Avoid Commission Delays: Tips for Good-Order Applications All Forms Never use whiteout on any of the forms Any correction to Agent-Only information needs to be crossed out, initialed and dated by the agent Any correction to Client-Only information needs to be crossed out, initialed and dated by the client. Annuity Application Page 1 – Section E – May need Replacement form if required by your state Page 3 – Section J – If replacement – Reason must be given Financial Needs Analysis Agent cannot write-in “N/A” in any location of this form Page 1 – Source of Funds – if “Other”, must provide the source (e.g. gift from father, inheritance, savings, etc.). An IRA is not a source of funds Page 1 – Section 1 – Questions 2a & 2b – Must be answered if “Yes” to other replacements in question 2 Disclosure & Comparison Form Surrender Charge Schedule – Complete surrender schedule must be given for Column A and Column B Do not write in dollar amount for “What is Paid at Death” Agent cannot write-in “N/A” in any location of this form Do not write in a dollar amount for question 3 Current Surrender Charge Trust Certification Forms & When Trust is Owner Trustee Certification Form Required All signatures of owner must include “Ttee”/trustee behind signatures Form must be notarized Power of Attorney Signing as Owner POA Certification Form Required All signatures of owner must include “POA” behind signatures Form must be notarized Specific Forms for Florida In addition to EquiTrust’s Financial Needs Analysis form, all clients in Florida must complete Florida-specific Annuity Suitability Questionnaire All clients must use Florida-specific Disclosure & Comparison for replacements EquiTrust Life Insurance Company • 7100 Westown Pkwy Suite 200 • West Des Moines, IA 50266-2521 866-598-3692 ET-2510 (7-14) Product: MarketPower Bonus Index Min. Premium: $20,000.00 TRAINING REQUIRED IN YOUR STATE
Transcript
Avoid Commission Delays:
Tips for Good-Order Applications
All Forms Never use whiteout on any of the forms
Any correction to Agent-Only information needs to be crossed out, initialed and
dated by the agent
Any correction to Client-Only information needs to be crossed out, initialed and
dated by the client.
Annuity Application Page 1 – Section E – May need Replacement form if required by your state
Page 3 – Section J – If replacement – Reason must be given
Financial Needs Analysis Agent cannot write-in “N/A” in any location of this form
Page 1 – Source of Funds – if “Other”, must provide the source (e.g. gift from
father, inheritance, savings, etc.). An IRA is not a source of funds
Page 1 – Section 1 – Questions 2a & 2b – Must be answered if “Yes” to other
replacements in question 2
Disclosure & Comparison
Form
Surrender Charge Schedule – Complete surrender schedule must be given for
Column A and Column B
Do not write in dollar amount for “What is Paid at Death”
Agent cannot write-in “N/A” in any location of this form
Do not write in a dollar amount for question 3 Current Surrender Charge
Trust Certification Forms
& When Trust is Owner
Trustee Certification Form Required
All signatures of owner must include “Ttee”/trustee behind signatures
Form must be notarized
Power of Attorney Signing
as Owner
POA Certification Form Required
All signatures of owner must include “POA” behind signatures
Form must be notarized
Specific Forms for Florida In addition to EquiTrust’s Financial Needs Analysis form, all clients in Florida must
Social Security/TIN # Daytime Phone # Social Security/TIN # Daytime Phone #
SECTION C – PLAN TYPE (CHECK ONE)
IRA Transfer IRA Rollover IRA Contribution - Tax Year _______
SEP IRA SIMPLE IRA Roth IRA Roth Conversion IRA Nonqualified Other __________
SECTION D – PREMIUM PAYMENTS
Premium Submitted with Application $ Anticipated Value of 1035 Exchange/Transfer/Rollover $__________
SECTION E – EXISTING COVERAGE/REPLACEMENT Does either the Owner or Proposed Insured have existing life insurance policies or annuity Yes No contracts with the Company or any other company? If “Yes”, and if required by your state, complete replacement form(s).
Is this Contract applied for fully or partially replacing or likely to replace any existing life insurance Yes No or annuity contract? If “Yes” complete replacement form(s).
EquiTrust Life Insurance Company 7100 Westown Pkwy Suite 200 West Des Moines IA 50266-2521
ANNUITY APPLICATION
ANN-APPFL(05-13) Page 2 of 3 – Incomplete without all pages
SECTION F – BENEFICIARY
Please note that in the case of joint ownership policy death proceeds are paid to the named beneficiaries upon the death of the first owner to die. If the joint owners are spouses and the surviving spouse wishes to have the option to continue the contract, the primary beneficiary designation should read, “surviving spouse.” Beneficiary proceeds will be split equally if no percentages are provided.
PRIMARY Share %: Relationship:
Complete Name (first-middle-last) SSN/TIN:
Birth Date: Phone #:
Address, City, State, Zip:
Primary Contingent Share %: Relationship:
Complete Name (first-middle-last) SSN/TIN:
Birth Date: Phone #:
Address, City, State, Zip:
Primary Contingent Share %: Relationship:
Complete Name (first-middle-last) SSN/TIN:
Birth Date: Phone #:
Address, City, State, Zip:
Primary Contingent Share %: Relationship:
Complete Name (first-middle-last) SSN/TIN:
Birth Date: Phone #:
Address, City, State, Zip:
Primary Contingent Share %: Relationship:
Complete Name (first-middle-last) SSN/TIN:
Birth Date: Phone #:
Address, City, State, Zip:
Please check here if you are attaching additional beneficiary information.
SECTION G – SPECIAL REQUESTS, REMARKS, CORRECTIONS OR ENDORSEMENTS
SECTION H – NOTICE State insurance law may prohibit the owner of an annuity contract from entering into any agreement to sell, transfer, or assign an annuity contract prior to the date the contract was issued, or within a period of time specified by state law after the contract was issued. You should consult with legal advisors if you have any questions about these matters.
ANN-APPFL(05-13) Page 3 of 3 – Incomplete without all pages
SECTION I – SIGNATURES CERTIFICATION
Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to
me), and 2. I am not subject to backup withholding due to failure to report interest and dividend income, and 3. I am a U.S. person (including a U.S. resident alien). Certification instructions. You must cross out Item 2 above if you have been notified by the IRS that you are currently subject to backup withholding I/We declare that all statements in this Application are true to the best of my/our knowledge and belief, and agree that this Application shall be a part of the Annuity Contract issued by the Company. Acceptance of any Annuity Contract issued on this Application shall constitute ratification of any corrections, additions, or changes made by the Company and recorded in the space “Special Requests, Remarks, Corrections or Endorsements” except that no change shall be made as to amount, classification, plan or benefits, unless agreed to in writing. It is understood that no producer or other unauthorized person except an Executive Officer or an Assistant Secretary of the Company is authorized to waive forfeitures, to make or alter contracts, or to waive any of the Company’s rights or requirements. The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.
If the contract applied for contains a Market Value Adjustment provision, payments and values are subject to a Market Value Adjustment which may result in upward or downward adjustments in amounts withdrawn or surrendered.
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.
____________________________________________________ Signed at: City and State Florida Agent License ID #
Signature of Owner Date
Signature of Joint Owner Date
SECTION J – PRODUCER CERTIFICATE – FOR PRODUCER USE ONLY
Will this plan replace any existing life insurance or annuity? Yes No
If “Yes”, please explain the reason for replacement:
For any replacement, indicate the source of funds to be replaced:
Term Life Whole Life Variable Life Fixed Annuity Variable Annuity
Other – be specific
Producer Certifications:
• I certify that I used only insurer-approved sales material with this Application and that an original or a copy of all sales material was left with the Owner.
• I certify that a printed copy of any electronically presented sales material was/will be presented to the Owner no later than the date the Contract is delivered.
• I certify that this Application is in accordance with the Company’s written statement of the Company’s position with respect to the acceptability of replacements.
Signature of Agent Date
ET-MPP-1101 (01-13)
MARKETPOWER BONUS INDEX Single Premium Fixed and Indexed
Form Series ET-MPP-2000 (02-05) Deferred Annuity Contract
DISCLOSURE STATEMENT Some features of this annuity may not be available in all states and may vary by state. If you have any questions, please contact your representative or EquiTrust Life Insurance Company (“the Company”) for details. This form is not intended to be a complete explanation of your annuity. Please refer to your Contract for complete details.
WHAT IS AN ANNUITY? An annuity is a long-term financial product offered by insurance companies. You may cancel your annuity Contract within a certain number of days of your receipt to receive a complete refund of your premium.
HOW MUCH WILL I EARN ON MY ANNUITY? When you purchase a MARKETPOWER BONUS INDEX Contract, you can choose different accounts for your money. Each account earns interest differently. You may make your allocation elections on page 3 of this disclosure statement.
1-Year Interest Account – The 1-Year Interest Account will earn a declared interest rate. The interest rate will be declared on each Contract Anniversary and is guaranteed for the following Contract Year. The declared interest rate can never be less than the Minimum Guaranteed Interest Rate. The Minimum Guaranteed Interest Rate will be no lower than 1% and no higher than 3%. Once your Contract is issued, the Minimum Guaranteed Interest Rate will not change. Ask your agent for the current interest rate and Minimum Guaranteed Interest Rate.
1-Year Point-to-Point Cap Index Account - Annual Index Credits are based on the percentage change in the Index Number from the previous Contract Anniversary to the current Contract Anniversary, after recognition of the Index Cap.
1-Year Average Cap Index Account - Annual Index Credits are based on the percentage change in the Index Number from the previous Contract Anniversary to the daily average of the Index Numbers for the Contract Year, after recognition of the Index Cap.
1-Year Average Participation Index Account - Annual Index Credits are based on the percentage change in the Index Number from the previous Contract Anniversary to the monthly average of the Index Numbers for the Contract Year, multiplied by the Participation Rate.
1-Year Monthly Cap Index Account – Annual Index Credits are based on the cumulative sum of capped monthly changes in the Index Number over a one-year period. Each of the monthly gains in the Index is subject to a Monthly Cap, but there is no floor on monthly declines in the index.
2-Year Monthly Average Cap Index Account – Index Credits are based on the percentage change in the Index Number from the beginning of the two-year Indexing Period to the monthly average of the Index Numbers for the two year Indexing Period, after recognition of the Index Cap.
Index Account Definitions The Index Number on any specified date is the closing value of the S&P 500® Index on the previous trading day. The Index Cap is the maximum annual percentage excess of the applicable average Index Numbers or the end-of-year Index
Number over the beginning-of-year Index Number. The Index Cap will be declared on each Contract Anniversary and is guaranteed for the following Contract Year. The minimum Index Cap is 1% for the 1-Year Point-to-Point Cap Account, 1% for the 1-Year Average Cap Account, and 3% for the 2-Year Monthly Average Cap Account.
The Monthly Cap is the maximum monthly percentage increase in the end-of-month Index Number over the beginning-of-month Index Number used to determine Index Credits. The Monthly Cap will be declared on each Contract Anniversary and is guaranteed for the following Contract Year. The minimum Monthly Cap is 0.50% for the 1-Year Monthly Cap Index Account.
The Participation Rate is the percentage of the excess of the Monthly Average Index Numbers over the beginning-of-year Index Numbers that is used in the calculation of the Index Credits. The Participation Rate will be declared on each Contract Anniversary and is guaranteed for the following Contract Year. The minimum Participation Rate is 10% for the 1-Year Average Participation Account.
The Index Credits will be added to the Index Accounts at the end of each Indexing Period. The Index Credits in any Indexing Period will never be less than zero.
The Indexing Period is one year for the 1-Year Accounts and two years for the 2-Year Account.
Accumulation Value – Your Accumulation Value is the total of the individual Account Accumulation Values.
Maximum Premium - The maximum premium allowed in the first Contract Year is $1,000,000 without Home Office approval.
Subsequent Premiums – In addition to the Single Premium, subsequent Premium(s) will be allowed in the first Contract Year only. All subsequent premium(s) will be allocated to the 1-Year Interest Account at the time of receipt. On the first Contract Anniversary, the Accumulation Value associated with any premium received since the Contract Date will be reallocated among the Accounts according to your most recent instructions.
COMPANY COPY Page 1 of 3 – incomplete without all pages
ET-MPP-1101 (01-13)
Premium Bonus – This Contract offers a Premium Bonus equal to the premium paid in the first year multiplied by 10%. The Premium Bonus is allocated to the Accounts proportionately in the same manner as your Premium allocation instructions. Annuities that offer bonus features may have higher fees and charges, longer surrender charge periods, lower credited interest rates and/or lower cap and participation rates than annuities that do not provide the bonus feature.
Minimum Guaranteed Contract Value – The Minimum Guaranteed Contract Value will be 87.5% of Premium Paid (excluding any Premium Bonus), less any partial withdrawals, plus interest earned at a rate no lower than 1% and no higher than 3%. Once your Contract is issued, your Minimum Guaranteed Contract Rate will not change. Ask your agent for the Minimum Guaranteed Contract Rate.
WHAT HAPPENS WHEN I NEED MY MONEY? You may receive partial surrenders or periodic income payments from your annuity by submitting a request acceptable to the Company. When you make withdrawals, surrender or annuitize your annuity, the amount withdrawn will not be credited with any index return in the current Indexing Period. Withdrawals do not participate in any index gains during the Indexing Period of the withdrawal.
Surrender Charges - This annuity product is a long-term contract with substantial penalties for early surrender. Surrender during the surrender charge period may result in a loss of principal. A surrender charge is assessed, according to the schedule below, on any amount withdrawn as a partial or full surrender that is in excess of the penalty-free amount. The surrender charges are for 14 years and decline as follows:
Market Value Adjustment – We may make a Market Value Adjustment (MVA) on amounts withdrawn or surrendered from this Contract. It may result in either an increase or a decrease to the amount withdrawn or surrendered. A MVA will be made only when a Surrender Charge is deducted. Generally, the MVA decreases the Accumulation Value surrendered when interest rates rise, and increases it when interest rates fall. The MVA will not reduce the amount surrendered below the Minimum Guaranteed Contract Value.
Partial Surrenders – Each Contract Year after the first, you may withdraw up to 10% of the Accumulation Value after the most recent Contract Anniversary without being subject to a Surrender Charge or MVA. If the Contract is subsequently surrendered during the Contract Year, the Surrender Charge and MVA will be applied to any previously uncharged Partial Surrender amounts taken in the same Contract Year.
Cash Surrender Value – The Cash Surrender Value equals the greater of (a) the Minimum Guaranteed Contract Value; or (b) the Accumulation Value less any applicable Surrender Charge, and adjusted for any applicable MVA, determined as of the date of surrender. In no event will the Cash Surrender Value be less than the Minimum Guaranteed Contract Value or greater than the Accumulation Value.
Tax Treatment – You may be subject to a 10% Federal penalty tax if you make withdrawals or surrender your annuity before age 59½. If this is a qualified annuity, all distributions may be taxable. Under current tax law, annuities grow tax deferred and an annuity is not required for tax deferral in qualified plans. Consult your tax attorney for more details.
Annuitization – You may choose to have the proceeds of this Contract paid under a payment option on your income date. This is called annuitizing your Contract. When you annuitize, you can choose from several options, including income for life and/or a specified period of years. Once you annuitize your Contract, you may not surrender it or have access to any values of your annuity, other than your income payments.
Death Benefit – The death benefit is the larger of (a) the Contract’s Accumulation Value; or (b) the amount that would have been payable in the event of a full surrender on the date of death, adjusted for any payments made since the date of death. Upon death of an Owner, the Beneficiary may choose to have the Death Benefit paid immediately or applied to a payment option.
Transfer Options – You may transfer amounts between Accounts without a Surrender Charge or MVA. Transfers are allowed each Contract Year on all Accounts except for the 2-Year Account. Transfers are only allowed at the end of each two-year Indexing Period for the 2-Year Account. A written request for transfer must be received prior to the Contract Anniversary. Transfers are subject to minimums.
Nursing Home Waiver Rider – After the first Contract Year, you may make a partial or a full surrender without incurring a Surrender Charge or MVA if you become confined to a Hospital or nursing Care Center for at least 90 consecutive days. Nursing Home Waiver availability may vary by state and issue age.
COMPANY COPY Page 2 of 3 – incomplete without all pages
ET-MPP-1101 (01-13)
OTHER NOTES Any examples of historical performance of the S&P 500® should not be considered a representation of future performance of the S&P 500®. Future performance of the S&P 500® may be greater or less than any index performance shown in connection with the sale and issue of your annuity Contract. Your Index Credits are based not only on the index, but also the Index Cap or the Participation Rate.
The MARKETPOWER BONUS INDEX Annuity is backed by the financial strength of the Company. It is not guaranteed by any bank
and is not insured by the Federal Deposit Insurance Corporation (FDIC) or any other agency of the federal government. Funded plans under the Employee Retirement Income Security Act of 1974 (ERISA) may not be used with this annuity. The Company can be contacted toll-free at (866) 598-3692 for further clarification if, for any reason, your understanding of
your annuity is different from this explanation.
“S&P 500®” is a trademark of The McGraw-Hill Companies, Inc., and has been licensed for use by the Company. The Product is not sponsored, endorsed, sold or promoted by Standard & Poor’s, and Standard & Poor’s makes no representation regarding the advisability of purchasing the Product. The S&P 500® Index does not reflect dividends paid on the underlying stocks.
INITIAL PREMIUM ALLOCATION
1-Year Interest Account __________% 1-Year Point-to-Point Cap Index Account __________%
1-Year Average Cap Index Account __________% 1-Year Average Participation Index Account __________%
1-Year Monthly Cap Index Account __________% 2-Year Monthly Average Cap Index Account __________%
Total 100% If this annuity is replacing an existing annuity, it is important that you compare the two, taking into account whatever charges you may incur on the surrender of the existing annuity and your need to access your funds. For information about your existing annuity, contact the issuing company.
The insurance producer is appointed to represent the Company and is approved to provide services to you on our behalf. The insurance producer will be compensated by us in connection with any business placed with our Company.
Applicant Statement: By signing below, I acknowledge that I have read, or have been read, this document and understand I am applying for an indexed annuity. I also acknowledge that the annuity meets my financial objectives. I have received a copy of this document, as well as any advertisement that was used in connection with the sale of this annuity. I understand this is not a registered security and that while the values of the policy may be affected by an external index, the policy does not directly participate in any stock or equity investments. Other than the minimum guaranteed values, there are no guarantees, promises, or warranties. I have read the Important Notice Regarding Sales to Military Personnel, if applicable.
____________________________________________________ _______________________________________________ Signature of Owner(s)/Applicant(s) Date Name of Owner(s)/Applicant(s) (please print)
____________________________________________________ _______________________________________________ Social Security # Daytime Telephone Number
Agent Statement: By signing below, I acknowledge I have reviewed this document with the applicant. I certify that a copy of this document, as well as any advertisement used in connection with the sales of this annuity, has been provided to the applicant. I have not made statements that differ in any significant manner from this material. I have not made any promises or guarantees about the future value of any non-guaranteed elements. I have provided the client the Important Notice Regarding Sales to Military Personnel, if applicable.
____________________________________________________ _______________________________________________ Signature of Agent Date Agent Name & Number (please print)
EquiTrust Life Insurance Company • www.equitrust.com • 866-598-3692 7100 Westown Pkwy Ste 200 • West Des Moines, Iowa 50266-2521
Mailing Address • PO Box 14500 • Des Moines, Iowa 50306-3500
COMPANY COPY
Page 3 of 3 – incomplete without all pages
Minimum allocation of $2,000 in an account. Percentages must be whole percentages.
Allocations must equal 100%. Percentages must be whole percentages.
ET-MPP-1101 (01-13)
MARKETPOWER BONUS INDEX Single Premium Fixed and Indexed
Form Series ET-MPP-2000 (02-05) Deferred Annuity Contract
DISCLOSURE STATEMENT Some features of this annuity may not be available in all states and may vary by state. If you have any questions, please contact your representative or EquiTrust Life Insurance Company (“the Company”) for details. This form is not intended to be a complete explanation of your annuity. Please refer to your Contract for complete details.
WHAT IS AN ANNUITY? An annuity is a long-term financial product offered by insurance companies. You may cancel your annuity Contract within a certain number of days of your receipt to receive a complete refund of your premium.
HOW MUCH WILL I EARN ON MY ANNUITY? When you purchase a MARKETPOWER BONUS INDEX Contract, you can choose different accounts for your money. Each account earns interest differently. You may make your allocation elections on page 3 of this disclosure statement.
1-Year Interest Account – The 1-Year Interest Account will earn a declared interest rate. The interest rate will be declared on each Contract Anniversary and is guaranteed for the following Contract Year. The declared interest rate can never be less than the Minimum Guaranteed Interest Rate. The Minimum Guaranteed Interest Rate will be no lower than 1% and no higher than 3%. Once your Contract is issued, the Minimum Guaranteed Interest Rate will not change. Ask your agent for the current interest rate and Minimum Guaranteed Interest Rate.
1-Year Point-to-Point Cap Index Account - Annual Index Credits are based on the percentage change in the Index Number from the previous Contract Anniversary to the current Contract Anniversary, after recognition of the Index Cap.
1-Year Average Cap Index Account - Annual Index Credits are based on the percentage change in the Index Number from the previous Contract Anniversary to the daily average of the Index Numbers for the Contract Year, after recognition of the Index Cap.
1-Year Average Participation Index Account - Annual Index Credits are based on the percentage change in the Index Number from the previous Contract Anniversary to the monthly average of the Index Numbers for the Contract Year, multiplied by the Participation Rate.
1-Year Monthly Cap Index Account – Annual Index Credits are based on the cumulative sum of capped monthly changes in the Index Number over a one-year period. Each of the monthly gains in the Index is subject to a Monthly Cap, but there is no floor on monthly declines in the index.
2-Year Monthly Average Cap Index Account – Index Credits are based on the percentage change in the Index Number from the beginning of the two-year Indexing Period to the monthly average of the Index Numbers for the two year Indexing Period, after recognition of the Index Cap.
Index Account Definitions The Index Number on any specified date is the closing value of the S&P 500® Index on the previous trading day. The Index Cap is the maximum annual percentage excess of the applicable average Index Numbers or the end-of-year Index
Number over the beginning-of-year Index Number. The Index Cap will be declared on each Contract Anniversary and is guaranteed for the following Contract Year. The minimum Index Cap is 1% for the 1-Year Point-to-Point Cap Account, 1% for the 1-Year Average Cap Account, and 3% for the 2-Year Monthly Average Cap Account.
The Monthly Cap is the maximum monthly percentage increase in the end-of-month Index Number over the beginning-of-month Index Number used to determine Index Credits. The Monthly Cap will be declared on each Contract Anniversary and is guaranteed for the following Contract Year. The minimum Monthly Cap is 0.50% for the 1-Year Monthly Cap Index Account.
The Participation Rate is the percentage of the excess of the Monthly Average Index Numbers over the beginning-of-year Index Numbers that is used in the calculation of the Index Credits. The Participation Rate will be declared on each Contract Anniversary and is guaranteed for the following Contract Year. The minimum Participation Rate is 10% for the 1-Year Average Participation Account.
The Index Credits will be added to the Index Accounts at the end of each Indexing Period. The Index Credits in any Indexing Period will never be less than zero.
The Indexing Period is one year for the 1-Year Accounts and two years for the 2-Year Account.
Accumulation Value – Your Accumulation Value is the total of the individual Account Accumulation Values.
Maximum Premium - The maximum premium allowed in the first Contract Year is $1,000,000 without Home Office approval.
Subsequent Premiums – In addition to the Single Premium, subsequent Premium(s) will be allowed in the first Contract Year only. All subsequent premium(s) will be allocated to the 1-Year Interest Account at the time of receipt. On the first Contract Anniversary, the Accumulation Value associated with any premium received since the Contract Date will be reallocated among the Accounts according to your most recent instructions.
APPLICANT COPY Page 1 of 3 – incomplete without all pages
ET-MPP-1101 (01-13)
Premium Bonus – This Contract offers a Premium Bonus equal to the premium paid in the first year multiplied by 10%. The Premium Bonus is allocated to the Accounts proportionately in the same manner as your Premium allocation instructions. Annuities that offer bonus features may have higher fees and charges, longer surrender charge periods, lower credited interest rates and/or lower cap and participation rates than annuities that do not provide the bonus feature.
Minimum Guaranteed Contract Value – The Minimum Guaranteed Contract Value will be 87.5% of Premium Paid (excluding any Premium Bonus), less any partial withdrawals, plus interest earned at a rate no lower than 1% and no higher than 3%. Once your Contract is issued, your Minimum Guaranteed Contract Rate will not change. Ask your agent for the Minimum Guaranteed Contract Rate.
WHAT HAPPENS WHEN I NEED MY MONEY? You may receive partial surrenders or periodic income payments from your annuity by submitting a request acceptable to the Company. When you make withdrawals, surrender or annuitize your annuity, the amount withdrawn will not be credited with any index return in the current Indexing Period. Withdrawals do not participate in any index gains during the Indexing Period of the withdrawal.
Surrender Charges - This annuity product is a long-term contract with substantial penalties for early surrender. Surrender during the surrender charge period may result in a loss of principal. A surrender charge is assessed, according to the schedule below, on any amount withdrawn as a partial or full surrender that is in excess of the penalty-free amount. The surrender charges are for 14 years and decline as follows:
Market Value Adjustment – We may make a Market Value Adjustment (MVA) on amounts withdrawn or surrendered from this Contract. It may result in either an increase or a decrease to the amount withdrawn or surrendered. A MVA will be made only when a Surrender Charge is deducted. Generally, the MVA decreases the Accumulation Value surrendered when interest rates rise, and increases it when interest rates fall. The MVA will not reduce the amount surrendered below the Minimum Guaranteed Contract Value.
Partial Surrenders – Each Contract Year after the first, you may withdraw up to 10% of the Accumulation Value after the most recent Contract Anniversary without being subject to a Surrender Charge or MVA. If the Contract is subsequently surrendered during the Contract Year, the Surrender Charge and MVA will be applied to any previously uncharged Partial Surrender amounts taken in the same Contract Year.
Cash Surrender Value – The Cash Surrender Value equals the greater of (a) the Minimum Guaranteed Contract Value; or (b) the Accumulation Value less any applicable Surrender Charge, and adjusted for any applicable MVA, determined as of the date of surrender. In no event will the Cash Surrender Value be less than the Minimum Guaranteed Contract Value or greater than the Accumulation Value.
Tax Treatment – You may be subject to a 10% Federal penalty tax if you make withdrawals or surrender your annuity before age 59½. If this is a qualified annuity, all distributions may be taxable. Under current tax law, annuities grow tax deferred and an annuity is not required for tax deferral in qualified plans. Consult your tax attorney for more details.
Annuitization – You may choose to have the proceeds of this Contract paid under a payment option on your income date. This is called annuitizing your Contract. When you annuitize, you can choose from several options, including income for life and/or a specified period of years. Once you annuitize your Contract, you may not surrender it or have access to any values of your annuity, other than your income payments.
Death Benefit – The death benefit is the larger of (a) the Contract’s Accumulation Value; or (b) the amount that would have been payable in the event of a full surrender on the date of death, adjusted for any payments made since the date of death. Upon death of an Owner, the Beneficiary may choose to have the Death Benefit paid immediately or applied to a payment option.
Transfer Options – You may transfer amounts between Accounts without a Surrender Charge or MVA. Transfers are allowed each Contract Year on all Accounts except for the 2-Year Account. Transfers are only allowed at the end of each two-year Indexing Period for the 2-Year Account. A written request for transfer must be received prior to the Contract Anniversary. Transfers are subject to minimums.
Nursing Home Waiver Rider – After the first Contract Year, you may make a partial or a full surrender without incurring a Surrender Charge or MVA if you become confined to a Hospital or nursing Care Center for at least 90 consecutive days. Nursing Home Waiver availability may vary by state and issue age.
APPLICANT COPY Page 2 of 3 – incomplete without all pages
ET-MPP-1101 (01-13)
OTHER NOTES Any examples of historical performance of the S&P 500® should not be considered a representation of future performance of the S&P 500®. Future performance of the S&P 500® may be greater or less than any index performance shown in connection with the sale and issue of your annuity Contract. Your Index Credits are based not only on the index, but also the Index Cap or the Participation Rate.
The MARKETPOWER BONUS INDEX Annuity is backed by the financial strength of the Company. It is not guaranteed by any bank
and is not insured by the Federal Deposit Insurance Corporation (FDIC) or any other agency of the federal government. Funded plans under the Employee Retirement Income Security Act of 1974 (ERISA) may not be used with this annuity. The Company can be contacted toll-free at (866) 598-3692 for further clarification if, for any reason, your understanding of
your annuity is different from this explanation.
“S&P 500®” is a trademark of The McGraw-Hill Companies, Inc., and has been licensed for use by the Company. The Product is not sponsored, endorsed, sold or promoted by Standard & Poor’s, and Standard & Poor’s makes no representation regarding the advisability of purchasing the Product. The S&P 500® Index does not reflect dividends paid on the underlying stocks.
INITIAL PREMIUM ALLOCATION
1-Year Interest Account __________% 1-Year Point-to-Point Cap Index Account __________%
1-Year Average Cap Index Account __________% 1-Year Average Participation Index Account __________%
1-Year Monthly Cap Index Account __________% 2-Year Monthly Average Cap Index Account __________%
Total 100% If this annuity is replacing an existing annuity, it is important that you compare the two, taking into account whatever charges you may incur on the surrender of the existing annuity and your need to access your funds. For information about your existing annuity, contact the issuing company.
The insurance producer is appointed to represent the Company and is approved to provide services to you on our behalf. The insurance producer will be compensated by us in connection with any business placed with our Company.
Applicant Statement: By signing below, I acknowledge that I have read, or have been read, this document and understand I am applying for an indexed annuity. I also acknowledge that the annuity meets my financial objectives. I have received a copy of this document, as well as any advertisement that was used in connection with the sale of this annuity. I understand this is not a registered security and that while the values of the policy may be affected by an external index, the policy does not directly participate in any stock or equity investments. Other than the minimum guaranteed values, there are no guarantees, promises, or warranties. I have read the Important Notice Regarding Sales to Military Personnel, if applicable.
____________________________________________________ _______________________________________________ Signature of Owner(s)/Applicant(s) Date Name of Owner(s)/Applicant(s) (please print)
____________________________________________________ _______________________________________________ Social Security # Daytime Telephone Number
Agent Statement: By signing below, I acknowledge I have reviewed this document with the applicant. I certify that a copy of this document, as well as any advertisement used in connection with the sales of this annuity, has been provided to the applicant. I have not made statements that differ in any significant manner from this material. I have not made any promises or guarantees about the future value of any non-guaranteed elements. I have provided the client the Important Notice Regarding Sales to Military Personnel, if applicable.
____________________________________________________ _______________________________________________ Signature of Agent Date Agent Name & Number (please print)
EquiTrust Life Insurance Company • www.equitrust.com • 866-598-3692 7100 Westown Pkwy Ste 200 • West Des Moines, Iowa 50266-2521
Mailing Address • PO Box 14500 • Des Moines, Iowa 50306-3500
APPLICANT COPY
Page 3 of 3 – incomplete without all pages
Minimum allocation of $2,000 in an account. Percentages must be whole percentages.
Allocations must equal 100%. Percentages must be whole percentages.
ET-2504 (02-12)
TO BE USED FOR FLEXIBLE PREMIUM INDEX PRODUCTS
Contract Owner Name (please print): __________________________________________________________
Joint Owner Name (please print): _____________________________________________________________
I/we understand this is a Flexible Premium product, and that while the initial premium is allocated as
specified on the application, subsequent premiums after policy issue are directed to the fixed account for the
remainder of the policy year. I/we want all premiums related to the initial issue allocated in like fashion.
I/we authorize EquiTrust Life Insurance Company to hold issuing the contract until all funds specified on the
application have been received. I/we also understand that the starting index value will not be set and/or
interest will not begin until the date funds are received.
EquiTrust Life Insurance Company • P.O. Box 14500 • Des Moines, IA 50306-3500 866-598-3692
ET-2506 (1-14) Page 1 of 2
Incomplete without all pages
FINANCIAL NEEDS ANALYSISTO BE COMPLETED BY THE CLIENT
SECTION 1: GENERAL INFORMATION
SECTION 2: FINANCIAL PROFILE
The information provided below will allow you and your agent to determine if the annuity product being applied for meets
your current fi nancial needs and objectives. If you elect not to provide the requested information, please be advised that the Company may elect to not issue the annuity contract for which you are applying.
1. SOURCE OF FUNDS: Indicate the source(s) of funds to be used for the purchase of this annuity (indicate all that apply)
2. Excluding the current replacement, have you replaced any other annuity contracts
1. In order to determine the suitability of the annuity applied for, please provide the following information to the best of your ability. If the annuity will be owned by a trust, please provide only the assets of the trust:
*Liquid Assets includes the value of fi nancial assets that can readily be converted into their cash equivalent without loss of principal,
such as checking/savings accounts, stocks, bonds or CDs. It does NOT include real estate, or the funds used to purchase this annuity.
Annual Household Income:
Annual Household Expenses:
Source of Income:
Liquid Assets*:
per year
per year
2a. Provide an explanation for each replacement transaction (excluding current replacement), including reason for replacement, whether a full or partial surrender was made and the amount of all surrender charges. Attach additional pages if necessary.
2b. Is the agent assisting you with this transaction the same agent who replaced other annuity contracts?
If the funds that are being used to purchase this annuity are coming from a life insurance policy, annuity or variable annuity, you must answer questions 2, 2a and 2b.
If replacing or fi nancing the purchase with an existing life insurance policy or annuity contract, complete the applicable Disclosure and Comparison of Annuity Contracts form as well as any state-required replacement forms.
Life Insurance Policy
Yes
Yes
Yes
No
No
No
Within the past 36 months?
Within the past 36-60 months?
AnnuityVariable Life Insurance Variable Annuity Other
CDStocks/Bonds/Mutual Funds
Owner/Applicant Full Name Social Security or Tax ID # Date of Birth Age
Joint Owner/Applicant Full Name Social Security or Tax ID # Date of Birth Age
Any missing, incomplete or incorrect information will require a new client signature and date prior to issuing a contract.
2. What is your net worth?
ET-2506 (1-14) Page 2 of 2
Incomplete without all pagesEquiTrust Life Insurance Company • PO Box 14500
Des Moines, Iowa 50306-3500 • 866-598-3692
4. Do you have a reverse mortgage on your primary residence?
7. Indicate your willingness to accept fi nancial risk:
10 Combined state and federal tax bracket:
12. Will you need access to these funds during your lifetime?
By signing below, I acknowledge that I have read and reviewed the product specifi c Disclosure Statement with my agent, in addition to the fi nancial factors listed above, and have determined that the product meets my needs and objectives.
By signing below I acknowledge that I have made a reasonable effort to obtain information concerning the fi nancial and tax status, investment objectives and other information considered reasonable for this purchase. It is my belief that based on this information and all circumstances known to me at this time, the annuity being applied for meets the fi nancial needs and objectives provided by my clients. In addition, I have verifi ed identity, believe the information provided to me is true and accurate and I understand the Company may contact my client directly for additional information, if necessary.
8. What is your fi nancial experience?
9. Types of current assets (Check all that apply)
5. Do you have an emergency fund for unexpected expenses?
6. Considering your fi nancial and tax status, why are you considering purchasing this annuity? (Check all that apply)
Yes
Conservative
10-20%
0-5 years 6-10 years 11-20 years Over 20 years
If you answered “No” to item 12, skip items 13 and 14, and go to Section 3: Signatures.
Moderate
21-30%
NoYes
31-40% 41-50%
Aggressive
Yes
No
No
Stocks/Bonds
Real Estate
CDs/Money Market Funds Life Insurance/Annuities
Mutual Funds 401k/Pension
Estate Planning Potential Growth Tax Deferral Flexible Income Options Other:
13. When will you need access to these funds?
Less than 1 year 1 to 5 years 6 to 10 years Over 10 years
14. How do you anticipate accessing funds from this annuity? (Check all that apply)
Other, please explain:
Other (provide details):
Penalty-free withdrawals AnnuitizeRequired minimum distributions (qualifi ed only)
Signature of Owner/Applicant
Signature of Agent
Signature of Joint Owner/Applicant
Printed Name of Owner/Applicant
Printed Name of Agent and Agent Number
Printed Name of Joint Owner/Applicant
Date
Date
Date
If purchasing Confi dence Income Immediate Annuity, do not answer items 12, 13 or 14, and go to Section 3: Signatures. For all other products, continue to item 12.
3. Are you aware that the fi xed annuity contract for which you are applying may be a long-term contract with substantial penalties for early withdrawal? Yes No N/A Confi dence Income Immediate Annuity
SECTION 3: SIGNATURES
11. Do you anticipate material changes in your annual income, fi nancial situation and needs, existing assets, liquidity needs, or liquid net worth? Yes If yes, please explainNo
DEPARTMENT OF FINANCIAL SERVICES Division of Agent & Agency Services - Bureau of Investigation
Do you currently own any annuities? Please list: Yes No
Do you currently own life insurance? Please list:
Yes No
Does your income cover all your living expenses including medical? Yes No Do you expect changes to your living expenses? Yes No
Do you anticipate changes in your out-of-pocket medical expenses? Yes No Is your income sufficient to cover future changes in your living and/or out-of-pocket medical expenses during the surrender charge period?
Yes No
Do you have an emergency fund for unexpected expenses? Yes No
Why are you purchasing this annuity?
What are your financial objectives for this purchase? (Check all that apply)
Income Growth (long term) Safety of Principal and Income
Safety of Principal and Growth Pass assets to a beneficiary or beneficiaries at death
Other:
Owner’s Signature Date Signed
DFS-H1-1980 Rule 69B-162.011, F.A.C. Effective 10/21/2014 Page 2 of 4
Describe your risk tolerance: (Check all that apply)
Describe your investment experience by type and length of time:
What is the source of the funds for the purchase of the proposed annuity?
How many years from today will you need access to your funds without a penalty?
Will the proposed annuity replace any product? Yes No
If yes, will you pay a penalty or other charge to obtain these funds? Yes No
If yes, the amount of the charge or penalty $
Additional Information:
Owner’s Signature Date Signed
DFS-H1-1980 Rule 69B-162.011, F.A.C. Effective 10/21/2014 Page 3 of 4
Note: The following three sections to be completed by the agent, insurer, or Managing General Agent proposing purchase; each section requires a response; no section may be left blank or contain a
response consisting of “None” or “N/A”.
Advantages of purchasing the proposed annuity: Disadvantages of purchasing the proposed annuity:
The basis for my recommendation to purchase the proposed annuity or to replace or exchange your existing annuity (ies):
Agent’s Signature Date Signed Note: No questions or response areas are to be left blank when offered to the Owner for signature. If any information requested is unavailable, not applicable or unknown, the insurance agent or insurer must indicate that.
ACKNOWLEDGEMENTS AND SIGNATURES I understand that should I decline to provide the requested information or should I provide inaccurate information, I am limiting the protection afforded me by the Florida Statutes regarding the suitability of this purchase.
I REFUSE to provide this information at this time.
I have chosen to provide LIMITED information at this time.
My annuity purchase IS NOT BASED on the recommendation of this agent or the insurer.
My annuity purchase IS BASED on the recommendation of this agent or the insurer.
APPLICANT:
DO NOT SIGN THIS FORM IF ANY ITEM HAS BEEN LEFT BLANK, BEFORE CAREFULLY REVIEWING THE
INFORMATION RECORDED, OR IF ANY OF THE INFORMATION RECORDED IS NOT TRUE AND CORRECT
TO THE BEST OF YOUR KNOWLEDGE. THE OWNER MAY SUBSTITUTE THEIR INITIALS FOR SIGNATURES ON ALL FORM PAGES WITH THE
EXCEPTION OF THE SIGNATURES BELOW, WHICH ARE REQUIRED.
Owner’s Signature Date Signed
DFS-H1-1980 Rule 69B-162.011, F.A.C. Effective 10/21/2014 Page 4 of 4
EXPLANATION OF TERMS
“Age” is the natural person’s attained age on the day the form is completed.
“Tax Status” is the owner’s Federal Income Tax filing status such as “single” or “married filing jointly”; if “Exempt”, so
state.
“Form of Ownership” is the type of entity, other than a natural person, including a corporation, trust, partnership, limited
liability company, or other business or not-for-profit entity.
“Supporting documents” are the documents that provide a basis for the relationship between the Proposed Annuitant,
and the Owner as it may exist.
“Annual income” is income received during a calendar year, whether earned or unearned.
“Source of annual income” is the income-generating source, such as pension income, dividends, or earned income etc.
“Annual household income” is the combined annual income received by all household members each calendar year.
“Existing Assets” are financial assets including life insurance and annuities.
“Existing Liquid Net Worth” is applicable to those net assets that can readily be converted into their cash equivalent,
without loss of principal after all surrender charges or other deductions have been taken
.“Financial Objectives” are the owner’s stated goals as described to the insurance agent or insurer, if no insurance
agent is involved. These may include but are not limited to the following: (1) Income, (2) Growth (long term capital
appreciation), (3) Safety of Principal and Income, (4) Safety of Principal and Growth, (5) To pass the investment to a
beneficiary or beneficiaries at death.
“Risk Tolerance” means the degree of uncertainty that an investor can reasonably tolerate with regard to a negative
change in his or her investments. Examples of risk tolerance levels may include the following: (1) Conservative (prefer
little or no risk), (2) Moderately conservative (some risk, reduced safety of principal), (3) Moderate (average risk with
potential losses and potentially higher returns), (4) Moderately aggressive (above average risk with potential losses,
risk of principal and potentially higher returns), (5) Aggressive (willing to sustain losses or loss of principal in pursuit of
higher returns).
“Source of the funds” to be used to purchase the proposed annuity means from where the funds will come to purchase
the annuity, and may include but are not limited to; (1) An existing annuity or life insurance contract, (2) Liquid Assets,
including but not limited to, cash in banks, maturing certificates of deposit, and money market accounts, (3) Personal
Loans, (4) Equity Loans, (5) Mortgages, Reverse Mortgages, (6) Death Benefit Proceeds, (7) Funds received upon
retirement from employment, including but not limited to, 401(k) accounts, pensions, and other tax-sheltered funds, (8)
Equities, mutual funds, or bonds, (9) Proceeds from real estate transactions.
Owner’s Signature Date Signed
ET-PRI-4905 (01-12)
This notice is required by law. It explains our information practices. Our practices apply to all current, former and future
customers.
Information We Collect: In order to help us serve your financial needs and to comply with legal and regulatory requirements,
we collect certain information about you. This information varies depending on the products or services you request, but may
include:
• Information we receive from you on your application or other forms (such as name, address, social security number and
financial and health information), including information you provide via the Internet by completing on-line forms;
• Information you allow us to collect (such as health information for underwriting purposes) or information we are
authorized or required by law to collect (such as your taxpayer ID number);
• Information about your transactions with us, our affiliates, or others (such as your payment history or account balances);
• Information we receive from a consumer reporting agency (such as an investigative consumer report, including credit
relationships and history); and
• Information we receive from public records (such as your driving record).
Personal information that has been collected about you may be retained both in our records and in your agent’s files. Reports
prepared by an insurance-support organization may be retained by the insurance support organization and disclosed to other
persons.
To the extent provided by law, you have the right to access and correct the information we have collected about you. You are
also entitled to certain information regarding disclosures of medical information we may have made. To exercise these rights,
provide a written request to the address below, which includes your complete name, address, date of birth, type(s) of policy(ies)
held or applied for and all policy numbers issued to you by us.
The Security of Your Information: We maintain physical, electronic, and procedural safeguards that comply with state and
federal regulations to guard your personal information. Our internal procedures limit access to customer information, and those
individuals permitted access are required to protect customer information and to keep it confidential.
Information We Share: We may share your information with our affiliates to assist us in providing service for your products
or account. This may include sharing information with our affiliates about your account history or experience with us; however,
our affiliates do not use such information for marketing purposes.
We may also share some of the information we obtain about you with certain business partners, such as:
• Sharing information with companies that service your accounts, or that perform services on our behalf,
• Sharing information with companies with whom we have a joint marketing agreement. A joint marketing agreement is
one where another financial institution offers a product or service jointly with us.
We require our business partners to protect customers’ personal information and to limit their use of information shared to the
purpose for which it was shared.
We may also disclose information to non-affiliated third parties as permitted or required by law, including in response to a
subpoena, to prevent fraud, to comply with inquiries from government agencies or other regulators, or in order to process a
transaction you request or authorize.
We do not share medical information except when needed to service your policies, accounts, claims or contracts; when laws
protecting your privacy permit it, or when you consent. Medical information and information obtained from a consumer
reporting agency or motor vehicle reports is not used for marketing purposes.
This notice is being provided on behalf of EquiTrust Life Insurance Company.
Receipt of this notice does not mean your application has been accepted. We may change our privacy practices at times. We
will give you a revised notice when required by law.
Mail inquiries to: EquiTrust Life Insurance Company, Customer Privacy, 7100 Westown Pkwy, Suite 200, West Des Moines,
Name of Distributing Plan/Company Contract/Policy Number Being Exchanged/Transferred
______________________________________________ ______________________ ______________ ________________________ OVERNIGHT MAILING ADDRESS (no PO Boxes) City State/Zip Phone Number
__________________________________________________________ ______________________________________________ Annuitant’s Name (please print) Annuitant’s Social Security Number
__________________________________________________________ ________________________________________________ Owner’s Name (please print) Owner’s Social Security Number
___________________________________________________________ ________________________________________________ Joint Annuitant’s Name – if applicable (please print) Joint Annuitant’s Social Security Number
___________________________________________________________ ________________________________________________ Joint Owner’s Name – if applicable (please print) Joint Owner’s Social Security Number
_______________________________________________ ________________________________ ____________________________ Owner(s) Address City State/Zip
Above account is: Fixed Annuity Certificate of Deposit (CD) Qualified Retirement Plan
Variable Annuity Life Policy Brokerage Account Mutual Fund Money Market Checking/Savings Account Other (specify) _____________________________________________
*Please note Qualified Plans may require separate forms. Please contact the Plan Administrator.
2. PLEASE TRANSFER THESE FUNDS □ immediately or □ on a specific date __/___/__ (not later than the maturity date)
RETURN OF CONTRACT/POLICY (Please choose one if you are transferring the full value of your current contract/policy).
□ I certify that I cannot find my contract/policy.
□ The contract/policy is attached.
3. PLEASE COMPLETE A, B, C, OR D BELOW (ONE ONLY)
A. □ 1035 EXCHANGE □ FULL □ PARTIAL $________ or _____% (Check with your representative for availability).
I hereby make a complete and absolute assignment and transfer all rights, titles, and interests of every nature and character in and to the above contract to the Company in an exchange intended to qualify under Section 1035 of the Internal Revenue Code. If this is an exchange into an existing contract, please provide the existing Contract Number _____________. Without this contract number, the exchange must be made into a new contract. Additionally, by signing this form, I acknowledge that this exchange qualifies under Section 1035 of the Internal Revenue Code as a “like-to-like” exchange. Upon receipt, the Company is directed to surrender all or part of my contract, as indicated above, and apply the value to the product for which I have submitted an application. I understand that by executing this assignment, I irrevocably waive all rights, claims and demand under the above contract. I acknowledge that the Company is furnishing this form and participating in this transaction as an accommodation to me and that the Company assumes no responsibility or liability for my tax treatment under Section 1035 of the Internal Revenue Code or otherwise.
B. NON-QUALIFIED TRANSFER – such as Mutual Fund shares, savings/checking account transfers This is not for 1035 Exchanges.
I wish to liquidate and transfer the: □ Full Value □ Partial Value of $___________ or _________%. The Company will apply all such funds received to an annuity contract issued to me. I understand that the Company assumes no responsibility for tax treatment of this matter and I shall be responsible for payment of all federal, state, and local taxes incurred with respect to the liquidation of such account. I acknowledge that the earnings credited under the annuity contract will begin to accrue when the Company receives these proceeds and all other necessary paperwork in good order.
EquiTrust Life Insurance Company • PO Box 14500 • Des Moines, Iowa 50306-3500 • 866-598-3692
ET-TRN/1035-4902 (10-14)
Special Instructions to Transferring Company for Qualified Plans: If the Owner is of RMD age please process the Required Minimum Distribution for the current year prior to transferring the funds.
C. QUALIFIED ACCOUNT TRANSFER – I wish to liquidate and transfer the:
□ Full Value □ Partial Value in the amount of $____________ or _______% (Certain restrictions may apply).
From: □ IRA □ SIMPLE IRA □ Roth IRA □ SEP IRA □ Stretch IRA □ Other
To: IRA SIMPLE IRA Roth IRA SEP IRA Stretch IRA NOTE: For IRA transfers, if we are issuing a Roth IRA at EquiTrust Life you are responsible for issuing a 1099R for the conversion at the time of surrender.
D. QUALIFIED ACCOUNT ROLLOVER – I wish to liquidate and rollover the:
□ Full Value □ Partial Value in the amount of $____________ or _______% (Certain restrictions may apply).
From: □ IRA □ Qualified Retirement Plan □ SEP IRA □ TSA □ 401(k) Plan □ 457 Plan □ Other
To: IRA SEP IRA This amount represents all or part of my eligible rollover distribution. I understand there will be no mandatory 20% withholding from this distribution because it is a direct rollover to an eligible retirement plan as defined under applicable tax laws. TSA/401(k)/457 Plan/ 401(a) to IRA Qualifying event:
□ Separated from service □ Age 59 ½ □ Termination of plan □ Disability □ Death
If this is a transfer into an existing contract, please provide the existing Contract Number _______________. Without this contract number, the transfer must be made into a new contract.
4. SIGNATURES AND AUTHORIZATIONS
Please make check(s) payable and mail to: EquiTrust Life Insurance Company (overnight) or EquiTrust Life Insurance Company (regular mail) Attn: Annuity New Business Attn: Annuity New Business 7100 Westown Pkwy Suite 200 P.O. Box 14500 West Des Moines, IA 50266-2521 Des Moines, IA 50306-3500
I understand that the Company is providing this form for my convenience and makes no representations concerning my tax treatment. I agree to execute any additional documents required to complete this transaction. If this is an exchange, I acknowledge that this qualifies under Section 1035 of the Internal Revenue Code as a “like-to-like” exchange.
___________________________________________ _____________________________________________ Signature of Owner (Note: A signature guarantee may be required) Signature of Joint Owner (if applicable) ____________________________________________________ _______________________________________________________ Date Spousal Signature (if required for Community Property State)
____________________________________________________ ________________________________________________________ Signature Guarantee by: Name of Bank/Firm Signature of Officer and Title Place Signature Guarantee Stamp here:
5. ACCEPTANCE FOR TRANSFER/1035 EXCHANGE (Home Office Use Only)
The Company requests this liquidation and transfer of the assets listed above. By its signature below, the Company represents that the above described receiving Annuity Contract is or is intended to be an Annuity Contract of the type indicated and that the Company will accept the Section 1035 Exchange/Transfer on behalf of the person(s) named on this form. Please provide us with a report of the pre-and post-TEFRA cost basis in the current contract, if applicable. _______________________________________________ __________________________________________________ Authorized Signature Date ____________________________________________________ _______________________________________________________ Title New Contract Number
EquiTrust Life Insurance Company • PO Box 14500 • Des Moines, Iowa 50306-3500 • 866-598-3692
