Common use of UNDERSTOOD AND AGREED THAT Clause in Contracts

UNDERSTOOD AND AGREED THAT. If the Owner is a Trustee or successor Trustee under a tax qualified plan or the employer under a tax qualified non-trusteed plan, Northwestern Mutual Life will be fully discharged of liability for any action taken by the Owner in the exercise of any contract right and for all amounts paid to, or at the direction of, the Owner and will have no obligation as to the use of the amounts. In all dealings with the Owner, Northwestern Mutual Life will be fully protected against the claims of every other person. The premium will be credited the date both the entire premium and the application are received at the Home Office. Receipt of the premium at a payment facility designated by Northwestern Mutual Life will be considered the same as receipt at the Home Office. If a Tax Qualified Employee Plan, an IRA or TDA is applied for, the Applicant and/or Annuitant have received and reviewed the appropriate ERISA, IRA or TDA disclosure statements. FIXED ANNUITY - SINGLE PREMIUM RETIREMENT ANNUITY POLICIES HAVE PROVISIONS FOR THE ASSESSMENT OF SURRENDER CHARGES ON CASH WITHDRAWAL. No agent is authorized to make or alter contracts or to waive the rights or requirements of Northwestern Mutual Life. X__________________________________________________________________ X_______________________________________________ Signature of Applicant (Indicate relationship below if applicable) Signature of Annuitant (if other than Applicant) [ ] Trustee [ ] Employer X_______________________________________________ Signature of Licensed Agent Date Signed at: City County State | | | | | | | | ___________________________________________________________________________________________________________________________ 50 -------------------------------------------------------------------------------- AGENT'S CERTIFICATE -------------------------------------------------------------------------------- Annuitant Name: First, MI, Last A | |_____________________________________________________________________ 1. To the best of your knowledge will the annuity applied for replace any life insurance or annuity contract in this company or elsewhere? [ ] YES [ ] NO 2. On |__________ the following Prospectus or Offering Circular and Report was delivered: [ ] ACCOUNT A OFFERING CIRCULAR DATED______________AND REPORT DATED _____________(CORPORATE PENSION PLANS) [ ] ACCOUNT A PROSPECTUS DATED______________(PARTNERSHIP OR SOLE PROPRIETORSHIP PENSION PLANS) [ ] ACCOUNT B PROSPECTUS DATED______________(ALL OTHERS) 3. Was any part of this application translated?

UNDERSTOOD AND AGREED THAT. If the Owner is a Trustee or successor Trustee under a tax qualified plan or the employer under a tax qualified non-trusteed plan, Northwestern Mutual Life will be fully discharged of liability for any action taken by the Owner in the exercise of any contract right and for all amounts paid to, or at the direction of, the Owner and will have no obligation as to the use of the amounts. In all dealings with the Owner, Northwestern Mutual Life will be fully protected against the claims of every other person. The premium will be credited the date both the entire premium and the application are received at the Home Office. Receipt of the premium at a payment facility designated by Northwestern Mutual Life will be considered the same as receipt at the Home Office. If a Tax Qualified Employee Plan, an IRA or TDA is applied for, the Applicant and/or Annuitant have received and reviewed the appropriate ERISA, IRA or TDA disclosure statements. FIXED ANNUITY - SINGLE PREMIUM RETIREMENT ANNUITY POLICIES HAVE PROVISIONS FOR THE ASSESSMENT OF SURRENDER CHARGES ON CASH WITHDRAWAL. No agent is authorized to make or alter contracts or to waive the rights or requirements of Northwestern Mutual Life. X__________________________________________________________________ X_______________________________________________ Signature of Applicant (Indicate relationship below if applicable) Signature of Annuitant (if other than Applicant) [ ] Trustee [ ] Employer X_______________________________________________ Signature of Licensed Agent Date Signed at: City County State | | | | | | | | ___________________________________________________________________________________________________________________________ 50 49 -------------------------------------------------------------------------------- AGENT'S CERTIFICATE -------------------------------------------------------------------------------- Annuitant Name: First, MI, Last A | |_____________________________________________________________________ 1. To the best of your knowledge will the annuity applied for replace any life insurance or annuity contract in this company or elsewhere? [ ] YES [ ] NO 2. On |__________ the following Prospectus or Offering Circular and Report was delivered: [ ] ACCOUNT A OFFERING CIRCULAR DATED______________AND REPORT DATED _____________(CORPORATE PENSION PLANS) [ ] ACCOUNT A PROSPECTUS DATED______________(PARTNERSHIP OR SOLE PROPRIETORSHIP PENSION PLANS) [ ] ACCOUNT B PROSPECTUS DATED______________(ALL OTHERS) 3. Was any part of this application translated?

UNDERSTOOD AND AGREED THAT. If (1) The application consists of this application form and the Owner medical questionnaire; (2) The representations are true and complete to the best of my knowledge and belief; (3) No liability exists and the insurance applied for will not take effect until the policy is delivered and the payment is made during the lifetime of the proposed Insured(s) and then only if the proposed Insured(s) has (have) not consulted or been treated by any physician or practitioner of any healing art or had any tests listed in the application since its completion; but if the payment is paid prior to delivery of the policy and a Trustee or successor Trustee under a tax qualified plan or conditional receipt is delivered by the employer under a tax qualified non-trusteed planregistered representative, Northwestern Mutual Life insurance will be fully discharged of liability for any action taken by the Owner in the exercise of any contract right and for all amounts paid to, or at the direction of, the Owner and will have no obligation as effective subject to the use terms of the amounts. In all dealings with the Owner, Northwestern Mutual Life will be fully protected against the claims of every other person. The premium will be credited the date both the entire premium conditional receipt; and the application are received at the Home Office. Receipt of the premium at a payment facility designated by Northwestern Mutual Life will be considered the same as receipt at the Home Office. If a Tax Qualified Employee Plan, an IRA (4) No registered representative or TDA is applied for, the Applicant and/or Annuitant have received and reviewed the appropriate ERISA, IRA or TDA disclosure statements. FIXED ANNUITY - SINGLE PREMIUM RETIREMENT ANNUITY POLICIES HAVE PROVISIONS FOR THE ASSESSMENT OF SURRENDER CHARGES ON CASH WITHDRAWAL. No agent broker is authorized to make amend, alter, or alter contracts or to waive modify the rights or requirements terms of Northwestern Mutual Lifethis agreement. X__________________________________________________________________ X______________________________________ Signature of Insured Date Signature of Spouse Date (if application is for Other Insured Rider) ______________________________________ Signature _______________________________________ Print Name of Applicant (Indicate relationship below if applicable) Signature Insured Print Name of Annuitant (if other than Applicant) [ ] Trustee [ ] Employer Spouse X_____________________________________ _______________________________________ Signature of Licensed Agent 2nd Insured Date Signed at: at City County State | | | | | | | | ___________________________________________________________________________________________________________________________ 50 -------------------------------------------------------------------------------- AGENT'S CERTIFICATE -------------------------------------------------------------------------------- Annuitant Name: First, MI, Last A | |Print Name of 2nd Insured X_____________________________________ Signature of Owner Date (if other than Insured) _____________________________________________________________________ 1_ Print Name of Owner Agent's Report -------------------------------------------------------------------------------- 15. To REPLACEMENT Agents are required to complete this section. -------------------------------------------------------------------------------- Is the best of your knowledge will the annuity insurance being applied for considered a replacement according to its definition in the replacement regulations (if any) of the state in which the business was written? (send Replacement and/or 1035 Exchange forms where applicable) |_| Yes |_| No Indicate any replacement in the chart below. -------------------------------------------------------------------------------- 16. LIFE INSURANCE IN EFFECT Agents are required to complete this section. -------------------------------------------------------------------------------- Please list all life insurance currently in effect; indicate if insurance being applied for will replace any of the listed policies: --------------------------------------------------------------------------------------------- Company/Policy # Year Amount Accidental Waiver Replacing Other Personal Business Death Benefit Policies?* --------------------------------------------------------------------------------------------- $ $ $ |_| Yes |_| No |_| Yes |_| No --------------------------------------------------------------------------------------------- |_| Yes |_| No |_| Yes |_| No --------------------------------------------------------------------------------------------- |_| Yes |_| No |_| Yes |_| No --------------------------------------------------------------------------------------------- |_| Yes |_| No |_| Yes |_| No --------------------------------------------------------------------------------------------- |_| Yes |_| No |_| Yes |_| No --------------------------------------------------------------------------------------------- Total $ $ $ -------------------------------------------------------------------- *If life insurance or annuity contract in applied for is replacing existing policy -------------------------------------------------------------------------------- 17. BUSINESS INSURANCE Please complete this company or elsewhere? [ ] YES [ ] NO 2section if business insurance is applied for. On |__________ the following Prospectus or Offering Circular and Report was delivered: [ ] ACCOUNT A OFFERING CIRCULAR DATED______________AND REPORT DATED _____________(CORPORATE PENSION PLANS) [ ] ACCOUNT A PROSPECTUS DATED______________(PARTNERSHIP OR SOLE PROPRIETORSHIP PENSION PLANS) [ ] ACCOUNT B PROSPECTUS DATED______________(ALL OTHERS) 3. Was any part of this application translated?--------------------------------------------------------------------------------

UNDERSTOOD AND AGREED THAT. If the Owner is a Trustee or successor Trustee under a tax qualified plan or the employer under a tax qualified non-trusteed plan, Northwestern Mutual Life will be fully discharged of liability for any action taken by the Owner in the exercise of any contract right and for all amounts paid to, or at the direction of, the Owner and will have no obligation as to the use of the amounts. In all dealings with the Owner, Northwestern Mutual Life will be fully protected against the claims of every other person. The premium will be credited the date both the entire premium and the application are received at the Home Office. Receipt of the premium at a payment facility designated by Northwestern Mutual Life will be considered the same as receipt at the Home Office. If a Tax Qualified Employee Plan, an IRA or TDA is applied for, the Applicant and/or Annuitant have received and reviewed the appropriate ERISA, IRA or TDA disclosure statements. FIXED ANNUITY - SINGLE PREMIUM RETIREMENT ANNUITY POLICIES HAVE PROVISIONS FOR THE ASSESSMENT OF SURRENDER CHARGES ON CASH WITHDRAWAL. No agent is authorized to make or alter contracts or to waive the rights or requirements of Northwestern Mutual Life. X__________________________________________________________________ X_______________________________________________ Signature of Applicant (Indicate relationship below if applicable) Signature of Annuitant (if other than Applicant) [ ] Trustee [ ] Employer X_______________________________________________ Signature of Licensed Agent Date Signed at: City County State | | | | | | | | ___________________________________________________________________________________________________________________________ 50 52 -------------------------------------------------------------------------------- AGENT'S CERTIFICATE -------------------------------------------------------------------------------- Annuitant Name: First, MI, Last A | |_____________________________________________________________________ 1. To the best of your knowledge will the annuity applied for replace any life insurance or annuity contract in this company or elsewhere? [ ] YES [ ] NO 2. On |__________ the following Prospectus or Offering Circular and Report was delivered: [ ] ACCOUNT A OFFERING CIRCULAR DATED______________AND REPORT DATED _____________(CORPORATE PENSION PLANS) [ ] ACCOUNT A PROSPECTUS DATED______________(PARTNERSHIP OR SOLE PROPRIETORSHIP PENSION PLANS) [ ] ACCOUNT B PROSPECTUS DATED______________(ALL OTHERS) 3. Was any part of this application translated?

UNDERSTOOD AND AGREED THAT. If the Owner is a Trustee or successor Trustee under a tax qualified plan or the employer under a tax qualified non-trusteed plan, Northwestern Mutual Life will be fully discharged of liability for any action taken by the Owner in the exercise of any contract right and for all amounts paid to, or at the direction of, the Owner and will have no obligation as to the use of the amounts. In all dealings with the Owner, Northwestern Mutual Life will be fully protected against the claims of every other person. The premium will be credited the date both the entire premium and the application are received at the Home Office. Receipt of the premium at a payment facility designated by Northwestern Mutual Life will be considered the same as receipt at the Home Office. If a Tax Qualified Employee Plan, an IRA or TDA is applied for, the Applicant and/or Annuitant have received and reviewed the appropriate ERISA, IRA or TDA disclosure statements. FIXED ANNUITY - SINGLE PREMIUM RETIREMENT ANNUITY POLICIES HAVE PROVISIONS FOR THE ASSESSMENT OF SURRENDER CHARGES ON CASH WITHDRAWAL. No agent is authorized to make or alter contracts or to waive the rights or requirements of Northwestern Mutual Life. X__________________________________________________________________ X_______________________________________________ Signature of Applicant (Indicate relationship below if applicable) Signature of Annuitant (if other than Applicant) [ ] Trustee [ ] Employer X_______________________________________________ Signature of Licensed Agent Date Signed at: City County State | | | | | | | | ___________________________________________________________________________________________________________________________ 50 44 -------------------------------------------------------------------------------- AGENT'S CERTIFICATE -------------------------------------------------------------------------------- Annuitant Name: First, MI, Last A | |_____________________________________________________________________ 1. To the best of your knowledge will the annuity applied for replace any life insurance or annuity contract in this company or elsewhere? [ ] YES [ ] NO 2. On |__________ the following Prospectus or Offering Circular and Report was delivered: [ ] ACCOUNT A OFFERING CIRCULAR DATED______________AND REPORT DATED _____________(CORPORATE PENSION PLANS) [ ] ACCOUNT A PROSPECTUS DATED______________(PARTNERSHIP OR SOLE PROPRIETORSHIP PENSION PLANS) [ ] ACCOUNT B PROSPECTUS DATED______________(ALL OTHERS) 3. Was any part of this application translated?

UNDERSTOOD AND AGREED THAT. If the Owner is a Trustee or successor Trustee under a tax qualified plan or the employer under a tax qualified non-trusteed plan, Northwestern Mutual Life will be fully discharged of liability for any action taken by the Owner in the exercise of any contract right and for all amounts paid to, or at the direction of, the Owner and will have no obligation as to the use of the amounts. In all dealings with the Owner, Northwestern Mutual Life will be fully protected against the claims of every other person. The premium will be credited the date both the entire premium and the application are received at the Home Office. Receipt of the premium at a payment facility designated by Northwestern Mutual Life will be considered the same as receipt at the Home Office. If a Tax Qualified Employee Plan, an IRA or TDA is applied for, the Applicant and/or Annuitant have received and reviewed the appropriate ERISA, IRA or TDA disclosure statements. FIXED ANNUITY - SINGLE PREMIUM RETIREMENT ANNUITY POLICIES HAVE PROVISIONS FOR THE ASSESSMENT OF SURRENDER CHARGES ON CASH WITHDRAWAL. No agent is authorized to make or alter contracts or to waive the rights or requirements of Northwestern Mutual Life. X__________________________________________________________________ X_______________________________________________ Signature of Applicant (Indicate relationship below if applicable) Signature of Annuitant (if other than Applicant) [ ] Trustee [ ] Employer X_______________________________________________ Signature of Licensed Agent Date Signed at: City County State | | | | | | | | ___________________________________________________________________________________________________________________________ 50 -------------------------------------------------------------------------------- AGENT'S CERTIFICATE -------------------------------------------------------------------------------- Annuitant Name: First, MI, Last A | |_____________________________________________________________________ 1. To the best of your knowledge will the annuity applied for replace any life insurance or annuity contract in this company or elsewhere? [ ] YES [ ] NO 2. On |__________ the following Prospectus or Offering Circular and Report was delivered: [ ] ACCOUNT A OFFERING CIRCULAR DATED______________AND REPORT DATED _____________(CORPORATE PENSION PLANS) [ ] ACCOUNT A PROSPECTUS DATED______________(PARTNERSHIP OR SOLE PROPRIETORSHIP PENSION PLANS) [ ] ACCOUNT B PROSPECTUS DATED______________(ALL OTHERS) 3. Was any part of this application translated?

UNDERSTOOD AND AGREED THAT. If the Owner is a Trustee or successor Trustee under a tax qualified plan or the employer under a tax qualified non-trusteed plan, Northwestern Mutual Life will be fully discharged of liability for any action taken by the Owner in the exercise of any contract right and for all amounts paid to, or at the direction of, the Owner and will have no obligation as to the use of the amounts. In all dealings with the Owner, Northwestern Mutual Life will be fully protected against the claims of every other person. The premium first purchase payment will be credited the valuation date coincident with or next following the date both the entire premium application and the application purchase payment are received at the Home Office. Receipt of the premium at a payment facility designated by Northwestern Mutual Life will be considered the same as receipt at the Home OfficeLife. If a Tax Qualified Employee Plan, an IRA or TDA is applied for, the Applicant and/or Annuitant have received and reviewed the appropriate ERISA, IRA or TDA disclosure statements. FIXED ANNUITY - SINGLE PREMIUM RETIREMENT ANNUITY POLICIES HAVE PROVISIONS FOR THE ASSESSMENT OF SURRENDER CHARGES ON CASH WITHDRAWAL. No agent is authorized to make or alter contracts or to waive the rights or requirements of Northwestern Mutual Life. X__________________________________________________________________ X_______________________________________________ I acknowledge receipt of the Prospectus and I understand that all payments and values provided by this contract, when based on the investment experience of a separate account, are variable and are not guaranteed as to amount. X -------------------------------------------------------------------- Signature of Applicant (Indicate relationship below if applicable) [ ] Trustee X -------------------------------------------------------------------- Signature of Annuitant (if other than Applicant) [ ] Trustee [ ] Employer X_______________________________________________ X -------------------------------------------------------------------- Signature of Licensed Agent Date Signed at: City County State | | | | | | | | ___________________________________________________________________________________________________________________________ 50 -------------------------------------------------------------------------------- ================================================================================ AGENT'S CERTIFICATE -------------------------------------------------------------------------------- ================================================================================ Annuitant Name: First, MI, Last A | |_____________________________________________________________________Last 1. To the best of your knowledge will the annuity applied for replace any life insurance or annuity contract in this company or elsewhere? [ ] YES [ ] NO NO Date of Delivery 2. On |__________ the following Prospectus or Offering Circular and Report was delivered: [ ] ACCOUNT A OFFERING CIRCULAR DATED______________AND REPORT DATED _____________(CORPORATE PENSION PLANS) [ ] ACCOUNT A PROSPECTUS DATED______________(PARTNERSHIP OR SOLE PROPRIETORSHIP PENSION PLANS) [ ] ACCOUNT ___ the Account B PROSPECTUS DATED______________(ALL OTHERS)Prospectus dated _____________ was delivered. 3. Was any part of this application translated?? [ ] YES, PLEASE EXPLAIN: [ ] NO ================================================================================ CERTIFICATION: ================================================================================ I certify that to the best of my knowledge I have presented to Northwestern Mutual Life all pertinent facts, have asked all questions and have completely and correctly recorded the Applicant's and Annuxxxxx'x xnswers in accordance with the instructions. I know nothing unfavorable about the Annuitant that is not stated in the application or accompanying letter. I further certify that I have reasonable grounds for believing the purchase of the annuity applied for is suitable as an investment for the Annuitant based on the information furnished by the Applicant and Annuitant and contained herein. I certify that a current Prospectus was delivered and that no written sales materials other than those furnished by the Northwestern Mutual Life were used. Print Name X -------------------------------------------------------------------------------- Signature of Agent Agent Number Baird Rep Number Agent Phone Number --------------------------------------------------------------------------------

UNDERSTOOD AND AGREED THAT. If the Owner is a Trustee or successor Trustee under a tax qualified plan or the employer under a tax qualified non-trusteed plan, Northwestern Mutual Life will be fully discharged of liability for any action taken by the Owner in the exercise of any contract right and for all amounts paid to, or at the direction of, the Owner and will have no obligation as to the use of the amounts. In all dealings with the Owner, Northwestern Mutual Life will be fully protected against the claims of every other person. The premium will be credited the date both the entire premium and the application are received at the Home Office. Receipt of the premium at a payment facility designated by Northwestern Mutual Life will be considered the same as receipt at the Home Office. If a Tax Qualified Employee Plan, an IRA or TDA is applied for, the Applicant and/or Annuitant have received and reviewed the appropriate ERISA, IRA or TDA disclosure statements. FIXED ANNUITY - SINGLE PREMIUM RETIREMENT ANNUITY POLICIES HAVE PROVISIONS FOR THE ASSESSMENT OF SURRENDER CHARGES ON CASH WITHDRAWAL. No agent is authorized to make or alter contracts or to waive the rights or requirements of Northwestern Mutual Life. X__________________________________________________________________ X_______________________________________________ Signature of Applicant (Indicate relationship below if applicable) Signature of Annuitant (if other than Applicant) [ ] Trustee [ ] Employer X_______________________________________________ Signature of Licensed Agent Date Signed at: City County State | | | | | | | | ___________________________________________________________________________________________________________________________ 50 87 -------------------------------------------------------------------------------- AGENT'S CERTIFICATE -------------------------------------------------------------------------------- Annuitant Name: First, MI, Last A | |_____________________________________________________________________ 1. To the best of your knowledge will the annuity applied for replace any life insurance or annuity contract in this company or elsewhere? [ ] YES [ ] NO 2. On |__________ the following Prospectus or Offering Circular and Report was delivered: [ ] ACCOUNT A OFFERING CIRCULAR DATED______________AND REPORT DATED _____________(CORPORATE PENSION PLANS) [ ] ACCOUNT A PROSPECTUS DATED______________(PARTNERSHIP OR SOLE PROPRIETORSHIP PENSION PLANS) [ ] ACCOUNT B PROSPECTUS DATED______________(ALL OTHERS) 3. Was any part of this application translated?? [ ] YES, PLEASE EXPLAIN: [ ] NO -------------------------------------------------------------------------------- CERTIFICATION -------------------------------------------------------------------------------- I certify that to the best of my knowledge I have presented to the Company all pertinent facts, have asked all questions and have completely and correctly recorded the Applicant's and Annuxxxxx'x xnswers in accordance with the instructions. I know nothing unfavorable about the Annuitant that is not stated in the application or accompanying letter. I further certify that I have reasonable grounds for believing the purchase of the annuity applied for is suitable as an investment for the Annuitant based on the information furnished by the Applicant and Annuitant and contained herein. If this application is for a Variable Annuity, I certify that a current Prospectus or Offering Circular and Report was delivered and that no written sales materials other than those furnished by the Home Office were used. Agent Phone Number | x_____________________________________________________|________________________ Signature of Agent General Agent's approval for VARIABLE ANNUITIES only (signature of GENERAL AGENT or APPOINTED REGISTERED REPRESENTATIVE) x________________________________ __________________________________________ Signature Print Name or use stamp | | | |_________________________________________ 88 -------------------------------------------------------------------------------- DEMOGRAPHICS -------------------------------------------------------------------------------- ANNUITANT'S EDUCATION [ ] Some Education [ ] High School [ ] Associate Degree [ ] Some College [ ] Bachelors [ ] Masters [ ] Attorney at Law [ ] Doctorate NUMBER OF CHILDREN Number | [ ] None | |_________ OCCUPATION INDUSTRY SOURCE OF APPLICANT [ ] Business Owner [ ] Agriculture, Forestry &Fishing [ ] Agent's Own Policyowner [ ] Clerical [ ] Construction [ ] Orphan Policyowner [ ] Consultant [ ] Finance, Insurance &Real Estate [ ] Referred Lead [ ] Craftsman [ ] Manufacturing [ ] Acquaintance [ ] Homemaker [ ] Mining [ ] Newcomer Service [ ] Legal [ ] Nonclassifiable Establishments [ ] Cold Canvass [ ] Managerial/Executive [ ] Public Administration [ ] Lead Letter Reply [ ] Medical [ ] Retail Trade [ ] Published Sources [ ] Professional [ ] Services [ ] Walk-in [ ] Sales [ ] Transportation, Communication [ ] Family member or yourself & Utilities [ ] Service Worker Other [ ] Technical [ ] Wholesale Trade | |______________________________ -------------------------------------------------------------------------------- CONTRACT DELIVERY INSTRUCTIONS -------------------------------------------------------------------------------- Deliver contract package to the servicing agent at the: [ ] GA office [ ] DA office [ ] Agent's own office -------------------------------------------------------------------------------- PRODUCTION AND COMMISSION CREDITS -------------------------------------------------------------------------------- Primary or Secondary If secondary contract, Agent Number Agents Full Name*: Last, First % Interest Contract (P or S) secondary Appt. Agt. No. | | | | | |__________________|__________________________________|___________________|________________________|_________________________ | | | | | |__________________|__________________________________|___________________|________________________|_________________________ | | | | | |__________________|__________________________________|___________________|________________________|_________________________ | | | | | |__________________|__________________________________|___________________|________________________|_________________________ | | | | | |__________________|__________________________________|___________________|________________________|_________________________ *Commissions are payable only to Registered Representatives of Northwestern Mutual Investment Services, LLC. General Agent's Number General Agent's Stamp | | |_______________________ | | |_________________ ----------------------------------------------------------------------------------------------------------------- A Annuitant Amount Plan | | | |_________________________________|$_________|_________________________________ RECEIPT If the premium or purchase Received of___________________________________________________________________ payment is paid at the time of application, this receipt the sum of $__________________________________________________________________ must be completed and given for the Annuity applied for in the application to The Northwestern Mutual LIfe to the Applicant. No other Insurance Company, 720 Xxxx Xxxxxxxxx Xxx., Xxxxxxxxx, XX 00000. xxceipt will be recognized by the Company. Place and Date Agent | | |_________________________________|____________________________________________ ALL CHECKS SHOULD BE PAYABLE TO NORTHWESTERN MUTUAL LIFE. DO NOT MAKE THE CHECK PAYABLE TO THE AGENT OR LEAVE THE PAYEE BLANK.