Documents Package Prepared for:
Prepared Date:
Consolidated Marketing Group, Inc.
6/10/2010 6:29 PM EST
Document Name Description Expiration Date
12/31/2199OMCO7119 OMGuarantee - Platinum 3,5,7 Consumer Brochu...12/31/2199ADMIN5234 ANNUITY SUITABILITY ACKNOWLEDGEMENT FORM
OMGuarantee-PlatinumTM
A Single Premium, Fixed Deferred Annuity with tax-deferred earnings featuring a choice of a 3, 5 or 7-year rate guarantee
OMCO 7119 (05-2009) OM Financial Life Insurance Company 10-083 Rev. 04-2010
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OMGuarantee-PlatinumA Single Premium, Fixed Deferred Annuity with tax-deferred earnings featuring a choice of a 3, 5 or 7-year rate guarantee
OMGuarantee-Platinum is a single premium, fixed deferred annuity
What is that?
Single Premium: The annuity is a single premium annuity which means you make a single lump sum premium payment at issue.
Deferred: The annuity is deferred which means income does not begin immediately. You pay no current income tax on interest earned. Taxes are deferred until you withdraw your earnings.
Fixed: The annuity is a fixed annuity which means that OM Financial Life Insurance Company guarantees a fixed rate of interest.
Annuity: An annuity is a vehicle to provide payments to the holder at specified intervals, usually at retirement. It is designed to be a long-term retirement tool and not be used to meet short-term financial goals.
In this document are important points to think about
before you buy the OMGuarantee-Platinum TM 3, 5 or 7
annuity from OM Financial Life Insurance Company.
OM Financial Life has prepared this summary to help
you understand OMGuarantee-Platinum’s many options
and advantages. Please confirm your understanding by
signing the enclosed confirmation statement.
Whether you want your annuity to become a source of
guaranteed income payments, or continued tax-deferred
interest accumulation, OMGuarantee-Platinum can
provide the means.
Choice!Select your guarantee period of three, five, or seven-years.
Certainty!Know your rate for the guarantee period.
FlexibilityFlexibility to continue for another period or search out other opportunities.
An annuity that allows you to control when you pay taxes on your interest.
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Getting Started with
OMGuarantee-Platinum
Minimum premium of $5,000 or
$2,000 for qualified accounts.
Choice of a three, five or seven-
year interest rate guarantee
period.
No front-end sales charges or
annual maintenance fees.
100% of your premium goes to
work for you right away!
OMGuarantee-Platinum
1. HOW DOES IT WORK?
Your annuity offers competitive returns
A. CHOICE OF A THREE, FIVE OR SEVEN-YEAR RATE GUARANTEE PERIOD
You get to choose from a three, five or seven-year interest rate guarantee period, a period during which the credited rate is guaranteed. The guarantee period begins on the date of issue, and subsequent guarantee periods begin immediately following the end of each prior guarantee period. The credited interest rate, which will be applied initially to your single premium and then to your account value during the initial guarantee period, is shown in your annuity. We will never credit less than the minimum guaranteed interest rate, which will be established between 1% and 3%.
with no currently taxable income
B. TAXES ARE DEFERRED UNTIL YOU WITHDRAW YOUR EARNINGS
Unlike many taxable traditional savings vehicles, you pay no current income tax on interest earned within your annuity. Taxes are deferred until you withdraw your earnings.
and grants you flexibility for the future
C. YOU HAVE THE FLEXIBILITY TO CONTINUE FOR
ANOTHER THREE, FIVE OR SEVEN-YEAR PERIOD OR SEARCH OUT OTHER OPPORTUNITIES
When your guarantee period expires, OM Financial Life will automatically renew your annuity for the same period at the then- current interest rate. If you would prefer to withdraw some or all of your account value at the end of any guarantee period, you will have a 30-day window to do so, free of any surrender charges.
At the end of each guarantee period, we will provide you with a new declared interest rate for the new guarantee period.
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Example: Maria purchases an OMGuarantee-Platinum annuity with a five-year guaranteed rate period. Her surrender charges will begin at 9% in the 1st year, and decrease to 8% in the 2nd year, 7% in the 3rd year, 6% in the 4th year, 5% in the 5th year, 4% in the 6th year, and 3% in the 7th year. At the end of the 7th year, Maria’s annuity will automatically renew into a new five-year interest guarantee period at the then current interest rate. Surrender charges will also be reset, so that in the 8th year of Maria’s annuity (or the first year of the renewal period) the surrender charge will again be 9%. Surrender charges will continue to follow the same pattern throughout each renewal period. Maria’s surrender charge will be 8% in the 9th year, 7% in the 10th year, 6% in the 11th year, 5% in the 12th year, 9% in the 13th year (first year of 2nd renewal period), 8% in the 14th year, etc.
Is there a way to withdraw money during the surrender charge period without paying surrender charges?You will not pay a surrender charge if you withdraw upto the amount of accumulated interest. Surrender charges will not apply if you qualify for a waiver under the riders listed below.*
• Nursing Home Benefit Rider If you are confined to a licensed nursing home for more than 60 days, and your confinement begins at least one year after the annuity’s date of issue, surrender charges will be waived on withdrawals made during the period of your confinement.• Terminal Illness Benefit Rider If a licensed physician certifies that you have been diagnosed with an illness or condition that causes your life expectancy to be less than one year, and the diagnosis takes place at least one year after the annuity’s date of issue, surrender charges will be waived during this period of terminal illness.• Unemployment Benefit Rider If you become unemployed and remain so for at least 30 consecutive days, and your unemployment takes place after the annuity’s date of issue, surrender charges will be waived during this time of unemployment as long as you are under the age of 65 at the time of your request.
You will not pay surrender charges if you surrender within 30 days following the end of each guarantee period. You will not pay surrender charges if you elect an annuity payment plan. Your spouse will not pay a surrender charge if you die unless your spouse is the beneficiary and elects to continue the contract.*Please refer to your representative for availability in your state.
2. HOW DO I GET INCOME FROM MY ANNUITY?
Partial withdrawals and options for systematic withdrawalsWithdrawals up to the amount of accumulated interest may be made free of surrender charge.You may make scheduled systematic withdrawals of at least $100 with just one request and unscheduled withdrawals (up to four times per year) in an amount of at least $500. Withdrawals in excess of the accumulated interest on the annuity will be subject to surrender charges. Interest will not be credited to any amounts withdrawn.
Annuity payoutsFrom day one of your annuity, you may elect to have the account value paid to you under an annuity payment plan.
Payment in the event of deathIf you should die before the annuity date, your beneficiary will receive the account value of your annuity. Surrender charges do not apply at death. Any gain in the annuity would be subject to income tax. If you should die after the annuity date, any benefits payable to your beneficiary would depend on the income option chosen.
Surrender ChargesWhat happens if I take some or all of the money from my annuity? Withdrawals in excess of the accumulated interest on the annuity will be subject to surrender charges. The surrender charges for OMGuarantee-Platinum will be 9% in the first year and decrease by 1% per year throughout the rate guarantee period.At the end of each guarantee period, you have 30 days in which to surrender this annuity with no surrender charge. If you do not surrender within those 30 days, this annuity will automatically renew into a new guarantee period of the same length with a new set of identical surrender charges.
Years into currentGuarantee Period:Surrender Charge
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9% 8% 7% 6% 5% 4% 3%
2 3 4 5 6 7
OMGuarantee-Platinum
4OMGuarantee-Platinum
Market Value AdjustmentA Market Value Adjustment (MVA) will increase or decrease your surrender value when you make a withdrawal to which a surrender charge is applied. The MVA is based on a formula that takes into account changes in yields on U.S. Treasuries between the start of the current guaranteed period and the date of the withdrawal. Generally, if interest rates have risen since you purchased your annuity (or since the start of your current interest rate guarantee period, if later), the MVA will decrease your surrender value. If interest rates have fallen, the MVA will increase your surrender value.
3. DO I PAY ANY FEES OR CHARGES?
There are no initial sales charges or fees. Your single premium is available to earn interest from the date your annuity is issued.
4. DOES THIS AFFECT MY TAXES?
How will payouts and withdrawals from my annuity be taxed?The annuity is tax-deferred, which means 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 pay ordinary income taxes on the earned interest. Withdrawals are treated as coming from earnings first and then as a return of your premium. Payments under an annuity payment plan are treated as coming partially from earnings and partially as return of premium. You may pay a federal income tax penalty on earnings you withdraw before age 59 ½. [If your state imposes a premium tax, it will be deducted from the money you receive].*
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 on the annuity you are exchanging. Also, you may start a new surrender charge period in the new annuity.
Does buying an annuity in a retirement plan provide extra tax benefit?Buying an annuity within an IRA, 401(k) or other tax- deferred retirement plan doesn’t give you any extra tax benefit. Choose the annuity based on its other features and benefits as well as its risks and costs, not its tax benefits. Please consult your tax advisor regarding your unique situation.
*Internal Revenue Code provides that if an annuity is held by a non-natural person and such person is not holding as an agent for a natural person, the contract shall not be treated as an annuity contract for income tax purposes.
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OMGuarantee-Platinum
5. WHAT ELSE DO I NEED TO KNOW?
Other Information
• We may change your annuity contract from time to time to follow federal or state laws and regulations. If we do, we’ll tell you about the changes in writing.
• You have a set number of days (at least 10) to look at the annuity after you buy it. If you decide during that time that you don’t want it, you can return the annuity and get all of your premium back, less any prior withdrawals. Read the cover page of your annuity contract as soon as you receive it to understand how many days you have to decide if you want to keep it.
• At least once each year, we will send you a report of the current annuity values.
• We pay the agent, broker or firm for selling the annuity to you.
• Certain tax qualified annuities are subject to minimum required distributions which generally require that distributions begin no later than your attainment of age 70½ or retirement, whichever is later, and that amounts be paid to you over a period not longer than your lifeexpectancy.
• Your annuity values are guaranteed by OM Financial Life Insurance Company. As a Legal Reserve Company, OM Financial Life Insurance Company is required by state regulation to maintain reserves equal to or greater than guaranteed surrender values.
Appropriate for IRA andPension Plan RolloversOMGuarantee-Platinum could be an adequate vehicle for a rollover of your IRA or to serve as a rollover IRA to receive dis-tributions from a corporate retirement plan, like a 401(k), 403(b), pension or profit sharing plan. When executed properly, these rollovers are not currently taxed. Tax-deferred compounding continues without interruption.
OMGuarantee-Platinum accepts minimum amounts for qualified plans as low as $2,000. See OM Financial Life’s IRA Disclosure Statement for more information on IRAs and rollovers.
At age 70½, the IRS requires you to begin receiving minimum annual distributions from your tax-qualified retirement plans, including IRAs. Upon request, we can help you calculate your minimum required distribution from your OMGuarantee-Platinum annuity.
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OMGuarantee-Platinum
6. WHAT SHOULD I KNOW ABOUT OLD MUTUAL?
In the U.S., Old Mutual is a provider of life insurance and annuity products. Globally, we are part of the Old Mutual plc group of companies which has provided long term savings, wealth protection and investment services since 1845. Old Mutual plc operates in over 38 countries and employs over 57,000 people worldwide. To learn more about our parent company, visit www.oldmutual.com.
Our U.S. customers benefit from a broad range of experience and insight that is increasingly valuable in a rapidly changing world. Old Mutual is serving its third generation of U.S. customers by building relationships with over one million customers and thousands of independent financial professionals who represent our products. “Old Mutual” is the marketing name for OM Financial Life Insurance Company (all U.S. jurisdictions except NY) and OM Financial Life Insurance Company of New York (NY only). Each Old Mutual company is solely responsible for its contractual commitments.
THE THINKING IS NEW. THE NAME IS OLD MUTUAL. TM
Contracts issued by OM Financial Life Insurance Company, Baltimore, MD.
OM Financial Life Insurance Company offers a diverse portfolio of fixed and indexed interest and variable annuities and optional additional features. Before purchasing, consider your financial situation and alternatives available to you. Your OM Financial Life Insurance Company financial professional can help you determine the best alternatives for your goals and needs, or visit us at www.omfn.com for more information.
Form Numbers: FGL SPDA MY-F-C (6-04); FGL SPDA-MY-F (7-04); et al.
Optional provisions and riders may have limitations, restrictions and additional charges.
Subject to state availability. Certain restrictions may apply.
This product is offered on a group or individual basis as determined by state approval.
Terms and conditions are set forth in the group certificate and master contract and are subject to the laws of the state in which they were issued.
Surrender charges may apply to withdrawals. Withdrawals may be taxable and, when made prior to age 59½, may result in tax penalties. Withdrawals will reduce available death benefit.
This document is not a legal contract. For the exact terms and conditions, please refer to the annuity contract.
Information provided regarding tax or estate planning should not be considered tax or legal advice. Consult your own tax professional or attorney regarding your unique situation.
Annuities are long-term investments to help with retirement income needs.
Interest rates subject to change at insurer’s discretion and are effective annual rates.
An additional bonus interest rate is paid on this contract annuity for 1 year. Annuities that offer bonus interest features may have higher fees and charges, and longer surrender charge periods than annuities that do not provide the bonus feature.
A market value adjustment may apply to withdrawals and may increase or decrease the surrender value.
1.888.513.8797 www.omfn.com
No bank guarantee. • Not FDIC/NCUA/NCUSIF insured. • May lose value if surrendered early.
Products for a sustainable retirement
sustainablesolutionsin t imes ofuncertainty
Instructions for AgentOMGuarantee-Platinum
1. Review this brochure with the customer(s).2. Have the customer(s) sign and date the Confirmation Statement.3. In the box marked “For Agent Use,” verify the identity of owner(s) and annuitant(s), fill-in your name and address, and sign.4. Detach and return the Confirmation Statement with the application to OM Financial Life.
Confirmation StatementPlease sign below to indicate your understanding. This form must be detached and returned with the application to OM Financial Life.
By signing here, you are telling us that you have read this summary and understand the descriptions of the OMGuarantee-Platinum deferred fixed annuity features. You also understand that subject to the guarantee values in the annuity, the cash surrender values in the annuity may increase or decrease based on an MVA adjustment prior to the date or dates specified in the annuity. You are also telling us that neither OM Financial Life nor your agent has made any guarantees or promises regarding interest rates under the annuity. The actual rate in your annuity will be based on current data as of the date the annuity is issued. You understand that the Company offers deferred annuity products with different features and benefits and that you can also apply for those products by contacting the Company or one of its agents.
__________________________________ __________Signature of Owner Date __________________________________ __________Signature of Joint Owner, if any Date
For Agent Use: The agent has received a copy of and has carefully read the OMGuarantee-Platinum Product Highlights.
_________________________ ____________________Agent Signature of Agent
_________________________ ____________________Agency Address City,State, Zip
OMCO 7217 (04-2010)
Annuity Application Product: ● SPDA FPDA
OMAD 6227 (08-2009) Page 1 of 3
OM Financial Life Insurance Company Home Office: Baltimore, Maryland Administrative Office: P.O. Box 81497; Lincoln, NE 68501-81497
Owner(s) Name: __________________________________________________ Joint Owner (if any):_________________________________________ SSN/TIN: _______________________________________________ SSN/TIN: _________________________________________________
Male Female Date of Birth:___________________________ Male Female Date of Birth: ____________________________ Address: _________________________________________________ Address: _________________________________________________ ________________________________________________________ _________________________________________________________ Phone No.: (_______)______________________________________ Phone No.: (_______)________________________________________ Employer Name & Address:_________________________________ Employer Name & Address: ___________________________________ ________________________________________________________ _________________________________________________________ Relationship to Annuitant: ___________________________________ Relationship to Owner: _______________________________________ Identification # & State:______________________________________ Identification # & State: _______________________________________ Type of Identification: Type of Identification:
State Issued Immigration State Issued Immigration Military Passport Military Passport Other __________________________________ Other __________________________________
Annuitant(s) (if other than Owner, complete this section) Name: ___________________________________________________ Joint Owner (if any):__________________________________________ SSN/TIN: _________________________________________________ SSN/TIN: __________________________________________________
Male Female Date of Birth:____________________________ Male Female Date of Birth: ____________________________ Address:__________________________________________________ Address: __________________________________________________ _________________________________________________________ __________________________________________________________ Phone No.: (_______)_______________________________________ Phone No.: (_______)________________________________________ Identification # & State:_______________________________________ Identification # & State: _______________________________________ Type of Identification: Type of Identification:
State Issued Immigration State Issued Immigration Military Passport Military Passport Other __________________________________ Other __________________________________
Beneficiary Note: If more than one beneficiary is named, indicate the class and percentage for each. Each class must total 100%.
Primary Contingent Name: _________________________________ SSN/TIN:________________ _________% Relationship to Owner: _______________________ Date of Birth: __________________ Name: _________________________________ SSN/TIN:________________ _________% Relationship to Owner: _______________________ Date of Birth: __________________ Name: _________________________________ SSN/TIN:________________ _________% Relationship to Owner: _______________________ Date of Birth: __________________ Name: _________________________________ SSN/TIN:________________ _________% Relationship to Owner: _______________________ Date of Birth: __________________
Purpose of Annuity (Choice ONE plan and if applicable, transfer/exchange form) Qualified Traditional IRA Roth IRA SEP IRA 403(b) TSA Other (specify plan type): ________________________________________
OMGuarantee-Platinum
Annuity Application Product: ● SPDA FPDA
Premium Initial/Single Premium Paid: (premium paid with application) $_______________________ Make check payable to OM Financial Life Insurance Company.
Rollover Contribution for Tax Year ___________________ Interest Rate Guaranteed Rate __________% Annuity Year 1___________% or Period ___________ Year(s) Remainder of Rate Period (if applicable)
Replacement Do you have an existing life insurance or annuity policy? Yes No (If yes, please list insurance Company name, Policy type, Policy # and Year issued.) _________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ Will the annuity applied for replace or change an existing life insurance or annuity policy? Yes No If a 1035 exchange or transfer, attach applicable forms. Exchange/Transfer Amount $________________________ Policy/Certificate No.: _______________________________________ Company: _______________________________________________________
Guaranteed Minimum Withdrawal Benefit (GMWB) Basic Enhanced Other ____________________ (Note: Optional riders have charges and fees.)
Special Instructions ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ Fraud Warning Notices (Please review the notice that applies in your state. If your state is not listed, please review the first notice listed.) Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which may be a crime and may be subject to criminal and civil penalties. AR/LA: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. CO: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or representative of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a contract holder or claimant for the purpose of defrauding or attempting to defraud the contract holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department regulatory agencies. DC: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. KY/OH: I understand that any person who, with intent to defraud, or knowingly that he or she is facilitating a fraud against an insurer, submits an application containing a false or deceptive statement is guilty of insurance fraud. ________________ (Owner’s Initials)
FL: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. _____________ (Owner’s Initials)
ME/TN/WA: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or denial of insurance benefit. MD: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NJ: Any person who includes any false or misleading information on an application for an insurance contract is subject to criminal and civil penalties. NM/PA: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such a person to criminal and civil penalties. OMAD 6227 (08-2009) Page 2 of 3
OMGuarantee-Platinum
Annuity Application Product: ● SPDA FPDA
OMAD 6227 (08-2009) Page 3 of 3
OK: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. OR/VT: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which may be a crime and may subject such person to criminal and civil penalties.
Authorizations I/(We) have read the statements made in this application. To the best of my (our) knowledge and belief, the statements made are complete, true, and correctly recorded. I/(We) understand that: a copy of this application will form a part of any annuity issued; the annuity will not take effect until delivered to the Owner; no agent has the authority to modify any annuity issued; and there are terms, conditions, charges, and fees for any optional rider selected. I/(We) understand that I/(we) have applied for an annuity. I/(We) have received a copy of the Company’s disclosure material for this annuity. If the annuity is issued with a market value adjustment rider, the cash surrender values may increase or decrease based on a market value adjustment prior to the date or dates specified in the annuity; the market value adjustment applies when the surrender charge applies.
Signature(s) I/(We) certify, under penalties of perjury, that I am/(we are) U.S. Citizen(s) or resident(s) of the U.S. (includes U.S. resident aliens) and that the taxpayer identification number(s) is (are) correct. I/(We) understand that federal law requires all financial institutions to obtain identity information in order to verify my (our) indentity(ies) and I (we) authorize its use for this purpose. This information includes, but is not limited to, the name(s), residential address(es), date(s) of birth, Social Security or taxpayer identification number(s), and any other information necessary to sufficiently verify indentity(ies). I/(We) understand that failure to provide this information could result in the application being rejected. Third party sources may be used to verify the information provided. Signed at: ___________________________________________________________ Date:_____________________________________________ Signature(s) of Owner(s): ____________________________________________________________________________________________________ Signature(s) of Annuitant(s): __________________________________________________________________________________________________
Agent Does the applicant have an existing life or annuity policy? Yes No To the best of your knowledge, does this application replace or change existing life insurance or annuities? Yes No I attest that I have witnessed all signatures. I certify that the Company’s disclosure material has been presented to the applicant and a copy was provided to the applicant. I have not made any statements which differ from this material nor have I made any guarantees or promises about the expected future values of the annuity. I have received a copy of, have carefully read and complied with the applied for fixed annuity’s training manual. I have verified the identity of the Owner, Joint Owner, Annuitant and/or Joint Annuitant through an examination of a state or federal government photo identification card provided by the Owner, Joint Owner, Annuitant and/or Joint Annuitant such as a driver’s license or passport. I have truly and accurately recorded on this application the information provided by the applicant.
Signature(s) Agent Signature: _______________________________________________________________ Date: ____________________________________ Print Agent’s Name: __________________________________________________ OM Financial Life Agent #: ______________________________ Agent’s License No. (required only in FL): ______________________________________________________________________________________ Agent’s Phone No: (________)__________________________________ Agent’s Fax No: (_________)____________________________________ Agent’s Email Address: ____________________________________________________________________________________________________
For Split Commissions second Agent complete the below section Agent Signature: _______________________________________________________________ Date: ____________________________________ Print Agent’s Name: __________________________________________________ OM Financial Life Agent #: ______________________________ Agent’s License No. (required only in FL): ______________________________________________________________________________________ Agent’s Phone No: (________)__________________________________ Agent’s Fax No: (_________)____________________________________ Agent’s Email Address: ____________________________________________________________________________________________________
OMGuarantee-Platinum
INSURER – OM Financial Life Insurance Company
OM Financial Life Insurance Company, Baltimore, MD ADMIN 5234 (7-2004) Rev. 04-2008 OMFLIC
2. CUSTOMER PROFILE
Annuity Suitability Acknowledgement Form
1. THIS FORM HELPS YOU. It is important you have the information you need to determine if purchasing a fixed annuity contract meets your needs for your financial situation. This form can help you make that determination.
Owner’s Name Age Occupation
Monthly Disposable Income (monthly income minus monthly expenses): ___________________
Net worth excluding equity in primary residence: ____________________
What is your marginal federal tax rate? ___ 0% ___ 10% ___ 15% ___ 25% ___ 28% ___ 33% ___ 35%
Which goal is most important to you with respect to this OM Life Annuity you are purchasing?
__ Retirement __ Principal Protection __ Tax Deferral __ Wealth Accumulation __ Emergencies __ College Funding
__ Guaranteed Income __ Vacations
Please list the amount of current savings and investments below:
Checking/Savings/Money Market $__________
Certificates of Deposit $__________
Primary Residence $__________
Other Real Estate $__________
Fixed Annuities $__________ Mutual Funds $__________
Variable Annuities $__________ Stocks/Bonds $__________
Life Insurance Cash Value $__________ Retirement Plans $__________
This annuity transaction represents approximately what percentage of your assets (excluding primary home)?
0 – 25% 25% - 50% 50% - 75% 75% - 100%
Is this a replacement of an annuity or a life contract/? ____ Yes ___ No
a) If yes, is there a penalty for early termination (surrender charge)? _____ Yes _____ No b) If there is a penalty or surrender charge, what percentage of the contract value being replaced will be subject to a penalty?
___0-2% ___ 3-5% ___ 6-8% ___ 9% or >
3. ACKNOWLEDGEMENT AND SIGNATURE I understand that: I have applied for and/or purchased an annuity contract. This is NOT a short-term savings vehicle. The premiums I pay for the annuity contract apply to a fixed annuity contract – not a mutual fund, savings account, certificate
of deposit, security or other financial product. Certain cash withdrawals from, or a complete surrender of, the contract are subject to certain limitations and charges as
described in the contract. I understand that the annuity contract permits certain charge–free withdrawal amounts; I believe these amounts are more than sufficient to meet my income and other financial needs.
Surrender/redemption charges/fees may be incurred as a result of liquidating existing accounts in order to fund this annuity. Income tax liability may be incurred as a result of withdrawals and/or liquidating my existing accounts; however, I believe this
transaction to be in my best interest. The Agent/Representative and OM Financial Life may not offer tax advice, and I am responsible for the tax consequences, if
any, related to this transaction. If needed, I will consult with my own professional tax advisor. The Agent/Representative and OM Financial Life may rely upon the information provided herein, and the information provided
herein is true and accurate to the best of my knowledge. I value the product features this contract provides, including its guarantees.
Owner’s Signature Date Joint Owner’s Signature (if applicable)
Date
Agent Signature Date
