Great Southern Bank Annuity Processing Procedures Equity Index Application Kit.pdf · Check Payable...

Please view regularly for updates - http://marketingfinancial.com/gsannuities/

GGrreeaatt SSoouutthheerrnn BBaannkk AAnnnnuuiittyy PPrroocceessssiinngg PPrroocceedduurreess

Please contact the following with product or rate questions. Marketing Financial

Stacey Douglas, Alan Lockhart, & other Associates (417) 831-4431 or (800) 677-1087

Please contact the following with annuity processing questions. Tabatha Wynn (417) 888-4389 or Laura Smith (417) 888-4385

RREEQQUUIIRRMMEENNTTSS:: • AGENT and GSB contact info on all annuity paperwork must be entered as the

investment department address and phone number. OMIT ALL EMAILS Great Southern Bank Phone: (417) 888-4389 2609-B E. Sunshine Fax: (417) 888-4433 Springfield, MO 65804

• NEW BUSINESS FORM

• CUSTOMER INVESTMENT & SUITABILITY CONFIRMATION WORKSHEET

• ANNUITY COMPANY FORMS

• OFAC printed the day of application – OFAC signed & dated by agent. • TWO current forms of Owner(s) ID: 1 primary/1secondary owner(s) must be provided to

GSB Investment Dept. with all applications. • Agent Anti-Money Laundering annual training - LIMRA site: http://nailba.limra.com/

SSPPRRIINNGGFFIIEELLDD MMEETTRROO RREEGGIIOONN:: • Dispatch all required documents to the Investment Dept. – Attn: New Business.

AALLLL OOTTHHEERR LLOOCCAATTIIOONNSS:: • Dispatch all required documents to the Investment Dept. – Attn: New Business – for

business written the day of your dispatch pick up.

• Mail all required documents via overnight UPS or FedEx to the Investment Dept – drop in the nearest drop box if possible.

UPS Account # 97V7R3

FedEx Account # 1201-0551-5

Shipping account numbers are to be used for investment dept new annuity business only. Please contact Tabatha or Laura for pre-printed labels, etc.

Rev 11/2010

New Business Form

Funds Info:

Internal Funds

External Funds

Qualified Non-Qualified

Agent Check List:

New Business Non-Qualified Annuity to Annuity IRA Trsf/Rollover

Application 1035 Exchange Form IRA Trsf Form

Disclosures MO Replacement Form Company Specific Forms

ID & OFAC Original Policy or Lost (401K Only)

Check Payable to CO Policy Affidavit IRA Annuity to IRA Annuity

IRA Trsf Form

Replacement Form

Original Policy or

Lost Policy Affidavit

1. Provide your detailed explanation regarding how this purchase meets the client's stated investment goal.

REV 1009

Owner's age: _______________ BC #: ______________

Transfer(s) Approx: $__________________________

Client Name(s): _________________________________

Bankers Report-Source of Funds: This section is required for All transactions.

Attach additional sheet if necessary.

Agent Name: ___________________________________ Referred by: _______________________________________

Check Enclosed: $____________________________

1035 Exchange Approx: $_______________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Agent Signature: _______________________________

Approver Signature: _____________________________

Date: ____________________

Date: ____________________

Company Name _______________________

Product Name ________________________

Rate Lock Selected ____________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Owner Information Joint Owner Information

1. Name:__________________________________ 3. Name:_________________________________

2. Occupation:_____________________________ 4. Occupation:_____________________________

5. U.S. Citizen: □ Yes □ No 6. U.S. Citizen: □ Yes □ No

7. Approximate Annual Income:

[ ] Under $25,000 [ ] $25,000 - $50,000

[ ] $50,000 - $100,000 [ ] $100,000 - $250,000 [ ] Over $250,000

8. Approximate Net Worth: Net Worth= Total Assets (not including home & auto) less total debts

[ ] Under $50,000 [ ] $50,000 - $100,000

[ ] $100,000 - $250,000 [ ] $250,000 - $500,000 [ ] Over $500,000

9. Source of Income: □ Current Wages □ Pension Plan □ Social Security □ Investment Income

□ Required Minimum Distribution or 72-t distributions □ Other

10. Federal Income Tax Bracket: □ 0% □ 10% □ 15% □ 20% □ 25% □ 28% □ 33% □ 35% □ Other

11. What is your financial objective in purchasing this product? Check all that apply:

□ Income Now □ Flexibility □ Tax Deferral □ Provides Guarantees □ Potential Growth Followed by Income

□ Pass Assets on to Beneficiaries □ Lifetime Income Payout □ Other:_____________________________

12. What is your risk tolerance?

□ Aggressive □ Moderate □ Conservative

Customer Investment & Suitability Confirmation Worksheet

13. What is your investment time frame?

□ 0-5 yrs □ 5-10 yrs □ Over 10 yrs

14. Do you have sufficient liquid assets available for monthly living expenses and emergencies other than the

money you plan to use to purchase this annuity?

□ Yes, please list dollar amount(s): CD's $________ Money Markets $________ Stocks $________ Bonds $________

DDA $________ Mutual Funds $________ Annuities $_________ Other $________

□ No

15. What is the source of premium for this annuity? Check all that apply:

□ Annuity □ Life Insurance □ Certificates of Deposit □ Other Investments □ Other______________________

15a. □ Yes □ No Are there any settlement fees, surrender charges or penalties of any kind associated

with any source(s) of the annuity premium checked above?

15b. If 15a is yes please list amount of penalty: $_________________________________

16. Do you now own, or have you previously owned, any of the following financial products? (check all that apply)

□ Certificates of Deposit □ Fixed Annuity □ Variable Annuity □ Stock/Bond/Mutual Funds □ Life Insurance

17. With the exception of any surrender charge free withdrawals, required minimum distribution, etc. do you

expect to take any money out of this product before the end of the withdrawal charge period? □ Yes □ No

If Yes, please explain:______________________________________________________________________

_______________________________________________________________________________________

Owner(s) please initial 18-20

18.Yes _____ No _____ Did the agent explain that if you take money out of this product in excess of the surrender

charge free withdrawal amount provided in the contract during the withdrawal window charge

period you will incur a penalty?

19. Yes _____ No _____ I understand that my annuity has: (NOT APPLICABLE TO FIXED INDEXED ANNUITIES)

____% current base rate for ____ year(s) only

____% bonus rate for the first year only (if applicable)

____% minimum base rate for renewals after ___ year(s)

20. Yes _____ No _____ I understand that Great Southern is not obligated to provide benefits under any annuity contract

and does not guarantee performance by the issuer.

21. Yes _____ No _____ I understand that any withdrawals prior to the age of 591/2 may be subject to a 10%

tax penalty.

22. To the extent you are willing, please provide any other information you considered material to your decision to

purchase this annuity:_________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

Owners Confirmation

□ Yes □ No Was your decision to purchase this annuity based on your agent's recommendation?

By signing below, I acknowledge the information I provided above, regarding my financial status, tax status, investment objectives, and

any other information requested by my agent is complete and accurate to the best of my knowledge. I further acknowledge that neither

Great Southern nor its representatives offer legal or tax advice and that I have been advised to consult my own personal attorney or tax

advisor on an tax matters. I acknowledge that the fixed annuity I am applying for is a long term contract with penalties for early

withdrawal; additionally I am aware that any withdrawals taken from the annuity may result in a taxable event. I believe the annuity I am

applying for is suitable according to my insurance needs and/or financial objectives.

__________________________________________________________________ __________________________

Owner's Signature Date

__________________________________________________________________ __________________________

Owner's Signature Date

Agent's Confirmation

□ Yes □ No Was the owner's decision to purchase this annuity based on your recommendation?

By signing below, I acknowledge that I have made a reasonable effort to obtain information from the Owner concerning the Owner(s)'

financial status, tax status, investment objectives and other information considered reasonable. It is my belief that based on the

information the Owner provided and based on all the circumstances know to me at the time the recommendation was made, the annuity

being applied for, based on my recommendation is suitable for the Owner(s)' insurance needs and/or financial objectives.

__________________________________________________________________ _______________________

Agent's Signature Date

Investment Products are:

REV 0509

unaffiliated entity.

Under Federal law the extension of credit for which you have applied

may not be conditioned upon your purchase of an insurance product or

annuity from the bank or its affiliates or agreement not to obtain, or

prohibition of obtaining, an insurance product or annuity from an

Not FDIC

Insured

May Lose Value

No Bank Guarantee

Application for AnnuityIssued by American National Insurance CompanyOne Moody Plaza, Galveston, TX 77550-7947

page 1 of 4 Overnight Address: 4500 Lockhill-Selma Road, San Antonio, TX 78249 Mailing Address: PO Box 696763, San Antonio, TX 78269 Phone Number: 1-800-252-9546

Form R10039-AR AMERICAN NATIONAL INSURANCE COMPANY RV 04-10AMERICAN NATIONAL INSURANCE COMPANY RV 04-10AMERICAN NATIONAL INSURANCE COMPANY

*APP*

1. ANNUITANTName: Last First M.I. Gender U.S. Citizen

| | | | M F | Yes No Date of birth Age SSN TIN Daytime telephone| | | | ( | ( )Address City State ZIP| | | |

2. OWNER (If other than Annuitant. If IRA or TSA, the Owner and Annuitant must be the same person.)

Name: Last First M.I. Gender U.S. Citizen| | | | M F | Yes NoDate of birth Age SSN TIN EIN Daytime telephone| | | | ( | ( )Address City State ZIP| | | | Note: If a Trust, Corporation, or Charity is named as Owner, copy of Trust Agreement or Corporate Resolution must be provided.

3. JOINT OWNER (Not available with Qualifi ed plans)

Name: Last First M.I. Relationship to Owner Gender| | | | | M FDate of birth Age SSN TIN EIN U.S. Citizen Daytime telephone| | | | Yes No | (| ( )Address City State ZIP| | | | Note: If a Trust, Corporation, or Charity is named as Owner, copy of Trust Agreement or Corporate Resolution must be provided.

4. PRIMARY BENEFICIARY (A Date of Birth and SSN is required for each benefi ciary. Complete Additional Benefi ciary Page if additional space is needed.)

A. Name: Last First M.I. Percent Payable Relationship Gender| | | | | | M FDate of birth Age SSN TIN EIN U.S. Citizen Daytime telephone| | | | Yes No | (| ( )Address City State ZIP| | | | Note: If a Trust is named as Benefi ciary, provide date trust was created. Month | Day | Year | B. Name: Last First M.I. Percent Payable Relationship Gender| | | | | | M FDate of birth Age SSN TIN EIN U.S. Citizen Daytime telephone| | | | Yes No | (| ( )Address City State ZIP| | | | Note: If a Trust is named as Benefi ciary, provide date trust was created. Month | Day | Year |

5. NAME OF ANNUITY PRODUCT APPLIED FOR (A signed copy of the product disclosure form given to owner must be submitted.)

| 6. APPLIED FOR ANNUITY TYPE

NON-QUALIFIED QUALIFIED If Qualifi ed, check the type of plan. CASH WITH APPLICATION ROLLOVER IRA SEP PENSION PLAN 1035 Exchange TRANSFER Roth IRA TSA-403b (Profi t Sharing or Defi ned Benefi t)

CASH WITH APPLICATION Other (ANICO does not offer SIMPLE IRA’s)Amount paid with application $ (Check must be payable to American National Insurance Company.)If a 1035 Exchange, Rollover, or Transfer is occurring, the expected premium amount is $ .

page 2 of 4


7. BILLING DATA FOR FLEXIBLE ANNUITY USE ONLY. (Minimum additional premium $100 EFT)

MODE: Annual Semiannual Quarterly Monthly Amount $ METHOD: Direct EFT (attach voided check) Government Allotment Salary Deduction*

*Complete for salary deduction selection: Franchise Name | Franchise Number |

8. RIDER SELECTION AND INITIAL PREMIUM ALLOCATIONOnly complete for applicable index annuity products when appropriate.

Not all products may be available in all states. Check product availability for your state.

ANICO Strategy Indexed Annuity Riders may only be added at issueLifetime Income Rider Enhanced Death Benefi t Rider Initial Premium Allocation

Declared Interest Option % Indexed Interest Option %

Total 100 %

9. INCOME OPTIONS - FOR IMMEDIATE ANNUITIES ONLY Complete a W-4P for withholdingsSingle Life Payout Options Joint Life Payout Options

With Cost of Living Adjustment With Cost of Living Adjustment Life Only Joint to Survivor Life with Certain Period years (5 - 20) Joint to Spouse Certain Period years (5 - 30) Payments to be made for a Certain Period Fixed Amount for years or $ of years (5 -20) years (5 -20)

Joint Annuitant Name: | Single Life Payout Options - Cost of Living Adjustment not available: SSN TIN | Gender M F

Life Cash Refund Date of Birth U.S. Citizen Y NLife Installment Refund Payments will be % upon death of 1st life

If you have elected a Cost of Living Adjustment, please complete the following: Simple Interest at % (1-5) Compound Interest at % (1-5)

Frequency of Payments: Monthly Quarterly Semiannual Annual Date Payments to Start | Method: EFT (Attach Voided Check)

10. TOTAL INSURANCE/ANNUITIES IN FORCE ON PROPOSED ANNUITANT Yes No Do you have existing life insurance or annuity coverage? Yes No Will the annuity applied for replace or use cash values of any existing life insurance or annuity issued by any company?

If “Yes”, agent must provide and complete the appropriate replacement form.

FRAUD WARNINGAny person who knowingly presents a false or fraudulent claim for payment of a loss of benefi t or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fi nes and confi nement in prison.

APPLICATION SIGNATURES

To the best of my knowledge and belief, the statements and answers in this application are true and complete. Under penalty of perjury, I certify that: 1.) The number shown on this form is my correct taxpayer identifi cation number (or I am waiting for a number to be issued to me), 2.) I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notifi ed by the Internal Revenue Services (IRS) that I am subject to backup withholding as a result of failure to report all interest or dividends, or (c) the IRS has notifi ed me that I am no longer subject to backup withholding, and 3.) I am a U.S. person (including a U.S. resident alien). You must cross out item 2 if you have been notifi ed by the IRS that you are currently subject to backup withholding. The IRS does not require your consent to any provision of this document other than the certifi cations required to avoid backup withholding.

Dated at this day of , .(State) (Day) (Month) (Year)

Signature of Annuitant Signature of Joint Annuitant (For Immediate Annuities)

Signature of Owner, if other than Annuitant Signature of Joint Owner, if other than Annuitant

Signature of Agent


page 3 of 4 *AGR*

AGENT’S REPORT

THESE QUESTIONS MUST BE ANSWERED IN EVERY CASE:

Yes No Does the applicant have existing life insurance policies or annuity contracts?

Yes No As Agent, do you have knowledge or reason to believe that replacement of existing Insurance/Annuities may be involved?

If “Yes”, agent must provide and complete the appropriate replacement form.

Print Agent’s Name Agent’s Signature Agent PC Number, SSN, or TIN

Telephone Number E-Mail Address

List name and Personal Code of all agents, besides yourself, entitled to any commission with appropriate percentage.

% Agent Personal Code

% Agent Personal Code

ADDITIONAL REQUIRED FORMS

• For Systematic Withdrawals, complete Form 3575 - Annuity Service Request Form and submit with application.

• For Required Minimum Distribution Requests, complete Form 4223 - IRA/TSA Required Minimum Distribution Election Request and submit with application.

• For Lifetime Income Rider withdrawals, complete Form 4470 - Lifetime Income Rider Request Form and submit with application. (For ANICO Strategy Index Annuity only)

• For TSA-403(b) plans, an Information Sharing Agreement must be submitted with application.

• For additional benefi ciary designations, complete Form 10073 - Additional Benefi ciary Page and submit with application.

• For Non-Qualifi ed 1035 Exchanges, complete Form 4394-NQ - Non-Qualifi ed 1035 Exchange Request and submit with application.

• For Qualifi ed Transfers or Rollovers, complete Form 4394-Q - Qualifi ed Transfer or Rollover Request and submit with application.


page 4 of 4 *PRCT*

Premium ReceiptAmerican National Insurance Company

One Moody Plaza, Galveston, Texas 77550-7947

Valid only for an annuity and for the premium amount shown in the application paid for an annuity.

Received from ___________________________________ this ________ day of _______________________________ year __________

the sum of ($ ____________) in cash as premium on an annuity on the life of ________________________________________________

for which an application has been made to this company, bearing the same number and date as this receipt.

Signature of soliciting agent _____________________________________________________

Print agent’s name _____________________________________________________________

The company accepts payment by check, draft, or money order subject to its being honored upon presentation. Checks, drafts, or money orders must be made payable to American National Insurance Company. Do not leave payee blank or make payable to agent.

American National Insurance CompanyOne Moody Plaza, Galveston, TX 77550

Disclosure Statement for the ANICO Equity Index Annuity

This document reviews important points to think about before you buy this American National Insurance Company annuity. It is a single premium deferred annuity which means you buy it with one premium.

This annuity is tax-deferred, which means you don’t pay taxes on the interest it earns until the money is paid to you. This annuity can earn interest that depends on how the S&P 500® Index performs.

You can use this annuity to save 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 agent, broker or advisor, or contact a company representative at 1-800-252-9546.

THE ANNUITY CONTRACT

How will the value of my annuity grow?The value in your annuity contract is called its annuity value. When your contract is issued, the amount of your annuity value is your initial premium. On the date your ANICO Equity Index Annuity is issued, your contract will receive a specified rate, which will be effective for the initial six-year term of the contract. At the end of your first contract year, a comparison will be made of the S&P 500® Index as of the issue date of your contract to the S&P 500® Index at the end of that first year. If the S&P 500® Index has increased or remains the same, i.e., zero gain, the specified rate is credited to your contract. If the S&P 500® Index is down, your annuity value remains the same. This comparison occurs at the end of each contract year of the initial six-year term. There will never be a negative index charge to the annuity, although you could earn 0% interest. A new non-indexed interest rate will be declared for each contract year after the initial six-year term.

After the first contract year, your annuity value equals the initial premium, plus any index credits and interest credits, minus any partial surrenders and their applicable surrender charges.

Past performance of the Index is no guarantee of future results.

BENEFITS

How do I get income (payments) from my annuity?After the surrender charge period (6 years) you may elect to receive the proceeds of your annuity in a lump sum or in a series of payments. We offer a variety of income payment options, including options that will pay you an income guaranteed for life. Your financial advisor can help you make the right choice for your needs at the time you elect to receive your annuity proceeds.

After your first contract year, you can withdraw up to 10% of your Annuity Value, as of the beginning of your second contract year, without any surrender charges. You may want to seriously consider other options before exercising this privilege. Any amount withdrawn in excess of 10% is subject to a surrender charge.

Continued on reverse side ...Please retain this page for your records

Form 9321 Page 1 of 4 Rev. 10/09

What happens after I die?This annuity provides a benefit upon the death of the owner (if prior to distribution) of the annuity to the beneficiary named in the contract. The Company will pay the greater of the Annuity Value or the Surrender Value upon receipt of proof of death. If death occurs before the end of the Initial Term, an Index Credit will be added to the Annuity Value as of the date of death if there has been an Index Gain between the beginning of the contract year and the date of death.

If the Annuitant is not the Owner and dies before the Maturity Date, this contract will terminate. We will pay the Death Benefit to the Beneficiary.

If the Annuitant dies after distribution under a Settlement Option has begun and before the guaranteed payments, if any, have been paid, any remaining payments will continue at least as rapidly as under the method of distribution in effect at the Annuitant’s death. Such payments will be paid to the Beneficiary.

FEES, EXPENSES & OTHER CHARGES

What happens if I take out some or all of the money from my annuity?Surrender ChargesIf you should decide to surrender your contract in the first 6 years. These surrender charges, which are expressed as a percentage of your annuity value, are as follows:

Contract Year 1st 2nd 3rd 4th 5th 6th 7th Surrender Charge 8% 8% 7% 6% 4% 2% 0%

Surrender charges may be waived in the event of disability or confinement to a licensed treatment facility. See Waiver of Surrender Charges (Form 10256) or the contract (Form REIA-NQ,PQ; GREIA-NQC,PQC; ROP-EIA) for complete details about these waivers.

TAXESHow will payments and withdrawals from my annuity be taxed?Federal income tax on annuity earnings is deferred until distributions are taken. Distributions taken before age 59½ are subject to a 10% penalty tax unless an exception applies. If your state imposes a premium tax, it may be deducted from the money you receive. Income received under a settlement option is treated as part income (taxable) and part return of basis (not taxed). Additional rules apply

Continued on next page ...Please retain this page for your records


to qualified annuities. Consult your tax advisor or tax attorney for your specific circumstances. Also, if you place your annuity in a tax-qualified retirement plan such as an IRA, you will receive no additional tax advantage from the annuity. Therefore, before purchasing an annuity for a tax-qualified plan, you should carefully consider the annuity’s other features before making your decision.

OTHER INFORMATION

What else do I need to know?This annuity is designed for people who are willing to let their assets build for at least 6 years.•

This annuity does not participate directly in any stock or equity investments. You aren’t buying shares • of stock or an index. Dividends paid on the stocks on which the indexes are based don’t increase your annuity earnings.

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.

We pay the agent, broker, or firm for selling the annuity to you.•

After you receive your contract, you have a number of days to review your annuity contract. During • that period, if you decide against the purchase, you can return the contract and receive a complete refund of your premium.

What should I know about the insurance company?Established in 1905, American National Insurance Company has been a consistent source of financial strength and long term planning which has earned the respect of its policyowners. American National’s financial strength and operating integrity have positioned it as a leader in the insurance industry. American National offers innovative insurance and related financial products, customer-focused service, and ranks among the larger life insurance companies in the United States.

For more information, please visit our website: www.anico.com

This Disclosure Statement is not intended to be a complete explanation of your contract. Please read your contract carefully for more complete details. The ANICO Equity Index Annuity may not be available in all states. Contact your agent or American National Insurance Company with any questions.

Continued on next page ...Please retain this page for your records


American National Insurance CompanyOne Moody Plaza, Galveston, TX 77550

Disclosure Statement for the ANICO Equity Index AnnuityOwner/Annuitant’s StatementI confirm that:

• I am purchasing an ANICO Equity Index Annuity from American National Insurance Company• I have read the ANICO Equity Index Annuity Product Brochure• I have read the ANICO Equity Index Annuity Disclosure statement and have kept a copy

I understand that:• Purchasing the ANICO Equity Index Annuity does not give me ownership in a stock or index• Past performance of the Index is no guarantee of future results. The Index may lose value, and I may receive only

the Minimum Guaranteed Surrender Value• Minimum Guaranteed Surrender Values are not related to the Index• The ANICO Equity Index Annuity has surrender charges for early surrenders prior to the end of the 6 year initial

term.

Name of Annuitant

Signature of Owner Date

Signature of Joint Owner Date

For the agent: I certify receipt of $ given to purchase an ANICO Equity Index Annuity contract. 1035 Exchange Transfer of Funds

I certify that the product brochure and disclosure material has been presented and explained to the Annuitant/Owner and a copy provided to the Annuitant/Owner. I have not made any statements that differ from this material, nor have I made any promises about the expected future values of this contract.

Signature of Agent Agent PC Number, SSN, or TIN (you must provide one)

Information provided is not intended to be legal or tax advice. You should consult with your attorney or tax advisor for your specific circumstances.

“Standard & Poor’s®”, “S&P®”, “S&P 500®”, and “Standard & Poor’s 500 TM” are trademarks of Standard & Poor’s Financial Services LLC (“Standard & Poor’s”) and have been licensed for use by American National Insurance Company. The ANICO Equity Index Annuity is not sponsored, endorsed, sold or promoted by Standard & Poor’s and Standard & Poor’s makes no representation regarding the advisability of purchasing the ANICO Equity Index Annuity.

This disclosure is intended to be used with Form REIA-NQ,PQ; GREIA-NQC,PQC; ROP-EIANot FDIC/NCUA insured Not a deposit Not insured by any federal government agency No bank/CU guarantee May lose value

White - Home Office Copy Pink - Client Copy Yellow - Agent CopyForm 9321 Page 4 of 4 Rev. 10/09

American National Insurance Company One Moody Plaza

Galveston, Texas 77550

COMPENSATION AND REPRESENTATION DISCLOSURE NOTICE (INSURANCE PRODUCER NOT ACTING AS A BROKER)

Form 4391 (Arkansas) 1-06

I represent American National Insurance Company and will provide services to you on behalf of the Company. I will receive compensation from American National Insurance Company for placement of the insurance for which you have applied. Customer Acknowledgement: I acknowledge receipt of this disclosure. __________________________________________ _________________________________ Signature of Customer Date Producer Acknowledgement: I have provided this disclosure notice to this customer. __________________________________________ _________________________________ Producer Signature Date

Non-Qualifi ed 1035 Exchange RequestIssued by American National Insurance CompanyOne Moody Plaza, Galveston, TX 77550-7999

Form 4394-NQ AMERICAN NATIONAL INSURANCE COMPANY RV 12-09

page 1 of 2

Complete this form for Non-Qualifi ed Accounts Only Complete this form for Non-Qualifi ed Accounts Only

1. FUNDS COMING FROM:

CHECK ONE:

❑ NEW SALE, APPLICATION ATTACHED

❑ ADDITIONAL DEPOSIT TO EXISTING POLICY NUMBER

TRANSFER COMPANY NAME AND ADDRESS:

TRANSFER COMPANY PHONE NUMBER:

NAME OF INSURED/ANNUITANT*: SSN:

NAME OF OWNER: SSN:

NAME OF JOINT OWNER: SSN:

POLICY/ACCOUNT NUMBER WITH TRANSFER COMPANY:

*JOINT ANNUITANTS ARE ONLY ACCEPTED ON SPIA’s*

2. TYPE OF TRANSACTION:

I/We direct the Institution named above to liquidate and transfer the assets to American National in order to set up a Non-Qualifi ed account:

(MUST SPECIFY:)

❑ Immediately ❑ Upon Maturity /// ///

❑ 1035 Exchange, Non-Qualifi ed Policy ❑ Non-1035 Exchange, Non-Qualifi ed Funds From: Mutual Fund, Bank CD, or Other Non-Qualifi ed Asset.

❑ Full 1035 Exchange The Assignor hereby designates American National Insurance Company as benefi ciary of the above policy/contract.

Immediately following the above benefi ciary designation, Assignor does hereby assign and transfer without exceptions, limitations or reservation to American National Insurance Company all assignable benefi ts, interest, property, rights, claims, options, privileges, obligations and title in the policy/contract in exchange for a new policy/contract as described in Assignor’s application to American National Insurance Company for such policy/contract.

Assignor and American National Insurance Company expressly represent and recognize that the sole purpose of this assignment is to affect an exchange of insurance policies/contracts. Assignor represents and agrees that Assignor has consulted his/her own tax advisor regarding the tax consequences of this transaction. Assignor represents and agrees that American National Insurance Company has made no representations concerning Assignor’s tax treatment under Internal Revenue Code Section 1035 or otherwise as a result of this transaction. American National Insurance Company assumes no responsibility or liability for the assignor’s tax treatment under Internal Revenue Code Section 1035(a) or otherwise as a result of this transaction.

$

❑ Partial 1035 Exchange

I understand the Internal Revenue Service may take the position that an exchange of a portion of an existing life insurance policy/contract for a new life insurance policy or an annuity contract, or the exchange of a portion of an existing life insurance or annuity contract for a new annuity contract, does not qualify as a valid exchange under Section 1035 of the Internal Revenue Code. I understand, acknowledge, and agree that American National assumes no liability or responsibility for any tax consequences associated with the proposed partial exchange.

❑ $ ❑ %

Please complete the information below if 1035 Exchange includes loan value:$ Amount of 1035 Exchange $ Amount of loan included in 1035 Exchange

(Not available with all products)

Appropriate loan form must be submitted with the application if transferring loan value.

*1035*

Form 4394-NQ AMERICAN NATIONAL INSURANCE COMPANY RV 12-09

page 2 of 2

3. CONTRACT STATEMENT:

❑ CONTRACT INCLUDED If contract is not lost, please submit with this form.

❑ CERTIFICATE OF LOST CONTRACT I/We certify that the above numbered contract has been lost or destroyed and to the best of my/our knowledge and belief, is

not in anyone’s possession.

4. SPECIAL INSTRUCTIONS:

5. SIGNATURES:

I/We agree that (1) American National is participating in this transaction at my specifi c request and as an accommodation to me: (2) American National and its representatives make no representation concerning treatment under IRC Section 1035(a) or otherwise; (3) American National assumes no responsibility nor any liability for the validity of this transaction or for the tax treatment under IRC Section 1035(a) and assumes that I/We consulted a tax advisor; (4) No person, fi rm, or corporation has a legal or equitable interest under the above referenced contract, except the undersigned, and no proceedings of either a legal or equitable nature have been instituted or are pending against the undersigned or involving the above referenced contract; and (5) the full-partial distribution from my existing contact may be subject to surrender charges.

I/We authorize the transaction described above.

For the benefi t of:

Date at this day of , (City, State)

Owner Witness

Joint Owner Witness

Annuitant

Agent

Guarantee (if required)

6. ACCEPTANCE: TO BE COMPLETED BY AMERICAN NATIONAL

The authorized signature below certifi es acceptance of the assignment and surrender or transfer of funds as instructed in this request. After deducting any sums as are permitted under the plan, please complete this transaction and send a check with a copy of this form to: ❑ ANNUITY SERVICES DEPARTMENT ❑ VARIABLE CONTRACTS DEPARTMENT ❑ LIFE NEW BUSINESS American National Insurance Company American National Insurance Company American National Insurance Company P O Box 696763 P O Box 696893 P.O. Box 696700 San Antonio Tx 78269 San Antonio Tx 78269 San Antonio Tx 78269 1-800-252-9546 1-800-306-2959 1-800-672-9960

If shipping via overnight service: If shipping via overnight service: If shipping via overnight service:

American National Insurance Company American National Insurance Company American National Insurance CompanyAnnuity Services Dept Variable Contracts Dept Life New Business4500 Lockhill-Selma Road 4500 Lockhill-Selma Road 4500 Lockhill-Selma RoadSan Antonio Tx 78249 San Antonio Tx 78249 San Antonio Tx 78249

PLEASE MAKE CHECK PAYABLE TO: AMERICAN NATIONAL

By Date (Signature/Title)

FOR ALL 1035 EXCHANGES, PLEASE PROVIDE THE COST BASIS INFORMATION FOR THE CURRENT POLICY. FOR ALL 1035 EXCHANGES, PLEASE PROVIDE THE COST BASIS INFORMATION FOR THE CURRENT POLICY.

Qualifi ed Transfer or Rollover RequestIssued by American National Insurance CompanyOne Moody Plaza, Galveston, TX 77550-7999

Form 4394-Q AMERICAN NATIONAL INSURANCE COMPANY RV 12-09

page 1 of 3

Complete this form for Qualifi ed Accounts Only Complete this form for Qualifi ed Accounts Only

1. FUNDS COMING FROM:

CHECK ONE:

❑ NEW SALE, APPLICATION ATTACHED

❑ ADDITIONAL DEPOSIT TO EXISTING POLICY NUMBER

TRANSFER COMPANY NAME AND ADDRESS:

TRANSFER COMPANY PHONE NUMBER:

NAME OF INSURED/ANNUITANT*: SSN:

NAME OF OWNER*: SSN:

POLICY/ACCOUNT NUMBER WITH TRANSFER COMPANY:

*ANNUITANTS AND OWNER MUST BE THE SAME*

2. COMPLETE THIS SECTION FOR TRANSFER REQUESTS AND DIRECT ROLLOVER REQUESTS:

❑ Total, Full Liquidation $

❑ Partial, % or $

❑ Annuitization, Term: Frequency of Payments:

Please send these funds to American National Insurance Company

❑ Immediately ❑ Upon Maturity /// ///

3. COMPLETE THIS SECTION FOR TRANSFER REQUESTS:

IRA/TSA Transfer into an annuity contract of the same qualifi cation type (i.e. TSA, IRA, or both ROTH IRA)

As owner of the account or policy indicated in Section 1, I hereby request transfer of:

❑ Tax-Sheltered Annuity (IRC Section 403(b)) ❑ ROTH I.R.A. or Annuity (IRC Section 408)

❑ Individual Retirement Account or Annuity (IRC Section 408) ❑ SEP IRA

❑ Governmental 457 Deferred Compensation Plan

By signing below, I authorize the transfer of the IRA assets in the manner described above and certify that all of the information pro-vided by me is correct and may be relied upon by the Trustee or Custodian. I understand that I am responsible for determining my eligibility to transfer within the limits set forth by tax laws, related regulations, and plan agreements. I assume responsibility for any tax consequences or penalties that may apply to the transfer of my assets.

Owner’s Signature Date Witness Signature Date

Agent’s Signature Date

*1035*


page 2 of 3

4. COMPLETE THIS SECTION FOR DIRECT ROLLOVER REQUESTS:

Direct Rollover into a Traditional IRA, 403(b) Plan, 457(b) Plan, or other qualifi ed plan.

As owner of the account or policy indicated in Section 1, I hereby request a direct rollover of my:

❑ Individual Retirement Annuity (IRC Section 408) ❑ Tax-Sheltered Annuity (IRC Section 403(b))❑ Governmental 457 Deferred Compensation Plan ❑ Qualifi ed Employer Plan (IRC Section 401)❑ SEP IRA ❑ ROTH IRA

into an❑ Individual Retirement Annuity (IRC Section 408) ❑ Tax-Sheltered Annuity (IRC Section 403(b))❑ Governmental 457 Deferred Compensation Plan ❑ SEP IRA ❑ ROTH IRA

I understand the rules and conditions applicable to direct rollovers and certify that I qualify for a direct rollover of the funds or assets listed above. Due to the important tax consequences of rolling funds over to an IRA or other qualifi ed plan, I have been advised to see a tax advisor.I hereby request payment from the plan designated above in the form of a direct rollover. I assume full responsibility for this direct rollover transaction and will not hold the Plan Administrator, Trustee, or Custodian of either the distributing or receiving plans liable for any adverse consequences that may result.

I hereby irrevocably designate this contribution of funds and/or property indicated above as a direct rollover contribution.

Owner’s Signature Date Witness Signature Date

Agent’s Signature Date

5. CONTRACT STATEMENT:

❑ CONTRACT INCLUDED If contract is not lost, please submit with this form.❑ CERTIFICATE OF LOST CONTRACT

I certify that the above numbered contract has been lost or destroyed and to the best of my knowledge and belief, is not in anyone’s possession.

6. REQUIRED MINIMUM DISTRIBUTION (RMD) INFORMATION:

If you have attained age 70½, the IRS requires annual minimum distribution from your qualifi ed account(s). If this rollover is being made during or after the fi rst year for which you must take a required minimum distribution, you may not roll over any distribution, which would constitute a required minimum distribution from the distributing plan.

7. SPECIAL INSTRUCTIONS:

8. ACCEPTANCE OF FUNDS: TO BE COMPLETED BY AMERICAN NATIONAL

This is to certify that American National Insurance Company will accept the funds to establish a qualifi ed annuity. Please do not with-hold any taxes from the amount being transferred.

❑ ANNUITY SERVICES DEPARTMENT ❑ VARIABLE CONTRACTS DEPARTMENT ❑ LIFE NEW BUSINESS American National Insurance Company American National Insurance Company American National Insurance Company P O Box 696763 P O Box 696893 P.O. Box 696700 San Antonio Tx 78269 San Antonio Tx 78269 San Antonio Tx 78269 1-800-252-9546 1-800-306-2959 1-800-672-9960

If shipping via overnight service: If shipping via overnight service: If shipping via overnight service:

American National Insurance Company American National Insurance Company American National Insurance CompanyAnnuity Service Dept Variable Contracts Dept Life New Business4500 Lockhill-Selma Road 4500 Lockhill-Selma Road 4500 Lockhill-Selma RoadSan Antonio Tx 78249 San Antonio Tx 78249 San Antonio Tx 78249

PLEASE MAKE CHECK PAYABLE TO: AMERICAN NATIONAL

By Date (Signature/Title)


page 3 of 3

DEFINITIONS

QUALIFIED RETIREMENT PLANS – Tax-qualifi ed retirement plans may include pension, profi t-sharing plan, 401(k), 403(b) Tax Sheltered Annuity (TSA), Simplifi ed Employee Pension (SEP) Plan, Keogh, Traditional or Roth Individual Retirement Account (IRA).

TRUSTEE-TO-TRUSTEE/DIRECT ROLLOVER TRANSFERS – The TRUSTEE-TO-TRUSTEE transfer is the transfer of funds from one Qualifi ed Retirement Plan to another Qualifi ed Retirement Plan. A DIRECT ROLLOVER is the movement of funds from and Employer’s Qualifi ed Retirement Plan directly to an IRA with a new trustee. In both instances, the plan participant does not take actual or constructive receipt of the funds, and the check is made payable and sent to the new trustee.

Trustee-to-trustee transfers are non-reportable events. Direct rollovers are reported to the IRS by the employee plan trustee and coded as a direct rollover. Both the trustee-to-trustee transfers and the direct rollovers are different than 60-day rollovers in that the IRS allows more than one transfer/direct rollover within a year. Direct rollovers are not subject to mandatory tax withholding.

NOTE – If a lump-sum distribution of funds is taken from a tax-qualifi ed employee retirement benefi t plan and the plan participant does not choose to use a direct rollover, the employer could be required to withhold 20 percent (20%) for taxes. For this reason, direct rollovers are the preferred method of moving tax-qualifi ed employee retirement benefi t plan funds.

60-DAY ROLLOVERS – A tax-qualifi ed 60-day rollover is the tax-free transfer of funds from one Qualifi ed Retirement Plan to another Qualifi ed Retirement Plan with the participant taking actual or constructive receipt of the funds. The check is made payable to the plan participant. The plan participant has 60 days to deposit these funds into another Qualifi ed Retirement Plan or the distribution will be taxable. Plan participants can make one 60-day rollover of funds within a 12-month period. A tax-qualifi ed 60-day rollover from a tax-qualifi ed plan could be subject to mandatory tax withholding by the plan.

Policy may be referred to as “contract” or “certifi cate” in some states.

USA Patriot Act Notifi cation and Customer Identifi cation Verifi cationIssued by American National Insurance CompanyOne Moody Plaza, Galveston, TX 77550-7999

Form 4439 AMERICAN NATIONAL INSURANCE COMPANY RV AMERICAN NATIONAL INSURANCE COMPANY RV AMERICAN NATIONAL INSURANCE COMPANY 05-07

page 1 of 1

*USA*1. Client Name Application or Policy Number

Source of Funds W-2 Wages Investments Social Security or Pension Savings another insurance contract

Other (please explain)

USA PATRIOT Act Notice – to be read by or to customer.to be read by or to customer.to be read by or to customer

2. The USA PATRIOT Act requires that we establish an Anti-Money Laundering (“AML”) Program, notify customers that we must verify the identity of the owner(s) of our contracts, and collect documents and information suffi cient to provide such verifi cation. You should know that failure to provide the requested identifi cation will result in delays in the issuance of the requested coverage and may result in a decision not to accept your business.

Customer Identifi cation Verifi cation In order to satisfy such obligations, we require our representative to review and verify a current government issued photo ID for each Owner/Trustee/Partner associated with a contract. Information on such identifi cation must be recorded below. We may use third party sources to verify the information provided.

a. Identifi cation Verifi ed (One for each Owner/Trustee/Partner. Use additional forms if necessary.)Owner/Trustee/Partner Joint Owner/Trustee/Partner

Check one form of ID: Check one form of ID: Driver’s license Driver’s license Resident Alien ID (Green Card) Resident Alien ID (Green Card) Passport Passport Other: (Describe) Other: (Describe)

The following information should be recorded exactly as it appears on the identifi cation reviewed

Name Date of Birth Name Date of Birth

Street Address (not PO Box) Street Address (not PO Box)

City, State, Zip City, State, Zip

Number on ID State or Country Number on ID State or Country

Identifi cation Expiration Date Identifi cation Expiration Date

b. Entity Verifi cation: Check the appropriate entity as listed below and submit copies of documentation viewed to gain fi rst-hand knowledge of the existence of a legitimate business. If the Owner is a minor or non-legal entity, review the identifi cation of the individual who submits an application on behalf of the minor or non-legal entity.

Corporation, LLC, professional association, or professional corporation: Articles of Incorporation, Organization or Association or similar document fi led in the state in which the entity is formedLimited Partnership: Certifi cate of Limited Partnership or similar document fi led in the state where the partnership is formedGeneral Partnership or Joint Venture: Agreement, Joint Venture Agreement or similar agreement governing the formation and operation of the partnershipTrust and All Other Entities: Document governing the formation and operation of the entity

3. I certify that I personally met with the proposed Owner(s)/Trustee(s)/Partners and reviewed the above identifi cation document. To the best of my knowledge, it accurately refl ects the identity of the proposed Owner(s)/Trustee(s)/Partners.

I was unable to personally review the identifi cation documents for the reason stated below. I certify that, to the best of my knowledge, the information provided by the Owner(s)/Trustee(s)/Partners is true and accurate.

Reason for not reviewing documents Reason for not reviewing documents

Note: Failure to personally review the identifi cation documents will result in processing delays in order to verify customer identity and may result in a decision not to accept the business.

Representative Name Personal Code

Representative Signature Date

Suitability AcknowledgementIssued by American National Insurance CompanyP O Box 1763, Galveston, TX 77553-1763

Form 4466 AMERICAN NATIONAL INSURANCE COMPANY RV 02-08

page 1 of 1

*SUIT*

This form must be completed for each Consumer who is purchasing a fixed annuity.This form must be submitted to American National Insurance Company prior to the annuity being issued.

1 Owner/Applicant Information

Owner/Applicant Name (please print) Social Security Number Date of Birth

Joint Owner/Applicant Name (please print) Social Security Number Date of Birth

COMPLETE EITHER SECTION 2 OR 3

If Section 2 and 3 are both signed the annuity will not be issued and a new form must be submitted.Complete only one section.

Provide the appropriate information and return the completed form to the insurer at the address shown above.

DO NOT COMPLETE IF SECTION 3 IS COMPLETED

2 Suitability Acknowledgement

Acknowledgement of Responsibility for Suitability Recommendation to Consumers

I have reasonable grounds for believing that the recommendation for this Consumer to purchase/exchange an annuity is suitable on the basis of the facts disclosed by the Consumer as to their investments and other insurance products and their financial situation and needs. I have made reasonable efforts to obtain information concerning the Consumer’s financial status, tax status, investment objectives and such other information I considered reasonable in making the recommendation.

Also, I agree to maintain and make available upon request to the insurer or the insurance commissioner records of the information collected and other information used as the basis for this insurance recommendation for a minimum of 5 years in most states and up to 10 years in certain other states, after the insurer completes the recommended transaction. Any process that accurately reproduces the actual document may be used to maintain these records.

Agent Name (please print) Telephone #

Agent/Producer Signature Date

DO NOT COMPLETE IF SECTION 2 IS COMPLETED

3 Consumer’s Acknowledgement of Responsibility

I elect not to provide information my agent has requested related to the purchase or exchange of an annuity and/or;

I have decided to enter into the purchase of a fixed annuity without a recommendation from my agent.

Owner/Applicant Signature (or Trustee if owner is Trust) Date Joint Owner Signature (if any) Date


Fixed Annuity Suitability Analysis FormIssued by American National Insurance CompanyOne Moody Plaza, Galveston, TX 77550-7999


page 1 of 2

*SUIT*This form must be completed for persons that are purchasing a fi xed annuity.

This form is designed to assist the agent and client in gathering information to determine whether the purchase of an annuity is suitable for the client.

This form or other documentation that contains substantially the same information that the agent used in evaluating suitability and making a recommendation must be maintained in the agent’s client fi le for a minimum of 5 years in most states and up to 10 years in certain other states, after the insurer completes the recommended transaction.

Section 1To be completed with your agent to determine if the proposed fi xed annuity purchase meets your fi nancial needs and objectives.

A - Personal Identifi cation

Owner Full Name SS#/Tax ID # Date of Birth Age

Joint Owner (if any) Full Name SS#/Tax ID # Date of Birth Age

Marital Status: Married Single Occupation List Number of Dependents __________________

Dependent ages ___________________________

B - Financial Profi le (For Joint Owners, information may be combined.)

1. Annual Gross Income

$0 - 29,999 $30,000 - 49,999 $ 50,000 - 74,999

$75,000 - 99,999 $100,000 - 149,999 $150,000 - 249,999

$250,000 - 399,999 $400,000 - Over

2. Source of Income (Check all that apply)

Salary (W 2) Investments Social Security Pension Plans

Other _______________________________________________

3. What type of investments and insurance products do you own?

Mutual Funds Stocks Bonds CDs Savings Account(s)

Life Insurance Other Annuities

4. What type of life insurance or other annuities do you own? _____________________________________________________

_____________________________________________________________________________________________________________

5. Estimated Net Worth (Exclude primary residence, furnishings, automobiles.)

$0 - 74,999 $75,000 - 149,999 $150,000 - 249,999

$250,000 - 499,999 $500,000 - 999,999 $1,000,000 - Over

6. Liquid Net Worth (After purchasing this annuity - These are assets that can be easily converted to cash without incurring penalty charges.)

Under $10,000 $10,000 - 25,000 $25,000 - 50,000 $50,000 - 100,000 Over $100,000

7. Why are you purchasing this annuity? (Check all that apply):

Income Stable Growth Tax Deferral Estate Planning

Safety of Principal Retirement Other_______________________________



Marital Status:

Dependent ages ___________________________



Single Occupation List Number of Dependents __________________

Dependent ages ___________________________



Single Occupation List Number of Dependents __________________

Dependent ages ___________________________


page 2 of 2

8. After the purchase of the annuity, will your income and liquid net worth be enough for living expenses and emergencies? Yes No

(Many fi nancial planners recommend that a person maintain an amount of liquid net worth equal to 3 to 6 months of a person’s monthly living expenses in case of emergencies.)

9. With the exception of any surrender charge free withdrawal, do you expect to withdraw any money from this annuity before the end of the surrender charge period? Yes No

If “Yes”, please explain. ______________________________________________________________________________________

10. What is your Federal Income Tax Bracket: 15% 28% 33% 38%

11. The agent has discussed with me whether an existing life insurance or annuity will be replaced in connection with the proposed sale of this annuity and whether surrender charges apply. Yes No

12. What source of funds will you use to buy this fi xed annuity? ____________________________________________________

Note to Producer: You should maintain in your fi les any other information you used or considered, not listed above, in making your recommendation.

Section 2 - Representations and Signatures

Complete Either A or B

If Box A and B are both signed the annuity will not be issued and a new form must be submitted.Complete only one box.

Do Not Complete if You Completed Box “B”

A. I acknowledge that the fi xed annuity product I am applying for is a long-term contract with substantial penalties for early withdrawal. I believe that this product meets my fi nancial needs and objectives.

Owner/Applicant Signature (or Trustee if owner is Trust) Date

Joint-Owner Signature (if any) Date

Agent’s Acknowledgement:Based on information collected, I believe the purchase of this annuity is suitable.


Do Not Complete if You Completed Box “A”

B. I elect not to provide information in Section 1 B or answers to certain questions in Section 1 B and/or I have decided to purchase this fi xed annuity without a recommendation from my agent or the Company. I understand that the annuity is a long-term contract with substantial penalties for early withdrawal. I believe that this product meets my fi nancial needs and objectives.

Owner/Applicant Signature (or Trustee if owner is Trust) Date

Joint-Owner Signature (if any) Date

Agent’s Acknowledgement:The Owner(s) has not provided complete information and has decided to purchase this fi xed annuity without my recommendation.


I acknowledge that the fi xed annuity product I am applying for is a long-term contract with substantial penalties for early withdrawal.

Appendix A - Important Notice: Replacement of Life Insurance orAnnuities for ProducersIssued by American National Insurance CompanyOne Moody Plaza, Galveston, TX 77550-7999

Form 10269 AMERICAN NATIONAL INSURANCE COMPANY 08-09

page 1 of 2

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 the 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 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 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 interests. 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 a lower 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 remainder 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 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:

INSURERNAME

CONTRACT ORPOLICY #

INSURED ORANNUITANT

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

.

*IRF*


page 2 of 2

I certify that the responses herein are, to the best of my knowledge, accurate:

Applicant’s Signature Printed Name Date

Producer’s Signature Printed Name Date

I do not want this notice read aloud to me. ____ (Applicants must initial only if they do not want the notice read aloud.)

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’re 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 “grandfathered” 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?

Appendix D - Comparison FormIssued by American National Insurance CompanyOne Moody Plaza, Galveston, TX 77550-7999


page 1 of 2

LIFE INSURANCE AND ANNUITIES REPLACEMENT MEMORANDUM

EXISTING CONTRACT/POLICY PROPOSED CONTRACT/POLICY

Owner/Annuitant(s) Owner/Annuitant(s)

Insurer Insurer

Contract # Application #

Product Type * Product Type *

Product Name Product Name

FOR BOTH LIFE INSURANCE AND ANNUITIES

(Complete all that is applicable)

CONTRACT OR POLICY PROVISION EXISTING CONTRACT/POLICY REPLACEMENT CONTRACT/POLICY

Current Proposed Premium/Annual Consideration

Current Contract Value

Current Surrender Value

Death Benefit Amount

Current Interest Rate &Guarantee Period

Guaranteed MinimumAccumulation/Interest Rate

* Deferred Fixed Annuity, Deferred Variable Annuity, Deferred Indexed Fixed Annuity, Immediate Annuity, Indexed Life Insurance, Variable Life Insurance, Whole Life Insurance, Universal Life Insurance, Term Life Insurance and Endowment

*IRF*


page 2 of 2

Surrender Charge Period in Years/Charge Percentage Per Year/Years Remaining

Are free withdrawals available?If yes, what percentage?List options.

Other significant policy or contractprovisions

FOR ANNUITIES ONLY

(Complete all that is applicable)

CONTRACT PROVISION EXISTING CONTRACT/POLICY REPLACEMENT CONTRACT/POLICY

Initial Bonus Percentage of Amount

Potential Loss of Bonus if Annuity isExchanged, Surrendered or FundsWithdrawn

Sub-Account Choices

Guaranteed Purchase/SettlementOptions

I have received a copy of this completed form.

Owner/Annuitant Date Joint Owner/Annuitant Date

I certify that the above provisions, and any other significant provisions, of the existing policy or contract and the proposed policy or contract were discussed the applicant(s).

Producer Signature Date

Date post:	20-Apr-2018
Category:	Documents
Upload:	doandan
View:	216 times
Download:	3 times

Great Southern Bank Annuity Processing Procedures Equity Index Application Kit.pdf · Check Payable...

Documents