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  • APPLICATION SINGLE PREMIUM DEFERRED ANNUITY (SPDA)

    A. PRODUCT SELECTION

    Preserve

    ProOption

    6-Year 7-Year 8-Year 9-Year3-Year 4-Year 5-Year 10-Year

    5-Year 7-Year 10-Year

    Product Choices

    B. ANNUITANT

    Annuitant Information Joint Annuitant Information (Not available for Qualified Plans)

    1. COMPLETE NAME (FIRST/MIDDLE/LAST)

    2. RESIDENTIAL ADDRESS (NO P.O. BOX)

    CITY STATE ZIP CODE

    8. COMPLETE NAME (FIRST/MIDDLE/LAST)

    9. RESIDENTIAL ADDRESS (NO P.O. BOX)

    3. SOCIAL SECURITY #

    CITY STATE ZIP CODE

    10. SOCIAL SECURITY #

    5. DATE OF BIRTH 6. AGE 7. PHONE NUMBER 12. DATE OF BIRTH 13. AGE 14. PHONE NUMBER

    MALE FEMALE 4. SEX

    C. OWNER

    Owner Information (Complete only if Owner is different from Annuitant) (If trust, include full trust document)

    Joint Annuitant Information (Not available for Qualified Plans)

    1. COMPLETE NAME (FIRST/MIDDLE/LAST)

    2. RESIDENTIAL ADDRESS (NO P.O. BOX)

    CITY STATE ZIP CODE

    8. COMPLETE NAME (FIRST/MIDDLE/LAST)

    9. RESIDENTIAL ADDRESS (NO P.O. BOX)

    CITY STATE ZIP CODE

    MALE FEMALE 11.SEX

    5. DATE OF BIRTH OR TRUST

    6. AGE 7. PHONE NUMBER

    MALE FEMALE 4. SEX

    NON-NATURAL OWNER

    3. SOCIAL SECURITY # OR TIN

    11.

    12.DATE OF BIRTH 13. AGE 14. PHONE NUMBER

    MALE FEMALE SEX10. SOCIAL SECURITY #

    401 PENNSYLVANIA PARKWAY, SUITE 300, INDIANAPOLIS, IN 46280 800 767 7749 PAGE 1 OF 4GLA-MYGA-GEN 06/2013

  • D. SPECIAL REQUESTS

    APPLICATION SINGLE PREMIUM DEFERRED ANNUITY (SPDA)

    E. TAX QUALIFICATION

    Non-Qualified Roth IRATraditional IRA

    Roth IRA Conversion SEP IRA (include IRS Form 5305)

    Inherited Beneficiary IRA

    Plan Type (check one) Please complete if applicable

    If Traditional IRA Contribution-Tax Year _________

    If Roth IRA Contribution-Tax Year______________

    If Roth IRA-Inception Date___________________

    F. PREMIUM AMOUNT

    AmountSource

    Check with Application

    Estimated 1035 Exchange Amount

    Estimated Qualified Transfer/ Rollover Amount

    Estimated Non-Qualified Transfer/ Rollover Amount

    (i.e. liquidation of mutual fund, money market)

    $

    $

    $

    $

    G. BENEFICIARIES

    Relationship to OwnerPrimary Beneficiary Full Name Date of Birth Social Security Numberor TIN Percentage

    Relationship to OwnerContingent Beneficiary Full Name Date of Birth Social Security Number or TIN Percentage

    401 PENNSYLVANIA PARKWAY, SUITE 300, INDIANAPOLIS, IN 46280 800 767 7749 PAGE 2 OF 4

    Please check here if you are attaching additional Beneficiary information

    GLA-MYGA-GEN 06/2013

    (Please list any special requests below)

    (If Spousal Joint Ownership, 'surviving spouse' is normally listed as primary beneficiary)

  • APPLICATION SINGLE PREMIUM DEFERRED ANNUITY (SPDA)

    H. EXISTING COVERAGES/REPLACEMENT Please answer the following questions

    I. OWNER AND ANNUITANT SIGNATURE(S)

    a. Do you have any other life insurance policies or annuity contracts?

    b. Is the Contract applied for replacing or likely to replace any existing life insurance or annuity contracts?

    If “Yes,” and required by your state, complete the necessary Replacement Notice.

    If “Yes,” and required by YOUR state, complete the necessary Replacement Notice.

    I acknowledge and understand that most annuities purchased with Qualified Funds are subject to the Required Minimum Distribution (”RMD”) Rules. If I am currently subject to RMDs or taking RMDs, I understand that the RMDs must be withdrawn before transferring funds.

    I believe this to be a suitable purchase for my financial status. Any applicable Surrender Charge, Early Withdrawal and Market Value Adjustment provisions have been explained to me.

    I agree to all terms and conditions as shown, and have read and understand all the statements made above. I agree that this application will be made part of the annuity Contract, and all statements made in this application are true, to the best of my knowledge and belief. I understand that amounts payable under the Contract may be subject to a Market Value Adjustment.

    Yes

    Yes No

    No

    401 PENNSYLVANIA PARKWAY, SUITE 300, INDIANAPOLIS, IN 46280 800 767 7749 PAGE 3 OF 4GLA-MYGA-GEN 06/2013

    Signed at: City, State, Zip Date

    Signature of Owner Date

    Signature of Annuitant Date

    Signature of Joint Owner Date

    Signature of Joint Annuitant Date

  • J. AGENT SIGNATURE(S)

    1. Will this plan replace any existing life insurance or annuity?

    If "Yes,” please explain: _________________________________________________________________________

    For any replacement, indicate the type of coverage proposed to be replaced:

    2. Advertising materials:

    • I certify that I used only insurer-approved sales material with this Application and that an original or a copy of all sales material was left with the Proposed Owner.

    • I certify that a printed copy of any electronically presented sales material was/will be presented to the Proposed Owner no later than the date the Contract is delivered.

    3. I certify that this Application is in accordance with the Guggenheim Life and Annuity Company’s Business Guidelines with respect to the acceptability of replacements.

    4. By signing below, I hereby certify, to the best of my knowledge and belief, that all information in this application is true. I also certify that I have explained any applicable Surrender Charges, Early Withdrawal Market Value Adjustments provisions contained in this Contract, and I certify that this annuity is suitable for the Applicant, based upon the Applicant's disclosure.

    Yes No

    Fraud Notice: Any person, who knowingly and with intent to defraud any insurance company or other person, files anapplication 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.

    If you haven't received your agent number please indicate "PENDING"

    401 PENNSYLVANIA PARKWAY, SUITE 300, INDIANAPOLIS, IN 46280 800 767 7749 PAGE 4 OF 4

    APPLICATION SINGLE PREMIUM DEFERRED ANNUITY (SPDA)

    Signature of Agent Date

    Signature of Agent (If Joint Case) Date

    GLA-MYGA-GEN 06/2013

    Agent Number Split %

    Producer Name Email Address

    Office Phone Number

    Agent Number Split %

    Producer Name Email Address

    Office Phone Number

    Term Life Whole Life Variable Life Fixed Annuity Variable Annuity Other: _______________

    1 COMPLETE NAME FIRSTMIDDLELAST: 8 COMPLETE NAME FIRSTMIDDLELAST: 2 RESIDENTIAL ADDRESS NO PO BOX: 9 RESIDENTIAL ADDRESS NO PO BOX: CITY: STATE: ZIP CODE: CITY_2: STATE_2: ZIP CODE_2: 3 SOCIAL SECURITY: 10 SOCIAL SECURITY: 6 AGE: 7 PHONE NUMBER: 13 AGE: 14 PHONE NUMBER: 1 COMPLETE NAME FIRSTMIDDLELAST_2: 8 COMPLETE NAME FIRSTMIDDLELAST_2: 2 RESIDENTIAL ADDRESS NO PO BOX_2: 9 RESIDENTIAL ADDRESS NO PO BOX_2: CITY_3: STATE_3: ZIP CODE_3: CITY_4: STATE_4: ZIP CODE_4: 3 SOCIAL SECURITY OR TIN: 3 SOCIAL SECURITY OR TIN_2: 6 AGE_2: 7 PHONE NUMBER_2: 6 AGE_3: 7 PHONE NUMBER_3: fill_2: fill_3: fill_4: fill_5: undefined_2: Agent Number: Check Box191: Off Check Box192: Off Check Box193: Off Check Box194: Off Check Box195: Off Check Box196: Off Check Box197: Off Check Box198: Off Check Box199: Off Check Box200: Off Check Box201: Off Text10: Check Box13: Off Check Box14: Off Check Box15: Off Check Box16: Off Check Box17: Off Check Box18: Off Text19: Text20: Text21: Text22: Text24: Text25: Text26: Text27: Text29: Text30: Text31: Text32: Text34: Text35: Text36: Text37: Text39: Text40: Text41: Text42: Text44: Text45: Text46: Text47: Text49: Text50: Text51: Check Box52: Off Check Box53: Off Check Box54: Off Check Box55: Off Check Box56: Off Check Box59: Off Check Box60: Off Check Box61: Off Check Box62: Off Check Box63: Off Check Box64: Off Text65: Text66: Text67: Text68: Text69: Text70: Text71: Text72: Text73: Text74: Text1: Check Box2: Off Check Box3: Off DOB1: DOB2: DOB3 or TRUST: DOB4 or TRUST: DOB6: DOB7: DOB8: DOB9: DOB10: DOB11: SIGNED DATE: Check Box1: Off Check Box4: Off Check Box5: Off Check Box6: Off Check Box7: Off Check Box8: Off Check Box9: Off Check Box10: Off Check Box11: Off