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Federal Xxxxxx Life Assurance Company
[1600 XxXxxxxx Xxxxxxx Xxx. 0000, Xxxxxxxxxx, XX 00000-0000]
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Variable Annuity Application
Product: . Zurich Archway(SM)
Plan Type: . Non-Qualified . 408(b) XXX (Traditional) . 401 . 403(b) B/D Client Acct. # (if applicable):
. Xxxx XXX . Simple XXX . SEP-XXX . 457(b) gov
. 457(b) non-gov . Other
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1. Employer Information [(For 401, 403(b), SIMPLE XXX, SEP-XXX and 457(b) plans)]
Employer Name: Date of Employment / /
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If this application is for an existing employer sponsored plan, please supply: Plan #: Xxxx #:
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If this application is for a new employer sponsored plan, please complete form [# L-8520]
2. Owner (If the owner is a Trust, please submit the first and last page of the Trust document and complete form [# ZL-1068].)
Name: Birth/Trust Date (mo/day/yr) / / Sex . M . F
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Street Address:* City: State: Zip: SSN/Tax I.D. #:
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Daytime Phone: Mother's Maiden Name:
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Driver's License # or State ID # or Other Government Issue ID # and Expiration Date:
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E-mail: Are you a U.S. Citizen? . Yes . No If no, country of origin:
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3. Joint Owner (Non-Qualified contracts only)
Name: Birth/Trust Date (mo/day/yr) / / Sex . M . F
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Street Address:* City: State: Zip: SSN/Tax I.D. #:
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Daytime Phone: Mother's Maiden Name:
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Driver's License # or State ID # or Other Government Issue ID # and Expiration Date:
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E-mail: Are you a U.S. Citizen? . Yes . No If no, country of origin:
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4. Annuitant (If different from owner)
Name (First, M.I., Last): Birth Date (mo/day/yr) / / Sex . M . F
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Street Address:* City: State: Zip: SSN/Tax I.D. #:
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Daytime Phone: E-mail:
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5. Joint Annuitant (Non-Qualified contracts only)
Name (First, M.I., Last): Birth Date (mo/day/yr) / / Sex . M . F
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Street Address:* City: State: Zip: SSN/Tax I.D. #:
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Daytime Phone: E-mail:
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6. Beneficiary
Unless you specify otherwise, payments will be shared equally by all primary
beneficiaries who survive or, if none, by all contingent beneficiaries who
survive. If additional space is needed, please use the Remarks section on page 5
or include a signed attachment to this application. If the beneficiary is a
trust, corporation or partnership please provide the entity's name, address and
date established.
If you named joint owners, do not select a primary beneficiary below since the
surviving joint owner is automatically the beneficiary of any death benefits
resulting from the death of a joint owner.
Primary Name: Relationship: Birth Date / / %
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.. Primary Name: Relationship: Birth Date / / %
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.. Contingent
.. Primary Name: Relationship: Birth Date / / %
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.. Contingent
.. Primary Name: Relationship: Birth Date / / %
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.. Contingent
.. Primary Name: Relationship: Birth Date / / %
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.. Contingent
.. Primary Name: Relationship: Birth Date / / %
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.. Contingent
7. Replacement
Do you have any existing annuity contracts or life insurance? . Yes . No
Will any existing life insurance or annuity contract be replaced or will values
from another insurance policy or annuity contract (through loans, surrenders or
otherwise) be used to pay purchase payments for the annuity contract applied
for?
.. Yes . No
If yes, please indicate company name and policy number. Company Name: Policy #:
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(If more than one company use Remarks section on page 5.)
8. Annuity Date
(mo/day/yr): / / (Not to be earlier or later than the dates
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permitted under the contract, as listed below)
Zurich Archway(SM)-At least 2 years from the issue date and no later than the
oldest owner's or annuitant's 90th birthday.
9. Purchase Payment(s) (Make checks payable to Federal Xxxxxx Life Assurance
Company)
A. Initial Payment $: . Check . Wire Bank Originating
Wire
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B. Expected Transfer Amount: Distributor Trade/Transaction ID (If applicable):
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Non-Qualified: . 1035 Tax-Free Exchange . Direct Investment (check/wire)
. CD/Mutual Fund Transfer
403(b)/Qualified: . Direct Transfer . Direct Rollover . Rollover
XXX/Xxxx: . Direct Transfer . Regular Contribution ( Contribution Tax Year)
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. Rollover . Direct Rollover
C. . Payroll Deduction
Purchase Payment Amount # of Purchase Payments Annual Purchase Payment
Purchase Payment Frequency
Employee x = $
Employer x = $
Total: $
D. . Pre-Authorized Checking (Systematic Accumulations)
.. I authorize automatic deductions of $ from my
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bank account to be applied to this contract. A [$100] minimum applies.
Please attach a voided check (voided withdrawal slip may be used with
savings accounts.)
Frequency: Every . 1 . 3 . 6 . 12 Months
Beginning:
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10. "Protect Your Future" Program
Allocate a portion of my initial or transfer payment (from section 9A and/or B)
to the year MVA Guarantee Period Account such that, at the end of
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the Guarantee Period, the MVA Guarantee Period Account would grow to an amount
equal to the total initial payment assuming no withdrawals or transfers of any
kind. The remaining balance will be applied as indicated in Section 11.
11. Purchase Payment Allocation Allocations must total 100%.
% American Century VP Value
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% American Century VP Income & Growth
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Fixed Account
%
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MVA Guarantee Period Accounts
% year
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% year
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% year
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% year
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12. Automatic Asset Rebalancing (Not available concurrently with Dollar Cost
Averaging)
.. I elect Automatic Asset Rebalancing
Frequency: Every . 1 . 3 . 6 . 12 Months
Beginning:
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Unless otherwise specified, rebalancing to the allocation percentages selected
in Section 11 of this application will occur each period on the same day as the
contract was issued.
13. Dollar Cost Averaging (DCA) (Not available with Automatic Asset Rebalancing.
DCA is not allowed from any MVA Guarantee Period Accounts.)
Please transfer $ ($100 minimum) from (enter name of account).
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Frequency: Every . 1 Month . 3 Months . 6 Months . 12 Months
Beginning:
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Unless otherwise specified, Dollar Cost Averaging will occur each period on the
date the contract is issued.
Transfer To (Allocations must total 100%):
% American Century VP Value
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% American Century VP Income & Growth
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Fixed Account
------ %
MVA Guarantee Period Accounts
% year
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% year
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% year
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% year
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14. Optional Riders (this section must be completed.)
I/We elect the following optional rider and understand there is an additional
charge: (check one of the following boxes)
.. Zurich SafeguardSM Death Benefit . Zurich SafeguardSM Plus Death Benefit . I
choose not to elect an optional rider.
15. Consent to Electronic Delivery
.. I agree to have prospectus updates, semi-annual reports, proxy solicitation
material and other applicable regulatory documents delivered to me on an IBM and
Macintosh compatible CD-Rom. I understand that at any time I may change my mind
and choose to receive paper copies of applicable regulatory documents by calling
(000) 000-0000.
If you do not check the box above, you will receive paper copies of all required
regulatory documents. You will not receive electronic copies in addition to
paper copies provided.
16. Telephone Authorization
By signing this application, I authorize and direct Federal Xxxxxx Life
Assurance Company (FKLA) to accept telephone instructions from the owner, active
insurance representative, and the individual listed below to effect transfers
and/or future purchase payment allocation changes. I agree to hold harmless and
indemnify FKLA and its affiliates and its directors, employees and
representatives against any claim arising from such action. I am aware that I
may deny the active insurance representative authorization to make telephone
transfers by checking the designated box below.
Name of additional authorized individual (if any)
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.. I do not authorize the active insurance representative to make telephone
transfers on my behalf.
.. I do not accept this telephone transfer privilege.
17. Remarks
18. Warnings, Notices And Statements
Arkansas, Colorado, District of Columbia, Kentucky, Louisiana, Maine, New
Mexico, Ohio, Oklahoma, Pennsylvania and Tennessee Fraud Warning - 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 any
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.
Florida Fraud Warning - Any person who knowingly and with intent to injure,
defraud, or deceive any insurer, files a statement of claim or an application
containing any false, incomplete, or misleading information is guilty of a
felony of the third degree.
Michigan Fraud Warning - Any person who submits an application or files a claim
with intent to defraud or helps commit a fraud against an insurer, as determined
by a court of competent jurisdiction, is guilty of a crime.
New Jersey Fraud Warning - Any person who includes any false or misleading
information on an application for an insurance policy is subject to criminal and
civil penalties.
Amounts received under a 403(b) annuity may be distributed only when the
employee a) reaches 591/2; b) xxxxxx employment; c) dies;
d) becomes disabled; or e) is eligible for hardship.
By signing below, you are indicating that you have received an XXX disclosure
statement (if applicable).
RECEIPT IS ACKNOWLEDGED OF THE CURRENT PROSPECTUSES FOR THIS VARIABLE ANNUITY
AND THE UNDERLYING FUNDS. Payments and values provided by the contract, when
based on investment experience of the subaccounts, are variable and are not
guaranteed as to dollar amount. They are not guaranteed by the company, any
other insurance company, the us government or any state government, and are not
insured by the FDIC, the federal reserve board or any other federal or state
agency. All risk is borne by the owner for those funds assigned to a separate
account. WITHDRAWALS AND TRANSFERS FROM A GUARANTEE PERIOD THAT ARE MADE PRIOR
TO THE END OF THAT GUARANTEE PERIOD ARE SUBJECT TO A MARKET VALUE ADJUSTMENT
THAT MAY INCREASE OR DECREASE THE CONTRACT VALUE. THE INITIAL INTEREST RATE IS
GUARANTEED ONLY FOR A LIMITED PERIOD OF TIME.
.. Please check here if you want a Statement of Additional Information.
I agree that the above statements are true and correct to the best of my
knowledge and belief and are made as a basis for my application.
19. Signatures
Application Made at (City): State: Date:
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Signature of Owner/Participant: Signature of Joint Owner: (if applicable)
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Signature of Plan Owner:(For 401, 403(b) and 457(b) plans, if applicable)
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20. Producer Information
Does the owner have any existing annuity contracts or life insurance? . Yes . No
To the best of your knowledge, will any existing life insurance or annuity
contract be replaced or will values from another insurance policy or
annuity contract (through loans, surrenders or otherwise) be used to pay
purchase payments for the annuity contract applied for? . Yes . No
If yes, please indicate annuity or life insurance below, enter the plan type
code and submit any required replacement forms.
.. Life Insurance . Annuity Plan Type Code
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(If more than one company use Remarks section on page 5.)
I certify that the information provided by the owner has been accurately
recorded; current prospectuses were delivered; no written sales materials other
than those approved by the Principal Office were used; and I have reasonable
grounds to believe the purchase of the contract applied for is suitable for the
owner. Suitability information has been obtained and filed with the
broker/dealer.
Signature of Producer 1: E-mail Address: Zurich Life Producer #:
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Printed Name of Producer 1: Phone #: Date: Commission Option:
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Signature of Producer 2 (If applicable): E-mail Address: Zurich Life Producer #:
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Printed Name of Producer 2 (If applicable): Phone #: Date:
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Printed Name of Broker/Dealer: Broker/Dealer Principal Approval
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Branch Office Street Address for Contract Delivery:
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Florida License ID # For Contracts Sold in Florida:
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