SINGLE PREMIUM MULTI-YEAR GUARANTEE DEFERRED ANNUITY APPLICATION

2721 North Central Avenue Phoenix, AZ 85004-1172 (866) 641-9999 SINGLE PREMIUM MULTI-YEAR GUARANTEE DEFERRED ANNUITY APPLICATION OWNER JOINT OWNER ...
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2721 North Central Avenue Phoenix, AZ 85004-1172 (866) 641-9999

SINGLE PREMIUM MULTI-YEAR GUARANTEE DEFERRED ANNUITY APPLICATION

OWNER

JOINT OWNER

Name_____________________________________________

Name_____________________________________________

Address____________________________________________ Address____________________________________________ City_________________ State__________ Zip____________ City_________________ State__________ Zip____________ Date of Birth__________ Age_________ Gender  M

 F Date of Birth__________ Age_________ Gender  M

F

SSN/Taxpayer ID_______________ Phone (_____)___________ SSN/Taxpayer ID_______________ Phone (_____)___________ Driver’s License No.________________________ State_______ Driver’s License No.________________________ State_______ E-mail_____________________________________________ E-mail_____________________________________________ ANNUITANT (If other than OWNER) Name____________________________________________________________Relationship___________________________ Address____________________________________________ City_________________ State__________ Zip____________ Date of Birth__________ Age_________ Gender  M  F SSN/Taxpayer ID_______________ Phone (_____)___________ Driver’s License No.________________________ State_______ E-mail_____________________________________________ PRIMARY BENEFICIARY Name

Address, City, State, Zip Code

Relationship

Date of Birth

SSN/Taxpayer ID Share %*

Address, City, State, Zip Code

Relationship

Date of Birth

SSN/Taxpayer ID Share %*

CONTINGENT BENEFICIARY Name

* Share % must equal 100%. If no share % is specified, payments will be made in equal shares.

PREMIUM Single Premium $______________ Tax Status of Single Premium  IRA  Roth IRA  Non-Qualified  Other _________ ©OLIC 2011 ICC11-MYGA-MVA-APP

1 of 2

Rev.9-2011

FRAUD NOTICE Any person who knowingly submits a false statement in an Application or files a claim containing false or deceptive statements may be guilty of insurance fraud and subject to penalties under state law. I have read, understand and acknowledge the Fraud Notice. ______________ ______________

Owner’s Initials

Joint Owner’s Initials

MARKET VALUE ADJUSTMENT - SURRENDER CHARGE The annuity policy applied for is subject to a market value adjustment during the first ten policy years. I understand that the market value adjustment may reduce or increase the amount I receive from a withdrawal or surrender of the annuity policy based on changes in the interest rate index identified in the annuity policy. I understand that withdrawal/surrender charges may also apply during the first ten policy years. ______________ ______________

Owner’s Initials

Joint Owner’s Initials

ELECTRONIC DOCUMENT DELIVERY By selecting “yes” to one of the options below and providing your e-mail address on page 1 of this application, you consent to receive communications and/or documents related to your policy electronically instead of by U.S. Mail. You may revoke your consent to electronic delivery and switch to delivery by U.S. Mail by sending a written request to our home office or by using any electronic revocation procedure that we may make available on our website. You must call or write to Oxford Life to notify us if your e-mail address changes. To use electronic delivery, you will need an e-mail account and a computer with internet access and an operating system that can support PDF format documents. Call or write to Oxford Life if you wish to obtain a paper copy of any items delivered electronically. If you do not consent to electronic delivery or if you revoke your consent to electronic delivery, Oxford Life may charge a reasonable fee for paper copies.  Yes, I want to receive the following by electronic delivery when electronic delivery is available (any items not checked will be sent in paper format):  My policy (including any riders, endorsements and amendments)  Disclosures  Other communications  No, I want to receive all communications and documents by U.S. Mail.

REPLACEMENT The Owner and Joint Owner  Do  Do Not have an existing insurance policy or annuity contract. All of the undersigned state that the Annuity  Does  Does Not replace an existing insurance policy or annuity. Name of the Company_________________________________________________ Policy or Contract Number_____________________ Address____________________________________________________________ Estimated Transfer Amount_ ___________________

ACKNOWLEDGEMENT The statements and answers in this Application are true and complete. All answers in this Application are representations and not warranties. I agree they shall be the basis for any annuity issued. I certify that the Social Security Number(s) and/or Taxpayer’s Identification Number(s) provided in this Application are correct and that I am not subject to backup withholding. Signature of Proposed Owner________________________________________ Signed at___________________ Date________________

City, State

Signature of Proposed Joint Owner____________________________________ Signed at___________________ Date________________

City, State

I certify that I have correctly recorded the information supplied by the Owner, Joint Owner and Annuitant (if other than Owner) in this Application. To the best of my knowledge and belief the proposed Owner and Joint Owner  Do  Do Not have any existing life insurance or annuity coverage and the annuity coverage applied for  will  will not replace any existing life insurance or annuity coverage. Producer’s Signature_______________________________________________________ Date_ _______________________________ Producer’s Printed Name____________________________________________________ Producer’s Number______________________ Second Producer’s Signature_________________________________________________ Date_ _______________________________ Second Producer’s Printed Name_ _____________________________________________ Second Producer’s Number________________ ©OLIC 2011 ICC11-MYGA-MVA-APP

2 of 2

Rev.9-2011

ANNUITY SUITABILITY ACKNOWLEDGMENT

2721 North Central Avenue • Phoenix, AZ 85004-1172

SECTION 1A Owner’s Name

Owner’s Last 4 Digits of S.S.N

Joint Owner’s Name

Joint Owner’s Last 4 Digits of S.S.N

Annuity Product Name

Estimated Premium Amount

$ Financial Status, Objectives, and Investment profile How is your net worth distributed?

What annual income do you require to maintain your current lifestyle?

(Must total 100%)

❑ $0 - $24,999 (1)

❑ $25,000 - $49,999 (2)

❑ Stocks, Bonds and Mutual Funds:

__________ %

❑ $50,000 - $99,999 (3)

❑ $100,000 or higher (4)

❑ Real Estate:

__________ %

❑ Annuities and Life Insurance:

__________ %

What is your current annual income?

❑ CDs and Cash:

__________ %

❑ $0 - $24,999 (1)

❑ $25,000 - $49,999 (2)

❑ Other:

__________ %

❑ $50,000 - $99,999 (3)

❑ $100,000 or higher (4) What is your primary goal in purchasing an annuity with us?

What is your primary source of annual income?

❑ Tax Savings (1)

❑ Growth for Future (2)

❑ Salary (1)

❑ Retirement Plan (2)

❑ Save for Emergencies (3)

❑ Safety of Principal (4)

❑ Investments (3)

❑ Social Security (4)

❑ Current Income (5)

❑ Retirement Income (6)

What is your Federal Income Tax Bracket?

How do you rate your investment knowledge?

❑ 10% (1)

❑ 15% (2)

❑ 25% (3)

❑ Limited (1)

❑ 28% (4)

❑ 33% (5)

❑ 35% (6)

❑ Average (2) ❑ Extensive (3)

When do you anticipate needing access to these funds? What is your approximate net worth (excluding car and primary residence)?

❑ 6 Years (1)

❑ 7 Years (2)

❑ 9 Years (4)

❑ Never (5)

❑ 8 Years (3)

❑ $0 - $74,999 (1)

❑ $75,000 - $149,999 (2)

❑ $150,000 - $249,999 (3)

❑ $250,000 - $499,999 (4) Do you have sufficient funds available in case of an ❑ $1,000,000 - or higher (6) emergency (not including this annuity)? ❑ Yes (1) ❑ No (2)

❑ $500,000 - $999,999 (5)

What is the source of funds for this annuity policy? ❑ Annuity* ❑ Life Insurance* ❑ CDs and Cash ❑ Other Investments ❑ Other: ____________________ * You must complete Section 1B if the source of funds includes a life insurance or annuity policy.

Owner’s Initials _________ Suitability 200

Joint Owner’s Initials _________ Page 1 of 3

© OLIC 2012

Rev 4-2012 Printed on recycled paper. Thank you for recycling.

SECTION 1B – Replacement Policy Comparison Worksheet Indicate Proposed Policy

If replacing multiple policies, use additional page

Product Data and Features

Replaced Policy

❑ Proposed Policy

❑ Proposed Policy

Income Protector

Bonus Ten

Oxford Life

Oxford Life

Fixed-MYGA

Fixed Index

N/A

N/A

Name of Company ❑ ❑ ❑ ❑

Type of Policy

Fixed Indexed Variable Life Insurance

Date of Issue Premium Payments

$

$

Premium Bonus

$

%

N/A

10% of Initial Deposit

Vested Premium Bonus Amount

$

N/A

10% Per Year

Current Accumulation Value

$

N/A

N/A

Current Surrender Value

$

N/A

N/A

10-Years 10%, 9%, 8%, 7%, 6%, 30-Day free withdrawal window, 5%, 4%, 3%, 2%, 1%

10-Years 10%, 9%, 8%, 7%, 6%, 5%, 4%, 3%, 2%, 1%

10% of Accumulated Value Starting Year 2

10% of Accumulated Value Starting Year 2

Yes

Yes

Accumulation Value on Death of Owner

Accumulation Value on Death of Owner

Surrender Charge Schedule for Remaining Years Free Withdrawal Percentage Market Value Adjustment

% ❑ Yes

❑ No

❑ Surrender Value ❑ Full Accumulation Value ❑ Other: $____________

Death Benefit Enhanced Benefits Writing Producer

1. Please list other features compared and considered, if any:_____________________________________________ _________________________________________________________________________________________ 2. How will the replacement policy better assist you in meeting your insurance needs and financial objectives? ❑ Immediate Income ❑ Interest Rate

❑ Index Credit Options

❑ Enhanced Benefits

❑ Full Accumulation Value Death Benefit

❑ Change in Purpose for Annuity

❑ Lifetime Income

3. Have you surrendered or exchanged any annuities within the preceding 36 months?

❑ Yes

❑ No

If Yes, please explain:_________________________________________________________________________ _________________________________________________________________________________________ Owner’s Initials _________ Suitability 200

Joint Owner’s Initials _________ Page 2 of 3

© OLIC 2012

Rev 4-2012

SECTION 2 Owner’s Certification The Owner must review and sign the “Owner’s Acknowledment of Suitability” if the producer has recommended this annuity product as suitable for the Owner. If the producer did not recommend this product as suitable, skip this section and proceed to the “Acknowledgment of No Suitability Recommendation” section. Pick only one.

 Owner’s Acknowledgment of Suitability

By signing this Acknowledgment of Suitability, I acknowledge and agree that: • All information provided above is true and may be relied upon by the producer and Oxford Life. • The annuity product recommended by the producer is suitable for my financial needs and objectives. • I do not need the funds used to purchase this product for my daily living expenses or emergencies. • If I am surrendering or exchanging another annuity or a life insurance policy to fund this annuity purchase, this transaction may result in a taxable event and surrender charges. • Neither Oxford Life nor any of its affiliates or representatives may provide tax or legal advice. I should consult my tax advisor or legal counsel for specific advice regarding my individual situation. • My producer relied on the information I provided to make a recommendation. ____________________________________________________ Owner’s Signature

__________________________________ Date

____________________________________________________ Joint Owner’s Signature

__________________________________ Date

 Owner’s Acknowledgment of No Suitability Recommendation

The Owner must review and sign this section if the producer did not recommend this annuity product as suitable. Neither my producer nor Oxford Life has made any recommendation as to the suitability of the proposed annuity purchase. I have determined that this annuity is suitable for my financial needs and objectives and I wish to purchase this product without a recommendation. ____________________________________________________ Owner’s Signature

__________________________________ Date

____________________________________________________ Joint Owner’s Signature

__________________________________ Date

Producer Certification

 Annuity Recommended as Suitable

Prior to making any recommendation to the Owner, I gathered all information reasonably appropriate to determine the suitability of my recommendation. I recommended the annuity product as suitable for this Owner on the basis of the facts disclosed by the Owner as to his or her financial situation and needs. I have reasonably informed the Owner of material features of the product, such as the surrender period, surrender charges, potential tax penalties, and expense charges. If this purchase involves a replacement, I have gathered all relevant information regarding the replaced product and determined that the transaction as a whole is suitable. ____________________________________________________ Producer’s Signature / Producer’s Number

__________________________________ Date

 No Suitability Recommendation

I did not recommend the proposed annuity purchase as suitable for this Owner. I made reasonable efforts to gather the Owner’s suitability information before declining to make a suitability recommendation. I did not make a suitability recommendation for this annuity purchase because:__________________________________________ _____________________________________________________________________________________________ ____________________________________________________ Producer’s Signature / Producer’s Number

Suitability 200

__________________________________ Date

Page 3 of 3

© OLIC 2012

Rev 4-2012

TRANSFER / 1035 EXCHANGE REQUEST FORM 1 Ownership & Annuitant / Insured Information (please print) Owner(s) and Annuitant(s)/Insured(s) must be exactly the same as the Owner(s) and Annuitant(s)/Insured(s) on the existing contract with the Surrendering Company. Please attach a copy of your latest statement.

Owner

Social Security Number

Co-Owner (if applicable)

Social Security Number

Annuitant / Insured

Social Security Number

Co-Annuitant / Insured (if applicable)

Social Security Number

2 Surrendering Company Information and Transfer / Exchange Instructions Contact the Surrendering Company to determine if specific forms are required to initiate the transfer / exchange.

If no selection is made, transfer will be initiated immediately. Apply Proceeds To:

Company Name Overnight Address (street address required) City

State

Account Number

Phone Number

Initiate transfer / exchange:  Immediately upon receipt  A new Contract / Certificate OR

OR

Zip

 After ________________

 An existing Oxford Life Contract / Certificate Number: _________________________________

3 Source of Transfer / Exchange Type of Transfer / Exchange

 Full Transfer / Exchange $ __________________________ (estimated amount)  I have enclosed the contract OR  I certify that the contract has been lost or destroyed.  Partial Transfer / Exchange $ __________________________ (exact amount)

Plan Type

From:  Non-Qualified (1035 Exchange)  IRA  Roth IRA  SEP IRA  401(k)  Other _______________________

For 403(b) Plans

 403(b) to IRA Rollover

OR

To:  Non-Qualified (1035 Exchange)  IRA  Roth IRA  SEP IRA  Other _______________________

 403(b) to Roth IRA

4 Surrendered Account Type  Variable Annuity

 Fixed Annuity

 Fixed Indexed Annuity

 Life Insurance

 Brokerage Account / Mutual Funds / Certificate of Deposit (CD) - I authorize the Surrendering Company listed above to liquidate my account and send the proceeds to Oxford Life Insurance Company. Form #403011 (Rev. 1/2010)

Page 1 of 2

5 Acceptance By Contract Owner / Participant For Qualified Transfer: I intend that this transfer be accomplished as a trustee-to-trustee transfer in a nontaxable manner in accordance with IRS rulings and not constitute actual or constructive receipt by me for federal income tax purposes. I hereby request and direct the transfer of the net proceeds of the account listed on the previous page. I understand that I am purchasing this annuity in an IRA or other tax-qualified plan as identified in Section 3 of this form. Since IRAs and other tax-qualified plans are already afforded tax-deferred status, there is no additional tax deferral benefit in this annuity. I am purchasing this annuity because I value other features, such as lifetime income payments, principal protection or death benefit protection. I understand that the proposed transfer may have important tax consequences and/or surrender or withdrawal penalties. I acknowledge that Oxford Life Insurance Company assumes no responsibility or liability for any tax treatment on this transfer under the Internal Revenue Code or otherwise. 403(b) Transfer Only: I acknowledge and agree that I have sole responsibility (1) for compliance with the Internal Revenue Service’s Section 403(b) Regulations and my employer’s or former employer’s 403(b) plan, if applicable, and (2) in determining and notifying Oxford Life Insurance Company as to whether the requested distribution is an eligible rollover distribution. For 1035 Exchange: I hereby assign and transfer the specified portion of my right, title, and interest in the above Contract (“the Contract”) to Oxford Life Insurance Company. I irrevocably waive all rights, claims, and demands under the Contract. The purpose of this transfer is to effect a direct nontaxable exchange of contracts pursuant to Section 1035 of the Internal Revenue Code. I understand and agree that the cost basis in the contract issued by Oxford Life Insurance Company shall be determined based upon the cost basis information provided by the above-referenced company (“Surrendering Company”). I further understand and agree that Oxford Life Insurance Company assumes no responsibility in determining or verifying the cost basis of the new contract issued by it. I acknowledge and agree that if Oxford Life Insurance Company does not receive cost basis information acceptable to it, the cost basis of the contract issued by Oxford Life Insurance Company will be zero. I hereby declare that the Contract is not subject to any assignment, pledge, collateral assignment, or other lien and that no proceedings in bankruptcy or insolvency, voluntary or involuntary, have been instituted by or against me and that I am not under guardianship or any legal disability. I understand and agree that Oxford Life Insurance Company will request that the Surrendering Company totally or partially surrender the original Contract and that Oxford Life Insurance Company assumes no responsibility for any delay by the Surrendering Company in paying the surrender proceeds or for any changes in the amount. Owner’s Initials

I understand that the proposed transfer or rescission of the Contract may have important tax consequences, and/or surrender or withdrawal penalties, and I represent and agree that Oxford Life Insurance Company is furnishing this form and participating in this transaction at my request. I understand and agree that Oxford Life Insurance Company makes no representations concerning my tax treatment under Internal Revenue Code Section 1035 or otherwise and that Oxford Life Insurance Company has no responsibility or liability for the validity of this assignment.

Signature (Contract Owner)

Date

X Signature (Co-Owner)

Signature Guarantee (If required by Surrendering Company)

Date

X Acceptance By Oxford Life Insurance Company - Home Office Use Only Oxford Life Insurance Company requests the liquidation and/or transfer of the account listed in Section 2. By our signature below, we represent that the account described is or is intended to be an account of the type indicated and that we accept the Section 1035 exchange / transfer on behalf of the person(s) named on this form. Please provide us with a report of the pre- and post-TEFRA cost basis in the current contract, if applicable. Authorized Signature:_ ____________________________________ Title:____________________ Date:_____________ Form #403011 (Rev. 1/2010)

Page 2 of 2

2721 North Central Avenue, Phoenix, Arizona 85004-1172 (866) 641-9999

Oxford Life Income Protector™ Single Premium Multi-Year Guarantee Annuity With Market Value Adjustment Feature Benefit Summary and Disclosure (Policy Forms ICC11-MYGA-MVA and ICC12-IP200 and state variations where applicable)

Minimum Premium: $10,000

Maximum Premium:

$350,000

ACCUMULATION VALUE The beginning Accumulation Value for any Policy Year refers to the value as of the end of the prior Policy Year. For the first Policy Year, the beginning Accumulation Value for the Policy Year shall be the Premium. Each Guarantee Period, We will declare a Guaranteed Minimum Annual Interest Rate that will be credited on the daily balance of the Accumulation Value. The Guaranteed Minimum Annual Interest Rate will not be less than 1.00%. At any time after the Policy is issued, the Accumulation Value is equal to:  The Accumulation Value at the start of the current Policy Year, less  Any Withdrawals, including any Withdrawal Charges and Market Value Adjustments thereon, from the Accumulation Value since the prior Policy Anniversary, plus  Interest on the Accumulation Value since the prior Policy Anniversary. DEATH BENEFIT If any Owner dies before the Maturity Date, the death benefit is equal to the greater of the Accumulation Value or the Guaranteed Minimum Value determined as of the date of death. WITHDRAWALS AND SURRENDER Each Withdrawal must be at least $600. The Accumulation Value remaining after any Withdrawal must be at least $2,000. You may take up to two Withdrawals in any Policy Year. Withdrawals taken and any Surrender during the first ten Policy Years are subject to Surrender/Withdrawal Charges and Market Value Adjustments. The penalty-free amount that may be withdrawn during the first Policy Year without incurring a Withdrawal Charge or a Market Value Adjustment is the Premium multiplied by the initial Guaranteed Minimum Annual Interest Rate. After the first Policy Year, the penalty-free amount for a Withdrawal is 10% of the Accumulation Value as of the beginning of that Policy Year. The penalty-free amount for Surrender is 10% of the Accumulation Value at the time of Surrender less any penalty-free Withdrawals since the last Policy Anniversary. Surrender/Withdrawal Charges are equal to the Surrender/Withdrawal Charge percentage times the excess of the Withdrawal or Surrender over the penalty-free Withdrawal or Surrender limit. Surrender/Withdrawal Charge percentages by Policy Year are:

IP200D

Policy Year

1

2

3

4

5

6

7

8

9

10

11+

Surrender/ Withdrawal Charge %

10%

9%

8%

7%

6%

5%

4%

3%

2%

1%

0%

3-2-12

FEDERAL TAX STATUS OF THE POLICY Federal income tax is deferred on interest credited to the Policy until Withdrawal or Surrender. Withdrawals and Surrenders are subject to federal income tax. Withdrawals taken or a Surrender of the Policy prior to the Owner’s age 59½ may be subject to a 10% federal tax penalty, in addition to federal income tax. State taxes may also apply. MARKET VALUE ADJUSTMENTS A Market Value Adjustment may increase or reduce the amount withdrawn or the Cash Surrender Value based on changes in the 5-year U.S. Treasury Constant Maturity rate published by the Federal Reserve. If the MVA Index Rate at the time of Withdrawal is lower than the MVA Index Rate at the beginning of the current Guarantee Period, then the Market Value Adjustment will increase the Withdrawal amount. If the MVA Index Rate at the time of Withdrawal is higher than the MVA Index Rate at the beginning of the current Guarantee Period, then the Market Value Adjustment will reduce the Withdrawal amount. The sample calculation of values on the next page includes a sample Market Value Adjustment calculation. The Market Value Adjustment equals the amount surrendered or withdrawn, minus the Penalty-Free Amount for Surrender or the Penalty-Free Amount for Withdrawal, multiplied by the Market Value Adjustment factor. We use the following formula to calculate the Market Value Adjustment factor:

[(1+ i)/(1+ j)]N/12 – 1 where i = The MVA Index Rate at the beginning of the current Guarantee Period j = The MVA Index Rate on the date of the Withdrawal or Surrender N = The number of full months remaining from the Withdrawal or Surrender date until the end of the current Guarantee Period WAIVER OF SURRENDER/WITHDRAWAL CHARGES AND MARKET VALUE ADJUSTMENT The Policy provides 30 days after the expiration date of each Guarantee Period to Surrender the Policy or make a Withdrawal without incurring a Surrender/Withdrawal Charge or a Market Value Adjustment. GUARANTEED LIFETIME WITHDRAWAL BENEFIT RIDER We will attach a Guaranteed Lifetime Withdrawal Benefit Rider (Form ICC11-GLWB100 or ICC12-GLWB120 and state variations where applicable) to the Policy only if the Annuitant is an Owner, unless the Owner is not a natural person. If the Policy has Joint Owners, we will attach a Guaranteed Lifetime Withdrawal Benefit Rider only if the Joint Owners are spouses. After the first Policy Year, the Rider allows the Owner to take annual Withdrawals in the amount of the Guaranteed Lifetime Withdrawal Benefit for the Owner’s lifetime (or for the joint lifetimes of the Owner and the Owner’s spouse if the Owner elects a joint lifetime payout), even if the Policy’s Accumulation Value has been reduced to zero. The person whose lifetime determines the Guaranteed Lifetime Withdrawal Benefit (or the younger person for a joint lifetime payout) must be at least 50 years old to qualify to begin receiving Guaranteed Lifetime Withdrawal Benefits. The amount of the Guaranteed Lifetime Withdrawal Benefit is equal to a payout factor percentage specified in the Rider multiplied by the Income Account Value at the time the Owner elects to receive the first Guaranteed Lifetime Withdrawal Benefit. The initial Income Account Value is equal to the Premium. During the first ten Policy Years, We will credit interest to the Income Account Value at an effective annual interest rate that is 5.00% higher than the interest rate credited to the Accumulation Value. We will not credit any more interest to the Income Account Value after the first Guaranteed Lifetime Withdrawal Benefit. Withdrawals will reduce the Income Account Value by the same percentage as the reduction on the Accumulation Value. The Income Account Value is only used to determine the amount of the Guaranteed Lifetime Withdrawal Benefits. The Income Account Value cannot be withdrawn as a partial or a lump sum and it is not payable as a death benefit. Guaranteed Lifetime Withdrawal Benefits are only guaranteed if the total amount withdrawn in a Policy Year is less than or equal to the Guaranteed Lifetime Withdrawal Benefit. Any Withdrawal above that amount will permanently reduce future Guaranteed Lifetime Withdrawal Benefits and may terminate the Rider.

IP200D

3-2-12

Oxford Life Income Protector™ Single Premium Multi-Year Guarantee Annuity With Market Value Adjustment Feature Sample Calculation of Interest Credits and Values for the Third Policy Year The following sample calculations show hypothetical Policy values as of the end of the third Policy Year. The sample calculations assume a Premium of $10,000, Guaranteed Minimum Annual Interest rate of 2.50% for the first three Policy Years and an increase in the MVA Index Rate from 3.00% to 4.00%. The MVA Index Rate is the 5-Year U.S. Treasury Constant Maturity Rate. The sample calculations also assume no Withdrawals were taken during the first three Policy Years. Hypothetical End of Third Policy Year Accumulation Value $10,000.00 2.50% $768.91 $10,768.91

A. Premium B. Annual Interest Rate for Premium C. Total Interest Credited Amount End of Year Accumulation Value = A + C = Hypothetical Surrender Charge

$10,768.91 $1,076.89 8.00% $775.36

A. End of Third Policy Year Accumulation Value for Surrender B. Penalty-Free Amount for Surrender C. Surrender Charge Percentage as shown on the Policy Data Page Surrender Charge = (A-B) x C = Hypothetical Market Value Adjustment (MVA) A. End of Third Policy Year Accumulation Value for Surrender B. Penalty-Free Amount for Surrender C. End of Third Policy Year Accumulation Value for Surrender Subject to MVA D. U.S. Treasury Constant Maturity Rate as of the Policy Date E. U.S. Treasury Constant Maturity Rate as of the Date of Policy Surrender F. Remaining Months From the Surrender Date Until the End of the Guarantee Period G. MVA Factor = [(1+D)/(1+E)]F/12-1 = MVA = C x G =

$10,768.91 $1,076.89 $9,692.02 3.00% 4.00% 24 -1.91% -$185.49

Hypothetical Cash Surrender Value A. End of Third Policy Year Accumulation Value for Surrender B. Surrender Charge C. MVA Cash Surrender Value = A - B + C =

$10,768.91 $775.36 -$185.49 $9,808.06

The example above is purely hypothetical and is not an indication of the annuity’s past or future performance. I have read and understand this summary of the annuity Policy features.

Owner’s Signature

Date

Joint Owner’s Signature

Producer’s Signature/Producer Number

Date

Producer’s State License Number (FL only)

IP200D

Date

3-2-12

2721 North Central Avenue • Phoenix, AZ 85004-1172 • 1-800-308-2318

Authorization to Hold Issue for Multiple Premiums TO BE USED FOR SINGLE PREMIUM ANNUITY PRODUCTS

Policy Owner Name ____________________________________________

Joint Owner Name ____________________________________________

I/we authorize Oxford Life Insurance Company to hold issuing the policy until all funds specified on the application and in the transfer paperwork have been received. I/we also understand that the starting index value will not be set and/or interest will not begin until the date all funds are received.

Policy Owner’s Signature ________________________________________ Date ___________________

Joint Owner’s Signature ________________________________________ Date ___________________

Writing Producer’s Signature _____________________________________ Producer # _______________

MULTIPLE PREMIUMS-100

© OLIC 2012

Rev 4-2012

OXFORD LIFE INSURANCE COMPANY 2721 North Central Avenue Phoenix, Arizona 85004 (602) 263-6666 or (800) 308-2318 IMPORTANT NOTICE: REPLACEMENT OF LIFE INSURANCE OR ANNUITIES This document must be signed by the applicant and the producer, if there is one, and a copy left with the applicant. You are contemplating the purchase of a life insurance policy or annuity contract. In some cases this purchase may involve discontinuing or changing an existing policy or contract. If so, a replacement is occurring. Financed purchases are also considered replacements. A replacement occurs when a new policy or contract is purchased and, in connection with the sale, you discontinue making premium payments on an existing policy or contract, or an existing policy or contract is surrendered, forfeited, assigned to the replacing insurer, or otherwise terminated or used in a financed purchase. A financed purchase occurs when the purchase of a new life insurance policy or contract involves the use of funds obtained by the withdrawal or surrender of or by borrowing some or all of the policy values, including accumulated dividends, of an existing policy or contract to pay all or part of any premium or payment due on the new policy. A financed purchase is a replacement. You should carefully consider whether a replacement is in your best interest. You will pay acquisition costs and there may be surrender costs deducted from your policy or contract. You may be able to make changes to your existing policy or contract to meet your insurance needs at less cost. A financed purchase will reduce the value of your existing policy and may reduce the amount paid upon the death of the insured. We want you to understand the effects of replacements before you make your purchase decision and ask that you answer the following questions and consider the questions on the back of this form. 1. Are you considering discontinuing making premium payments, surrendering, forfeiting, assigning to the insurer, or otherwise terminating your existing policy or contract? YES NO 2. Are you considering using funds from your existing policies or contracts to pay premiums due on the new policy or contract? YES NO If you answered “YES” to either one of the above questions, list each existing policy or contract you are contemplating replacing (include the name of the insurer, the insured or annuitant and the policy or contract number if available) and whether each policy or contract will be replaced or used as a source of financing: INSURER NAME

CONTRACT OR POLICY #

INSURED OR ANNUITANT

REPLACED (R) OR FINANCING (F)

1. 2. 3. Make sure you know the facts. Contact your existing company or its agent for information about the old policy or contract. If you request one, an in force illustration, policy summary or available disclosure documents must be sent to you by the existing insurer. Ask for and retain all sales material used by the agent in the sales presentation. Be sure that you are making an informed decision. The existing policy or contract is being replaced because___________________________________________________. I certify that the responses herein are, to the best of my knowledge, accurate: ________________________________________________________ (Applicant’s Signature and Printed Name)

_______________________________ (Date)

________________________________________________________ (Producer’s Signature and Printed Name)

_______________________________ (Date)

I do not want this notice read aloud to me.

(Applicant must initial only if they do not want the notice read aloud.)

RN100 (04/12) [AL, AK, AR, AZ, CO, HI, IA, KY, LA, ME, MD, MS, MT, NC, NE, NH, NJ, NM, OH, OR, RI, SC,TX, UT, VA, WI, WV]

WHITE – Applicant

YELLOW – Home Office

PINK – Producer

GOLDENROD – Existing Insurer

A replacement may not be in your best interest, or your decision could be a good one. You should make a careful comparison of the costs and benefits of your existing policy or contract and the proposed policy or contract. One way to do this is to ask the company or agent that sold you your existing policy or contract to provide you with information concerning your existing policy or contract. This may include an illustration of how your existing policy or contract is working now and how it would perform in the future based on certain assumptions. Illustrations should not, however, be used as a sole basis to compare policies or contracts. You should discuss the following with your agent to determine whether replacement or financing your purchase makes sense: PREMIUMS: • Are they affordable? • Could they change? • You are older—are premiums higher for the proposed new policy? • How long will you have to pay premiums on the new policy? On the old policy? POLICY VALUES: • New policies usually take longer to build cash values and to pay dividends. • Acquisition costs for the old policy may have been paid; you will incur costs for the new one. • What surrender charges do the policies have? • What expense and sales charges will you pay on the new policy? • Does the new policy provide more insurance coverage? INSURABILITY: • If your health has changed since you bought your old policy, the new one could cost you more, or you could be turned down. • You may need a medical exam for a new policy. • Claims on most new policies for up to the first two years can be denied based on inaccurate statements. • Suicide limitations may begin anew on the new coverage. IF YOU ARE KEEPING THE OLD POLICY AS WELL AS THE NEW POLICY: • How are premiums for both policies being paid? • How will the premiums on your existing policy be affected? • Will a loan be deducted from death benefits? • What values from the old policy are being used to pay premiums? IF YOU ARE SURRENDERING AN ANNUITY OR INTEREST SENSITIVE LIFE PRODUCT: • Will you pay surrender charges on your old contract? • What are the interest rate guarantees for the new contract? • Have you compared the contract charges or other policy expenses? OTHER ISSUES TO CONSIDER FOR ALL TRANSACTIONS: • What are the tax consequences of buying the new policy? • Is this a tax free exchange? (See your tax advisor.) • Is there a benefit from favorable “grand-fathered” treatment of the old policy under the federal tax code? • Will the existing insurer be willing to modify the old policy? • How does the quality and financial stability of the new company compare with your existing company?

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