchase of a Income Advantage Plus Annuity. Certain serious health conditions may affect assumptions about the duration of lifetime payments – and could result in higher payments than would otherwise be paid. Please refer to the Medical Underwriting section in this guide or the Consumer’s Guide to Annuity Underwriting (WCLAC.1041.12.06).
Payment Options Annuity payments are available monthly, quarterly, semi-annually or annually. They may begin immediately, or they may be
deferred for up to one year from purchase. You may choose any one of the following annuity payment options: • Payments for Life (single life annuity). Annuity payments are made as long as the annuitant is still living. Annuity payments stop upon the annuitant’s death, even if that occurs shortly after the annuity payments begin – no matter how many or how few annuity payments have been made. • Payments for two lives (joint and survivor annuity). Annuity payments are made as long as either of the two joint annuitants is still living. Annuity payments can remain level or be reduced upon the death of one of the annuitants. Annuity payments stop upon the surviving annuitant’s death, even if that occurs shortly after the annuity payments begin – no matter how many or how few annuity payments have been made. • Certain period. Annuity payments are made for a period specified by the owner, from five to 30 years. Annuity payments continue until the end of that certain period, regardless of whether an annuitant is still living.* Please note the Certain Period is generally available from five to 30 years, but a four year Certain Period may also be available in some situations with prior West Coast Life home office approval. • Payments for Life or for Two lives, with a certain period. Annuity payments are made as long as an annuitant is still living, or for a certain period specified by the owner, whichever is longer.* • Payments for life or for two lives, with an installment refund. Annuity payments are made as long as an annuitant is still living, or until the entire purchase amount has been paid out in the form of annuity payments, whichever is longer.* • Payments for life or for two lives, with a cash refund. Annuity payments are made as long as an annuitant is still living. When no annuitant is still living, any remaining purchase amount will be paid in a lump sum. The remaining purchase amount, if any, will be the amount of the original purchase payment less all annuity payments that have been made. * When no annuitant is still living, the owner (or the beneficiary if the owner is no longer living) may elect to terminate the contract and receive the commuted value of any remaining annuity payments in a lump sum. The commuted value of any remaining annuity payments will be less than the total of those remaining annuity payments.
The Income Advantage Plus Annuity can help solve different payment challenges.
The following examples are hypothetical and are only intended to show how the Income Advantage Plus Annuity can help solve different payment challenges by using different payment options.* Payment Challenge
Client needs an immediate payment stream and is concerned about outliving assets
Annuity payments continue for life
• Purchase payment of $100,000 • Male age 65 • Monthly annuity payment of $662.97 for life
Client needs an immediate monthly payment, but is worried that inflation will impact the amount of payment needed in the future
Life payments with PAYPlusSM Option
Annuity payments for life with annual increases up to ten percent
• • • •
Purchase payment of $100,000 Male age 65 Annual increase of 3.0% Monthly annuity payment of $495.64, increasing 3.0% annually for life
Clients want annuity payments to continue for the surviving spouse should something happen to one of them
Joint Life payments
Annuity payments are made over the lives of two individuals
• • • •
Purchase payment of $100,000 Male age 65 & Female age 62 Monthly annuity payment of $533.73 Monthly annuity payment of $533.73 will continue for life of the survivor
Client needs an immediate payment stream because of unexpected early retirement at age 60, but wants to wait on defined benefits until age 70
Certain Period payments
Annuity payments can be defined for specified period of time
• • •
Purchase payment of $100,000 Male age 60 Monthly annuity payment of $1,004.25 for 10 years
Client needs payments for a minimum period of time and is concerned about outliving assets
Life payments with ten- year Certain Period
Annuity payments can be defined for a specified period of time and continue after the specified period, as long as the annuitant is living
• Purchase payment of $100,000 • Male age 65 • Monthly annuity payment of $636.19
Client needs an immediate payment stream and wants payments to continue until the purchase amount has been returned
Life payments with Installment Refund
Annuity payments for life with payments continuing after the annuitant’s death
• Purchase payment of $100,000 • Male age 65 • Monthly annuity payment of $616.35
Client needs an immediate payment stream and wants any remaining payments paid-out in a lump-sum should something happen
Life payments with Cash Refund
Annuity payments for life with a lump-sum payment to the beneficiary
• Purchase payment of $100,000 • Male age 65 • Monthly annuity payment of $604.71
* Examples are hypothetical. Assumes rates effective as of 2/06/07 and a one-month delay between the contract date and the payment date. The interest rates and benefits are for illustration purposes only and are subject to change at any time.
Medical Underwriting Client Benefits Medical Underwriting may be a benefit for clients with serious medical conditions. This type of underwriting makes assessments based on your client’s medical condition(s) and their life expectancy by rating their age higher (rated-up) than it actually is – which is the opposite of life underwriting where the aim is to get a lower rating. Clients with a serious medical condition may qualify for a larger annuity payment for the same purchase payment, or a smaller purchase payment for the same benefit.
The shorter the life expectancy the higher the rating: The following examples are hypothetical and are only intended to show the differences in annuity payments and purchase payments based on an actual age and a rated-up age.* A rated age results in higher annuity payments. • With a purchase payment of $100,000, a male age 65 can purchase an Income Advantage Plus Annuity that will pay a monthly annuity of $662.97 for life. If the same individual is rated to age 71 upon underwriting review, his $100,000 purchase payment would purchase an annuity payment of $786.67 a month for life. • Similarly, with a purchase payment of $100,000, a female age 70 can purchase an Income Advantage Plus Annuity that will pay a monthly annuity of $702.07 for life. If the same individual is rated to age 77 upon underwriting review, her purchase payment of $100,000 would purchase an annuity payment of $892.69 a month for life. A rated age results in lower purchase payments. • A female age 60 can purchase an Income Advantage Plus Annuity that will pay a monthly annuity of $1,000 for life with a purchase payment of $177,665.14. If the same individual is rated to age 67 upon underwriting review, the monthly annuity of $1,000 for life would require an initial purchase amount of only $154,113.51. • A male age 70 can purchase an Income Advantage Plus Annuity that will pay a monthly annuity of $1,000 for life with a purchase amount of $131,155.90. If the same individual is rated to age 77 upon underwriting review, the monthly annuity of $1,000 for life would require an initial purchase amount of only $102,742.89.
* Examples are hypothetical. Assumes rates effective as of 2/06/07 and a one-month delay between the contract date and the payment date. The interest rates and benefits are for illustration purposes only and are subject to change at any time.
Medical Underwriting Suitability Below is a list of medical conditions that may be considered for Medical Underwriting. Use the list as a guide to help determine whether you should submit your client’s medical records for a Medical Underwriting review. Eligibility: • Medical Underwriting is only applicable when a life contingent payment option is selected. • Must be issue age 84 or less. Maximum rated-up age is 85. • Minimum $50,000 purchase payment. • Your client must have a serious medical condition that will reduce their life expectancy and allow a rated-up age. Serious medical conditions may include the following: Alcoholism Heart Attack or Angina Multiple Sclerosis (MS) ALS (Lou Gehrig’s Disease) Heart Surgery Muscular Dystrophy Alzheimer’s Heart Valve Disease Organic Brain Syndrome Cirrhosis of the Liver Hodgkin’s Disease Paraplegia or Quadriplegia Congestive Heart Failure (CHF) Injury Due to Fall or Imbalance Parkinson’s Disease Emphysema/COPD Mental Illness Stroke Please remember that with life only payments, annuity payments stop upon the annuitant’s death, even if that occurs shortly after the annuity payments begin – no matter how many or how few annuity payments have been made. Refer to the Product Guide for more payment options.
How to Apply: If your client can answer yes to one or more of the medical conditions that are listed or any other condition they feel should be considered, please complete the following: 1. Obtain copies of your client’s medical records supporting the condition(s). They may include followup records, discharge summaries from hospitals, or most recent medical exams. 2. Complete the Authorization to Obtain and Disclose Information form LAD-1190 (sample on page 9). This allows West Coast Life to review your client’s medical records. 3. Email ([email protected]
) or fax the Underwritten Request form (LAD-1192) along with the medical records to 888-811-1236. Important Note: In order to ensure that your request is processed quickly and correctly, please follow these helpful guidelines when faxing medical records: • Fax original documents only. Copies of original documents will transmit illegibly and cause delays in processing. • Check fax machine settings. The optimal resolution setting should be “fine” with “standard” as the minimal setting. Select these optimal settings or poor quality images will be imported into our system. • Watch for double-feeds. Make sure each page feeds into the fax machine one at a time. Be sure to compare the actual page count to the number of pages transmitted. 4. Or, you can mail the Transmittal for Medically Underwritten Annuity form and medical records to:
Attn: SPIA Underwriting Protective Life Insurance Company P.O. Box 10648 Birmingham, AL 35202-0648
Overnight Mail Attn: SPIA Underwriting Protective Life Insurance Company (2-4 LAD) 2801 Highway 280 South Birmingham, AL 35223
Income Advantage Plus Annuity
Sales Process • How Can I Get a Quote? Payout rates change frequently on this interest-sensitive product. Please ensure you are using current rates each time you run a quote. For quotes of $2 million or less:
• Internet quotes are available 24 hours a day at: www.winflexweb.com. If you have not previously registered, just go to "Register Now" under New Visitor. • Or you may download illustration software in the Agent Center at www.westcoastlife.com. Just go to the "Download Forms and Software" section and choose to download the annuity software. • Or you may order a CD under "Order Supplies" in the Agent Center. For additional information, please contact your Brokerage General Agent (BGA). For all quote requests over $2 million, or for complex quotes that cannot be generated on the Web site or via stand-alone CD:
Please work with your BGA. They can contact The Annuity Resource Center at 800-421-5614 from 8 a.m. to 6 p.m. EST. • Where Can I Get Sales Forms? All forms are located in the Agent Center under "Download Forms and Software" section at: www.westcoastlife.com • How Can I Submit New Business? Complete the West Coast Life Income Advantage Plus Annuity Application, form WCL-2110 (sample on pages 10 & 11), attach the quote and mail to: Regular Mail: Annuity Service Center P.O. Box 10648 Birmingham, AL 35202-0648
Overnight Mail: Annuity Service Center (2-4 IPD) 2801 Highway 280 South Birmingham, AL 35223
• Where Can I Get More Information? If you have questions, need support, or want to learn more about other annuity products issued by West Coast Life Insurance Company: • Please contact your BGA or visit our website at: www.westcoastlife.com
Sample Underwriting Transmittal
Life and Annuity Division
Protective Life Insurance Company1 1
West Coast Life Insurance Company
Protective Life and Annuity Insurance Company
Underwritten SPIA Information Request
Post Office Box 10648 / Birmingham, AL 35282-0648 Toll Free: 800-456-6330 / Fax: 205-268-6479
CLIENT INFORMATION: Name:
Date of Birth:
SSN / Tax ID:
Today's Date: AGENT INFORMATION: Agent Name:
Firm Name: MEDICAL INFORMATION: (Protective Life will not pay for medical documents including Attending Physician's Statements) Attached is the following information: (Check all that apply) Hospital discharge summary Report from a medical examination at the time of diagnosis Report from the most recent medical examination Reports reflecting significant conditions preceding the primary condition Reports of significant hospitalizations, surgeries or rehabilitation Other (please indicate)
Protective Life does not participate in Investor Owned or Stranger Owned annuity programs, or those programs involving non-recourse premium financing. MAIL, FAX or E-MAIL MEDICAL INFORMATION TO: E-MAIL Address:
Fax Number: 1-888-811-1236
Mail to: Protective Life Insurance Company Attn: SPIA Underwriting P.O. Box 10648 Birmingham, AL 35202
Overnight Mail to:
Protective Life Insurance Company Attn: SPIA Underwriting 2801 Highway 280 South Birmingham, AL 35223
This information is intended only for the use of the individual or entity to which it is addressed and may contain information that is privileged, confidential and exempt from disclosure. If the reader of this message is not the intended recipient or an employee or an agent responsible for the delivering the message to the intended recipient, you are hereby notified that any distribution or duplication of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately by telephone and return the original message to us by mail. Thank you.
Not authorized in New York.
Page 1 of 1
Sample Authorization to Obtain & Disclose Information Insurance Companies:
__________________________________________________ AGENT/BUSINESS ADDRESS
Protective Life Insurance Company * West Coast Life Insurance Company * Protective Life and Annuity Insurance Company
__________________________________________________ AGENT/BUSINESS PHONE NUMBER
P.O. Box 830619 • Birmingham, AL 35283-0619
__________________________________________________ AGENT/BUSINESS NAME
Authorization To Obtain and Disclose Information 1.
4. 5. 6. 7.
This authorization to obtain and disclose information complies with HIPAA regulations as they relate to life insurance and annuities. I (we) authorize (here in after known as my agent or agency) to obtain and use any information about or relating to me (us) that may affect my (our) insurability. My agent or agency may obtain and use health and medical information, including but not limited to information about drug use, alcohol use, nicotine use, physical and mental diseases and illness, and psychiatric disorders. My agent or agency may also obtain and use non-health and non-medical information, including but not limited to financial information, credit reports, consumer reports, driving record, criminal record, and information about avocations and aviation activity. All of this information may be used to evaluate an application for insurance or an annuity. Information relating to communicable diseases and other risk factors relating to me or to my spouse and life partner may be used to evaluate an application for insurance on either me or my spouse and life partner. My agent’s or agency’s sales agent or regional sales office representing me on my (our) application for insurance may obtain the information described in this paragraph directly from any of the persons or organizations listed in paragraph 2 in order to expedite the delivery of the information to the insurance companies named above. I (we) authorize the following persons and organizations to release and disclose the information described in paragraph 1 to my agent or agency or its agents acting on its behalf: (i) my (our) doctor(s); (ii) medical practitioners; (iii) pharmacists and Pharmacy Benefit Managers; (iv) medical and related facilities, including hospitals, clinics, facilities run by the Veteran’s Administration, Kaiser Permanente, The Cleveland Clinic Foundation and The Mayo Clinic; (v) insurers; (vi) reinsurers; (vii) Medical Information Bureau, Inc. (MIB); (viii) my (our) current and previous employers; and (ix) commercial consumer reporting agencies (CRA). All of these persons and organizations other than MIB may release the information described above to a CRA acting for my agent or agency . MIB may not release the information described in paragraph 1 to a CRA. I (we) authorize my agent or agency to release and disclose the information described in paragraphs 1 and 2 to the insurance companies named above, persons or organizations providing services relating to insurance underwriting for the companies named above, MIB, my personal physician(s), and as otherwise required by law. My agent or agency may release and disclose the information described in paragraphs 1 and 2 to other insurers if I (we) have applied or apply to the other insurers for insurance. My agent or agency may release and disclose the information described in paragraphs 1 and 2 to the sales agent representing me on my (our) application for insurance if it is necessary to provide an explanation of the reasons for my agent’s or agency’s decision to impose special underwriting requirements, whenever my application cannot be approved as submitted, or in connection with a claim for benefits. This authorization shall be valid for 24 months from the date shown below or, in the event of a claim for benefits, for the duration of such claim. During the evaluation of my (our) insurance or annuity application, I (we) understand that I (we) have the right to revoke the authorizations in paragraphs 1 through 4 by writing to my agent or agency. If this authorization is revoked, this would result in the file being closed and no coverage provided. � I (we) have been given a copy of this authorization form. � I (we) would like to be interviewed if an investigative consumer report will be made. (Please check the box if you wish to be interviewed if an investigative consumer report will be made.) I (we) understand that information about me (us) may be disclosed under this authorization to persons or organizations that are not subject to the Health Insurance Portability and Accountability Act (HIPAA) and that the information would then no longer be protected by HIPAA and any related regulations. I acknowledge that any agreements I have made to restrict my protected health information do not apply to this authorization and I instruct any physician, health care professional, hospital, clinic, medical facility, or other health care provider to release and disclose my entire medical record without restriction. Any modifications to this authorization may preclude our ability to process this application. I understand I do not have to sign this authorization in order to obtain health care benefits (treatment, payment or enrollment). Date of Authorization: ____________________________
_______________________________________________ Proposed Annuitant 2 (Signature)
________________________________________________ Proposed Annuitant 1 (Signature)
_______________________________________________ Print Name
________________________________________________ Print Name
_______________________________________________ Parent or Legal Guardian (Signature) When applicable, print name(s) of minor(s) below: _______________________________________________
THIS AUTHORIZATION MUST BE SIGNED WITHOUT MODIFICATION AND BE ACCOMPANIED BY THE TRANSMITTAL AND MEDICAL INFORMATION FOR PURPOSES OF REVIEW AND PROVIDING A QUOTE.
* Not authorized in New York
Sample Application Please send the application and check to:
IncomeAdvantage Plus Income Advantage Plus A Single Premium Immediate Annuity
2-4 IPD P.O. Box 10648 Please send the application and check to: 2801 Highway 280 South WEST COAST LIFEBirmingham, ANNUITIESAL 35202-0648 Birmingham, AL 35223 343 Sansome Street Ɣ San Francisco, California Ɣ 94104
A Single Premium Immediate Annuity
APPLICATION APPLICATION Owner 1 (Last, First, M.I.)
Certificate Authority# #0448-1 0448-1 CA CA Certificate of of Authority Birth Date __ __ / __ __ / __ __ __ __ m m
01 01____/ __ 1y 9
# Female Date __ ____ / __ __ 0 __ ✔ SS/Tax : __ __ __ __ __Birth __ __ __ __ __ __ __y 6 m m / d d / y y
Owner 1 (Last, First, M.I.)
_____________________________________________________________________________________________________________________________ 2__3__-__4Daytime 5 __- __ 6Telephone 7 __ 89 SS/Tax __ __ __ __ Doe, John Q. Address Street City State ID # : __ __1__ Zip No.__ __ __ _____________________________________________________________________________________________________________________________ Address Street City State Zip Daytime Telephone No.
123 Main Street
Owner 2 (Last, First, M.I.) Owner 2 (Last, First, M.I.)
Birth Date __ __ / __ __ / __ __ __ __ / d__d/ __ / y __ y __ y y Birth Date __ m__m/ __ __ m m / d d / y y y y SS/Tax ID # : __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ SS/Tax ID # : __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ Address Street City State Zip Daytime Telephone No. Address Street City State Zip Daytime Telephone No.
Annuitant Annuitant11(Last, (Last,First, First,M.I.) M.I.)
Same Same as as Owner Owner 1
BirthDate Date ________/ __ / __ / __ __ __ __ Birth ____ / __ __ __ __ m m / d d / y y y y m m
SS/TaxID ID##: : __ ____ ____ ____ ____ ____ __________________________ SS/Tax ____ ____ ____ ____ _____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ Address Street City State Zip DaytimeTelephone Telephone No. Address Street State Zip Daytime No.
Annuitant22(Last, (Last,First, First,M.I.) M.I.) Annuitant
Same Same as as Owner Owner 2
Birth ____ / __ ____ ____ ____ BirthDate Date __ ______/ __ / __ / y__ m m / d d / y y y m m
SS/Tax ____ ____ ____ ____ SS/TaxID ID##: : __ ____ ____ ____ ____ ____ __________________________ _____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ Address Street City State Zip Daytime Telephone No. Address Street State Zip Daytime Telephone No.
PrimaryBeneficiary Beneficiary Primary
Male Male ✔
Birth Birth Date Date
Mary Jane Doe
Relationship RelationshiptotoOwner Owner
Social Number SocialSecurity Security Number
__________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ ContingentBeneficiary Beneficiary
Female Female Birth Relationship Social Number Contingent
Birth Date Date RelationshiptotoOwner Owner SocialSecurity Security Number
250,000.00 PurchasePayment: Payment: $_____________ $_____________ Purchase Plan Type: Plan Type:
Replacement Replacement Do you currently have an annuity contract or life insurance policy?
Other Qualified Plan _______________________________
Other Qualified Plan _______________________________ (Type of Qualified Plan) (Type of Qualified Plan)
Yes Do you currently an or annuity contract or life insurance policy? Yes Will this annuity have change replace an existing annuity contract or life insurance policy?
*Yes Will this annuity change or replace an existing annuity contract or life insurance policy?
*Yes * If ‘Yes’ please provide the company name and policy or contract number in the spaces below and complete additional required forms.
* If ‘Yes’ please provide the company name and policy or contract number in the spaces below and complete additional required forms.
Special Remarks Special Remarks
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 anyorother government agency and by is subject to investment including possible loss An annuity contract is not a deposit obligation of, or guaranteed any bank or financialrisk, institution. It the is not insured by of theprincipal. Federal Deposit Insurance Corporation or any other government agency and is subject to investment risk, including the possible loss of principal. WCL-2110
(application continued) Initial Income Payment $___________
Income payments begin within 30 days of the Effective Date and are payable to Annuitant 1. Please use ‘Special Remarks’ to delay the income date (up to 1 year) or to select a different payee.
For income options based on one or two lives, please attach a copy of a birth certificate, state driver’s license or U.S. Passport as proof of age for each Annuitant. Under the “Single Life, only” or “Joint Life, only” options, income payments end at the death of the last surviving Annuitant regardless of the number of payments made. Certain periods may not be less than 5 years nor more than 30 years without prior Company approval. Income Options Based on One Life
Income Options Based on Two Lives
Single Life, with ___ years & ____ months certain
Single Life, with installment refund
Single Life, with cash refund
Single Life, only
Joint Life, with ___ years & ____ months certain
Joint Life, with installment refund
Joint Life, with cash refund
Joint Life, only
If you selected an option based on two lives, the income payments may be reduced upon the death of either Annuitant. To elect this feature, enter the percentage of the current income payment each Annuitant should receive upon the death of the other. If no percentages are entered, income payments will not be reduced due to an Annuitant’s death. (Please use whole percentages.) Annuitant 1: ____ %
Annuitant 2: ____ %
Income Options Not Based on a Life
___ years & ____ months certain
Unless you select the PAYPlus income escalation feature below, future income payments under this option may be surrendered according to the terms of the Contract. Check the box to the left to waive your right to surrender future income payments.
Issue my contract as non-surrenderable. Income Payment Frequency: PAYPlus:
PAYPlus, the annual income escalation feature, is not available with surrenderable income options.
Yes, increase income payments ____ % on each income date anniversary.
No, do not increase my income payments.
(10.00% maximum, in 0.01% increments)
NOT INSURED BY ANY GOVERNMENT AGENCY · NO BANK GUARANTEE · NOT A DEPOSIT This application is part of the annuity contract. The information I provide is true and correct to the best of my knowledge and belief, but my statements are representations and not warranties. This application is made with the knowledge and consent of the proposed Annuitant(s). The company may accept instructions from any Owner on behalf of all Owners. If no certain period is selected, Income Payments stop at the death of the last surviving Annuitant.
Application signed at: ____________________________________________ on ________________________________ (City and State)
Owner 1: _________________________________________ Annuitant 1: _______________________________________ (If other than Owner 1)
Owner 2: ______________________________________ Annuitant 2: ____________________________________
(If other than Owner 2)
Federal law requires the following notice: We may request or obtain additional information to establish or verify your identity. Producer Report To the best of your knowledge and belief, does the applicant have an existing life insurance policy or annuity contract?
To the best of your knowledge and belief, does this annuity purchase change or replace any existing annuity or life insurance?
Did you determine the suitability of this annuity product to the applicant’s financial objectives and situation by inquiring into: * The applicant’s financial status?
__ Yes __ No
* The applicant’s tax status?
__ Yes __ No
* The applicant’s investment objectives?
__ Yes __ No
* Other relevant information?
__ Yes __ No
* Comments: _________________________________________________________________________________________________ Type of unexpired government-issued photo I.D used to verify the applicant’s identity? ______________________
Sign Producer Name: ___________________________________
Print Producer Name: _________________________________
Producer #: __________________________________________
Agency /Brokerage: __________________________________
Producer Phone #: _____________________________________
FL Lic. # (if applicable): _________________________________