[LOGO] NEA [LOGO] SECURITY BENEFIT SM
VALUEBUILDER (R) Life Insurance Company
Program
VARIABLE ANNUITY
Please type or print in black ink.
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1. TYPE OF ANNUITY CONTRACT
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[ ] 403(b) TSA
[ ] Xxxx 403(b) TSA
[ ] Traditional IRA
[ ] Xxxx XXX
For IRAs only: Contribution Information
Current Year $ ______________
Previous Year $ ______________
Rollover $ ______________
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2. ANNUITANT
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--------------------- ------ ----------------------
Name of Xxxxxxxxx
(First) (MI) (Last)
[ ] Male [ ] Female
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Mailing Address (Do not use P.O. Box) Apt.
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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)
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3. OWNER (APPLICANT)
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[ ] Same as Annuitant
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Name of Owner
(First) (MI) (Last)
[ ] Male [ ] Female
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Mailing Address Apt.
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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)
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Residential Address (if different than mailing address) Apt.
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City
-------------- --- --- ---- ---- ---- ---- ---- ----
State Zip Code
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4. PRIMARY BENEFICIARY(IES)
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Name DOB Relationship % of
to Owner Benefit
1. -----------------------------------------------------------------------------
2. -----------------------------------------------------------------------------
3. -----------------------------------------------------------------------------
4. -----------------------------------------------------------------------------
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5. CONTINGENT BENEFICIARY(IES)
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Name DOB Relationship %
to Owner
1. -----------------------------------------------------------------------------
2. -----------------------------------------------------------------------------
MAIL TO: SECURITY BENEFIT o PO BOX 750497 o TOPEKA, KANSAS 00000-0000 OR FAX TO:
0-000-000-0000
ALSO VISIT US ONLINE AT XXX.XXXXX.XXX
QUESTIONS? CALL OUR CUSTOMER SERVICE CENTER AT 0-000-000-0000.
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6. ALLOCATION OF PURCHASE PAYMENTS
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______% AIM Technology
______% American Century Intl Growth
______% Security Global
______% Security Small Cap Growth
______% AIM Small Cap Growth
______% Fidelity Advisor Value Strat
______% Xxxxx Fargo Advtg SmCp Value
______% Xxxxx
______% Security Mid Cap Growth
______% AIM Dynamics
______% Xxx Xxxxxx Aggressive Growth
______% Calamos Growth
______% American Century Heritage
______% Xxxxx Fargo Advtg Opportunity
______% AIM Mid Cap Core Equity
______% Dreyfus Midcap Value
______% Security Mid Cap Value
______% Xxxxx Fargo Advtg Growth
______% Security Large Cap Growth
______% AIM Blue Chip
______% American Century Select
______% Security Social Awareness
______% Fidelity Advisor Div Growth
______% Xxxxx Fargo Advtg Gro & Inc
______% Security Equity
______% Dreyfus Appreciation
______% Dreyfus Premier Strat Value
______% AIM Basic Value
______% Xxx Xxxxxx Xxxxxxxx
______% Security Large Cap Value
______% American Century Equity Income
______% Xxx Xxxxxx Equity and Income
______% Calamos Growth and Income
______% PIMCO High Yield
______% Security Diversified Income
______% Xxxxxx Brothers Core Bond
______% Security Capital Preservation
______% Security Income Opportunity
______% Dreyfus General Money Market
MUST TOTAL 100%
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7. 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 Xxxx Contribution of $ ______________ per
year or ______________ % per pay period.
Beginning Date: ---- ---- / ---- ---- / ---- ---- ---- ----
Please skip the following month(s): ----------------------------
Will your employer match contributions? [ ] Yes [ ] No
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Employer Name
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Mailing Address
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City
-------------- --- --- ---- ---- ---- ---- ---- ----
State Zip Code
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Billing Statement Address.(if different from above)
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City
-------------- --- --- ---- ---- ---- ---- ---- ----
State Zip Code
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8. REPLACEMENT
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1. Do you currently have any existing annuity or insurance policies?
[ ] No [ ] Yes
2. Does this proposed contract replace or change any existing annuity or
insurance policy? [ ] No [ ] Yes If yes, please list company and policy
number
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9. GUARANTEED MINIMUM ACCUMULATION BENEFIT ELECTION
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Please base this election on the estimated number of years until you will need
retirement income.
[ ] 2-year [ ] 7-year [ ] 12-year
[ ] 3-year [ ] 8-year [ ] 13-year
[ ] 4-year [ ] 9-year [ ] 14-year
[ ] 5-year [ ] 10-year [ ] 15-year
[ ] 6-year [ ] 11-year
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10. ELECTRONIC TRANSFER PRIVILEGE
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Security Benefit will make transfers, account changes and effect various other
transactions based on instructions received via telephone, Internet, or other
available electronic means from both my representative and myself.
[ ] I do NOT wish to authorize Electronic Transfers for myself or my
representative.
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11. 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 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 (subject to availability).
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.
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12. SIGNATURES
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My signature below indicates 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) below 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);
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12. SIGNATURES (continued)
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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
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Signature of Owner Date (Month/Day/Year)
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Signed at (City-State) Date (Month/Day/Year)
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13. 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. (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.)
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Print Name of Representative
X
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Signature of Representative Date (Month/Day/Year)
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Address
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City
-------------- --- --- ---- ---- ---- ---- ---- ----
State Zip Code
-------------- --- --- ---- ---- ---- ---- ----
Daytime Phone Number
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E-mail Address
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Representative License I.D. Number
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Zip Code
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Print Name of Broker/Dealer
For Company Representative's Use Only
Option: [ ] A (default) [ ] B [ ] C [ ] D
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[LOGO] NEA [LOGO] SECURITY BENEFIT SM
VALUEBUILDER (R) Life Insurance Company
Program
VARIABLE ANNUITY APPLICATION
STATE FRAUD DISCLOSURES
THIS STATE FRAUD DISCLOSURE APPLIES TO ALL JURISDICTIONS EXCEPT KS, MN, VA AND
THE STATES LISTED BELOW.
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.
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.
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.
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.
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