Click here to clear page Home Office: 260 Madison Avenue, 8th Floor | New York, NY 10016 Mail to Administrative Office: PO Box 305160 | Nashville, TN 37230-5160 Overnight to Administrative Office: 100 Centerview Drive, Suite 100 | Nashville, TN 37214-3439 Phone 1-800-796-3872 | TTY/TDD 1-800-833-6388
FIXED DEFERRED ANNUITY APPLICATION Custom 7 Initial Interest Rate Guarantee Period: 3-Year 5-Year 7-Year RESPONSE REQUIRED Guaranteed Return of Purchase Payment Yes Owner
Name (first, middle initial, last)
All policyholder correspondence will be sent to this address.
Address
Sex
Trust
Name (first, middle initial, last)
Optional, nonqualified annuities only.
Address
Citizenship
City
Sex
RSA-0036/NY 9/12
Date of Birth
SSN or TIN
City
Date of Birth
Address
Zip
Phone No. (include area code)
Email
SSN or TIN
Date of Birth
City
Address
City
Date of Birth
City
Zip
Relationship to Owner
State
SSN or TIN
Zip
Relationship to Owner
State
SSN or TIN
Zip
Relationship to Owner
State
SSN or TIN
Date of Birth
Relationship to Owner
State
City
Address
Address
SSN/EIN
Marital Status
Address
Name (first, middle initial, last)
C
Email
In the event of death of owner, surviving joint owner becomes primary beneficiary.
Name (first, middle initial, last)
C
State
Citizenship
Name (first, middle initial, last)
P
Phone No. (include area code)
F
Name (first, middle initial, last)
P
Zip
Relation to Owner
Name (first, middle initial, last)
P
SSN/EIN
Marital Status
Name (first, middle initial, last)
Owner’s Beneficiary Designation
Email
F
Address
P - primary C - contingent
State
Citizenship
M
Phone No. (include area code)
Relation to Owner
Sex
Date of Birth
Zip
Marital Status
City
Date of Birth
SSN/EIN
F
Address
M
List any additional beneficiaries on a separate page, signed and dated by the owner(s).
State
Name (first, middle initial, last)
Beneficiary(ies)
Email
Relation to Owner
Sex
M
Joint Annuitant
Marital Status
Phone No. (include area code)
F
City
Date of Birth
Required if owner is non-natural person. If joint owners are listed, default annuitant is the primary owner.
Zip
Type of Owner (e.g. Individual, Joint, Trust, Corporation, Partnership, Guardianship, Custodian)
Joint Owner
Annuitant
State
Citizenship
M
Page 1 of 2 SSN/EIN
City
Date of Birth
No
Zip
Relationship to Owner
State
Zip
Percentage(%)
Phone
Percentage(%)
Phone
Percentage(%)
Phone
Percentage(%)
Phone
Percentage(%)
Phone
RSA-0036/NY/C7/NG 11/12
Click here to clear page Fixed Deferred Annuity Application (continued)
Nonqualified IRA
Plan Type
Page 2 of 2
SEP Employer Name _______________________
Roth IRA* *First tax year contribution made:
Contribution: Year_________ Purchase Payment
Year ________
Purchase Payment $_______________________ (Minimum is $10,000.00)
Transfer Information
IRC 1035 Exchange
Non-Direct Rollover
Direct Rollover
Direct Transfer
Roth Conversion
Do you have any existing life insurance policies or annuity contracts with this or any other company? Yes (complete any state specific replacement forms, if required) No
Owner’s Statement and Signatures
Is this contract intended to replace any existing life insurance policies or annuity contracts with this or any other company? Yes (complete the following and submit state specific replacement forms, if required) No Company Name
Contract No.
Company Name
Contract No.
I understand this annuity is not federally insured. On behalf of myself and any person who may claim any interest under this policy, I declare that the statements and answers on this application are full, complete, and true, to the best of my knowledge and belief, and shall form a part of the annuity contract issued hereon. Owner’s Signature
Signed in State
Date
Joint Owner’s Signature (if applicable)
Signed in State
Date
SIGN AND DATE
Agency Statement
To the best of my knowledge does the owner have any existing life insurance policies or annuity contracts? Yes (complete any state specific replacement forms, if required) No
Mail contract directly to: Owner Producer’s office for delivery to owner
Do you have any reason to believe the annuity applied for will replace or change any existing life insurance policies or annuity contracts? Yes (complete any state specific replacement forms, if required) No I have reviewed the applicant’s financial status and objective and find this coverage is appropriate for his/her needs. I certify that I have truly and accurately recorded on the application the information provided by the applicant. Licensed Primary Producer’s Signature
Agency Name and Phone Number
SIGN AND DATE Licensed Producer (print name)
Signed (county)
State License Number
State
Producer Number
Date
You may contact First Symetra National Life Insurance Company of New York to receive a free Buyer's Guide.
RSA-0036/NY 9/12
Symetra® is a registered service mark of Symetra Life Insurance Company. Symetra Life Insurance Company, not a licensed insurer in New York, is the parent company of First Symetra National Life Insurance Company of New York.
Home Office: 260 Madison Avenue, 8th Floor New York, NY 10016 Mail to Administrative Office: PO Box 305160 Nashville, TN 37230-5160 Phone 1-800-796-3872 | TTY/TDD 1-800-833-6388
PRELIMINARY INFORMATION Custom 7 Annuity Individual Modified Single-Premium Fixed Deferred Annuity This document reviews important points to think about before you buy a First Symetra National Life Insurance Company of New York annuity. This is a modified single premium annuity, which means you submit an initial Purchase Payment and then may submit subsequent Purchase Payments within the first 12 months of the contract date. It is a fixed deferred annuity, which means the annuity earns interest at rates specified by us, with payouts beginning on a future date. This annuity is tax-deferred, which means you do not pay taxes on the interest it earns until the money is paid to you. You can use an annuity to save money for retirement and to receive retirement income for life. It is not meant to be used to meet short-term financial goals . If you have questions about this annuity, please contact your Insurance Producer, broker, or contact a company representative at 1-800-796-3872. THE ANNUITY CONTRACT How will the value of my annuity grow? You select an initial guaranteed interest period on the contract application. The initial guaranteed interest period begins on the contract date and lasts through the guaranteed period chosen. Each Purchase Payment will be credited with the effective interest rate on the date we receive the payment. The rate in effect on the contract date will apply to the initial Purchase Payment during the initial guaranteed interest period. Any subsequent Purchase Payment will be credited with the interest rate in effect on the date we receive the subsequent payment. The interest rates in effect for subsequent Purchase Payments will be credited for the remainder of the initial guaranteed interest period that is already in progress. Starting on the contract anniversary following the initial guaranteed interest period, we may adjust the effective interest rate that applies to your contract value. The adjusted rate will apply to the contract value for no less than 12 months. From then on, we will not adjust the effective interest rate more frequently than every 12 months. When you stop making Purchase Payments, we will continue to credit the balance of the contract value with the current renewal effective interest rate, which will never be lower than the guaranteed minimum interest rate. We establish the annual effective interest rates that apply to Purchase Payments. We credit interest on each purchase payment from the day following the receipt of your payment up through the date you withdraw the funds from your contract. Annual effective interest rates show the effect of daily compounding of interest over a 12-month period. The account value of your annuity will not decrease unless withdrawals or any applicable charges and fees are taken. BENEFITS How do I get income (payouts) from my annuity? To start the income phase of your annuity, you must notify us in writing at least 30 days prior to the date you want the payouts to begin, and you must choose a payout option. Your payout options include: Life Annuity: Guarantees income for as long as you live. Life Annuity with Guaranteed Period: Guarantees income for as long as you live. If you die within the “guaranteed period” (usually 5-20 years) your beneficiary receives payouts for the remainder of the period. Joint and Survivor Life Annuity: Guarantees income for as long as you or your joint annuitants live. Symetra® is a registered service mark of Symetra Life Insurance Company. Symetra Life Insurance Company, not a licensed insurer in New York, is the parent company of First Symetra National Life Insurance Company of New York.
RSC-0329/NY/PI 10/11
-1-
Ed. 2 7/2012
Payments Based on a Number of Years: Pays income for a specific number of years. This option is available if your contract value is $25,000 or more. Automatic Option: If you do not choose a payout option at least 30 days before the latest date allowed under this Contract, we will make annuity payments under the Life Annuity with Guaranteed Period payout annuity option. The guaranteed period will be equal to 10 years, unless a shorter period is otherwise required. After your first contract year, you may change both the date you want payouts to begin and the payout option up until the date payouts begin. After payouts begin, you cannot make any changes. What happens after I die? If you are the owner of the annuity and you die before payouts begin, the death benefit may be paid in a single sum distribution, a series of payments, or payments under an annuity option offered in the Contract, subject to the restrictions described in the Contract, or required by law. If you are the owner of the annuity and you die after payouts have begun, the death benefit amount and the way it is paid will depend on the payout option previously selected by you.
CHARGES AND TAXES What happens if I take out some or all of the money from my annuity? Before payouts begin, you can take out all of your annuity’s value (full surrender) or part of it (partial surrender). Each withdrawal must be at least $500. If any withdrawal reduces the contract value to less than $2,000, the remaining balance will also be withdrawn and the Contract will be terminated. To take withdrawals or surrender your Contract, you must send a written request to our Home Office. We take a Surrender Charge from amounts you withdraw in any Contract Year that exceed 10% of the annuity fund value. The Surrender Charge is based on the following percentages: If withdrawal is Taken During Contract Year: The Surrender Charge is:
1 8%
2 8%
3 7%
4 7%
5 6%
6 5%
7 4%
8+ 0%
Example: If you withdraw $5,000.00 from your annuity in the fifth contract year your Surrender Charge is $5000.00 x 0.06 = $300.00. If you take a withdrawal after the end of the seventh contract year, there is no Surrender Charge.
The types of withdrawals that are not subject to Surrender Charges include:
repetitive withdrawals, if the withdrawals are equal or substantially equal and are expected to deplete the contract value over your life expectancy or the joint life expectancies of you and your joint Owner (or, if applicable, you and your Beneficiary). However, if you take additional withdrawals or otherwise modify or stop the repetitive withdrawals, the repetitive withdrawals taken during the Contract Year will be included when determining whether more than 10% of the contract value has been withdrawn; annuity payments; withdrawals taken on account of your death; and withdrawals taken after you have been confined to a hospital or nursing home for 30 consecutive days if: the confinement begins after the contract date; and the withdrawal is taken within 60 days after confinement ends.
If you are confined to a hospital or nursing home on the contract date, you are not eligible for this waiver of Surrender Charges until after the first contract year. Do I pay any other fees or charges? A $25.00 ‘annual systematic charge’ will be deducted on each contract anniversary if in the prior Contract Year, you received more than one repetitive withdrawal or more than one annuity payment from the ‘Payment Based on a Number of Years’ payout option. This fee will be waived if such payments were made by electronic funds transfer. How will payouts and withdrawals from my annuity be taxed? This annuity is tax-deferred, which means that you don’t pay taxes on the interest it earns until the money is paid to you. When you take payouts, or make a withdrawal you may pay ordinary income taxes on the earned interest. You may also pay a 10% federal income tax penalty on distributions you receive before age 59 ½. If your state imposes a premium tax, it will be included in the cost of your annuity. Premium tax does not apply to contracts issued in New York. It is recommended that you seek the counsel of your attorney, accountant or other qualified financial advisor regarding annuity taxation as it applies to you. RSC-0329/NY/PI 10/11
-2-
You can exchange one tax-deferred annuity for another without paying taxes on the earnings when you make the exchange. Before you do, compare the benefits, features, and costs of the two annuities. You may pay a Surrender Charge if you make the exchange during the surrender charge period. Also, you may pay a surrender charge if you make withdrawals from the new annuity during the first years you own it. Does buying an annuity in a retirement plan provide extra tax benefits? Buying an annuity within an IRA, 401(k), or other tax deferred retirement plan doesn’t give you any extra tax benefits. Choose your annuity based on its other features and benefits as well as its risks and costs, not its tax benefits. OTHER INFORMATION What else do I need to know? Changes to your contract We may change your annuity contract from time to time to follow federal or state laws and regulations. If we do, we will tell you about the changes in writing. Compensation We pay the Insurance Producer, broker, or firm for selling the annuity to you. Free Look The contract may be returned to us or the Insurance Producer who sold you this contract within 30 days from the date you receive it for a full refund of your purchase payment. What should I know about First Symetra National Life Insurance Company of New York? First Symetra National Life Insurance Company of New York has over a half-century of experience providing retirement plans, employee benefits, annuities and life insurance through a nationwide network of benefit brokers, financial institutions and independent agents. For our latest financial strength ratings, please visit www.symetra.com/ratings. Guaranteed Cash Surrender Value The Guaranteed Surrender Value is calculated based on 100% of the Purchase Payments accumulated at 1% interest in year 1 (surrender charges are applied to calculate the surrender value). Your actual surrender value will vary depending on such things as your Purchase Payments, withdrawals and age.
End of Year 1
Purchase Payment 10,000
Guaranteed Surrender Value with Guaranteed Return of Purchase Payments 10,000
Guaranteed Surrender Value without Guaranteed Return of Purchase Payments 9,373
For inquiries regarding this document, contact: First Symetra National Life Insurance Company of New York Retirement Division PO Box 305160 Nashville, TN 37230-5160
Telephone: 1-800-796-3872 www.symetra.com/ny
This is a summary document and not part of any contract issued by First Symetra National Life Insurance Company of New York. ______________________________ Insurance Producer’s Name
Phone Number
______________________________ Street Address
City
State
______________________________ Date A free copy of the Annuities Buyer’s Guide or this document will be provided upon request. RSC-0329/NY/PI 10/11
-3-
Zip
Mail to Administrative Office: PO Box 305160 | Nashville, TN 37230-5160 Physical/Overnight Address: Retirement Division 100 Centerview Drive, Suite 100 | Nashville, TN 37214-3439 Phone 1-800-796-3872 | TTY/TDD 1-800-833-6388
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 _____
LP-1256/NY 5/12
Page 1 of 2
Symetra® is a registered service mark of Symetra Life Insurance Company. Symetra Life Insurance Company, not a licensed insurer in New York, is the parent company of First Symetra National Life Insurance Company of New York.
IF YOU HAVE ANSWERED YES TO ANY OF THESE QUESTIONS, A REPLACEMENT AS DEFINED BY NEW YORK INSURANCE DEPARTMENT 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.
Date
Signature of Applicant
Date
Signature of Applicant
TO THE BEST OF MY KNOWLEDGE, A REPLACEMENT IS INVOLVED IN THIS TRANSACTION: YES _____ NO _____ Date
LP-1256/NY 5/12
Signature of Agent or Broker
Page 2 of 2
Home Office: 260 Madison Avenue, 8th Floor | New York, NY 10016 Mail to Administrative Office: PO Box 305160 | Nashville, TN 37230-5160 Phone 1-800-796-3872 | TTY/TDD 1-800-833-6388
ANNUITY SUITABILITY PROFILE
Page 1 of 4
Important Information You Should Know Before Purchasing an Annuity Your agent must ask you certain questions about your financial situation, objectives, and goals. The financial information you share will be used by your agent to determine if the annuity product he or she is recommending is suitable to meet your needs. The information you share will remain confidential and is not used for any other purpose than to determine the suitability of your purchase. Collection of this information is essential in ensuring that your agent has the opportunity to thoroughly review your financial needs before determining what product to recommend. Please take time to discuss all of your questions with your agent and to review any sales materials that he or she may have given you. When your questions have all been answered and you fully understand the recommendation your agent has made and agree that it does meet your needs, please review this form for accuracy before signing. Note that incomplete or inaccurate information on this Annuity Suitability Profile form may impact our ability to process your purchase in a timely manner. Do not sign this form if any item has been left blank, before carefully reviewing the information recorded or if any of the information recorded is not true and correct to the best of your knowledge. If more room is needed to answer any question, please attach additional pages as needed. Owner/Applicant name (first, middle initial, last)
Owner
Date of birth
Sex
M
Trust
Marital status
SSN
Number of dependents
F
Primary occupation (If retired, please note former occupation. If Active Military, also submit form LU-894.)
Employed
Not Employed
Retired
Please list current source(s) of income other than employment
Joint Owner
Joint Owner name (first, middle initial, last)
Date of birth
Sex
M
SSN
Relationship to Owner
F
Annuitant
Annuitant if other than Owner
Trust
If Owner is a Trust, name of person representing the trust
Attach Trust Certification Form (RSNB-0024/NY) indicating that the person named above is authorized to purchase an annuity on behalf of the trust. Please complete the Financial Status and Financial Objectives below on behalf of the annuitant. Current Financial Status Please complete the Financial Status and Financial Objectives below on behalf of the annuitant.
1.
Gross Annual Household Income
$ __________________
Please include income from wages, Social Security, pension/retirement benefits and investments. Do not include income from funds used to purchase this annuity.
2.
Total Net Worth
$ __________________
Including existing assets, real estate, investment and cash value life insurance holdings, cash, savings, etc.
3.
Liquid Net Worth
$ __________________
Checking, savings, CDs under 1 year to maturity, bonds, annuities with no surrender fee, etc. Exclude funds used to purchase this annuity. LP-1514/NY 8/12
Symetra® is a registered service mark of Symetra Life Insurance Company. Symetra Life Insurance Company, not a licensed insurer in New York, is the parent company of First Symetra National Life Insurance Company of New York.
Annuity Suitability Profile (continued)
Page 2 of 4
4a. After purchasing this annuity, are you able to access sufficient funds to cover your living expenses and emergencies without incurring a penalty? 4b. Annual Living Expenses
Yes
No
$ __________________
(Monthly Expenses x 12 = Annual Expenses)
5a. Source of funds used to purchase this annuity (Check all that apply.) Other Annuity Life Insurance Surrender IRA Employer Retirement Plan Inheritance Savings/Checking Sale of Stocks/Bonds/Mutual Funds Certificate of Deposit Reverse Mortgage Other (Specify) 5b. Even if you are not using a reverse mortgage as a source of funds to purchase this annuity, please indicate if you have a reverse mortgage. Yes No Please explain the use of the reverse mortgage funds: ____________________________________________ _______________________________________________________________________________________ 6.
Federal income tax bracket: Exempt 10% 15%
25%
28%
33%
35% +
Financial Objectives 7.
Owner’s current financial experience: None (In the past two years, the owner has not personally engaged in financial transactions.) Limited (Includes: credit card, bank account, and transactions for managing monthly expenses.) Moderate (Includes items above, plus: auto purchase/lease, retirement/pension accounts, certificate of deposit, etc.) Extensive (Includes items above, plus: stocks, bonds, mutual funds, real estate, or other material investments.)
8.
Owner’s risk tolerance: Conservative (Cautious investments with little volatility) Moderate (Cautious investments with some volatility) Moderately Aggressive (Investments that may fluctuate significantly short term) Aggressive (Investments that may fluctuate significantly)
9a. What is the time horizon anticipated for the first withdrawal/disbursement from this annuity? Less than 1 year 1 to 5 years 6 to 9 years 10 or more years Combination (Please explain) _____________________________________________________________ 9b. If the time horizon in 9a is within the annuity's surrender period, please indicate the reason for withdrawal/disbursement. Repetitive Payments Required Minimum Distribution Systematic Withdrawal (Please explain) Other (Please explain) Not Applicable 10. The purchase of this annuity is for (Check all that apply): Income now Future income Contract guarantees provided Pass inheritance to beneficiaries Tax-deferred growth Better interest rate than current contract 10% maximum withdrawal per year Other (Specify) ________________________________
LP-1514/NY 8/12
Annuity Suitability Profile (continued)
Page 3 of 4
Information About This Purchase 11. Does the purchase of this annuity involve replacement of an existing annuity or life insurance policy? Yes No If no, skip to Question 12 If yes, please answer all three of the following: a. Enter the amount or the percentage of any surrender charge or fee incurred. $______________________ or ___________% b.
Please explain how the features of the annuity you are purchasing today are beneficial to your needs. _______________________________________________________________________________________ _______________________________________________________________________________________
c.
Will the replacement of your existing annuity or life insurance policy result in the loss of death benefit or policy value? Yes No If yes, enter the amount of any death benefit value lost as a result of this transaction $__________________
12a. Have you had another exchange or replacement of an annuity within the preceding 36 months?
Yes
No
12b. If yes, enter the amount or the percentage of any surrender charge or fee incurred. $______________________ or ___________% 13. Is there a surrender or withdrawal charge for the annuity that you are considering purchasing today? Yes No If yes, indicate the withdrawal percent associated with the annuity to be purchased: Year 1 ______% Year 2 ______% Year 3 ______% Year 4 ______% Year 5 ______% Year 6 ______% Year 7 ______% Year 8 ______% Year 9 ______% Year 10 ______% 14. Are you aware that there may be tax penalties associated with a withdrawal from the annuity you are considering purchasing today? Yes No If yes, please specify. ______________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Owner Acknowledgement I understand that the product recommendation made is based on the accuracy and completeness of the financial information, goals, and objectives I discussed with my agent. I understand withdrawals in excess of 10% of the contract value per contract year may result in a penalty. I acknowledge that I was given a comparison of the costs, advantages and disadvantages if I am replacing existing policies. I understand that I should consult my tax advisor regarding possible tax implications of the purchase of an annuity or the exchange of an existing annuity or life insurance contract. If I am purchasing an Immediate Annuity, I understand the need to carefully consider the payout option selected as payments may not be advanced, accelerated or commuted except as specifically stated in the contract. I have been informed that fixed annuity contracts have a free look provision, that I may cancel the policy within the free look period and receive all monies paid without penalty minus any withdrawals/disbursements, and that I will not be entitled to interest. Also, I have informed any family members that are required to be involved in this financial decision. I understand that should I decline to provide the requested information or should I provide inaccurate information, I am limiting the protection afforded me by state statute or regulation regarding the suitability of this purchase.
LP-1514/NY 8/12
Annuity Suitability Profile (continued)
Page 4 of 4
15. Please check one box: The product I am purchasing was recommended by my agent. At this time, I believe it meets my financial objectives. OR The product I am purchasing was not recommended by my agent or I choose not to provide personal financial information. I understand this may impact the ability of the agent and/or the insurance company to gauge suitability of the selected annuity and may result in further review or a rejection of my application. Signature of Annuitant
Date
Signature of Owner
Date
Signature of Joint Owner (if applicable)
Date
Agent Acknowledgement The owner(s) and I discussed their investment objectives, time horizon, risk tolerance, and liquidity needs. I maintain a Client File of the interview(s) and data collected that support my product recommendation. This Suitability Form (LP-1514/NY) was completed using data maintained in my Client File. I understand First Symetra National Life Insurance Company of New York (and state regulation) requires me to maintain my Client File for five (5) years (or longer if required by law). My Client File supports the data presented on this form and is evidence that a thorough discussion and suitability review occurred with the client prior to making a product recommendation. I believe this fixed annuity is suitable for the financial needs and objectives of the owner(s). I base this belief on the information the client provided and on what I know at this time. Agent, if your client refuses to disclose certain data, please provide an explanation on Page 4. Please note that any missing information may affect our ability to gauge the suitability of a purchase. If we are unable to gauge the suitability, the application may be rejected. 16. I verified the identity of the owner(s) using the following unexpired government-issued ID and believe it is true and accurate: Driver’s License Passport Other (specify) _________________________________________ Expiration Date ___________________________________________________________________________ Agent signature
Date
Print name
Agent ID#
Name of Agency/Bank/Firm
Agent Phone Number
You are required to give a copy of this Annuity Suitability Profile to your client and to keep a copy in your client file. Please submit the original to First Symetra National Life Insurance Company of New York’s Administrative Office along with the corresponding Annuity Application. If the Annuity Suitability Profile is dated more than 10 days after the date of the Annuity Application, the submission may be considered out of date and may be returned.
Additional Remarks
LP-1514/NY 8/12
Annuities
Regulation 60 Sales Material Checklist INSURANCE PRODUCER AND ADVISOR USE ONLY
New York Replacement Regulation 60 requires you to submit with the application all sales material and proposals used in the replacement sale of life insurance or annuities. Please complete this form and include it with the application rather than sending copies of the actual materials. Indicate which forms were used in this sale. All material includes a form number and date extension. The form number is on the bottom left corner and the date extension is on the bottom right. The date extension must be specified for this form to be valid.
Applicant Name _____________________________________________________________________________________________
First Symetra Materials Company Brochure
Form Number
Date Extension
________________
___________
________________
___________
First Symetra Custom 5 Fixed Annuity Interest Rate Sheet Fact Sheet
________________ ________________
___________ ___________
First Symetra Custom 7 Fixed Annuity Interest Rate Sheet Fact Sheet
________________ ________________
___________ ___________
First Symetra Select 5 Fixed Annuity Interest Rate Sheet Fact Sheet
________________ ________________
___________ ___________
First Symetra Flex Premium Plus Annuity Interest Rate Sheet Fact Sheet
________________ ________________
___________ ___________
Fixed Deferred Annuities Fixed Deferred Annuity Brochure
SYM-1031/NY
10/12
Fixed Income Annuities
Form Number
Date Extension
First Symetra Advantage Income Annuity Fact Sheet Product Brochure
________________ ________________
___________ ___________
First Symetra Freedom Income Annuity Fact Sheet Product Brochure
________________ ________________
___________ ___________
First Symetra Income Builder Annuity Fact Sheet Product Brochure
________________ ________________
___________ ___________
________________ ________________
___________ ___________
Additional Material (Use only First Symetra material) _________________________________________________ _________________________________________________
Insurance Producer or Broker Signature ________________________________________________________________________ Phone ___________________________________________________ Stat No. __________________________________________
New York, NY Mailing address: PO Box 34690, Seattle, WA 98124 www.symetra.com/ny Symetra® is a registered service mark of Symetra Life Insurance Company. Symetra Life Insurance Company, not a licensed insurer in New York, is the parent company of First Symetra National Life Insurance Company of New York.
Click here to clear form. Home Office: 260 Madison Avenue, 8th Floor | New York, NY 10016 Mail to Administrative Office: PO Box 305160 | Nashville, TN 37230-5160 Phone 1-800-796-3872 | TTY/TDD 1-800-833-6388
ROLLOVER, TRANSFER AND/OR EXCHANGE REQUEST Existing Contract Check with existing contract carrier for additional requirements
Authorization to Transfer/ Direct Rollover
Company Contract issued by
Phone
Company Address (number and street, city, state, zip)
Attention
Contract/Policy(s) number
Contract Owner(s)
SSN
I agree that I am responsible for any Required Minimum Distribution (RMD) due me in the year of this transfer / rollover. First Symetra National Life Insurance Company of New York will not be responsible for determining any RMD until calendar years following the year it receives the transfer. I intend that this transfer be a nontaxable carrier-to-carrier transfer in accordance with IRS rulings and that it will not constitute actual or constructive receipt by me for Federal income tax purposes. I hereby request and direct the transfer of proceeds of the account listed above. The type of transfer is as follows: From Account (must check one) IRA SEP/SARSEP IRA SIMPLE IRA 401(k) 403(b) Roth IRA
Nonqualified Contracts
Amount Requested and Directed for Payment
401(a) 401(k) 403(b) 457
To Account (must check one) IRA SEP/SARSEP IRA SIMPLE IRA 401(k) Roth IRA
401(a) 401(k) 457
Transfers to 403(b) use form RGRP-0050/NY
Transfer or 1035 Exchange I assign my contract(s) identified above to First Symetra. I agree First Symetra will surrender the contract(s) and apply the entire cash surrender value it receives from the contract(s) for the new First Symetra policy. First Symetra furnishes this form and participates in this exchange at my request. I agree that First Symetra makes no representation and takes no responsibility concerning my tax treatment under Section 1035(a). Yes
No The existing contract I wish to surrender is an insurance contract (annuity or life insurance).
Type of Annuity Transfer/Rollover
Fixed
Variable Apply Proceeds
Partial liquidation $ _________________ (Amount)
or ______ % $ Amount if %: $ ________________ (Approximate Amount)
Contract (for full surrender only)
To new Contract To existing Contract Contract #____________________
I have enclosed the Contract I certify that the Contract has been lost or destroyed
Full liquidation $ ___________________ (Approximate Amount)
Owner’s Statement and Signatures
Acceptance
I request that the check be made payable to: First Symetra National Life Insurance Company of New York Mailing Address: First Symetra National Life Insurance Company of New York, PO Box 305160, Nashville, TN 37230-5160 If this is a partial exchange, I understand that cost basis will be allocated between my old contract and new contract in accordance with IRS Rev. Ruling 2003-76. I acknowledge that the IRS has raised concerns about annuity contract owners using partial exchanges to avoid income tax, and I certify that I am not entering into this transaction for the purpose of reducing or avoiding income tax. I acknowledge that pursuant to Revenue Procedure 2008-24, withdrawals from, annuitization, taxable owner or annuitant changes, or surrenders of either the original contract or the new contract during the 12 month period following the partial exchange will retroactively negate the partial exchange unless certain exceptions apply. Please contact your tax advisor for more details. Owner/Participant signature
Date
Joint Owner, if applicable
Date
Plan Administrator’s authorization
Date
First Symetra National Life Insurance Company of New York will accept the proceeds transferred and credit them to an annuity as described above. Please do not withhold any taxes from the amount being transferred.
Chantel Balkovetz, Vice President Life & Retirement Operations
LP-1278/NY 8/12
Symetra® is a registered service mark of Symetra Life Insurance Company. Symetra Life Insurance Company, not a licensed insurer in New York, is the parent company of First Symetra National Life Insurance Company of New York.
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TRUSTEE CERTIFICATION AND DISCLOSURE Under section 72(u) of the Internal Revenue Code (the “Code”), a trust that holds a non qualified deferred annuity contract may be taxed each year on the increase in the contract’s value regardless of whether contract earnings are withdrawn or distributed. Furthermore, tax treatment otherwise accorded to the holder of an annuity contract may be unavailable. An exception may apply if a trust holds an annuity contract as an “agent for a natural person” (i.e., an individual) as provided under the Code and applicable regulations. If you are unsure about the status of your trust, you should consult your legal advisor before completing this form. Do not send a copy of the trust document to First Symetra National Life Insurance Company of New York (“First Symetra”). This document will be used to certify that the contract is being held by a trust as agent for a natural person (unless the trust is a charitable remainder trust) and to verify the trustee(s) who is (are) authorized to act for the trust that owns the First Symetra annuity contract. Trust, Annuitant and Contract Information
Name of Trust
Tax ID Number
Date of Trust
Annuity Contract Number (if issued)
Annuitant Name(s)
Phone Number
Address (number and street, city, state, zip)
Authorized Trustee(s)
Provide the names of all authorized trustees. This list will supersede any previously provided certifications, if any. Trustee Name
Trustee Name
If the box is Address (number and street, city, state, zip) checked, trustees Trustee Name can act independently.
Address (number and street, city, state, zip)
Trustee Name
Address (number and street, city, state, zip)
Signatures
Address (number and street, city, state, zip)
By signing below, each and all of the undersigned certify: (a) They constitute all of the trustees of the trust, that they have read and understand the information on this form, and that they have all requisite authority to complete this form and to bind the trust and all of its beneficiaries with respect to all matters relating to the contract; if this form is submitted for a change of trustee, this form will supersede any previously provided certifications; (b) The trust holds the contract as agent solely for one or more natural persons within the meaning of 72(u) of the Internal Revenue Code (for trusts that are not charitable remainder trusts); they and not First Symetra are solely responsible for any consequences of having the contract held by the trust including, but not limited to, estate tax consequences; (c) They have obtained all legal and tax advice (from sources other than First Symetra, its employees, and agents) necessary to complete this form correctly; (d) They will notify First Symetra promptly in writing of any amendments to or revocation of the trust which would cause the representations in this Trustee certification to be incorrect, or of any change in circumstances which would cause the trust to no longer hold the contract as the agent for a natural person under 72(u); (e) They will jointly and severally defend, indemnify and hold First Symetra, its affiliates and agents harmless from and against any and all claims, demands, liabilities, damages, costs or expenses, including, but not limited to, reasonable attorney’s fees, arising from any transactions that they make or authorize as trustees of the trust. First Symetra’s acceptance of this form does not constitute its conclusion or advice as to the tax or other consequences arising from the trust owning the contract.
RSNB-0024/NY 8/12
Trustee Signature
Date (mm/dd/yyyy)
Trustee Signature
Date (mm/dd/yyyy)
Trustee Signature
Date (mm/dd/yyyy)
Trustee Signature
Date (mm/dd/yyyy)
Symetra® is a registered service mark of Symetra Life Insurance Company. Symetra Life Insurance Company, not a licensed insurer in New York, is the parent company of First Symetra National Life Insurance Company of New York.