Application for Variable Annuity Contract
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|_| Male Social
Annuitant Name |_| Female Security No._____________________
First Middle Last
Address Date of Birth __
Street City State ZIP Month Day Year
Home Work
Phone No. ( ) Phone No. ( ) ext. State of Birth
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|_| Female
Owner Name |_| Trustee |_| Male
First Middle Last
Address _
Street City State ZIP
Tax ID or State of Date of
Social Security No. Birth Birth
Month Day Year
Annuitant will be the Owner, unless otherwise stated. For non-qualified annuities only - If the Owner is other than the
Annuitant, the beneficiary, in the event of the Owner's death, will automatically be the Annuitant unless otherwise
specified below.
Owner's Beneficiary Relationship to Owner
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With right to change. Unless otherwise stated, benefits are payable equally to the named beneficiary(ies) or to the
Beneficiary survivors or survivor.
If benefits are payable other than equally, please indicate a contingent beneficiary for each primary beneficiary.
Primary Beneficiary Relationship to Annuitant
Contingent Beneficiary Relationship to Annuitant
Contingent Beneficiary Relationship to Annuitant
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Plan Plan |_| Flexible Premium Annual
Name |_| Single Premium Premium $________________________
Market |_| Non-qualified |_| 403(b) |_| 401(k) |_| 501(c)(3)*|_| SEP *|_| IRA *|_| XXXX XXX *|_| SIMPLE IRA |_|
Other
|_| Pension Plan - Please indicate if Profit Sharing or Money Purchase (circle one) *Contribution is for_________ tax year
Rollover |_| Yes |_| No Amount of Transfer $ Are any funds the result of a transfer from a Qualified Plan?|_| Yes|_| No
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Billing Payment |_| |_| |_| |_| Collection |_| |_| |_| |_| |_|
Information Mode Xxx SA Qtly Mo Type PAC GA CB FAP Single
Send Notices and Statements to: |_| Annuitant |_| Owner |_| Other (give name and address)___________________________________
Branch of Service for Government Allotment_________________ Payor's SSN for GA______________________________
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Replacement
1. Will any existing life, health or annuity contract be lapsed, reissued, surrendered, or converted (to reduce amount of
payment or period of coverage including surrender options) if the proposed contract is issued?........................|_| Yes |_| No
2. Will the proposed contract be part of an IRC Section 1035 Exchange?...............................................|_| Yes |_| No
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Premium
Allocations Initial Premium $_________________________________________
Select initial premium allocations on page 4 of this application. Show percent allocated to each fund. Use whole
percentages - total must equal 100%.
A maximum of 15 fund selections is available at any one time.
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Monthly Dollar
Cost Averaging |_| Match initial premium allocations shown on page 4 of this application.
If fund selection options for the Monthly Dollar Cost Averaging Plan are different than the initial premium allocations,
make fund selections for this plan on page 4 of the application.
To participate in the Monthly Dollar Cost Averaging Plan, a percentage must be directed to the Federated Prime Money Fund
II Subaccount when selecting the initial premium allocation.
Transfer $____________________ monthly over a ________ month period from the Federated Prime Money Fund II
Subaccount to the selected subaccounts. The Monthly Dollar Cost Averaging Plan may be elected for a period from 3 to 36
months.
At least $250 must be transferred from the Federated Prime Money Fund II Subaccount each month. Transfers under this plan
may not commence until the later of: (1) 30 days after the contract date; or (2) five days after the end of the free
look period.
Transfers made under this plan will not count toward the six free transfers permitted each contract year.
To start this plan in the future, you must complete a Dollar Cost Averaging Request Form and send it to Kansas City Life.
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Quarterly Portfolio
Rebalancing |_| Match initial premium allocations shown on page 4 of this application.
If fund selection options for the Quarterly Portfolio Rebalancing Plan are different than the initial premium
allocations, make fund selections for this plan on page 4 of the application.
Fixed account assets will not be included in the Quarterly Portfolio Rebalancing Plan.
If you are not currently participating in the Monthly Dollar Cost Averaging Plan, Kansas City Life will redistribute
funds in the variable account on a quarterly basis according to the percentages selected, provided the account is in good
order. The Quarterly Portfolio Rebalancing Plan will not be available until the Monthly Dollar cost Averaging Plan has
been completed.
If you make a change to premium allocations, we automatically change Quarterly Portfolio Rebalancing allocations to match
the new premium allocations, unless you give us other instructions.
Any requested transfer, either by written request or telephone transfer, will automatically cancel the Quarterly
Portfolio Rebalancing Plan, unless you authorize a change in premium allocation at that time. You may also cancel this
plan by sending a written notice to Kansas City Life.
Transfers made under this plan will not count toward the six free transfers permitted each contract year.
To start this plan in the future, you must complete a Quarterly Portfolio Rebalancing Request Form and send it to Kansas
City Life.
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Telephone Access
Authorization |_| Yes If answered Yes, I am giving Kansas City Life authority to honor telephone instructions from me to
|_| No transfer among subaccounts and the fixed account, change the premium allocation, change Dollar Cost
Averaging allocations or change Portfolio Rebalancing allocations.
|_| Yes If answered Yes, I am giving the Registered Representative/Agent of record authority to transfer among
subaccounts and
|_| No the fixed account, change the premium allocation, change Dollar Cost Averaging allocations or change Portfolio
Rebalancing allocations.
This authorization is subject to the terms and provisions in the contract and prospectus. Kansas City Life will not be
held liable for any loss, liability, cost, or expense for acting on the telephone instructions. Kansas City Life's
liability for erroneous transactions, unless clearly contrary to instructions received, will be limited to the correction
of the allocations on a current basis. I understand that Kansas City Life will provide written confirmation of the
telephone transaction, and that Kansas City Life will monitor and record my telephone call.
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Switch/Replacement Since most investments are and should be considered long term in nature, we feel it is necessary to review
Disclosure your understanding of your current position and the possible consequences of switching and/or exchanging
your investment.
Reason for requesting switch/replacement:___________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
Please acknowledge the following statements by placing a check mark next to each statement. If the statement does not apply,
indicate N/A.
_____ This exchange will result in a surrender charge on my current investment of__________%.
_____ This exchange subjects my investment to a surrender charge for the next___________ years.
_____ This exchange may result in a taxable gain on the liquidation of my current investment.
My representative and I have reviewed the above items and have carefully considered my selection and believe that it
coincides with my investment objectives.
Name of product being replaced _____________________________________________________________________________________________________
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Special Requests (Contract date, additional contract, existing PAC or CB number, etc.) Home Office Endorsements
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Agreement and Acknowledgment By signing below you understand that:
1. The annuity value may increase or decrease daily depending on the contract's investment results;
2. No minimum cash value is guaranteed;
3. This variable annuity plan is a long term commitment to meet financial goals; and I acknowledge receipt of the most
recent prospectus dated__________________; and
4. The variable annuity plan applied for is suitable for my investment objectives, financial situations and needs.
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose
of defrauding the company. Penalties may include imprisonment, fines or denial of insurance benefits.
Dated at__________________________________________________________ this__________ day of________________,___________.
City State Month Year
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Annuitant's Signature (if under 15, parent/guardian signature) Applicant's Signature (if other than Annuitant)
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Statement of Agent
To the best of my knowledge the annuity applied for in this application |_| will |_| will not replace existing insurance.
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Agent Code Registered Representative/Agent Signature* Agent Code Signature of Other Agent(s)(if split case)
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Agency Code Agency
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Broker-Dealer Information
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Broker-Dealer Name (print) R/R Code Registered Representative/Agent Phone No.
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Broker-Dealer Address Broker-Dealer Authorized Signature
*Registered Representative/Agent Certification
By signing above, the Registered Representative/Agent certifies that he/she is NASD registered and state licensed for
variable annuity contracts in the appropriate state.
All checks must be made payable to Kansas City Life Insurance Company.
Do not make check payable to the registered representative/agent or leave the payee blank.
Portfolio of Funds for Variable Contracts
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PREMIUM ALLOCATIONS
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MONTHLY QUARTERLY
FUND SELECTION* LUMP PLANNED DOLLAR COST PORTFOLIO
SUM PERIODIC AVERAGING** REBALANCING**
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[MFS Emerging Growth Series % % % %
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MFS Research Series % % % %
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MFS Total Return Series % % % %
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MFS Utilities Series % % % %
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MFS Global Governments Series % % % %
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MFS Bond Series % % % %
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American Century VP Capital Appreciation % % % %
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American Century VP Income & Growth % % % %
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American Century VP International % % % %
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American Century VP Value % % % %
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Federated American Leaders Fund II % % % %
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Federated High Income Bond Fund II % % % %
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Federated International Small Company Fund II % % % %
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Federated Prime Money Fund II % % %
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Dreyfus Appreciation Portfolio % % % %
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Dreyfus Small Cap Portfolio % % % %
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Dreyfus Stock Index Fund % % % %
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The Dreyfus Socially Responsible Growth Fund, Inc. % % % %
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X.X. Xxxxxx U. S. Disciplined Equity Portfolio % % % %
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X.X. Xxxxxx Small Company Portfolio % % % %
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Franklin Real Estate Fund (Class 2) % % % %
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Franklin Small Cap Fund (Class 2) % % % %
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Xxxxxxxxx Developing Markets Securities Fund (Class 2) % % % %
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Xxxxxxxxx International Securities Fund (Class 2) % % % %
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Calamos Convertible Portfolio % % % %
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AIM V.I. Dent Demographic Trends Fund % % % %
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AIM V.I. Telecommunications and Technology Fund % % % %
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AIM V.I. Value Fund % % % %
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Seligman Capital Portfolio (Class 2) % % % %
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Xxxxxxxx Communications and Information Portfolio (Class 2) % % % %
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KCL Fixed Account] % % % %
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(Use whole percentages only. 100% 100% 100% 100%
Percentages must total 100 %) Total
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*A maximum of 15 fund selections is available at any one time.
** NOTE: It is not necessary to fill in the percentages on this page for Monthly Dollar Cost Averaging and/or
Quarterly Portfolio Rebalancing allocations if they are the same as the initial premium allocations. Simply
check the appropriate box in the Monthly Dollar Cost Averaging Section and the Quarterly Portfolio
Rebalancing Section of this application that tells us they are the same.
