APPLICATION FOR INDIVIDUAL DEFERRED ANNUITY · APPLICATION FOR INDIVIDUAL DEFERRED ANNUITY UNITED...

1. ANNUITANT

Name(last,first,middle) ____________________________________________________________________________________

StreetAddress _____________________________________________________________________________________________

City ___________________________________________________ State ______________________ Zip _________________

Home Phone ______________________ DateofBirth ______________ Age _________ q Male q Female

SocialSecurityNumber ______________________________ U.S.Citizen? q Yes q No

IstheAnnuitantconfinedtoaNursingHome? q Yes q No

2. JOINT ANNUITANT (Notavailableforqualifiedplans)


StreetAddress _____________________________________________________________________________________________

City ___________________________________________________ State ______________________ Zip _________________


SocialSecurityNumber ______________________________ U.S.Citizen? q Yes q No

3. OWNER(ifotherthanAnnuitant)


StreetAddress ______________________________________City _______________________ State _____ Zip __________

SocialSecurityNumber _______________________ U.S.Citizen? q Yes q No Email _______________________________

Home Phone ___________________________ DateofBirth ________________ Age _____ q Male q Female

Owner’sBeneficiary _____________________________ Relationship _____________ SS# ___________________________

Address ___________________________________________________________________ DateofBirth ___________________

4. JOINT OWNER(Notavailableforqualifiedplans)


StreetAddress ______________________________________City _______________________ State _____ Zip __________

SocialSecurityNumber _____________________________ U.S.Citizen? q Yes q No


JointOwner’sBeneficiary __________________________ Relationship ______________ SS# ________________________ (Do not name if joint owner and joint tenancy.)

Address ___________________________________________________________________ DateofBirth ___________________

JOINT OWNERSHIP IS TO BE: q JointTenancywiththerightofsurvivorshipq orTenantsinCommon(OwnershipwillbeJointTenantsifnoselectionismade.)

5. CONTRACT TYPE PremiumAmount$ _______________________ Policytobedated ________________________

q SPDA6 q SPDA5 q SPDA4 q FlexPrem Billing: q Ann q Semi-Ann q Qrtly q Mon q EFT

PLAN q Nonqualified Dateoffirstnotice _______________________________ (submitvoidedcheck)

q Qualified Addressforbillings _____________________________________________________

q IRA q SEP q SIMPLE

q RothIRA– ________Yr.established

q BeneIRA-Non-Spouse q OTHER ______________________________

Ifqualified,forwhichyearispremiumpaid?_____________________________

Doestheapplicanthaveexistinglifeinsuranceorannuitycontractswiththecompanyoranyothercompany? q Yes q No

Istheinsuranceappliedforintendedtoreplaceorchangeanylifeinsuranceorannuitycontractwiththecompany oranyothercompany? q Yes q No

APPLICATION FOR INDIVIDUAL DEFERRED ANNUITY

UNITED LIFE INSURANCE COMPANY118SecondAvenueSE POBox73909 CedarRapids,IA52407-3909

1-800-637-6318 FAX:888-726-9736 www.unitedlife.com

ICC12 LIU-119 (11-12) C SPDA of 5

qRevocableorqIrrevocable qPerStirpesorqPerCapita

1. Name ____________________________________________

Relationship ________________________________________

SS# _________________________ Birthday ______________

Address ____________________________________________

____________________________________________________

2. Name ____________________________________________

Relationship ________________________________________

SS# _________________________ Birthday ______________

Address ____________________________________________

____________________________________________________

3. Name ____________________________________________

Relationship ________________________________________

SS# _________________________ Birthday ______________

Address ____________________________________________

____________________________________________________

4. Name ____________________________________________

Relationship ________________________________________

SS# _________________________ Birthday ______________

Address ____________________________________________

____________________________________________________

5. Name ____________________________________________

Relationship ________________________________________

SS# _________________________ Birthday ______________

Address ____________________________________________

____________________________________________________

ASSIGNMENTIsthispolicyassigned?q Yes q NoIfyes,mustattachacompletedassignmentforminorderforassignmenttobeeffectiveforthispolicy.

ANNUITANT’S BENEFICIARY DESIGNATION(willbeRevocableandPerStirpesifnotindicated.)

PER STIRPES—ifanamedbeneficiarydiesbeforetheinsured;proceedswillbepaidtothesurvivingdirectdescendants ofthatbeneficiary.

PER CAPITA—ifnamedbeneficiarydiesbeforetheinsured;proceedsthatwouldhavebeenpaidtothatbeneficiarywill bedividedequallyamongtheothersurvivingnamedbeneficiariesofthatsameclass.

Iftheplanofpaymentdesignatedistoincludeajointannuitant;thebeneficiary(ies)indicatedbelowwillbeforthesurvivoroftheannuitantandjointannuitant,ifthereisabenefittobepaidupontheseconddeath.

Ifthereareadditionalbeneficiaries,includetheinformationbelowonaseparatepagesignedanddatedbytheowner(s).

qRevocableorqIrrevocable qPerStirpesorqPerCapita

1. Name ____________________________________________

Relationship ________________________________________

SS# _________________________ Birthday ______________

Address ____________________________________________

____________________________________________________

2. Name ____________________________________________

Relationship ________________________________________

SS# _________________________ Birthday ______________

Address ____________________________________________

____________________________________________________

3. Name ____________________________________________

Relationship ________________________________________

SS# _________________________ Birthday ______________

Address ____________________________________________

____________________________________________________

4. Name ____________________________________________

Relationship ________________________________________

SS# _________________________ Birthday ______________

Address ____________________________________________

____________________________________________________

5. Name ____________________________________________

Relationship ________________________________________

SS# _________________________ Birthday ______________

Address ____________________________________________

____________________________________________________

ICC12 LIU-119 (11-12) C SPDA of 5

PRIMARY CONTINGENT

ICC12 LIU-119 (11-12) C SPDA of 5

6. PAYOUT INSTRUCTIONS

Doyouwanttoreceivepayoutsonaregularbasis? q Yes qNo Interestonly?Yes ____ orAmount$ _____________

qMonthly qQuarterly qSemi-annual qAnnual (Note:Minimumpayoutis$50.00)

IspayouttobeRequiredMinimumDistribution?q Yes qNo (ForqualifiedplansandAnnuitantsage701/2.)

Ispayouttosatisfy72t? q Yes q No

Forautomaticdepositofthepayoutpleasesubmitavoidedcheck.PayoutsrequireacompletedW-4P.

SPECIALINSTRUCTIONS

7. SUITABILITY

Hasanypartytotheapplication;suchastheapplicant,proposedannuitant,owner,ifotherthantheapplicant,oranybeneficiary;enteredorhasmadeplanstoenterintoanyagreementorcontracttosellorassigntheownershipof,orabeneficialinterestintheappliedforcontact? Yes q No q

Hasanypersonpromisedoragreedtogive;orhasgiven;anypartytotheapplication;orthatanypartytotheapplica-tionhasreceivedorwillreceivefromanyperson;anyinducement,feeorcompensationasanincentivetopurchasethecontract? Yes q No q

Ifyestoeitherquestion,pleaseprovidedetails:

Hasanypartytotheapplicationeversold,transferred,orassignedanyannuitycontracttoathirdparty,suchasa viaticalsettlemententity,lifesettlemententity,insurancecompany,orothersecondarymarketprovider,orpremiumfinancingentity? Yes q No q

Orhavethesepersonseverreceivedanyinducement,feeorcompensationasanincentivetopurchase,sell,transferorassignanannuitycontract? Yes q No q

Ifyestoeitherquestion;pleaseprovidedetails.

NOTICE:Stateinsurancelawmayprohibittheownerofanannuitycontractfromenteringintoanyagreementtosell,transferorassignanannuitycontractpriortothedatethecontractwasissued.Youshouldconsultwithlegaladvisorsifyouhaveanyquestionsaboutthesematters.

FRAUD WARNING:

Anypersonwhoknowinglypresentsafalsestatementinanapplicationforinsurancemaybeguiltyofacriminaloffenseandsubjecttopenaltiesunderstatelaw.

AcknowledgementandSignaturesTheundersigneddeclareandagree

(a)Thattheyhavereadtheapplicationandallstatementsandanswersastheypertaintothem.Andtheyagreethatthesestatementsandanswersaretrueandcompletetothebestoftheirknowledgeandbelief;

(b)Thatthestatementsandanswersintheapplicationarethebasisforanycontractissuedbythecompany,and thatnoinformationaboutthemwillbeconsideredtohavebeengiventothecompanyunlessitisstatedinthe application;

(c)Thatasalesrepresentativedoesnothavethecompany’sauthorizationtoacceptrisk,passoninsurability,ormake,void,orchangeanyconditionsorprovisionsoftheapplication,contract,orreceipt,asapplicable;

(d)Thatthecompanywillhavenoliabilityuntil;(i) Acontractisissuedonthisapplicationanddeliveredtoandacceptedbytheowner;and

(ii)Thefirstpremiumdueispaidinfullwhileeachproposedownerandannuitantisalive;(e)Thatevidenceofagemustbefurnishedbeforecommencementofannuitypayments.

Foranon-taxqualifiedannuity,theundersigned(s)acknowledgethatifeachproposedownerpurchasesanothersuchannuityinthesamecalendaryearfromthecompanyoritsaffiliates;bothannuitieswillbeconsideredasoneannuityfortaxpurposes.

Theundersigned(s)acknowledgethatfederallawrequiressufficientinformationtoidentifythepartiestothepurchaseofanannuity;andthatfailuretoprovidesuchinformationcouldresultintheannuitynotbeingissued,delayed,unprocessedtrans-actionrequests,orannuitycontracttermination.

I/weacknowledgethattothebestofmy/ourknowledgeandbelief,theannuityandanyadditionalbenefitsappliedforaresuit-ableformy/ourinvestmenttimehorizon,goalsandobjectivesandfinancialsituationandneeds.

I/weacknowledgethattheannuitycontractcontainsaRighttoCancelprovision.

Forentityownedcontacts:Itisacknowledgedthat:1) Authorizedindividualsaresigningonbehalfoftheentitypurchasingtheannuityandthattheseindividualsareauthorized

andempoweredtoindividuallyorcollectivelyauthorizedtoenterintocontractsandfinancialtransactionsincludingbutnotlimitedtothepurchaseofanannuity,makeanysubsequentwithdrawalsorsurrendersandexerciseallownershiprightsundertheannuityintheentity’sname;

2) Theentityisdulyorganizedandexistingincompliancewithalllawsandregulations;and3) Theentityshallnotifythecompanyinwritingofachangeinorrevocationofauthorizedindividuals,oranychangeinthe

entity’sstatusthatwouldcauseanyofthestatementsintheapplicationtobeincorrectorincomplete;and4) Theentityorrepresentativehasconsultedanindependenttaxand/orlegaladvisorformoreinformationdeemedneces-

sarytounderstandthetaxtreatmentoftheannuity;and5) Theauthorizedindividualsandentityagreetoindemnifythecompany,itsaffiliatesorrepresentativesforliabilityofany

kindarisingoutoforrelatedtoanyactsoromissionstakenbythecompanyupontheirinstructionsandinrelianceontheirrepresentativestothecompanyinconnectionwiththeannuity.

Ifownerisacorporation,partnership,trust,custodianorUTMA/GUMA,listthetitleoftheownersigning.

CityandStatewheresigned ____________________________________________________________________________________

Owner’ssignature _______________________________________________________ Date ______________________________

JointOwner’ssignature(ifapplicable) ______________________________________ Date ______________________________

IfownerisaTrust,pleasesubmitacopyoftheTrustdocumentandiftheTrustisovertwoyearsold,submitanaffidavitofvalidity.IfPowerofAttorneyissigning,pleasesubmitPOAdocument.IfPOAisineffectovertwoyears,submitanaffidavitofvalidity.

Witnessprintedname _____________________________ Witnesssignature __________________________ Date ___________

I, the AGENT,certifythatIhaveusedonlyinsurer-approvedorprovidedsalesmaterial.IalsocertifythatIhaveleftacopyofallsalesmaterial,replacementformsanddisclosureswiththeapplicant.

Arethereexistinglifeinsuranceorannuitycontractsonthelifeoftheinsured(s)?Yesq No q

Isthispolicyintendedtoreplaceexistinginsuranceorannuitywiththisoranyothercompany?Yesq No q

Agent’sprintedname _____________________________________ AgencyName ______________________________________

Agent’ssignature ______________________________________________ AgencyNumber ______________________________

Date ________________________________________

ICC12 LIU-119 (11-12) C SPDA of 5

SocialSecurityNumber

TaxpayerIdentificationNumber(TIN)Enterowner’sTINintheappropriatebox.Forindividuals,thisisthesocialsecuritynumber(SSN).Forotherentities,itistheEmployerIdentificationNumber(EIN).

Certification–Underpenaltiesofperjury,I(theowner)certifythat:

1. Thenumbershownonthisformismycorrecttaxpayeridentificationnumber(orIamwaitingforanumbertobeissuedtome),and

2.Iamnotsubjecttobackupwithholdingbecause:(a)Iamexemptfrombackupwithholding,or(b)IhavenotbeennotifiedbytheInternalRevenueServicethatIamsubjecttobackupwithholdingasaresultofafailuretoreportallinterestordividends,or(c)theIRShasnotifiedmethatIamnolongersubjecttobackupwithholding.

3. IamaU.S.person(includingaU.S.residentalien).

CertificationInstructions–Youmustcrossoutitem2aboveifyouhavebeennotifiedbytheIRSthatyouarecurrentlysubjecttobackupwithholdingbecauseofunderreportinginterestordividendsonyourtaxreturn.Forrealestatetrans-actionsitem2doesnotapply.Formortgageinterestpaid,acquisitionorabandonmentofsecuredproperty,cancellationofdebt,contributionstoanindividualretirementarrangement(IRA),andgenerally,paymentsotherthaninterestanddividends,youarenotrequiredtosigntheCertification,butyoumustprovideyourcorrectTIN.

SignHere U.S.Owner’sSignature Date Signedat:

JointU.S.Owner’sSignature Date Signedat: (ifapplicable)

PleasecompletetheformW-4Pbelow.Failuretodosowillresultinourwithholdingforincometaxpurposesonanyfuturedistributions.

FormW-4PDepartmentoftheTreasuryInternalRevenueService

Withholding Certificate forPension or Annuity Payments

OMB No. 1545-0415

20_____Typeorprintyourfullname

Homeaddress(numberandstreetorruralroute)

Cityortown,stateandZIPcode

Yoursocialsecuritynumber

Claimoridentificationnumber(ifany)ofyourpensionorannuitycontract

Completethefollowingapplicablelines:

1 Ielectnottohaveincometaxwithheldfrommypensionorannuity.(Donotcompletelines2or3.). . . . . . . . . .

2 Iwantmywithholdingfromeachperiodicpensionorannuitypaymenttobefiguredusingthenumber ofallowancesandmaritalstatusshown.(Youmayalsodesignateanamountonline3. . . . . . . . . . . . . . . . . . . . . Maritalstatus:q Singleq Marriedq Married,butwithholdathigherSinglerate

3 Iwantthefollowingadditionalamountwithheldfromeachpensionorannuitypayment.NOTE: For periodic payments, you cannot enter an amount here without entering the number (including zero) of allowances on line 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

s

(Enternumber ofallowances)

ss

q

$

Owner’ssignature Date

s s

EmployerIdentificationNumberor

X

ICC12 LIU-119 (11-12) C SPDA of 5

Always Required:

For Deferred Annuity q Application LIU-119q Product-specific Disclosure Formq Annuity Suitability Form LIU-892 for ALL ages and states

For Income Annuity q Application LIU-118q Copy of proposalq Product-specific Disclosure Formq Annuity Suitability Form LIU-892 for ALL ages and states

Be sure to indicate, on the application, the contract and plan type and the city and state where application was signed.

Required When Applicable: q Replacement Form—State Specific for both internal and external replacements q 1035/Qualified Transfer Form—LIU-464 q Roth IRA—Roth IRA Form 5305

The premium will be paid by: q Check (copy included). Amount of check $ __________ q Internal 1035/Qualified Transfer—If Renewal, Current Policy No. ____________________ q Company initiated external 1035/Qualified Transfer q Agent initiated 1035/Qualified Transfer from ________

Approximate Total Premium Amount $ _____________

Special Instructions not otherwise noted on app: ___________________________________________________

*****************************************************************************************

To avoid delays, please review the application to verify as needed:If the owner has a Power of Attorney or is a Trust

Include a copy of the supporting documentation. If it is more than two years old, provide an affidavit of validity form (on our website)

Important: Trustee/POA must sign every document as Trustee/POAExample: George A. Harrison Trust by Ringo Starr-TrusteeExample: Ringo Starr by George A. Harrison, POA

If Joint Owner, Deferred Application section 4 must be completed *No exceptions*

Beneficiary—Names, relationships, dates of birth and social security numbers must be provided. If information is on a separate page, owner must also sign and date this page.If payouts requested, we require the W-9 and W-4P be completed.

LIP-828 (5-14)

ANNUITY SUBMISSION COVER & CHECK LIST

For Agent Use Only

Date: _______________ Agent’s Name: ___________________________________ Agent Code #: ________________

Phone: ________________________________ E-mail ______________________________________________________

If faxing all documents to 1-888-726-9736, please do not mail the original, EXCEPT if you are submitting Checks and Company initiated External 1035/Qualified Transfer forms. Mail those to United Life with a copy of this cover sheet.

**************************************************************************************************

Annuitant’s Name: ____________________________________________________________________________________

Reminder: Check progress online under Pending Business at www.unitedlife.com

UNITED LIFE INSURANCE COMPANY118 Second Avenue SE PO Box 73909Cedar Rapids, Iowa 52407-3909 1-800-637-6318

Please help your agent meet the above requirement by providing the following information to the best of your ability. If you are unwilling or unable to do so, please so indicate at the bottom, signing and dating our statement.

Owner Information

Owner Name (First, M.I., Last) Date of Birth SS# or Tax ID #Month Day Year

_______________________________________________________________________________

Annual Gross Income: Net Worth*: Current Tax Bracket:(Include Spousal Income) (Include Spousal Assets)

If a range is used, please limit range to $50k. q 0-15% q 16-28%

$___________________________________ $___________________________________ q Over 28%

Please specify investment and life insurance

holdings on the lines provided.

*Net worth excludes value of primary residence, furnishings, automobile(s), and face amount of life insurance.

Joint Owner Information

Joint Owner Name (First, M.I., Last) Date of Birth SS# or Tax ID # Relationship to OwnerMonth Day Year q Spouse

q Other:_______________________________________________________________________________(If the Joint Owner is the spouse of the Owner, financial information should be included in 1 above and the financial information may be left blank.)

Annual Gross Income: Net Worth*: Current Tax Bracket:(Include Spousal Income) (Include Spousal Assets)

If a range is used, please limit range to $50k. q 0-15% q 16-28%

$___________________________________ $___________________________________ q Over 28%

Please specify investment and life insurance

holdings on the lines provided.

*Net worth excludes value of primary residence, furnishings, automobile(s), and face amount of life insurance.

Annuity Specific Supplemental Suitability Information Form

Before recommending that someone purchase a deferred or immediate annuity, the agent is obligated by regulation, statute or otherwise to make an effort to determine certain information concerning the purchaser and the circumstances surrounding the purchase. This includes but is not limited to data concerning the applicant’s (1) Age; (2) Annual income; (3) Financial situation and needs, including the financial resources used for the fundingof the annuity; (4) Financial experience; (5) Financial objectives; (6) Intended use of the annuity; (7) Financial timehorizon; (8) Existing assets, including investment and life insurance holdings; (9) Liquidity needs; (10) Liquid networth; (11) Risk tolerance; (12) Tax status and any other pertinent information to ascertain the suitability of therecommendation made to you.

Page 1 of 3LIU 892 0317 A

www.unitedlife.com

Source and objective for this annuity

What is the source of the funds you are putting into this annuity?

What is your primary objective for purchasing this annuity?

q Tax-deferred accumulation

q Guaranteed lifetime income at the annuity commencement date

q Immediate guaranteed lifetime income

q Immediate guaranteed income for a fixed period of years

q Other: _________________________________________________________________________________________

_________________________________________________________________________________________________

Please describe your client’s objectives in purchasing the annuity and their financial situation surrounding that pur-chase keeping in mind those items 1–12 noted on page one. _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________


www.unitedlife.com

Disclosures

If you are purchasing a Deferred Annuity, there are certain provisions allowing for withdrawals that may not be subject to surrender charges. However, generally speaking, surrender charges may be applied to early withdrawals during the interest guarantee period (4, 5, 6 years). It is important that you have sufficient income and net worth (apart from the premium for this annuity) to cover your day to day living expenses.

If you are purchasing an Immediate Annuity, it provides for a series of cash payments. Unless there is a life contingency provision, you may outlive the series of payments to you. The Liquidity Feature is only available on Period Certain payouts, otherwise there is no intrinsic value available for withdrawal, to be borrowed against or for which the contract may be surrendered.

If you are purchasing an annuity with monies from an existing insurance policy or annuity, there may be surrender charges or penalties. There may be other instances where using this money may not be in your best interest. You should consult your legal and/or tax advisor to determine the impact of this transaction.

Signatures

q I hereby acknowledge that I am unwilling or unable to provide the information requested above. OR

q I have provided the above information, which is complete to the best of my knowledge and belief.

Taking into consideration the above, as well as other factors, it is my decision to enter into a q Deferred Annuityq Immediate Annuity

I hereby acknowledge that I have read and understand the contents of this form and the potential consequences of my purchasing this annuity. I further confirm that the statements in this form are true to the best of my knowledge and belief and are recorded as reported.

X _________________________________________________ ____________________Owner’s signature Date

X _________________________________________________ ____________________Owner’s signature Date

I believe that this is q is not q a suitable transaction based on the information provided by the Owner(s) and hereby recommend that the annuity be q not be q purchased.

___________________________________________________ ____________________Agent’s signature Date


www.unitedlife.com

of 4LIU 900 1118©United Life 2018. All rights reserved.

a) premiums paid, lessb) partial cash surrenders

The annuity fund value cannot go down if you make no partial cash surrenders.

Premiums & Interest: The annuity allows for multiple premium payments for a Flexible Premium Deferred Annuity, or for one single premium option with the Single Premium Deferred Annuity (explained further below). It is a fixed annuity which means earnings are based on an interest rate fixed by our Board of Directors. It is never less than the Basic Interest Rate (guaranteed interest rate) as described below. Interest is accrued daily and compounded annually. The general type of deferred annuity for which you are applying is described below:

Flexible Premium Deferred Annuity (FPDA): This annuity allows you to make multiple premium payments into the policy prior to the commencement of any regular income payments. You may determine the amount and frequency of those payments. The annuity fund value will increase during the surrender period by additional premium deposits and interest credited. Each month there is a rate declared to be credited to new premiums applied to all flexible premium annuities that month. New premiums earn that monthly rate until the end of the calendar year. Our Board of Directors declares an interest rate for all monies on deposit at the end of the period ending December 31st of the prior calendar year. This rate may be redetermined by our Board of Directors once during the current calendar year. The crediting rate will never be less than the Basic Interest Rate. Monies on deposit as of December 31st of the prior calendar year earn this rate.

Single Premium Deferred Annuity (SPDA): This annuity allows for a single premium payment. The minimum premium you may make is $5,000. Interest rate guarantees are outlined below. The amount of interest to be credited is somewhat dependent on the amount of premium deposited. If the premium is less than $10,000, the interest rate guaranteed after December 31st of the year of issue is ½ % less than for premium deposits at the same time for a similar policy over $10,000. The annuity fund value will increase during the surrender period by interest credited at a conditionally guaranteed rate shown on the policy data pages. If the amount of the annuity fund value drops below the threshold shown on the data pages, then we will credit interest at the rate that has been determined by our Board of Directors for all monies on deposit at the end of the period ending December 31st of the prior calendar year or as may be redetermined by our Board of Directors once during the current calendar year. The crediting rate will never be less than the Basic Interest Rate.

Basic Interest Rate (Guaranteed Interest Rate): The Basic Interest Rate (guaranteed interest rate) for this policy is determined as of the Date of Issue. It is redetermined at the earlier of the end of the surrender period or, for an SPDA at such time as the account value is less than $5,000. It is redetermined only once during the life of the policy.

Policy # ________________________________

118 Second Avenue SE | Cedar Rapids, Iowa 52401 | www.unitedlife.com | 800-637-6318

IMPORTANT DISCLOSURES CONCERNING THE PURCHASE OF YOUR SINGLE PREMIUM DEFERRED ANNUITY WITH UNITED LIFE INSURANCE COMPANY

Deferred Annuity DisclosureThis document reviews important points to consider before you purchase this United Life Insurance Company (ULIC) annuity.

THE ANNUITY CONTRACT

This annuity is deferred, which means it is accumulating money to be paid at a future date, either as a lump sum or as a series of income payments. You don’t pay taxes until money is paid to you. There are a number of reasons that you can use a deferred annuity. You may use it to save money for retirement or for other need in the distant future. Some of the options for how income might be paid are shown below. A deferred annuity is not meant to be used to meet short-term financial goals.

If you have questions about this annuity, please ask your agent, broker or advisor, or contact United Life at 800-637-6318.

How will the value of my annuity grow?The annuity fund value is the accumulation at interest of:


The basic interest rate on the Date of Issue and at each subsequent redetermination is the lesser of 3% or,a) The average monthly five-year Constant Maturity Treasury Rate, or other such index as may be prescribed

by law, for the month of: November (for policies with an issue date of January through June) in theyear preceding the year of issue and initial rate determinate or the year preceding the interest rateredetermination; or the month of May (for policies with an issue date of July through December) in theyear of issue and initial rate determination or the year of the interest rate redetermination.

b) Rounded to the nearest 1/20 of 1%;c) Reduced by 1.25%; butd) Not less than 1%.

BENEFITSWhat happens to the money in the annuity after I die?If you are the annuitant and die before we start to pay you income from your annuity, we pay the annuity fund value to your beneficiary. If you are the owner of the deferred annuity but not the annuitant, death benefit proceeds may also be payable at your death. See the “Ownership” provision in your annuity contract for details. If you elect to take regular monthly income payments of principal and interest, we will issue you a supplemental contract. If you die after the payouts start, whether or not there is a death benefit payable to your beneficiary and how that benefit, if any, would be paid, is dependent on the type of payout you chose. More information regarding what happens at death can be found in the TAXES section of this document.

What happens if I take out some or all of the money from my deferred annuity?Unless there is a specific provision in the supplemental contract that is issued when you decide to begin to take regular annuity payments, you can not take any of the money out of your annuity after the payout begins. Prior to beginning to take regular annuity payments you can take out all of your deferred annuity’s fund value (full surrender) or part of it (partial surrender). A partial surrender that reduces the annuity fund value below the amount set forth in the conditional interest rate provision may reduce the rate at which interest is credited to you policy. If the annuity fund value is reduced to less than $5,000, interest will be credited to your policy at the Guaranteed Interest Rate.

Do I pay any other fees or charges?No. There are not any other fees or charges that we will charge you on this annuity.

How do I get income (payouts) from my annuity?This is a deferred annuity. If you elect to begin regular income payments of principal and interest, we will move your annuity fund value to a new policy (a supplemental contract). You may select at that time (or may have elected previously) how you want the policy’s benefits paid to you. You must elect your payment option no later than one year prior to the annuity income date shown on the declaration pages of the deferred annuity. The following are some of the payout options available to you (there may be others as may be mutually agreed upon in writing between You and Us):

l Life: Guarantees income for as long as you live.l Joint and survivor life: Guarantees income for as long as you or your joint annuitant (usually a spouse or

civil union partner) live.l Life income with period certain: Guarantees income for as long as you live. If you die within the “period

certain” (usually 10 or 20 years), it pays income to your beneficiary for the rest of the period.l Full cash refund: Guarantees income for as long as you live. When you die, the beneficiary will receive the

difference (if positive) between the proceeds applied to buy this option and the sum of the payments made prior to the death of the annuitant.

l Lump sum: One payout.

The guaranteed purchase rates for the above options are referenced in the “Annuity Income Options” provision in your annuity contract. Additional payout options or more favorable rates may be available at the time your elect to take payments. To compute the monthly payment amount on a guaranteed basis, divide your cash surrender value by 10,000 and multiply the result by the factors shown in the schedule in Section IIIa of the Annuity Income Options, Monthly Income Tables.

If you should elect to place your annuity fund value into a supplemental contract, once the payments begin, the benefits cannot generally be changed unless there is a specific provision in the payout option you select that allows them to be.



TAXESHow will payouts and withdrawals from my annuity be taxed?

You should consult your tax professional for complete information regarding annuity taxation. Every situation is unique and even a seemingly “small” factor can change the tax implications. Following is a basic summary of certain but not all tax considerations of which you should be aware:

Income Tax Qualified Annuities: If you have an IRA funded by pre-tax dollars, it is taxed identically to any other qualified account such as a 401(k), profit sharing plan or other tax-deferred retirement account. In this case, distributions are generally fully taxable. You must comply with the Required Minimum Distribution (RMD) rules. These distributions will reduce the policy values.

Nonqualified annuities are taxed differently from most investments. A nonqualified annuity grows tax-deferred until withdrawals begin, the contract is annuitized or there is a death benefit payable.

1. Withdrawals—Withdrawals of earnings from a nonqualified annuity are fully taxable at ordinary income tax rates.The earnings are considered withdrawn first and are therefore subject to taxation. All withdrawals will be fullytaxable as ordinary income until the account value reaches the amount invested. Also, if you are under age 59½when you make the withdrawal, you may be assessed a 10% penalty on any taxable earnings by the IRS.

2. Annuitized Payments from a Supplemental Contract—If you annuitize a nonqualified annuity, a portion of yourpayment will be considered a return of premium and will not be subject to ordinary income tax. The amount that istaxable will be determined at the time you elect to annuitize the policy. A calculation will be made to determine the“exclusion ratio,” which will determine the percentage of each payment that will be excluded from income tax.

3. Taxation at Death–Non-Spousal Beneficiary—At your death, the death benefit may be paid to a non-spousalbeneficiary you have designated. Any deferred income (earnings) in the contract will be taxable to the beneficiariesas ordinary income at their tax rates. Beneficiaries have the choice of taking full distribution of the benefits withinfive (5) years of your death or receiving the death proceeds as periodic payments over a period of time. (see 2above) If the beneficiary chooses to spread the payments over time, this election must be made within one (1) yearof your death.

4. Taxation at Death–Spousal Continuation—In addition to the options noted in 3 above, if your spouse is thebeneficiary, he or she may continue the contract at your death and preserve tax-deferred growth. Choosing thedeath benefit instead of spousal continuation would be a taxable event; your spouse would be taxed at ordinaryincome tax rates on the difference between the death benefit and the amount you invested, adjusted for anywithdrawals.

5. Tax-Free Exchanges—You can exchange one tax-deferred annuity for another without paying taxes on theearnings when you make the exchange. Before you do, compare the benefits, features, and costs of the twoannuities. You may pay a surrender charge if you make the exchange during the surrender period of the existingannuity. You may also pay a surrender charge if you make withdrawals from the new annuity during the first yearsyou own it

Does buying an annuity in a retirement plan provide extra tax benefits?Buying an annuity within an IRA, 401(k), or other tax-deferred retirement plan doesn’t give you any extra tax benefits. Choose your annuity based on its other features and benefits as well as its risks and costs, not its tax benefits.

OTHER INFORMATION TO KNOWChanges to your contract We may change your annuity contract from time to time to follow federal or state laws and regulations. If we do, we will tell you about the changes in writing.

Compensation We pay the agents who sell our products with various compensation structures. The base commission we pay our agents is a fixed percentage of policy premium and varies for each type of product sold. We may provide variable compensation in the form of cash or non-cash amounts (such as the ability to receive items of value, travel, career educational opportunities, etc.) as incentives for selling our products and servicing our clients. The compensation we pay our agents for deferred annuities never reduces the account value or premium of the policy you select.

Free look (Right to Cancel) The owner of the deferred annuity has 30 days from the day he or she receives the policy to review the contract and if dissatisfied, return it and receive a prompt refund of any premium paid.



What should I know about the company? United Life Insurance Company offers a wide variety of retirement and financial security products, including life insurance and annuities. Established in 1962, our company has maintained a strong focus on quality products, excellent service and financial strength. United Life is highly-capitalized and is recognized in the industry for financial stability. We remain dedicated to continuing the tradition of excellence upon which our company was founded.

United Life Insurance Company118 Second Avenue SECedar Rapids, IA 52401

Telephone: 800-637-6318

FEES, EXPENSE & OTHER CHARGESYou are allowed to withdraw up to the greater of 10% of the annuity fund value, or accumulated interest- (but not both) on an annual basis without incurring surrender charges. If you withdraw more than the 10% amount, we will assess a surrender charge from amounts you withdraw before the end of the contract surrender charge period. The contract year is based on the date of the first premium. The surrender charge is based on the original amount of the premiums deposited to the deferred annuity, not of the current value. Here are the charges by annuity plan name:

Exceptions: There is no surrender charge if we pay the annuity fund value of your deferred annuity to a beneficiary after your death.

This is a summary document and not part of your contract with United Life Insurance Company. If there are differences between this summary and the contract itself, the contract will prevail.

I am purchasing the following deferred annuity plan and understand the basics of how the plan works. One of the following plans must be checked.

Please check one:

q Flexible Premium Deferred Annuity (FPDA) q Single Premium Deferred Annuity – 5 years (SPDA-5)

q Single Premium Deferred Annuity – 4 years (SPDA-4) q Single Premium Deferred Annuity – 6 years (SPDA-6)

_____________________________________________________ ________________ _________________________Signature of Owner(s) Date Policy Number

_____________________________________________________ ________________Signature of Agent Date

SPDA-4 SPDA-5 SPDA-6 FPDA

Early Surrender Charge




Year Percentage Year Percentage Year Percentage Year Percentage

1 4% 1 5% 1 6% 1 7%

2 4% 2 4% 2 5% 2 7%

3 3% 3 3% 3 4% 3 6%

4 2% 4 2% 4 3% 4 5%

5 0% 5 1% 5 2% 5 4%

6 0% 6 0% 6 1% 6 3%

7 2%

8 1%


United Life Insurance Company118 Second Avenue SE Cedar Rapids, Iowa 52401800-637-6318 1035 Exchange/Transfer Form

Existing Company Phone Number (important)

Existing Company Street Address (Required) City State Zip

Existing Contract Number or Numbers Approximate Amount of Transfer q Transfer funds immediately

Account Type q Life q Annuity Name of Fund

Insured’s/Annuitant’s Name Insured’s/Annuitant’s S.S. No.

Owner/Owner’s Name Owner’s Social Sec. No.

I hereby absolutely assign all of my right, title and interest in and to the above referenced contract to United Life Insurance Company, includ-ing, but not limited to, the right to surrender, assign, transfer or change beneficiary.

Section 1035 of the Internal Revenue Code permits certain nontaxable exchanges of insurance and annuity policies. It is my intention that this transfer qualify as a Section 1035 exchange and that no portion of this exchange be actually or constructively received by me. United Life Insur-ance Company makes no representation concerning my tax treatment for this transaction and the company has no responsibility nor liability for my tax treatment. I understand the exact amount of the proceeds may vary depending upon the date of transfer, and I agree to execute any additional documents required to complete the transfer. I understand that the exchange is not complete if the company issuing the contract is unable or unwilling to pay the value of the above referenced contract to United Life Insurance Company within six (6) months of the request for surrender or if said company is placed under the control or supervision of a state insurance department. I request that this transfer be accom-plished as quickly as possible.

q Please liquidate account in full.

q Please liquidate $ ____________________ of my account.

q Please liquidate on the Maturity Date of _______________

q Lost Policy. I cannot locate the policy

q The account to which the funds are being transferred is a life policy.

q The account to which the funds are being transferred is a non-quali-fied annuity

_____________________________________________________________ Owner’s Signature Date

_____________________________________________________________ Co-Owner’s Signature or Spouse* Date

COMPLETE ONE SECTION ONLY

NOTE: A signature guarantee may be required by transferring company.

_______________________________________________________________Signature Guarantee By: Name of Bank or Firm

_______________________________________________________________Signature of Officer & Title

*Spouse signature required in community Property statesAZ, ID, LA, NM, TX, WA, WI, CA, NV

Below: to be completed by United life Insurance Company

Acceptance by United Life Insurance Company United Life Policy Number: ________________________________________

By signing below, United Life Insurance Company agrees to accept the transfer described above for the Plan established on behalf of the above named individual. We request the liquidation and transfer of funds indicated above.

REQUEST FOR 1035 EXCHANGE LIFE INSURANCEOR NON-QUALIFIED ANNUITY CONTRACT

AUTHORIZATION TO TRANSFER FUNDS

q Please liquidate account in full.

q Please liquidate $ _____________________of my account.

q Please liquidate ______ % of my account.

q Please liquidate:

q on the Maturity Date of _________________

q upon receipt of this request. I/we are aware of any penalty that may be imposed from an early withdrawal. (initials)

and transfer to the annuity I have established through United Life Insurance Company

q Lost Policy. I cannot locate the policy.

The account to which the funds are being transferred is:

q IRA q Roth IRA q SEP

q Rollover Roth IRA q Inherited IRA

q Other ____________________________________________________

_______________________________________________________________Owner’s Signature Date

_______________________________________________________________Co-Owner’s Signature or Spouse*

NOTE: Age 70 1/2 restrictions apply to a transfer from a qualified plan retire-ment account. If you are age 70 1/2 or older this year, you may not trans-fer or rollover required minimum distribution amounts. If necessary, instruct your present trustee/custodian, prior to effecting this request to either: (1) pay your own required minimum distribution to you now; or (2) retain the amount for distribution to you later.

QUALIFIED PLANTRANSFER REQUEST

MAILING INSTRUCTIONS: Mail proceeds directly to: United Life Insurance Company118 Second Avenue SE PO Box 73909Cedar Rapids, Iowa 52407-3909

LIU-464 (6-14)

Date __________________________ By _______________________________________________________ Title _______________________________________

This form applies only to life and annuity accounts. Use LIU-409 for other types of fund transfers: CDs, mutual funds, etc.

APPENDIX A IMPORTANT NOTICE:

REPLACEMENT OF LIFE INSURANCE OR ANNUITIESThis document must be signed by the applicant and the producer, if there is one, and a copy left with the applicant.

You are contemplating the purchase of a life insurance policy or annuity contract. In some cases this purchase may involve discontinuing or changing an existing policy or contract. If so, a replacement is occurring. Financed purchases are also considered replacements.

A replacement occurs when a new policy or contract is purchased and, in connection with the sale, you discontinue making premium payments on the existing policy or contract, or an existing policy or contract is surrendered, forfeited, assigned to the replacing insurer, or otherwise terminated or used in a financed purchase.

A financed purchase occurs when the purchase of a new life insurance policy involves the use of funds obtained by the withdrawal or surrender of or by borrowing some or all of the policy values, including accumulated dividends, of an existing

policy, to pay all or part of any premium or payment due on the new policy. A financed purchase is a replacement.

You should carefully consider whether a replacement is in your best interest. You will pay acquisition costs and there may be surrender costs deducted from your policy or con-tract. You may be able to make changes to your existing policy or contract to meet your insurance needs at less cost. A financed purchase will reduce the value of your existing policy or contract and may reduce the amount paid upon the death of the insured.

We want you to understand the effects of replacements before you make your purchase decision and ask that you answer the following questions and consider the questions on the back of this form.

1. Are you considering discontinuing making premium payments, surrendering, forfeiting,assigning to the insurer, or otherwise terminating your existing policy or contract? ......................................q YES q NO

2. Are you considering using funds from your existing policies or contracts to pay premiumsdue on the new policy or contract? .............................................................................................................q YES q NO

If you answered “yes” to either of the above questions, list each existing policy or contract you are contemplating replacing (include the name of the insurer, the insured, and the contract number if available) and whether each policy will be replaced or used as a source of financing:

INSURER NAME CONTRACT OR POLICY # INSURED REPLACED (R) OR FINANCING (F)

1. _______________________________________________________________________________________________ ( ______ )

2. _______________________________________________________________________________________________ ( ______ )

3. _______________________________________________________________________________________________ ( ______ )

Make sure you know the facts. Contact your existing company or its agent for information about the old policy or contract. [If you request one, an in-force illustration, policy summary or available disclosure documents must be sent to you by the exist-ing insurer.] Ask for and retain all sales material used by the agent in the sales presentation. Be sure that you are making an informed decision.

The existing policy or contract is being replaced because ________________________________________________________

I certify that the responses herein are, to the best of my knowledge, accurate:

_________________________________________________________________________ _______________________________APPLICANT’S SIGNATURE AND PRINTED NAME DATE

_________________________________________________________________________ _______________________________PRODUCER’S SIGNATURE AND PRINTED NAME DATE

I do not want this notice read aloud to me. __________(Applicants must initial only if they do not want the notice read aloud.)

(continued)

LIU-460 (6-00) Page 1 of 2

UNITED LIFE INSURANCE COMPANY | 118 Second Avenue SE, Cedar Rapids, Iowa 52401 | www.unitedlife.com | 800-637-6318

A replacement may not be in your best interest, or your decision could be a good one. You should make a careful comparison of the costs and benefits of your existing policy or contract and the proposed policy or contract. One way to do this is to ask the company or agent that sold you your existing policy or contract to provide you with information concern-ing your existing policy or contract. This may include an illustration of how your existing policy or contract is working now and how it would perform in the future based on certain assumptions. Illustrations should not, however, be used as a sole basis to compare policies or contracts. You should discuss the following with your agent to determine whether replacement or financing your purchase makes sense:

PREMIUMS:• Are they affordable?• Could they change?• You’re older—are premiums higher for the proposed

new policy?• How long will you have to pay premiums on the new

policy? On the old policy?

POLICY VALUES:• New policies usually take longer to build cash values

and to pay dividends.• Acquisition costs for the old policy may have been

paid; you will incur costs for the new one.• What surrender charges do the policies have?• What expense and sales charges will you pay on the

new policy?• Does the new policy provide more insurance

coverage?

INSURABILITY:• I f your health has changed since you bought your old

policy, the new one could cost you more, or you couldbe turned down.

• You may need a medical exam for a new policy.

[Claims on most new policies for up to the first two years can be denied based on inaccurate statements. Suicide limitations may begin anew on the new coverage.]

IF YOU ARE KEEPING THE OLD POLICY AS WELL AS THE NEW POLICY:

• How are premiums for both policies being paid?• How will the premiums on your existing policy be

affected?• Will a loan be deducted from death benefits?• What values from the old policy are being used to pay

premiums?

IF YOU ARE SURRENDERING AN ANNUITY OR INTER-EST SENSITIVE LIFE PRODUCT:

• Will you pay surrender charges on your oldcontract?

• What are the interest rate guarantees for the new con-tract?

• Have you compared the contract charges or otherpolicy expenses?

OTHER ISSUES TO CONSIDER FOR ALL TRANSACTIONS:

• What are the tax consequences of buying thenew policy?

• Is this a tax-free exchange? (See your tax advisor.)• Is there a benefit from favorable “grandfathered” treat-

ment of the old policy under the federal tax code?• Will the existing insurer be willing to modify the

old policy?• How does the quality and financial stability of

the new company compare with your existingcompany?

LIU-460 (6-00) Page 2 of 2

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