See All of This Company's Exhibits
EX-99.5.A.
4
file004.txt
INDIVIDUAL AND GROUP APPLICATION
[LOGO] SECURITY BENEFIT SM VARIFLEX VARIABLE ANNUITY APPLICATION
ISSUED BY SECURITY BENEFIT LIFE INSURANCE COMPANY, TOPEKA, KANSAS. QUESTIONS? CALL OUR NATIONAL SERVICE CENTER AT 1-800-888-2461.
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INSTRUCTIONS
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Complete the entire form to establish a new Variflex Variable Annuity Contract. Please type or print.
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1. CHOOSE TYPE OF ANNUITY CONTRACT
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Select the type:
|_| Flexible Premium Deferred |_| Single Premium Deferred |_| Single Premium Immediate
Select the Qualification:
|_| Non-Qualified |_| 403(b) TSA |_| Roth 403(b) TSA |_| Traditional IRA |_| Roth IRA
|_| 401(a) |_| 401(k) |_| Roth 401(k) |_| 457 |_| SEP-IRA |_| SIMPLE IRA
Initial Contribution $ _________________________
FOR IRAS ONLY: Current Year $ _________________ Prior Year $ _________________ Rollover $ _________________________
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2. PROVIDE ANNUITANT INFORMATION
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Name of Annuitant ______________________________________________________________________________________________ |_| Male |_| Female
First MI Last
Mailing Address ____________________________________________________________________________________________________________________
Street Address City State ZIP Code
Residential Address_________________________________________________________________________________________________________________
(if different from mailing address) Street Address City State ZIP Code
Social Security Number/Tax I.D. Number _____________________________________ Date of Birth _______________________________________
(mm/dd/yyyy)
Daytime Phone Number _____________________________________ Home Phone Number _______________________________________________________
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3. PROVIDE CONTRACTOWNER INFORMATION
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|_| Same as Annuitant
Name of Contractowner __________________________________________________________________________________________ |_| Male |_| Female
First MI Last
Mailing Address ____________________________________________________________________________________________________________________
Street Address City State ZIP Code
Residential Address ________________________________________________________________________________________________________________
(if different from mailing address) Street Address City State ZIP Code
Social Security Number/Tax I.D. Number _____________________________________ Date of Birth ______________________________________
(mm/dd/yyyy)
Daytime Phone Number _____________________________________ Home Phone Number _______________________________________________________
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Please Continue
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4. PROVIDE JOINT OWNER INFORMATION
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Name of Joint Owner ____________________________________________________________________________________________ |_| Male |_| Female
First MI Last
Mailing Address ____________________________________________________________________________________________________________________
Street Address City State ZIP Code
Residential Address ________________________________________________________________________________________________________________
(if different from mailing address) Street Address City State ZIP Code
Social Security Number ______________________________________________________ Date of Birth ______________________________________
(mm/dd/yyyy)
Daytime Phone Number _____________________________________ Home Phone Number ____________________________________________________
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5. PROVIDE PRIMARY AND CONTINGENT BENEFICIARY(IES)
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For additional Primary Beneficiaries, please attach a separate list to the end of this application.
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PRIMARY BENEFICIARY NAME DOB (MM/DD/YYYY) RELATIONSHIP TO OWNER % OF BENEFIT
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1.
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2.
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3.
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4.
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For additional Contingent Beneficiaries, please attach a separate list to the end of this application.
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CONTINGENT BENEFICIARY NAME DOB (MM/DD/YYYY) RELATIONSHIP TO OWNER % OF BENEFIT
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1.
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2.
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6. PROVIDE REPLACEMENT INFORMATION
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DO YOU CURRENTLY HAVE ANY EXISTING ANNUITY OR INSURANCE POLICIES? |_| YES |_| NO
DOES THIS PROPOSED CONTRACT REPLACE OR CHANGE ANY EXISTING ANNUITY OR INSURANCE POLICY? |_| YES |_| NO
IF YES, PLEASE LIST THE COMPANY AND POLICY NUMBER.
Company Name _______________________________________________________ Policy Number _______________________________________________
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7. INDICATE INVESTMENT DIRECTIONS
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Please indicate your investment preferences below. Please use whole percentages totaling 100%
________ % AIM V.I. Basic Value
________ % AIM V.I. Capital Development
________ % AIM V.I. Global Health Care
________ % AIM V.I. International Growth
________ % AIM V.I. Mid Cap Core Equity
________ % AIM V.I. Real Estate
________ % American Century VP Ultra
________ % American Century VP Value
________ % Dreyfus IP Technology Growth
________ % Dreyfus VIF International Value
________ % MFS VIT Research International
________ % MFS VIT Total Return
________ % MFS VIT Utilities
________ % Oppenheimer Main Street Small Cap Fund/VA
________ % PIMCO VIT All Asset
________ % PIMCO VIT Commodity Real Return Strategy
________ % PIMCO VIT Foreign Bond (U.S. Dollar-Hedged)
________ % PIMCO VIT Low Duration
________ % PIMCO VIT Real Return
________ % Royce Micro-Cap
________ % Rydex VT Sector Rotation
________ % Salomon Brothers Variable Aggressive Growth
________ % Salomon Brothers Variable Small Cap Growth
________ % SBL Alpha Opportunity
________ % SBL Diversified Income
________ % SBL Enhanced Index
________ % SBL Equity
________ % SBL Equity Income
________ % SBL Global
________ % SBL High Yield
________ % SBL Large Cap Growth
________ % SBL Large Cap Value
________ % SBL Main Street Growth & Income
________ % SBL Managed Asset Allocation
________ % SBL Mid Cap Growth
________ % SBL Mid Cap Value
________ % SBL Money Market
________ % SBL Select 25
________ % SBL Small Cap Growth
________ % SBL Small Cap Value
________ % SBL Social Awareness
________ % Van Kampen LIT Comstock
________ % Van Kampen LIT Government
________ % Van Kampen UIF Equity and Income
________ % General Account
MUST TOTAL 100%
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8. SALARY INFORMATION
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PLEASE COMPLETE THIS SECTION ONLY IF YOU ARE CONTRIBUTING THROUGH SALARY REDUCTION AND/OR DEDUCTION.
Contribution Amount (select all that apply):
|_| Pre-tax Qualified Contribution of $_______________per year or_____________% per pay period.
|_| After-tax Roth Contribution of $_______________per year or_____________% per pay period.
Beginning: ____________________________________________ Please skip the following month(s): ________________________________________
Date (mm/dd/yyyy)
Will your employer match contributions? |_| Yes |_| No
Employer Name ______________________________________________________________________________________________________________________
Mailing Address ____________________________________________________________________________________________________________________
Street Address City State ZIP Code
Billing Statement Address __________________________________________________________________________________________________________
(if different from above) Street Address City State ZIP Code
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9. SET UP ELECTRONIC PRIVILEGES
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Transactions may be requested via telephone, Internet, or other electronic means by the Owner and/or servicing sales
representative based on instructions of the Owner.
|_| I do NOT wish to authorize electronic privileges.
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10. STATEMENT OF UNDERSTANDING
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I have been given a current prospectus that describes the Contract for which I am applying and a current prospectus for each of the
funds underlying Investment Options above. I UNDERSTAND THAT ANNUITY PAYMENTS AND WITHDRAWAL VALUES, IF ANY, WHEN BASED ON THE
INVESTMENT EXPERIENCE OF THE INVESTMENT OPTIONS ARE VARIABLE AND DOLLAR AMOUNTS ARE NOT GUARANTEED and that any benefits, values or
payments based on performance of the Investment Options may vary and are NOT guaranteed by the U.S. Government or any State
Government; and are NOT federally insured by the FDIC, the Federal Reserve Board or any other agency, Federal or State. I further
understand that I bear all investment risk unless some of my funds are placed in the Security Benefit Fixed Account.
If my annuity contract qualifies under Section 403(b), I declare that I know: (1) the limits on withdrawals from my Contract imposed
by Section 403(b)(11) of the Internal Revenue Code; and (2) the investment choices available under my employer's Section 403(b) plan
to which I may elect to transfer my account balance. I understand that the amount paid and the application must be acceptable to
Security Benefit under its rules and practices. If they are, the contract applied for will be in effect on the Contract Date. If
they are not, Security Benefit will be liable only for the return of the amount paid.
|_| Check this box to receive a Statement of Additional Information.
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Please Continue
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11. PROVIDE SIGNATURE
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My signature below indicates to the best of my knowledge and belief the information provided within the application is accurate and
true, including my tax identification number.
TAX IDENTIFICATION NUMBER CERTIFICATION
INSTRUCTIONS: You must cross out item (2) in the below paragraph if you have been notified by the IRS that you are currently subject
to backup withholding because you have failed to report all interest or dividends on your tax return. For contributions to an
individual retirement arrangement (IRA), and generally payments other than interest and dividends, you are not required to sign the
certification, but you must provide your correct Tax Identification Number.
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 because: (a) I am exempt from backup
withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a
result of a failure to report all interest or dividends or the IRS has notified me that I am no longer subject to backup
withholding; and (3) I am a U.S. Person (including a U.S. Resident Alien).
THE INTERNAL REVENUE SERVICE DOES NOT REQUIRE YOUR CONSENT TO ANY PROVISION OF THIS DOCUMENT OTHER THAN THE CERTIFICATIONS REQUIRED
TO AVOID BACKUP WITHHOLDING.
X_________________________________________________________________ ______________________________________________________________
Signature of Owner Date (mm/dd/yyyy) Signed at (City/State)
X_________________________________________________________________
Signature of Joint Owner Date (mm/dd/yyyy)
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REGISTERED REPRESENTATIVE/DEALER INFORMATION
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Will the Annuity being purchased replace any prior insurance or annuities of this or any other Company?
|_| No, to the best of my knowledge, this application is not involved in the replacement of any life insurance or annuity
contract, as defined in applicable Insurance Department Regulations, except as stated in Statement above. I have complied with
the requirements for disclosure and/or replacement.
|_| Yes. If Yes, please comment below. (Submit a copy of the Replacement Notice with this application and leave with the applicant
a copy of any written material presented to the applicant.)
Comments: __________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
Print Name of Representative _______________________________________________________________________________________________________
X __________________________________________________________________________________________________________________________________
Signature of Representative Date (mm/dd/yyyy)
Address ____________________________________________________________________________________________________________________________
Street Address City State ZIP Code
Daytime Phone Number_________________________________________________ Email Address _____________________________________________
Representative License I.D. Number _____________________________________________________
Print Name of Broker/Dealer ________________________________________________________________________________________________________
For Registered Representative's Use Only
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Mail to: Security Benefit o PO Box 750497 o Topeka, KS 66675-0497 or
Fax to: 1-785-368-1772
Visit us online at www.securitybenefit.com
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[LOGO] SECURITY BENEFIT SM VARIABLE ANNUITY APPLICATION
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STATE FRAUD DISCLOSURES
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Any person who, with intent to defraud or knowing that he/she is facilitating
fraud against an insurer, submits an application or files a claim containing a
false or deceptive statement is guilty of insurance fraud. This state fraud
disclosure applies to all jurisdictions except KS, MN and the states listed
below.
AR, DC, KY, ME, NM, OH AND PA ONLY - Any person who, knowingly and with intent
to defraud any Insurance Company or other person, files an application for
insurance or statement of claim containing materially false information or
conceals for the purpose of misleading, information concerning any fact material
thereto commits a fraudulent insurance act which is a crime and subjects such
person to criminal and civil penalties.
AZ ONLY - Upon written request, the Company will provide additional information
regarding the benefits and provisions of this annuity contract to the
Owner/Applicant. If for any reason, the Owner/Applicant is not satisfied with
this annuity contract, the Owner/Applicant may return the contract within 10
days after the contract is delivered and receive a refund equal to the sum of
the difference between the premiums paid, including any contract fees or other
charges, and the amounts allocated to any separate accounts under the contract,
and the value of the amounts allocated to any separate accounts under the
contract on the date the returned contract is received by the Company.
CT ONLY - Any person who, with intent to defraud or knowing that he/she is
facilitating a fraud against an insurer, submits an application or files a claim
containing a false or deceptive statement may be guilty of insurance fraud, as
determined by a court of competent jurisdiction.
FL ONLY - Any person who knowingly and with intent to injure, defraud, or
deceive any insurer files a statement of claim or an application containing
false, incomplete, or misleading information is guilty of a felony of the third
degree.
LA ONLY - Any person who knowingly presents a false or fraudulent claim for
payment of a loss or benefit or knowingly presents false information in an
application for insurance is guilty of a crime may be subject to fines and
confinements in prison.
NJ ONLY - Any person who includes any false or misleading information on an
application for an insurance policy is subject to criminal and civil penalties.
OK ONLY - WARNING: Any person who knowingly and with intent to injure, defraud
or deceive any insurer, makes a claim for the proceeds of an insurance policy
containing any false, incomplete or misleading information is guilty of
insurance fraud.
OR ONLY - Any person who, with intent to defraud or knowing that he/she is
facilitating fraud against an insurer, submits an application or files a claim
containing a false or deceptive statement may be guilty of insurance fraud.
TX ONLY - Any person who, with intent to defraud or knowing that he/she is
facilitating a fraud against an insurer, submits an application or files a claim
containing a false or deceptive statement is guilty of insurance fraud, as
determined by a court of competent jurisdiction.
WA AND VT ONLY - Any person who knowingly presents a false or fraudulent claim
for the payment of a loss or knowingly makes a false statement in an application
for insurance may be guilty of a criminal offense under state law.
VA ONLY - Any person who, with intent to defraud or knowing that he/she is
facilitating a fraud against an insurer, submits an application or files a claim
containing a false or deceptive statement may have violated state law.
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IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING A NEW ACCOUNT
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To help the government fight the funding of terrorism and money laundering
activities, Federal law requires all financial institutions to obtain, verify
and record information that identifies each person who opens an account.
What this means to you: When you open an account, we will ask for your name,
address, date of birth, and other information that will allow us to identify
you. We may also ask to see your driver's license or other identifying
documents.
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