Transamerica Life Insurance Company v. Caramadre et al

Filing 1

COMPLAINT against all defendants ( Filing fee $ 350.00; Receipt number 14670001993), filed by Transamerica Life Insurance Company. (Attachments: #1 Civil Cover Sheet, #2 Exhibit A: Program Specifics, #3 Exhibit C: Affidavit of Patrick Garvey, #4 Exhibit D: Annuity Application, #5 Exhibit F: Rescission Letter) -- NOTE: Exhibits B and E docketed separately. (Duhamel, John)

Transamerica Life Insurance Company v. Caramadre et al

Doc. 1 Att. 4

100519 L K 8

T r a n s a m e r i c a L a n d m a r k Variable A n n u i t y
Home Office: C e d a r Rapids, l A
4333 Edgewood Road NE, C e d a r Rapids, IA 52499

Mailing Address: Tran5america Life Insurance Company Telephone: (800) 5 2 5 - 6 2 0 5

11. ANNUITANT
F u l l Name: Patrick G a r v e y = = Residential Address:* M a i l i n g Address: _ Cranston, RI 02910

_

s s N m N : _ - - - - - - - - - - - - D a t e o f Birth:
Telephone: Sex: G{ Male -"---_ E - m a i l Address: _

c

Citizenship: G( U.S. Citizen/Resident Alien

o Female

o Non-Resident Alien (Country o f Residence:

_

* R e s i d e n t i a l A d d r e s s m u s t b e c o m p l e t e d a n d c a n n o t b e a P.O. Box.

12. OWNERSHIP
A. P R I M A R Y O W N E R

o

S a m e a s Annuitant

Linking N u m b e r ( i f applicable):

_

F u l l Name: Residential A d d r e s s : · M a i l i n g Address:

....:E~s~te:la~R~odiriiglules.CiiyiStit=,==p===~r~ing:o:_RI~~8~0;~~~~~======= i t , i a e Z i : Ba r ~ t n. ; 0 2 6 3
= = = - _ _ _ _ _ _ _ _ _ _ _ _ _ City, S t a t e , Z i p :
Date o f B i r t h : _ Citizenship: _

SSNfTlN-.
Telephone:
Sex.:

$

..

_
_

E-mail A d d r e s s :

0 Male

G! U.S. Citizen/Resident Alien

(if' Female
B. J O I N T OWNER ( i f a p p l i c a b l e ) Relationship to Primary Owner:
Full N a m e : R e s i d e n t i a l Address:* M a i l i n g Address:

a

Non-Resident Alien (Country o f Residence:

_

--;,.....:::::=-r:...-_
---,,....:;_ City, S t a t e , Z i p : City, S t a t e , Z i p : Date o f Birth: E-mail A d d r e s s :

_

SSNffiN:
Sex:

----------..".e:------enship:

Telephone: - - - - - - - - - - - - 7 " " - - - - - - - - - -

0

Male Female

0

U.S. C i t i z e n / R e s i d e n t A l i e n

o

o N o n - R e s i d e n t Alien ( C o u n t r y o f R e s i d e n c e :

)

· R e s i d e n t i a l A d d r e s s m u s t be c o m p l e t e d a n d c a n n o t b e a P . O . Box.

A T r u s t e e C e r t i f i c a t i o n F o r m i s r e q u i r e d i f a T r u s t is n a m e d a s O w n e r .

VA-APP01l08
....

8 1 6 0 1 5 0 5 12107 Page 5 o f 1 2

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Dockets.Justia.com

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3 . B E N E F I C I A R Y D E S I G N A T I O N ( I f t h e r e a r e m o r e t h a n 3 beneficiaries, a t t a c h a s e p a r a t e s h e e t )
Full Name: Relationsh ip: Estela Rodrigues owner C i t y , S t a t e , ZiP:.

M a i l i n g Address:

~. ~pg
Contingent
100

'..,
o
u.

SSNrrIN
Sex: 0 M a l e Full N a m e : Relationship: M a i l i n g Address: _

Date o f B i r t h : _ - - - - - - - -

r:i Female

Gf Primary 0

%

-.
C i t y , State, Z i p : D a t e o f Birth:

SSNmN:
Sex: 0 M a l e 0 Female

_

a

o

-"
---_%

Primary 0 Contingent

Full Name:
Relationship: M a i l i n g Address: _ City, S t a t e , Z i p : Date o f Birth:

_

SSNrrIN:
Sex:

_
Male

a

0 Female

o Primary 0

Contingent

---_%

B e n e f i c i a r y designation(s) m u s t t o t a l 100 %. A T r u s t e e C e r t i f i c a t i o n F o r m is r e q u i r e d i f a T r u s t is n a m e d a s B e n e f i c i a r y .

14. INITIAL PURCHASE PAYMENT
[i( Chc:ckIWire Enclosed S QC\O, 0 ( 5 0 . 0 D

o

C a r r i e r t o request release o f funds $,

_ _

o Agent/Client to request release o f funds S

/5. NON--QUALIF1ED INFORMATION
GtNewMoney

o CDJMutual F u n d Liquidation

o

1035 E x c h a n g e

!6. QUALIFIED INFORMATION
o IRA 0
o
Roth IRA

0

SEPIIRA

0

403(b)

0

Other

_

Source o f Funds:

a N e w Money: T a x Y e a r o T r u s t e e Trustee Transfer
(0

(Defaults t o C u r r e n t C a l e n d a r Y e a r )

Rollover From:

o R O T H I R A - D a t e first e s t a b l i s h e d o SEP/IRA o 403(b) o C o n v e r t e d ROTH - D a t e o f c o n v e r s i o n o Other _
VA-APPOl/OS

o IRA

_

_

81601505 12107
Page 6 o f 12

17. GUARANfEED DEATH BENEFITS
I f n o option is specified, t h e R e t u r n o f P r e m i w n D e a t h B e n e f i t will a p p l y . Y o u r s e l e c t i o n c a n n o t b e c b a n g e d a i t e r t h e p o l i c y has b e e n issued.

T h e L i v i n g / W i t h d r a w a l B e n e f i t R i d e r ( s ) i n S e c t i o n 8 a r e n o t a v a i l a b l e i f y o u h a v e c h o s e n t h e Double E n h a n c e d D e a t h BeoefiL

a Return of Premium Dealh Benefit (Issue Ages: 0 to 90) a Annual Step-Up Death Benefit (Issue Ages: 0 to 75)
51 Double Enhanced Death Benefit (Issue Ages: 0 to 75)
Additional D e a t b Benefit Rider(s) - only o n e Additional D e a t h Benefit c a n b e elected:

<::)

w

....
..

!if Additional Death Distribution (Issue Ages: 0 to gO) - Not a v a i l a b l e i n MN a n d W A

a

A d d i t i o n a l Death D i s t r i b u t i o n

+

(Issue Ages: 0 to 75) - Not a v a i l a b l e i n M N a n d W A

~

Is. AVAILABLE LIVING IW ITHDRAWAL BENEFIT RIDERS
F o r t h e d e s c r i p t i o n a n d a p p l i c a b l e f e e s f o r t h e r i d e r ( s ) l i s t e d below, c h e c k t h e p r o s p e c t u s . I f a r i d e r is n o t s e l e c t e d , i t will n o t a p p l y . O n l y one L i v i n g l W i t h d r a w a l B e n e f i t c a n b e elected.

a a

G u a r a n t e e d Principal S o l u t i o n R i d e r ( I s s u e Ages: 0 t o 80) Retirement Income Choice Rider (Issue Ages: 0 to 85)

o

a

Single Joint (Joint Owner in Section 2B o r Sole Beneficiary in Section 3 must b e a spouse).

A d d i t i o n a l R e t i r e m e n t I n c o m e C h o i c e R i d e r o p t i o n s ( m o r e t h a n o o e o p t i o n may b e s e l e c t e d ) :

o

o Death Benefit
Income Enhancement - Not a v a i l a b l e i n

cr

19. OTHER AVAILABLE RIDERS
F o r t h e d e s c r i p t i o n a n d a p p l i c a b l e fees f o r t h e r i d e r ( s ) l i s t e d below, c h e c k t h e p r o s p e c t u s . I f a r i d e r is not s e l e c t e d , i t will not a p p l y .

o

L i q u i d i t y R i d e r (Issue A g e s : 0 t o 9 0 )

110. PORTFOLIO INVESTMENT STRATEGY o I m m e d i a t e I n v e s t m e n t ( F u t u r e P r e m i u m A l l o c a t i o n s w i l l b e invested i n t h i s m a n n e r u n l e s s o t h e r w i s e s p e c i f i e d . )
I elect t o allocate 100% o f my contributions according to l h e percentage(s) listed in " I m m e d i a t e [nv~tment Allocation". C o m p l e t e Section 11. For CA Residents a g e 6 0 a n d over, please include t h e Immediate I n v e s t m e n t F o r m .

o
o

D o l l a r Cost A v e r a g i n g (DCA) P r o g r a m I e l e c t t o allocate 100% o f m y c o n t r i b u t i o n s a c c o r d i n g t o t h e p e r c e n t a g e ( s ) l i s t e d i n " D o l l a r C o s t A v e r a g i n g P r o g r a m " . C o m p l e t e Section 12.

C o m b i n e d : Immediate Investment a n d DCA Program Please complete Section 11 a n d Section 12.

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8160150512107 P a g e 7 o f 12

Ill. IMMEDIATE INVESfMENT/COMBINED ALLOCATION
Portion o f Initial P r e m i u m to b e allocated to Dollar Cost A v e r a g i n g P r o g r a m (if applicable): _ _ .0% Dollar Cost Averaging ($500 minimum per- transfer) - Please complete Section 12. 'tt P o r t i o n o f I n i t i a l P r e m i u m t o b e i m m e d i a t e l y invested: FIXed A c c o u n t s : ·

_ _ .0% I Year Fixed Guaranteed Period Option'"
_ _ .0% 3 Year Fixed Guaranteed Period Option'"

_ _ .0% 5 Year Fixed Guaranteed Period O p t i o n ' " _ _.0% 7 Year Fixed Guaranteed Period Option'"

-"
V a r i a b l e Sub-Accounts:

100 .0% T r a n s a m e r i c a Money M a r k e t '"
_ _ .0% A s s e t Allocation - C o n s e r v a t i v e Portfolio ,,' _ _ .0% Asset Allocation - M o d e r a t e P o r t f o l i o ("

_ _ .0% I n t e r n a t i o n a l M o d e r a t e G r o w t h Fund'" _ _ .0% P I M C O T o t a l R e t u r n " I _ _ .0% T r a n s a m e r i c a B a l a n c e d '" _ _ .0% T r a n s a m e r i c a U.s. G o v e r n m e n t S e c u r i t i e s " I _ _ .0% Marsico Growth _ _.0% MFS High Yield
_ _.0% MFS New Discovery Series

-"

_ _.0% Asset Allocation - M o d e r a t e G r o w t h Portfolio (II
_ _ .0% Asset Allocation - Growth Portfolio _ _ .0% AIM V.I. Basic Value Fund _ _ .0% AIM V.I. Capital Appreciation Fund

_ _ .0% AllianceBernstein Growth a n d Income Portfolio _ _.0% AllianceBemstein Large Cap Growth Portfolio
.0% American Century Large Company Value

_ _.0% MFS International Equity
_ _.0% MFS Total Return Series

_ _.0% Mutual Shares Securities Fund

_ _.0% BlackRock Large Cap Value
_ _.0% Capital Guardian Global

_ _.0% Templeton Foreign Securities F u n d
_ _.0% Templeton Transamerica Global

_ _ .0% Capital Guardian U.S. Equity
_ _.0% Capital Guardian Value
_ _.0% Clarion Global Real Estate Securities _ _ .0% Fidelity - V I P Contrafund ® Portfolio _ _.0% Fidelity - VIP Equity-Income Portfolio

_ _.0% Transamerica Convertible Securities _ _ .0% Transamerica Equity _ _ .0% Transamerica Growth Opportunities

_ _ .0% Transamerica Science & Technology _ _ .0% Transamerica SmalllMid Cap Value
_ _ .0% T. Rowe Price Equity Income _ _.0% T. Rowe Price Growth Stock
_ _.0% T. Rowe Price Small C a p

_ _.0% Fidelity - VIP Growth Portfolio
_ _ .0% Fidelity - VIP Mid C a p Portfolio

_ _ .0% Fidelity - VIP Value Strategies Portfolio
_ _.0% Franklin Income Securities F u n d

_ _.0% Van Kampen Active International Allocation _ _.0% V a n Kampen Large Cap Core _ _.0% Van Kampen M i d - e a p Growth _ . 0 % Other _
_ _.0% O t h e r

_ _ .0% Janus Aspen - Mid C a p Growth Portfolio _ _.0% J a n u s Aspen - Worldwide Growth Portfolio
_ _.0% Jennison Growth

_ _.0% I P M o r g a n Enhanced Index _ _ .0% Legg Mason Partners All Cap

_

100%

· G u a r a n t e e d P e r i o d O p t i o n p r e m i u m limits may apply. O n l y t h e 1 y e a r G u a r a n t e e d P e r i o d is a v a i l a b l e i n t h e following s t a t e s : C T , PA, VT, VA. G u a r a n t e e d P e r i o d O p t i o n s a r e n o t a v a i l a b l e i n t h e following s t a t e s : AL, KY, MD, MN, WA.
1"

I f e i t h e r t h e Double E n h a n c e d D e a t h B e n e f i t i n S e c t i o n 7 o r t h e R e t i r e m e n t I n c o m e C h o i c e R i d e r i n S e c t i o n 8 is elected, a l l o c a t i o n s a r e o n l y allowed a m o n g t h e s e D e s i g n a t e d F u n d s .

VA-APPOl/08

81601505 12107 Page 8 o f 12

o
G

112. D O L L A R cosr A V E R A G I N G ( D C A ) P R O G R A M
T h e r e is a m i n i m m n o f $ 5 0 0 f o r e a c h D C A T r a n s f e r _ T h e m i n i m u m l e n g t h f o r a D C A P r o g r a m i s s i x (6) m o n t h s · T r a n s f e r from: D C A F i x e d Account Transamerica Money M a r k e t Transamerica US Government Securities

IJ1

t--"

If!

(.0

o a a

FrefJuency: o Monthly

a

Quarterly

Number of Transfers:*

a

4

06

08

a

12

a

24

a

Other.

_

T r a n s f e r t o Subaccounts:

_ _ .0% T r a n s a m e r i c a M o n e y M a r k e t '-I _ _ .0% Asset A l l o c a t i o n · C o n s e r v a t i v e P o r t f o l i o '" _ _ .0% Asset A l l o c a t i o n · M o d e r a t e P o r t f o l i o C" _ _.0% Asset Allocation - M o d e r a t e G r o w t h P o r t f o l i o ("

_ _ .0% I n t e r n a t i o n a l M o d e r a t e G r o w t h Fund")
_ _ .0% P I M C O T o t a l R e t u r n ' "

~"

_ _ .0% T r a n s a m e r i c a Balanced (0)

_ _ .0% T r a n s a m e r i c a U.S. G o v e r n m e n t S e c u r i t i e s

C·)

c::)
_ _.0% Asset Allocation - Growth Portfolio _ _.0% A I M V.I. Basic V a l u e F u n d _ _.0% Marsico Growth

_ _.0% MFS High Yield
_ _.0% MFS Total Return S e r i e s _ _.0% MFS International E q u i t y _ _.0% MFS New Discovery Series _ _ .0% Mutual Shares Securities F u n d _ _ .0% Templeton Foreign S e c u r i t i e s F u n d _ _ .0% Templeton T r a n s a m e r i c a GlobaJ

_ _.0% A I M V.l. Capital Appreciation Fund
_ _ .0% AllianceBernstein Growth a n d I n c o m e Portfolio _ _ .0% AlJianceBernstein L a r g e C a p Growth Portfolio

_ _.0% American Century L a r g e C o m p a n y Value
_ _ .0% BlackRoclc: L a r g e C a p V a l u e _ _ .0% Capital Guardian Global _ _ .0% Capital Guardian U.S. Equity _ _ .0% Capital Guardian VaJue _ _ .0% Clarion Global ReaJ E s t a t e Securities _ _ .0% Fidelity - VIP C o n l r a f u o d ® Portfolio
_ _. 0 % F i d e l i t y - V I P E q u i t y - I n c o m e P o r t f o l i o
_ _.0% Fidelity - VIP Growth Portfolio

_ _.0% T r a n s a m e r i c a C o n v e r t i b l e Securities
_ _ .0% T r a n s a m e n c a E q u i t y

_ _ .0% T r a n s a m e r i c a G r o w t h O p p o r t u n i t i e s _ _ .0% T r a n s a m e r i c a S c i e n c e & T e c h n o l o g y
_ _.0% T r a n s a m e r i c a S m a l l l M i d C a p Value _ _.0% T. Rowe Price Equity I n c o m e

_ _.0% Fidelity - VIP M i d C a p Portfolio

_ _.0% T. Rowe Price G r o w t h S i o c k

_ _.0% Fidelity - VIP Value Strategies Portfolio
_ _ .0% Franklin Income Securities F u n d
_ _.0% J a n u s Aspen - Mid C a p Gfj>wth Portfolio

_ _.0% T. Rowe Price Small C a p
_ _.0% Van K a m p e n A c t i v e I n t e r n a t i o n a l Allocation _ _.0% Van K a m p e n Large C a p C o r e _ _ .0% Van K a m p e n M i d - C a p G r o w t h _ _ .0% Other _

_ _.0% J a n u s Aspen - Worldwide G r o w t h Portfolio
_ _. 0 % J e n n i s o n G r o w t h

_ _ .0% JPMorgan Enhanced Index
_ _.0% Legg Mason P a r t n e r s AU C a p

_ _.0% Other
100~

-

_

* W a s h i n g t o n a p p l i c a n t s , D C A c a n n o t e x c e e d t w e l v e months o r ( o u r q u a r t e r s .

" ' I f e i t h e r t h e Double E n h a n c e d D e a t h B e n e f i t in S e c t i o n 7 o r t h e R e t i r e m e n t I n c o m e C h o i c e R i d e r i n S e c t i o n 8 i s
elected, allocations a r e ooIy allowed a m o n g these Designated Funds. VA-APPOI108

81601505 12101 P a g e 9 o f 12

113. ASSET REBALANCING
Rebalancing will n o t begin until completion o f DCA P r o g r a m . i f applicable. Money invested in t h e Fixed Account is not included. More t h a n o n e fund must b e selected t o participate in t h i s p r o g r a m . I f you would like to rebalance to a m i x o t h e r t h a n indicated in " I m m e d i a t e I n v e s t m e n t A l l o c a t i o n . · p l e a s e c o m p l e t e t h e O p t i o n a l Services F o r m . I elect A s s e t R e b a l a n c i n g :

c. c o
tJl

1.11

iD

Gf No 0
0

Yes

Rebalance the variable subaccounts a c c o r d i n g to my Immediate I n v e s t m e n t Allocation using t h e frequency indicated below.

a

Monthly

0

Quarterly

Semi-Annually

a

Annually

114. REPLACEMENT LWORMATION
AU q u e s t i o n s i n t h i s s e c t i o n m u s t be a n s w e r e d .

.....
A. Do you have· any e x i s t i n g a n n u i t y policies o r life i n s u r a n c e contracts? No ctYes

a

B. Will t h i s annuity replace o r c h a n g e a n y existing annuity o r life i n s u r a n c e ? clNo

a

Yes (Complete t h e following information.) Company: Policy#: _ _

lIS. APPLlCANf INFORMATION
o Check here if you want to be sent a copy o f ·Statement o f Additional Information.'
Did t h e a g e n t o r r e g i s t e r e d r e p r e s e n t a t i v e p r e s e n t a n d l e a v e t h e a p p l i c a n t s a l e s m a t e r i a l ? No ctYes

o

/16. TELEPHONE AUIHORIZATION
Please complete t h i s s e c t i o n t o a u t h o r i z e you and/or your A g e n t o f r e c o r d t o m a k e t r a n s f e r requests via o u r recorded telephone l i n e o r inlernet. I f n o o p t i o n i s s e l e c t e d , t h e a u t h o r i z a t i o n w i l l d e f a u l t t o t h e O w n e r ( s ) .

a O w n e r ( s ) Only

ij{ O w n e r ( s ) and Owner's Agent o f record

VA-APP 01108

8 1 6 0 1 5 0 5 12107

Page l O o f 12

117. SIGNATURE(S) OF AUTHORIZATION ACCEPTANCE
· Unless I have notified the Company o f a community o r marital property interest this contract, the C o m p a n y will rely on good faith b e l i e f t h a t no such interest exists and will assume no responsibility for inquiry. T o t h e best o f m y knowledge and belief, all o f my statements a n d answers on this application are correct a n d true. I am in receipt o f a current prospectus for t h i s variable annuity. ( am in receipt o f t h e privacy notice. This application is subject to acceptance by Transamerica u f e Insurance Company. I f this application is rejected for any reason, T r a n s a m e r i c a Life Insurance Company will be liable o n l y for return o f purchase payment paid. [ u n d e r s t a n d that federal law requires all financial institutions t o obtain customer information. including t h e name, residential address. date o f birth. Social Security Number o r T a x Identification Number and any other information Decessary t o sufficiently identify e a c h customer. I understand t h a t failure t o provide this information could result in t h e annuity contract n o t being issued, delayed or unprocessed transactions. or annuity contract termination. "
1-,)

in

· · · ·

(J)

·

·

F o r A p p l i c a n t s in a l l s t a t e s e x c e p t AL, C T . KY, MD, M N , P A , VT, VA, WA: When funds a r e allocated t o t h e Fixed Accounts i n Section 11. policy values may increase o r decrease i n accordance with a n Excess Interest Adjustment prior to the e n d o f the Guaranteed Period.
C o n n e c t i c u t A p p l i c a n t s : An illustration has been provided showing the minimum interest rate percentage applicable t o t h e Fixed Account and I have reviewed it.

·

T H E FIXED ACCOUNT OF T I l l S POLICY GUARANTEES A MINIMUM INTEREST PERCENTAGE O F 1.50. T I l l S RATE MAY BE L O W E R THAN T H E REQUIRED INTEREST RATE F O R CALCULATING MINIMUM SURRENDER
VALUES.READYOURCONTRACTCAREFULL~
I HAVE REVIEWED MY FINANCIAL OBJECTIVES A N D INSURANCE NEEDS, INCLUDING ANY EXISTING ANNUITY COVERAGE, A N D FIND TIIE ANNUITY BEING A P P U E D F O R IS APPROPRIATE FOR M Y NEEDS.

I h a v e read t h e Fraud a n d Disclosure Statements listed on pages 3 and 4 o f this application.

Account v a l u e s w h e n a l l o c a t e d to a n y o f the s u b a c c o u n t s i n S e c t i o n 11 a n d Section 12 a r e not g u a r a n t e e d a s t o fixed dollar amount.
Signwat: Date:

c~<Q.~bv\'
X

' o "3\ \'d- ~ B
X

"

State

I<::C

... Owner(s) Signature:

~ ~ Q~::~~5--Owner):).Ai~1L,~p~~~·~0--:::!.~;--"A~~~~~~~ ~ z;Y~
7i

w J o i n t Owner(s} S i g n a t u r e :

" . A n n u i t a n t Signature ( i f n o t

_

VA-APP 01108

81601505 12107
Page 11 o f 12

r

118. REPRESENTATIVEfAGENT INFORMATION

lfl

.....

I
I

A. D o e s t h e a p p l i c a n t h a v e a n y e x i s t i n g a n n u i t y p o l i c i e s o r l i f e i n s u r a n c e c o n t t a c t s ? No

.../"1

o

iLl

Glyes
B . Do y o u h a v e a n y r e a s o n t o b e l i e v e t h e a n n u i t y a p p l i e d f o r w i l l r e p l a c e o r c h a n g e a n y e x i s t i n g a n n u i t y o r l i f e i n s u r a n c e ? [iJ' N o
-.J

Dyes
C. D i d you p r e s e n t a n d leave t h e a p p l i c a n t i n s u r e r - a p p r o v e d sales material?

r:t Yes
R E M I N D E R - I f applicable, s u b m i t t h e a p p r o p r i a t e s t a t e replacement formes) i f t h e A p p l i c a n t ' s state h a s Replacement Regulations. F o r C o n n e c t i c u t A p p l i c a n t s - I have p r o v i d e d a n i l l u s t r a t i o n s h o w i n g t h e minimum interest r a t e p e r c e n t a g e applicable to t h e F i x e d A c c o u n t a n d reviewed i t with t h e A p p l i c a n t .

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IMPORTANT NOTICE: R E P l A C E M E N T O F l i F E INSURANCE O R A N N U I T I E S
T h i s d o c u m e n t m u s t b e signed by t h e a p p l i c a n t a n d t h e p r o d u c e r , i f t h e r e is o n e , a n d a c o p y left w i t h t h e a p p l i c a n t . You are c o n t e m p l a t i n g t h e p u r c h a s e o f a life i n s u r a n c e policy o r a n n u i t y c o n t r a c t . In s o m e c a s e s t h i s p u r c h a s e may involve d i s c o n t i n u i n g o r c h a n g i n g a n existing policy o r c o n t r a c t . If s o . a replacement is o c c u r r i n g . F i n a n c e d p u r c h a s e s are also considered replacemenlS. A replacement o c c u r s when a n e w p o l i c y o r c o n t r a c t is p u r c h a s e d a n d . i n c o n n e c t i o n w i t h t h e sale, you d i s c o n t i n u e m a k i n g p r e m i u m p a y m e n t s o n t h e existing p o l i c y o r c o n t r a c t , o r a n e x i s t i n g policy o r c o n t r a c t i s s u r r e n d e r e d , forfeited, assigned t o t h e r e p l a c i n g i n s u r e r , o r o t h e r w i s e terminated o r used i n a financed p u r c h a s e . A financed p u r c h a s e occurs w h e n t h e p u r c h a s e o f a n e w life i n s u r a n c e policy involves t h e u s e o f f u n d s o b t a i n e d b y t h e wit.hdrawal o r s u r r e n d e r o f o r b y b o r r o w i n g s o m e o r all o f t h e policy values, i n c l u d i n g a c c u m u l a t e d d i v i d e n d s , o f a n existing policy, t o pay all o r p a n o f a n y p r e m i u m o r p a y m e n t d u e o n t h e n e w policy. A financed p u r c h a s e is a replacement. You s h o u l d carefully c o n s i d e r w h e t h e r a r e p l a c e m e n t is i n y o u r best interest. You will p a y a c q u i s i t i o n c o s t s a n d t.here may be s u r r e n d e r c o s t s d e d u c t e d from y o u r policy o r c o m r a c t . You m a y be able to make c h a n g e s t o y o u r e x i s t i n g p o l i c y o r c o n t r a c t t o meet y o u r i n s u r a n c e n e e d s a t less cost. A financed p u r c h a s e will r e d u c e t h e v a l u e o f y o u r existing p o l i c y a n d m a y r e d u c e t h e a m o u n t p a i d u p o n t h e d e a t h o f t h e i n s u r e d . W e w a n t y o u t o u n d e r s t a n d t h e effects o f r e p l a c e m e n t s before y o u m a k e y o u r p u r c h a s e d e c i s i o n a n d a s k t h a l y o u a n s w e r t h e foHowing q u e s t i o n s a n d c o n s i d e r t h e q u e s t i o n s o n t h e b a c k o f t h i s form. I . Are y o u c o n s i d e r i n g d i s c o n t i n u i n g m a k i n g p r e m i u m p a y m e n t s . s u r r e n d e r i n g , f o r f e i t i n g . a s s i g n i n g t o t h e i n s u r e r , o r o t . h e r w i s e t e r m i n a t i n g y o u r existing policy o r c o n t r a c t ? D YES ri/ NO 2 . Are y o u considering u s i n g f u n d s from y o u r e x i s t i n g policies o r c o n t r a c t s t o p a y p r e m i u m s d u e o n t h e n e w policy o r contract? DYES ~NO I f y o u a n s w e r e d "yes- to e u h e r o f t h e a b o v e q u e s t i o n s , list e a c h existing policy o r c o n t r a c t y o u a r c comemplaLing replacing ( m c l u d e t h e n a m e o f t h e insurer, t h e i n s u r e d . a n d t h e c o n t r a c t n u m b e r i f available) a n d w h e t h e r e a c h p o l i c y w i l l b e replaced o r u s e d a s a s o u r c e o f financing: INSURER NAME

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M a k e s u r e you k n o w t h e facts. C o n t a c t y o u r e x i s t i n g c o m p a n y o r its a g e n t for i n f o r m a t i o n a b o u t t h e o l d policy o r c o n t r a c t . ( I f y o u r e q u e s t o n e . a n i n - f o r c e i l l u s t r a t i o n , p o l i c y s u m m a r y o r a v a i l a b l e d i s c l o s u r e d o c u m e n t s m u s t b e s e n l t o y o u b y t h e e x i s t i n g i n s u r e r . ) A s k for a n d r e t a i n all sales material u s e d b y t h e a g e n t i n t h e sales presentation. Be s u r e t h a t y o u a r e m a k i n g a n i n f o r m e d decision. T h e e x i s t i n g p o l i c y o r c o m r a c t i s b e i n g r e p l a c e d because
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3 0 DAY RIGHT T O CANCEL [f y o u are replacing t h e above c o v e r a g e a n d for a n y reason y o u are n o t satisfied with t.he c o n t r a c t o r polic}~ if i s s u e d b y Company. y o u m a y r e t u r n it t o u s wit.hin 3 0 d a y s o f t h e d e l i v e r y o f t h e c o n t r a c t o r policy a n d receive a n u n c o n d i t i o n a l full r e f u n d o f all premiu~s o r c o n s i d e r a t i o n s p a i d o n it. i n c l u d i n g a n y c o n t r a c t fees o r charges or, i n t h e case o f a variable o r m a r k e t value a d j u s t m e m contr:act o r policy. a p a y m e n t o f the cash s u r r e n d e r v a l u e p r o v i d e d u n d e r the c o n t r a c t o r policy, p l u s t h e fees a n d o t h e r c h a r g e s d e d u c t e d from t.he gross p r e m i u m s o r c o n s i d e r a t i o n s o r i m p o s e d u n d e r s u c h c o m r a c t o r policy. You m a y r e t u r n i t b y d e l i v e r i n g o r mailing i t to o u r A d m i n i s t r a t i v e Office. 4333 E d g e w o o d R o a d NE. C e d a r Rapids, IA 52499. o r t o t h e a g e n t from w h o m y o u p u r c h a s e d t h i s c o n t r a c t o r policy.
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A replacement may not b e i n your best interest, o r y o u r decision c o u l d be a good one. You should make a careful c o m p a r i s o n o f the costs :lnd benefits o f y o u r existing policy o r contract a n d the proposed policy o r contracr. O n e way t o do this is t o ask the c o m p a n y o r agent that sotd you your existing policy o r c o n t r a d t o provide yOll with i n f o r m a t i o n c o n c e r n i n g y o u r existing policy or contract. T h i s may include an illustration of h o w y o u r existing policy o r contract is working n o w a n d h o w it w o u l d perform in the future based o n c e r t a i n assumptions. Illustrations should not, however, b e used as a sole basis to c o m p a r e policies o r contracts. You should discuss the following with y o u r agent t o d e t e r m i n e w h e t h e r replacement o r financing y o u r purchase m a k e s sense: PREMIUMS: Are they affordable? C o u l d t h e y change? You're older - are p r e m i u m s higher for the proposed n e w policy? How long will y o u have t o pay premiums on the new policy? O n t h e o l d policy? POLICY VALUES: New policies usuaUy take longer to build cash values a n d to pay dividends. Acquisition costs for the old policy may have been paid; you will i n c u r costs for the new one. What s u r r e n d e r charges d o the policies have? What expense a n d sales charges will you pay o n the n e w policy? Does t h e n e w policy provide more insurance coverage? INSURABILllY: If y o u r health has changed since you b o u g h t y o u r o l d policy; t h e n e w o n e could cost you more, o r you c o u l d b e t u r n e d down. You may need a medical exam for a new policy. (Claims o n m o s t new polices for u p to the fir-a two years c a n be d e n i e d based on inaccurate statements. S u i c i d e l i m i t a t i o n s m a y b e g i n a n e w o n t h e n e w coverage.) IF YOU ARE KEEPING THE OLD POLICY AS WELL AS THE N E W POLICY: How are p r e m i u m s for b o t h policies being paid? How wtll the p r e m i u m s o n your existing policy be affected? Will a loan b e d e d u c t e d from death benefits? W h a t values from t h e o l d policy are being used to pay premiums? IF YOU ARE SURRENDERING AN ANNUllY OR INTEREST SENSITIVE LIFE PRODUCT: WiU you pay s u r r e n d e r charges on your old contract! W h a t a r e t h e interest rate guarantees for the new contract? Have y o u c o m p a r e d the contract charges o r o t h e r policy expenses? OTHER ISSUES T O CONSIDER FOR ALL TRANSACTIONS: W h a t a r e m e tax consequences o f buying the new policy? Is this a tax-free exchange? (See y o u r t a x advisor.) Is there a benefLt from favorable "grandfathered" treatment o f m e old policy u n d e r the federalta.:< code? Will t h e existing i n s u r e r b e willing to modify t h e o l d policy? How d o e s m e quality a n d financial stability o f the new c o m p a n y c o m p a r e w i t h your existing company? What Insurer-approved sales materials were presented and given t o t h e applicant? Description o f Material (ex: brochure. folder. highlight sheet): Identifying n u m b e r given to the sales material (Usually found i n t h e b o t t o m comer)·~_ _

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What Insurer-approved sales materials were presented and given to t h e applicant? Description o f Material (ex: brochure, folder, highlight shcct): . Identifying n u m b e r given to t h e sales material (Usually found in t h e b o t t o m c o r n e r ).:... _ _

\Vhat Insurer-approved sales materials were presented a n d given to t h e a p p l i a t n t ? Description o f Material (ex: b r o c h u r e . folder, highlight sheet): Identifying n u m b e r given to the sales material (Usually found in the b o t t o m corner):..; _ _

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