(LOGO) SECURITY BENEFIT LIFE(SM)
INSURANCE COMPANY
VARIABLE ANNUITY
Please type or print in black ink.
1. TYPE OF ANNUITY CONTRACT
[ ] Non Qualified [ ] 408A Xxxx XXX
[ ] 403(b) TSA
[ ] 408 IRA CONTRIBUTION YEAR ____________
2. ANNUITANT
__________________ ________ _______________________________
Name of Annuitant
(First) (MI) (Last)
_________________________________________________________________
Mailing Address Apt.
_________________________________________________________________
City
__ __ __ __ __ __ __ - __ __ __ __
State Zip Code
__ __ / __ __ / __ __ __ __
Date of Birth
__ __ __ __ __ __ __ __ __ __
Social Security Number / Tax I.D. Number
__ __ __ - __ __ __ - __ __ __ __
Phone Number (for confidential calls between 8:00am and 6:00pm CST)
_________________________________________________________________
E-Mail Address
3. OWNER (APPLICANT)
__________________ ________ _______________________________
Name of Owner
(First) (MI) (Last)
_________________________________________________________________
Mailing Address Apt.
_________________________________________________________________
City
__ __ __ __ __ __ __ - __ __ __ __
State Zip Code
__ __ / __ __ / __ __ __ __
Date of Birth
__ __ __ __ __ __ __ __ __ __
Social Security Number / Tax I.D. Number
__ __ __ - __ __ __ - __ __ __ __
Phone Number (for confidential calls between 8:00am and 6:00pm CST)
_________________________________________________________________
E-Mail Address
_________________________________________________________________
Residential Address (if different than mailing address) Apt.
_________________________________________________________________
City
__ __ __ __ __ __ __ - __ __ __ __
State Zip Code
4. JOINT OWNER
___________________ ________ _______________________________
Name of Joint Owner
(First) (MI) (Last)
_________________________________________________________________
Address Apt.
_________________________________________________________________
City
__ __ __ __ __ __ __ - __ __ __ __
State Zip Code
__ __ / __ __ / __ __ __ __
Date of Birth
__ __ __ __ __ __ __ __ __ __
Tax I.D. Number / Social Security Number
__ __ __ - __ __ __ - __ __ __ __
Phone Number (for confidential calls between 8:00am and 6:00pm CST)
_________________________________________________________________
E-Mail Address
5. PRIMARY BENEFICIARY(IES)
Name DOB Relationship %
to Owner
1. ______________________________________________________________
2. ______________________________________________________________
3. ______________________________________________________________
4. ______________________________________________________________
6. CONTINGENT BENEFICIARY(IES)
Name DOB Relationship %
to Owner
1. ______________________________________________________________
2. ______________________________________________________________
MAIL TO: SECURITY BENEFIT - ONE SECURITY BENEFIT PLACE - TOPEKA, KANSAS
00000-0000 OR FAX TO: 0-000-000-0000
ALSO VISIT US ONLINE AT XXX.XXXXXXXXXXXXXXX.XXX
QUESTIONS? CALL OUR CUSTOMER SERVICE CENTER AT 0-000-000-0000.
V9494 (R5-05) U AdvisorDesigns
00-00000-00 R (1/4)
7. ALLOCATION OF PURCHASE PAYMENTS
__ % Rydex VT Electronics __ % Rydex VT Small Cap Value
__ % Rydex VT Internet __ % AIM V.I. Capital Appreciation
__ % Rydex VT Telecommunications __ % Rydex VT Mid Cap Growth
__ % Rydex VT Technology __ % Rydex VT Medius
__ % Rydex VT Precious Metals __ % Strong Opportunity II
__ % Rydex VT Biotechnology __ % Rydex VT Mid Cap Value
__ % Rydex VT Energy Services __ % RVT CLS AdvisorOne Xxxxxxx
__ % Rydex VT Utilities __ % Rydex VT Velocity 100
__ % Rydex VT Basic Materials __ % Rydex VT OTC
__ % Rydex VT Energy __ % Fidelity VIP Growth Opp
__ % Rydex VT Retailing __ % Rydex VT Large Cap Growth
__ % Rydex VT Financial Services __ % Rydex VT Titan 500
__ % Rydex VT Transportation __ % Rydex VT Nova
__ % Rydex VT Banking __ % Fidelity VIP Index 500
__ % Rydex VT Leisure __ % Fidelity VIP Contrafund
__ % Rydex VT Health Care __ % Xxxxxxxxx Xxxxxx AMT
__ % Rydex VT Consumer Products Partners
__ % Rydex VT Real Estate __ % Xxxxxxxxx Xxxxxx AMT
__ % Rydex VT Arktos Guardian
__ % Rydex VT Ursa __ % RVT CLS AdvisorOne Clermont
__ % Rydex VT Sector Rotation __ % Rydex VT Large Cap Value
__ % Rydex VT Juno __ % Federated High Income Bond II
__ % Rydex VT Inverse Dynamic Dow __ % Potomac Dynamic VP XX Xxxx
__ % Rydex VT Long Dynamic Dow __ % PIMCO VIT Real Return
__ % Rydex VT Inverse Small Cap __ % Fidelity VIP Inv Grade Bond
__ % Rydex VT Inverse Mid Cap __ % PIMCO VIT Total Return
__ % Rydex VT Large Cap Europe __ % Rydex VT US Government Bond
__ % Rydex VT Large Cap Japan __ % Federated Fund US Govt Sec II
__ % SBL Global __ % Rydex VT US Govt Money
__ % Rydex VT Small Cap Growth Market
__ % Rydex VT Mekros __ % Potomac VP Money Market
__ % SBL Small Cap Value MUST TOTAL 100%
8. SALARY REDUCTION INFORMATION
[ ] Salary Savings
Annual Contribution Amount $ ___________
Number of Payments Per Year ___________
Payor I.D. ___________________________________________
(to be completed by Representative)
_________________________________________________________________
Employer Name
_________________________________________________________________
Mailing Address Apt.
_________________________________________________________________
City
__ __ __ __ __ __ __ __ __ __ __
State Zip Code
_________________________________________________________________
Billing Statement Address Apt.
_________________________________________________________________
City
__ __ __ __ __ __ __ __ __ __ __
State Zip Code
Beginning Date __________________________________________________
Will Employer match contributions? [ ] Yes [ ] No
__ __ __ - __ __ __ - __ __ __ __
Employer Phone Number
_________________________________________________________________
Employer E-Mail Address
Skip Payment Frequency Applicable? [ ] Yes [ ] No
Months to Skip: _________________________________________________
9. REPLACEMENT
1. Do you currently have any existing annuity or insurance policies? [ ] No [ ]
Yes, see list below.
2. Does this proposed contract replace or change any existing annuity or
insurance policy? [ ] No [ ] Yes If yes, please list company and policy
number
_________________________________________________________________
_________________________________________________________________
Please note that if this proposed contract replaces or changes an existing
policy, the agent shall submit a copy of the Replacement Notice with this
application and is required to leave with the applicant a copy of any written
material presented to the applicant.
10. POLICY AND OPTIONAL RIDERS
INCOME RIDERS:
[ ] Guaranteed Minimum Income Benefit*
[ ] 3% [ ] 5%
[ ] Dollar for Dollar Living Benefit**
DEATH BENEFIT RIDERS:
[ ] Combination Annual Stepped Up and Guaranteed Growth at 5% Death Benefit*
[ ] Combination Enhanced and Annual Stepped Up Death Benefit
[ ] Combination Enhanced and Guaranteed Growth at 5% Death Benefit*
[ ] Combination Enhanced, Annual Stepped Up and Guaranteed Growth at 5% Death
Benefit*
[ ] Dollar for Dollar Combination Benefit**
[ ] Annual Stepped Up Death Benefit
[ ] Guaranteed Growth Death Benefit*
[ ] 3% [ ] 5% [ ] 6% [ ] 7%
[ ] Enhanced Death Benefit
CREDIT ENHANCEMENT RIDERS:
[ ] 3% [ ] 4% [ ] 5%
SURRENDER CHARGE RIDERS:
[ ] Nursing Home, Terminal Illness, Disability
[ ] 0-year Alternate Withdrawal Charge Rider
[ ] 4-year Alternate Withdrawal Charge Rider
TOTAL PROTECTION RIDER:
[ ] 5% Total Protection
GUARANTEED WITHDRAWAL BENEFITS RIDERS:
[ ] Annual Withdrawal Benefit 5%; Benefit Amount 130%
[ ] Annual Withdrawal Benefit 6%; Benefit Amount 110%
[ ] Annual Withdrawal Benefit 7%; Benefit Amount 100%
Please select only one Rider from each Rider Category above. For example, you
may select only one Death Benefit from those listed under "Death Benefit Riders"
above.
* Under these riders, the maximum annual effective interest rate used in
computing benefits is 4% for Contract Value allocated to the Money Market
Subaccounts and the Fixed Account even if you select a rider that calculates
benefits based upon a rate of 5%, 6% or 7%. If you expect to invest
significantly in those Accounts, you may want to select a rate of 4% or less.
Otherwise, you may pay for a higher rate without realizing the benefit.
**Under these riders, the maximum interest rate used in computing benefits is 3%
for Contract Value allocated to the Low Duration Subaccounts (as defined in
the rider) and the Fixed Account although these riders otherwise calculate
benefits based upon an annual effective interest rate of 6%.
V9494 (R5-05) U AdvisorDesigns 00-00000-00 R (2/4)
11. ELECTRONIC TRANSFER PRIVILEGE
[ ] If you do not wish to authorize Electronic Transfers, you must check this
box. SBL will make transfers, account changes and effect various other
transactions based on instructions received via telephone, Internet, or other
available electronic means.
12. STATEMENT OF UNDERSTANDING
I have been given and understand a current prospectus that describes the
contract for which I am applying and a current prospectus for each of the funds
which underlie each Subaccount above. I UNDERSTAND THAT ANNUITY PAYMENTS AND
WITHDRAWAL VALUES, IF ANY, WHEN BASED ON THE INVESTMENT EXPERIENCE OF THE
SUBACCOUNTS ARE VARIABLE AND DOLLAR AMOUNTS ARE NOT GUARANTEED and that any
benefits, values or payments based on performance of the Subaccounts 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 risk of
investment 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 redemption 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.
13. TAX IDENTIFICATION NUMBER 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 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.
13. TAX IDENTIFICATION NUMBER CERTIFICATION (CONTINUED)
X________________________________________________________________
Signature of Owner Date (Month/Day/Year)
_________________________________________________________________
Signed at (City-State) Date (Month/Day/Year)
X
_________________________________________________________________
Signature of Joint Owner Date (Month/Day/Year)
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 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.
14. REGISTERED REPRESENTATIVE/DEALER INFORMATION
Representative's Statement - 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 question 9
above. I have complied with the requirements for disclosure and/or
replacement.
[ ] Yes. If yes, please comment below.
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
X________________________________________________________________
Signature of Agent Date (Month/Day/Year)
_________________________________________________________________
Print Name of Agent
_________________________________________________________________
Registered Agent's License I.D. Number
_________________________________________________________________
Print Name of Broker/Dealer
_________________________________________________________________
Phone Number (for confidential calls between 8:00am and 6:00pm CST)
_________________________________________________________________
Broker Account Number
_________________________________________________________________
Brokerage Group Number
For Registered Representative Use Only:
Option(1): [ ] A [ ] B (default) [ ] C [ ] D
(1) Only options A and B are available if you have selected the 0-year or 4-year
Alternate Withdrawal Charge Rider.
V9494 (R5-05) U AdvisorDesigns 00-00000-00 R (3/4)
(LOGO) SECURITY BENEFIT LIFE(SM)
INSURANCE COMPANY
VARIABLE ANNUITY APPLICATION
STATE DISCLOSURES
ALL JURISDICTIONS EXCEPT AR, AZ, CT, DC, FL, KS, KY, LA, ME, MN, NJ, NM, OH, OK,
PA, TX, VA, VT AND WA. 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.
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.
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.
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.
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.
CT AND 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.
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.
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.
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.
IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING A NEW ACCOUNT
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.
V9494 (R5-05) U AdvisorDesigns 00-00000-00 R (4/4)
