Life and Annuity Division Protective Life Insurance Company Annuity New Business ... ·...

Life and Annuity Division Annuity New Business Checklist

Protective Life Insurance Company1 West Coast Life Insurance Company1

Protective Life and Annuity Insurance Company APPLICATION

Customer information completed in its entirety where applicable.

Beneficiary information completed in its entirety. Please note the following:

✓ Beneficiary allocations must equal 100% for both Primary and Contingent Beneficiaries.

✓ Percentage and Designation are required for each beneficiary.

✓ Any additional beneficiaries not included on the application must be submitted in writing with a signature of the

owner(s) and dated.

Plan Type. Please note the following:

✓ Include the plan type that we are to issue the contract and ensure that it is applicable to the product being sold.

✓ Include the amount being submitted as well as any transfer and tax information applicable to this contract.

Fund Allocations must equal 100%.

Replacement Questions completed in their entirety by both customer and agent.

Customer Signature. All owners must sign.

✓ Annuitant signature is required if different than the owner(s).

✓ Complete Date, City and State fields.

Agent Signature. To ensure timely processing, please include the following:

✓ Agent’s name printed, Agency name, and Agent’s phone number.

✓ Florida License ID # if applicable.

Indexed Annuities 14 Calendar days. Application and funds or Application and Transfer/Exchange form must be

received within 14 calendar days of sign date.

✓ All Initial Premiums should be identified on application (checks & transfers) - funded premium (checks) must

accompany the new business – do not wait to forward

✓ Client-initiated transactions – 60 day rate/cap lock given if completed LAD 1120 Transfer/Exchange form, with Client

Initiated box checked, is completed

SUITABILITY FORM Required for all annuity business submitted through an IMO/BGA. Where FINRA firms have a certified program for Protective to accept your firm’s Registered Principal approval, the form is not required.

REPLACEMENT FORM(S) Please complete all applicable Replacement Forms.

TRANSFER / ROLLOVER / EXCHANGE FORM Please complete all applicable forms.

TRUST DOCUMENTATION If the owner is a Trust, we must receive a copy of the Trust Certification form or the first and last page of the trust in order to issue the contract.

POWER OF ATTORNEY DOCUMENTATION If applicable, POA documentation is required.

1 Not authorized in New York FOR AGENT / BROKER DEALER INFORMATION ONLY. NOT FOR USE WITH CONSUMERS.

“Annuity contracts issued by Protective Life Insurance Company (PLICO-not authorized to sell insurance in NY), West Coast Life Insurance Company (WCL - not authorized to sell insurance in NY) and Protective Life and Annuity Insurance Company (PLAICO-authorized to sell life insurance in NY). Securities offered by Investment Distributors, Inc. (IDI). PLICO, PLAICO, and IDI are located at Birmingham, AL 35223, WCL located at San Francisco, CA 94104. All are subsidiaries of Protective Life Corporation. Protective Life Corporation is a separate company and is not responsible for the financial condition or the contractual obligations of PLICO, WCL, PLAICO, or IDI. PABD.4504 Rev. 03/19/20

Enroll today at www.edelivery.protective.com!

You can sign up to receive email notifi cations when copies of important account documents are available for viewing.

Reduce clutter, stay organized, and help the environment with eDelivery!

For questions or assistance, please contact Customer Service at 1-800-456-6330.

GO PAPERLESS. eDelivery is simple and free

�� Prospectuses

�� Supplements

�� Semi-Annual Reports

�� Annual Reports

CLAC.1000 (07.18)

Protective Life refers to Protective Life Insurance Company (PLICO) and its affi liates, including Protective Life & Annuity Insurance Company (PLAICO). Life insurance and annuities are issued by PLICO in all states except New York and, in New York, by PLAICO. Securities issued by Investment Distributors, Inc. (IDI), principal underwriter for registered products issued by PLICO and PLAICO, its affi liates. All companies located in Birmingham, AL. Product availability and features may vary by state. Each company is solely responsible for the fi nancial obligations accruing under the products it issues. Product guarantees are backed by the fi nancial strength and claims-paying ability of the issuing company.

STATEMENT OF UNDERSTANDING FOR OPTIONAL PROTECTED LIFETIME INCOME BENEFITS: (PROTECTIVE INCOME MANAGERSM or SECUREPAYSM)

Required Minimum Distributions: A protected lifetime income benefit rider, if purchased, permits withdrawals in excess of the Optimal Withdrawal Amount (for Protective Income Manager) or the Annual Withdrawal Amount (for SecurePay) to satisfy the required minimum distributions (RMD) under Internal Revenue Code Section 401(a)(9) as they apply to amounts attributable to this Contract. These withdrawals will not be treated as ‘excess withdrawals’ provided: a) you notify us in writing at the time you request the withdrawal that it is intended to satisfy RMD requirements; and, b) we calculate the RMD amount based solely on the applicable end-of-year value of this Contract. The timing and amount of the non-excess RMD protected lifetime income benefit withdrawal we permit from this Contract may be more restrictive than allowed under IRS rules, and may not satisfy the annual RMD requirements for all of the tax-qualified contracts you own. You should consult your tax advisor.

Allocation Guidelines and Restrictions: While a protected lifetime income benefit rider is in effect, your Contract’s Investment Option allocations are restricted, as described on page 2 of the application. Either the entire allocation must be to a single permissible Model Portfolio (the Growth Focus model is not available); or the entire allocation must be to a single permissible Individual Option; or the entire allocation must comply with investment risk category restrictions: At least 40% of your total Contract allocation must be allocated to sub-accounts in Category 1. Not more than 60% of your total Contract allocation may be allocated to sub-accounts in Category 2. Not more than 25% of your total Contract allocation may be allocated to sub-accounts in Category 3. Sub-accounts in Category 4 are not available. The Fixed Account is not available. You may allocate Purchase Payments directly to the sub-accounts or a permissible Model Portfolio or Individual Option, or to any of the available DCA Accounts subject to the limitations in the Contract's 'Dollar Cost Averaging' provision. We systematically and automatically transfer amounts allocated to the DCA Accounts to the Variable Account according to your Contract allocation. We systematically and automatically rebalance to your current Variable Account allocation quarterly, semi-annually, or annually, according to your current portfolio rebalancing instructions.

Purchase Payments, Transfers, and Withdrawals: While a protected lifetime income benefit rider is in effect, we will not accept any purchase payment that we receive after the 120th day following the Rider Effective Date (for Protective Income Manager) or on or after the earlier of the Benefit Election Date or the 2nd anniversary of the Rider Effective Date (for SecurePay). You may transfer Contract Value among the Investment Options, but the Contract Value immediately after the transfer must meet the Allocation Guidelines and Restrictions. You may also change your Contract allocation provided it meets the Allocation Guidelines and Restrictions. A change in your Contract allocation will result in an automatic rebalancing of the Contract Value. Partial surrenders and withdrawals including applicable surrender charges, if any, are deducted from the Investment Options in the same proportion that the value of each bears to the total Contract Value.

Prohibited Instructions: The protected lifetime income benefit rider, every benefit it provides, and deduction of the monthly fee terminate at the end of the Valuation Period on which we execute your instruction to: 1. Do any of the following in a manner that violates the Allocation Guidelines and Restrictions or rider provisions: allocate a

Purchase Payment, process dollar cost averaging transfers, transfer Contract Value, or deduct a partial surrender orwithdrawal; or,

2. Stop portfolio rebalancing; or3. Terminate the rider more than 10 years after its Rider Effective Date; or4. Change a Covered Person at any time after the Rider Effective Date (for Protective Income Manager) or the Benefit

Election Date (for SecurePay); or5. Annuitize or terminate the Contract to which the rider(s) are attached.

APPLICATION INSTRUCTIONS Mailing Address for Applications: Overnight U. S. Postal Mail

Annuity New Business Annuity New Business 2801 Hwy 280 South P. O. Box 10648 Birmingham, AL 35223 Birmingham, AL 35202-0648

Percentages: Always use whole (not fractional) percentages. Percentage totals must equal 100% per category (i.e. "Primary" and "Contingent" Beneficiaries; "Purchase Payment" and "DCA Allocation" instructions; etc.).

Withholding on Withdrawals: All withdrawals from the Contract, including Protective Income Manager, SecurePay and Automatic Withdrawals must include your instructions regarding Federal Tax Withholding. Complete "Federal Tax Withholding on Non-Periodic Annuity Payments" form # LAD-1133. If not completed, Federal Tax Withholding at a rate of 10% will automatically apply.

PROTECTIVE LIFE AND ANNUITY INSURANCE COMPANY Home Office: Birmingham, Alabama

AF-2119-R6 APPLICATION COVER PAGE PVA NY II B Series 4/20

CONTRACT # __________________________ VARIABLE ANNUITY APPLICATION

Owner 1 Name: __________________________________________________________ __ Male __ Female

Address: ________________________________________________________ Birthdate: _____________________

City: _________________________ State: __________ Zip: _________ Tax ID: ______________________

Email Address: ___________________________________________________ Phone: ______________________

Owner 2 Name: __________________________________________________________ __ Male __ Female




Annuitant Name: __________________________________________________________ __ Male __ Female




Beneficiary, if there is no surviving Owner

Use Administrative Form LAD-1225 to name or change a beneficiary anytime before the death of an owner.

Initial Purchase Payment: $ ________________ (minimums: B Series - $5,000; or if Protective Income Manager is purchased - $25,000.)

Funding Source: __ Cash __ Non-Qualified 1035 Exchange __ Non-Insurance Exchange

__ Transfer __ Direct Rollover __ Indirect Rollover

Plan Type: __ Non-Qual __ IRA __ Roth IRA __ Other: __________________________

Complete if an IRA and includes new contributions: $ ____________ (Amount) ___________ (Tax Year)

$ ____________ (Amount) ___________ (Tax Year)

Replacement: Do you currently have an annuity contract or life insurance policy? __ Yes __ No

Will this annuity change or replace an existing annuity contract or life insurance policy? __ Yes __ No (If yes, please provide the company name and contract or policy number below.)

Company 1 ___________________________________________________________ Contract or Policy # ______________________



PROTECTIVE LIFE AND ANNUITY INSURANCE COMPANY

Home Office: Birmingham, Alabama

An annuity contract is not a deposit or obligation of, nor guaranteed by any bank or financial institution. It is not insured by the Federal Deposit Insurance Corporation or any other government agency, and is subject to investment risk, including the possible loss of principal.

CONTRACT BENEFITS ARE VARIABLE, MAY INCREASE OR DECREASE, AND ARE NOT GUARANTEED AS TO FIXED DOLLAR AMOUNT.

AF-2119-R6 PVA NY II B Series 4/20


Select Product: X Protective Variable Annuity NY II B Series

Page 1

ALLOCATE PURCHASE PAYMENTS - Unless you give us instructions for allocating subsequent Purchase Payments when you make them, we will use the Variable Account allocation in effect at that time. Use whole percentages. Purchase Payment and DCA Allocation percentage totals must equal 100%, each. If using a Model Portfolio, allocate to the Guaranteed Account and one Model Portfolio, only. If purchasing a protected lifetime income benefit (PLIB) and using a Model Portfolio, do not also allocate to individual sub-accounts.

Purchase Payment Protective Life Guaranteed Account _____ % Fixed Account – Not Available if a protected lifetime income benefit (PLIB) is purchased. _____ % DCA Account 1 – Make DCA transfers on the ____ day (1st – 28th) of the month for ____ months (3 – 6 months). _____ % DCA Account 2 – Make DCA transfers on the ____ day (1st – 28th) of the month for ____ months (7 – 12 months).

Sub-Accounts of Variable Annuity Account A

Purchase DCA Category 1 - Conservative Purchase DCA Category 3 – Aggressive Payment Allocation (Min. 40% allocation if a PLIB is purchased.) Payment Allocation (continued)

_____ % _____ % American Funds IS Bond _____ % _____ % Goldman Sachs Strategic Growth _____ % _____ % American Funds IS U.S.Govt/AAA-Rated Securities _____ % _____ % Invesco American Value _____ % _____ % **Clayton St Protective Life Dynamic Allocation - Conservative _____ % _____ % Invesco Comstock _____ % _____ % Fidelity Investment Grade Bond _____ % _____ % Invesco Growth and Income _____ % _____ % Franklin U. S. Government Securities _____ % _____ % Invesco International Growth _____ % _____ % Goldman Sachs Core Fixed Income _____ % _____ % Invesco Oppenheimer Capital Appreciation _____ % _____ % Invesco Government Securities _____ % _____ % Invesco Oppenheimer Main Street® _____ % _____ % Invesco Oppenheimer Government Money _____ % _____ % Lord Abbett Dividend Growth

_____ % _____ % PIMCO Low Duration _____ % _____ % Lord Abbett Fundamental Equity _____ % _____ % PIMCO Short-Term _____ % _____ % PIMCO Total Return Purchase DCA Category 4

Payment Allocation (Not Available if a PLIB is purchased.) Purchase DCA Category 2 - Moderate _____ % _____ % American Funds IS Global Small Capitalization Payment Allocation (Max. 60% allocation if a PLIB is purchased.) _____ % _____ % American Funds IS International

_____ % _____ % American Funds IS Asset Allocation _____ % _____ % American Funds IS New World _____ % _____ % American Funds IS Capital Income Builder _____ % _____ % Franklin Flex Cap Growth _____ % _____ % **Clayton St Protective Life Dynamic Allocation - Moderate _____ % _____ % Franklin Small Cap Value _____ % _____ % Franklin Income _____ % _____ % Franklin Small-Mid Cap Growth _____ % _____ % Franklin Strategic Income _____ % _____ % Goldman Sachs Growth Opportunities _____ % _____ % Goldman Sachs Global Trends Allocation _____ % _____ % Goldman Sachs International Equity Insights _____ % _____ % Invesco Balanced Risk Allocation _____ % _____ % Goldman Sachs Mid Cap Value _____ % _____ % Invesco Equity and Income _____ % _____ % Invesco Global Real Estate _____ % _____ % Invesco Oppenheimer Global Strategic Income _____ % _____ % Invesco Oppenheimer Discovery Mid Cap Growth _____ % _____ % Legg Mason QS Dynamic Multi-Strategy _____ % _____ % Invesco Oppenheimer Global _____ % _____ % Lord Abbett Bond Debenture _____ % _____ % Invesco Small Cap Equity _____ % _____ % PIMCO All Asset _____ % _____ % Legg Mason ClearBridge Mid Cap _____ % _____ % PIMCO Global Diversified Allocation _____ % _____ % Legg Mason ClearBridge Small Cap Growth _____ % _____ % PIMCO Long-Term U.S. Government _____ % _____ % Lord Abbett Growth Opportunities _____ % _____ % PIMCO Real Return _____ % _____ % Lord Abbett Mid Cap Stock _____ % _____ % Templeton Global Bond _____ % _____ % Royce Small-Cap _____ % _____ % Templeton Developing Markets

Purchase DCA Category 3 - Aggressive _____ % _____ % Templeton Foreign Payment Allocation (Max. 25% allocation if a PLIB is purchased.) _____ % _____ % Templeton Growth

_____ % _____ % American Funds IS Blue Chip Income & Growth _____ % _____ % American Funds IS Global Growth Purchase DCA MODEL PORTFOLIOS _____ % _____ % American Funds IS Global Growth and Income Payment Allocation (Do not allocate to more than one Model Portfolio.) _____ % _____ % American Funds IS Growth _____ % _____ % Conservative Growth _____ % _____ % American Funds IS Growth-Income _____ % _____ % Balanced Growth & Income _____ % _____ % **Clayton St Protective Life Dynamic Allocation - Growth _____ % _____ % Balanced Growth _____ % _____ % Fidelity Contrafund _____ % _____ % Growth Focus - Not Available if a PLIB is purchased. _____ % _____ % Fidelity Index 500 _____ % _____ % Fidelity Mid Cap Purchase DCA _____ % _____ % Franklin Mutual Global Discovery Payment Allocation *INDIVIDUAL OPTIONS _____ % _____ % Franklin Mutual Shares _____ % _____ % **Clayton St Protective Life Dynamic Allocation - Conservative _____ % _____ % Franklin Rising Dividends _____ % _____ % **Clayton St Protective Life Dynamic Allocation - Moderate (Category 3 continues in next column.)

*If purchasing a protected lifetime income benefit (PLIB), as an alternative to other allocation options you may choose to allocate 100% of your purchase payment to one (and only one) of the two “Individual Options” sub-accounts (with or without the use of dollar cost averaging).

**Clayton Street Protective Life Dynamic Allocation

Series Managed by Janus Capital Management, LLC.

Portfolio Rebalancing – Must be completed if a protected lifetime income benefit (PLIB) is purchased.

Rebalance to my current Variable Account allocation __ quarterly __ semi-annually __ annually on the ____ day (1st – 28th) of the month.



AF-2119-R6 PVA NY II B Series 4/20

CONTRACT # __________________________

VARIABLE ANNUITY APPLICATION

OPTIONAL BENEFITS AND FEATURES - Not Required. Select the options to be included in your Contract.

Optional Death Benefit: Not available if any Owner or Annuitant is age 76 or older, or with Protective Income Manager. ___ Maximum Anniversary Value ___ Maximum Quarterly Value

Optional Protected Lifetime Income Benefits: You may purchase a rider now or use RightTime® to purchase a rider later, provided the age limits are met when the rider is purchased.

Protective Income Manager sm Not available if any Covered Person (or both Covered Persons) are younger than age 60 or older than age 80 when the rider is purchased. The Annuitant must be a Covered Person.

Please add Protective Income Manager to my Contract when it is issued, based on __ one Covered Person -or- __ two Covered Persons. Complete LAD-1216, "Protective Income Manager Withdrawal Form" to start withdrawals.

SecurePay Not available if any Owner or Annuitant is younger than age 60 or older than age 85 when the rider is purchased.

___ SecurePay 5

Automatic Purchase Plan: Not available with Automatic Withdrawals or Protective Income Manager. Attach a voided check.

Draft $ _____ per __ month -or- __ quarter from my account on the ___ day (1st – 28th) of the month and apply to my Contract.

Automatic Withdrawals: Not available with Automatic Purchase Plan or Protective Income Manager. Attach a voided check.

Withdraw $ _____ per __ month -or- __ quarter from the Contract on the ___ day (1st – 28th) of the month and deposit to my account.

SPECIAL REMARKS ____________________________________________________________________________________________________ ____________________________________________________________________________________________________

SUITABILITY Did you receive a current prospectus for this annuity? __ Yes __ No Do you believe the annuity meets your financial needs and objectives? __ Yes __ No

SIGNATURES I understand this application will be part of the annuity contract. The information I provide is true and correct to the best of my knowledge and belief. The company will treat statements made by me or under my authority as representations and not warranties. The company may accept instructions from any Owner on behalf of all Owners.

Variable annuities involve risk, including the possible loss of principal. The Contract Value, annuity payments and termination values, when based upon the investment experience of the separate account, are variable and are not

guaranteed as to any fixed dollar amount.

Application signed at: (City & State) __________________________________________ on (Date) _____________________. Owner 1: ________________________ Owner 2: _______________________ Annuitant: _______________________

Federal law requires the following notice: We may request or obtain additional information to establish or verify your identity.

PRODUCER REPORT - This section must be completed and signed by the agent for the Contract to be issued. To the best of your knowledge and belief… Does this annuity change or replace an existing annuity contract or life insurance policy? __ Yes __ No Does the applicant have any existing annuity contract or life insurance policy? __ Yes __ No This annuity is suitable based on information I obtained from the applicant after reasonable inquiry into the applicant's financial and tax status, investment objectives, and other relevant information. Producer Remarks: ____________________________________________________________________________________ Type of unexpired government issued photo I.D. used to verify applicant’s identity: __________________________ # ___________ I certify that I have truly and accurately recorded on this application the information provided to me by the applicant. Signature: ___________________________________________ Print Name: ___________________________________ Producer # __________________________________________ Brokerage: ___________________________________ Florida License # (if applicable) ____________________________ Phone # ___________________________________

AF-2119-R6 __ A __ B __ C __ D PVA NY II B Series 4/20




Life and Annuity Division Protective Life Insurance Company 1 West Coast Life Insurance Company 1 Protective Life and Annuity Insurance Company Beneficiary Information Request Post Office Box 1928 / Birmingham, AL 35201-1928 Use this form for initial beneficiary designations. Toll Free: 800-456-6330 / Fax: 205-268-6479 Owner’s Name: _________________________________________ Annuitant’s Name: __________________________________________ Contract Number: _______________________________________ Owner’s SSN/TIN: __________________________________________ PLEASE NOTE: If multiple beneficiaries are named, proceeds will be paid equally to all primary beneficiaries surviving the owner (or annuitant if non-material owner) unless instructed otherwise. If all primary beneficiaries have predeceased the owner, proceeds will be paid to the named contingent beneficiaries equally unless instructed otherwise. If there are no surviving beneficiaries, proceeds will be paid to the owner’s estate. BENEFICIARY INFORMATION:

Beneficiary Type: Name: _____________________________________________ Social Security Number: ______________________ (select one) Address: ______________________________________________________________________________________ �� Primary Date of Birth: __________________________ Telephone Number: _______________________________________ �� Contingent Relationship to Owner: _____________________ (select one) �� Spouse �� Non-spouse Percentage: _______%

Beneficiary Type: Name: _____________________________________________ Social Security Number: ______________________ (select one) Address: ______________________________________________________________________________________ �� Primary�� Date of Birth: __________________________ Telephone Number: _______________________________________ �� Contingent�� Relationship to Owner: _____________________ (select one) �� Spouse �� Non-spouse Percentage: _______%





SPECIAL INSTRUCTIONS:

SIGNATURES: ___________________________________________ ___________________________________________________ _______________ Owner’s Name (please print) Owner’s Signature Date ___________________________________________ ___________________________________________________ _______________ Joint Owner’s Name (please print) Joint Owner’s Signature Date 1 Not authorized in New York Page 1 of 1 LAD-1225 R:7/13

NY MVOL DISC Protective Life and Annuity Insurance Company ‐ 8/15

Disclosure Statement for Guaranteed Lifetime Withdrawal Benefit Riders Supported by Mutual Funds employing Volatility Management Strategies

As an owner of a variable annuity contract that contains a guaranteed lifetime withdrawal benefit rider, we wanted to call your attention to an investment strategy that is utilized by certain mutual funds that are available under your contract. For owners who have elected the guaranteed lifetime withdrawal benefit rider, this investment strategy may not be aligned with your goals and expectations under the rider and you should carefully evaluate with your financial advisor whether to invest in funds with this strategy, taking into consideration the potential impact, discussed below, that this strategy may have on your guaranteed lifetime withdrawal benefit. We have identified the funds that employ these strategies and included them in the listing that follows.

Goldman Sachs Global Trends Allocation Invesco Balanced Risk Allocation Portfolio Legg Mason Dynamic Multi-Strategy Portfolio PIMCO Global Diversified Allocation Portfolio

What is a volatility management strategy? This strategy is used as a risk mitigation tool. It seeks to provide returns that are less volatile over full market cycles to help reduce your concerns about staying in the market to achieve your retirement income goals. Based on an analysis of risks present in the fund, the investment manager may make adjustments to the fund’s exposure to certain equity asset classes. For example, when anticipated market volatility is expected to be higher, equity exposure is reduced. When anticipated volatility is expected to be lower, equity exposure is increased. In general, the strategy seeks to minimize the effects of adverse equity market conditions, mitigate both extreme losses and outsized gains, and improve returns through lower volatility. While designed to smooth out the performance of the funds, there is no guarantee that the funds’ strategy will be successful in managing portfolio volatility. This risk management strategy could also limit the upside participation of the fund in strong, increasing markets. How will the volatility management strategy affect my guaranteed living benefits? Your guaranteed lifetime withdrawal benefit rider provides minimum guarantees in the form of withdrawals if you meet certain conditions. You pay an additional charge for your rider, which in part pays to protect your guaranteed withdrawals from decreasing even if there are downturns in the market. Since your withdrawal benefit cannot decrease as a result of declines in the market, a volatility management strategy may, under certain market conditions, provide little or no additional benefit to you under the rider. These risk management strategies could limit the upside participation of the fund in strong, increasing markets resulting in your account value rising less than would have been the case without this strategy. This may result in lower guaranteed lifetime withdrawal benefits. Any negative impact to the underlying funds as a result of the risk management strategies may limit contract values, which in turn may limit your ability to achieve step‐ups of the benefit base under your rider.

pl14mc1

Typewritten Text

BG-VA-13

Life and Annuity Division Protective Life Insurance Company1

West Coast Life Insurance Company1

Protective Life and Annuity Insurance CompanyDCA Allocation, Portfolio Rebalancing, Post Office Box 1928 / Birmingham, AL 35201-1928Telephone Authorization Toll Free: 800-456-6330 / Fax: 205-268-6479

Owner's Name: Contract Number:

DOLLAR COST AVERAGING (DCA) - The "To" funds cannot include any of the Dollar Cost Averaging Fixed Accounts. The maximum number of months available for transfers from the DCA Fixed Account 1 is 6 months. The maximum number of months available for transfers from the DCA Fixed Account 2 is 12 months. All funds may not be available at all times or in all states. Funds are available for allocations from any of the DCA Accounts.

Begin Dollar Cost Averaging on _____________ (1st - 28th)

Monthly from DCA Fixed Account 1 for _____________ (1 - 6) months

Monthly from DCA Fixed Account 2 for _____________ (7 - 12) months

Monthly transfers of $________ from the _______________________ investment option for ____ months.

Transfer to: (Total must equal 100%)

____ % to ________________ ____ % to ________________ ____ % to ________________

____ % to ________________ ____ % to ________________ ____ % to ________________

End Dollar Cost Averaging - Please stop my participation in the DCA program and transfer the remainingbalance from the DCA Fixed Accounts to:

____ % to ________________ ____ % to ________________ ____ % to ________________

____ % to ________________ ____ % to ________________ ____ % to ________________

PORTFOLIO REBALANCING - Portfolio rebalancing is based on your current allocation instructions for the variable investment options. Guaranteed/General Accounts do not participate in portfolio rebalancing.Contracts with a SecurePay rider must rebalance at least annually. If no selection is made, we will rebalanceyour Contract Value semi-annually.

Begin Portfolio Rebalancing for the variable account value

Begin on the _____ / _____ / ________ (1st - 28th)

Rebalancing should occur: Quarterly

Semi-Annually

Annually

End Portfolio Rebalancing

LAD-1123 AIC R:10/12Page 1 of 2

Contracts with a SecurePay rider must allocate DCA transfers according to the rider's Allocation Guidelines and Restrictions. If they elect to stop their DCA, any remaining money in the DCA Fixed Account must also be transferred accordingly. Any fund allocation instructions not consistent with these Allocation Guidelines and Restrictions will terminate your SecurePay rider. Please see prospectus for complete details.

TELEPHONE TRANSFER AUTHORIZATION - The Company will not be held liable for any loss, liability, cost or expense for acting on telephone instructions.

I / We authorize the Company to honor telephone instructions from the Owner to transfer account values among the investment options.

I / We authorize the Company to honor telephone instructions from the Registered Representative to transfer account values among the investment options.

SIGNATURES - By signing below I / we authorize the Company to act on the instructions indicated above. I / We understand that I / we may cancel or change these instructions by giving 10 days advance written notification.

Owner's Signature Date Joint Owner's Signature Date

1 Not authorized in New York LAD-1123 AIC R:10/12Page 2 of 2

"Application State" is the state where the owner signs the application and where the contract is solicited and delivered.

1. REASON FOR EXCEPTION (Select one.)� The applicant has a residence address in the state where the product is being solicited.

� The applicant works or has a business address in the state where the product is being solicited.

� The applicant is an existing customer or the producer has an existing relationship with the owner in the statewhere the product is being solicited.

� The applicant is a relative of the producer who is licensed in the state where the product is being solicited.

� The owner is not the annuitant and the application was signed in the annuitant's state of residence.

� This sale is to a New York resident and complies with New York laws for issuing contracts in a non-resident state.

2. ACKNOWLEDGEMENT AND SIGNATURE

In connection with the above referenced application, the undersigned acknowledges and affirms:

A. All communications, solicitation and negotiation of the application occurred in the Application State.

B. The application was signed by the owner and the producer in the Application State.

C. The owner will take delivery of the contract issued in the Application State.

D. The applicable Insurer will rely on this verification in issuing a contract under the application.

E. I am properly licensed and appointed in the state where the applicant/owner has a resident address.(Please check with your agency or state laws to see if dual registration is required.)

F. I am also properly licensed and appointed in the state where the solicitation was made, the application was taken,and where the contract will be delivered.

G. I have advised the applicant/owner of the differences (if any) between the product as approved in the applicant's/owner's primary state of residence or place of business, and the product as approved in the state of solicitation,execution of application and contract issue.

Page 1 of 1

Owner/Entity Name ________________________________________________________

Annuitant Name ___________________________________________________________ SSN ______________________

I hereby represent and warrant to the Company that, after conducting a reasonable inquiry into the validity of therepresentations set forth herein, the representations set forth herein are true and correct to the best of my knowledge.

Producer Signature __________________________________________________________ Date ___________________

1 Not Authorized in New York2 Authorized to sell in New York

Protective Life Insurance Company 1

Protective Life and Annuity Insurance Company 2P.O. Box 10648

Birmingham, AL 35202-0648Phone: 1-800-456-6330OUT-OF-STATE VERIFICATION

LAD-1215 R:10/13

SSN/TIN __________________

Life and Annuity Division Protective Life Insurance Company 1 West Coast Life Insurance Company 1 Request for Transfer or Protective Life and Annuity Insurance Company Exchange of Assets Post Office Box 10648 / Birmingham, AL 35202-0648 Toll Free: 800-456-6330 / Fax: 205-268-3151 Existing Protective Contract Number: __________________ (for additional payments only) Check here and complete Box 4 if this is being submitted for a Rate Lock only. (If Rate Lock request is for a CD,

you must include proof of maturity from the Financial Institution.)

Please do not select this option for the Protective Indexed Annuity, because the interest crediting elements for that product are determined as of the date the contract is purchased.

Complete this form to transfer assets to Protective Life Insurance Company, West Coast Life Insurance Company or Protective Life and Annuity Insurance Company (each, the “Company”) for the issuance of a new annuity contract. EXISTING ACCOUNT, CONTRACT OR POLICY TO BE TRANSFERRED _____________________________________________________________ _____________________________ Company Name Telephone Number _____________________________________________________________ _____________________________ Email Address Fax Number ____________________________________________________________________________________________ Company (Overnight) Address _____________________________________________ _____________________ ______________________ Contract/Account Owner’s Name Contract/Account Number Owner’s SSN/Tax ID The contract is: attached lost or destroyed Please check this box if the existing contract being surrendered is a Fixed Annuity. (If box is checked, and your

new Protective Life annuity is being issued in the state of Nevada, please complete form A-1128-NEV-Annuity.) EXISTING ACCOUNT, CONTRACT OR POLICY TO BE TRANSFERRED CLIENT/AGENT INITIATED INTERNAL EXCHANGE EXTERNAL EXCHANGE

Non-Qualified: Qualified: 1035 Exchange 1. Plan Type: 2. Transfer Type: Non-1035 Exchange IRA CD Trustee Transfer Mutual Fund 401(k) Roth IRA Direct Rollover Bank CD Mutual Fund 403(b)/TSA Other Non-1035 Exchanges Other _____________ Proposed Plan Type: Non-Qual IRA Roth IRA Other _________________________ TRANSFER INSTRUCTIONS 1. Amount to be transferred: Complete: Liquidate and transfer all assets in my account, contract or policy Partial: Liquidate and transfer assets totaling $_______________________ 2. When should transfer occur: Immediately Upon maturity date of ______/______/______ (mm/dd/yy) 3. Current estimated value of the assets to be transferred are $__________________ 4. RATE LOCK I wish to lock in the interest rate that is in effect when this signed form is received by the

Company. If this box is not checked, you will receive the interest rate in effect on the day we receive the transferred amounts.

(Please do not select this option for the Protective Indexed Annuity, because the interest crediting elements for that product are determined as of the date the contract is purchased.)

1 Not authorized in New York Page 1 of 2 LAD-1120 R:01/20

Complete 1035 Exchange: I hereby make a complete and absolute assignment and transfer all rights, title and interest of every nature in the above contract to the accepting insurance company indicated below.

Partial 1035 Exchange: I hereby direct the issuer of the above-referenced existing annuity contract to process a partial 1035 exchange to the accepting insurance company indicated below. I intend for this transaction to qualify as a tax-free exchange for Federal income tax purposes.

Based on our understanding of IRS guidance in Rev. Proc. 2011-38, if a contract is involved in a tax-free partial exchange under Internal Revenue Code section 1035 that is completed on or after October 24, 2011, and an amount is withdrawn from or received in surrender of either contract within 180 days of the exchange, the IRS will apply general tax principles to determine the substance, and hence the treatment of the partial exchange and the subsequent withdrawal or surrender. Such a withdrawal or surrender could affect how the partial exchange and the withdrawal or surrender is reported to you and the IRS.

For Other Transfers: Unless it is noted above to hold for a future date, I request the surrendering company to immediately complete the transfer or rollover. Do not withhold any amount for taxes from the proceeds.

SIGNATURES: ____________________________________ _________ ________________________________ _________ Owner’s Signature Date Joint Owner’s Signature Date ____________________________________ _________ Annuitant’s Signature Date FOR HOME OFFICE USE ONLY NOTICE OF ACCEPTANCE: The Company will accept the assets and credit them to an annuity contract as described above. The Company has received an application from the Owner to establish an annuity contract for this transaction. ____________________________________ ___________________________________________ _________ Authorized Signature Title Date SETTLEMENT: Please make check payable for the proceeds and mail to: Protective Life Insurance Company Protective Life and Annuity Insurance Company (New York Only) West Coast Life Insurance Company Mailing Address: PO Box 10648 Overnight Address: 2801 Highway 280 South Attn: 3-1 Annuity New Business Attn: 3-1 Annuity New Business Birmingham, AL 35202-0648 Birmingham, AL 35223 Page 2 of 2 LAD-1120 R:01/20

Annuity – General Instructions for NY Page 1 of 3 R: 03/2020

Protective Life and Annuity Insurance Company P.O. Box 10648, Birmingham, AL 35202-0648

Telephone: 1-800-456-6330 Fax: 1-205-268-3151

GENERAL AGENT INSTRUCTIONS FOR REGULATION 60 APPLICATIONS

Regulation 60 establishes the requirements regarding New York Replacements of life insurance and annuities. Producers are obligated to comply with the regulation when proposing and submitting new business. The purpose of Regulation 60 is to:

(a) To implement the New York Insurance Law of New York by regulating the acts and practices of insurers, insurance agents, insurance brokers, and other licensees of the Department of Financial Services department with respect to the internal and external replacement of life insurance policies and annuity contracts; and

(b) To protect the interest of the public by establishing minimum standards of conduct to be observed in the replacement and proposed replacement of life insurance policies and annuity contracts; by making available full and clear information on which an applicant for life insurance or annuities can make a decision in his or her own best interest by reducing the opportunity for misrepresentation and incomplete comparison in replacement situations (commonly referred to as twisting); and by precluding unfair methods of competition and unfair practices.

New York’s Replacement Regulation 60 sets forth the procedures and forms which are required for any new life insurance or annuity application to be purchased and delivered, or issued for delivery, in the state of New York, where it is known that as a part of the transaction, existing life insurance policies or annuity contracts are likely to be, or have been, replaced by a proposed life insurance policy or annuity contract, to include:

1) lapsed, surrendered, partially surrendered, forfeited, assigned to the insurer replacing the life insurance policy or annuity contract, or otherwise terminated;

2) changed or modified into paid-up insurance; continued as extended term insurance or under another form of nonforfeiture benefit; or otherwise reduced in value by the use of nonforfeiture benefits, dividend accumulations, dividend cash values or other cash values;

3) changed or modified so as to effect a reduction either in the amount of the existing life insurance or annuity benefit or in the period of time the existing life insurance or annuity benefit will continue in force;

4) reissued with a reduction in amount such that any cash values are released, including all transactions wherein an amount of dividend accumulations or paid-up additions is to be released on one or more of the existing policies;

5) assigned as collateral for a loan or made subject to borrowing or withdrawal of any portion of the loan value, including all transactions wherein any amount of dividend accumulations or paid-up additions is to be borrowed or withdrawn on one or more existing policies; or

6) continued with a stoppage of premium payments or reduction in the amount of premium paid.


The following provides you with the forms, instructions and procedures necessary to ensure a correct application package and quality issuance of the contract. Required Forms – Note: Please verify that all forms are accurately completed. Incomplete forms, or forms missing signatures, dates, etc. will delay issue.

1. Definition of Replacement – LAD-1226-NY (1 pg.) 2. Notice to Insurer of Proposed Replacement – LAD-1110-NY (2 pgs.) 3. Important Notice Regarding Replacement or Change of Life Insurance Policies or

Annuity Contracts – LAD-1255-NY (2 pgs.) 4. Disclosure Statement – LAD-1254-NY (5 pgs.)

Website Instructions – 1) Log on to www.myprotective.com. 2) Click on MARKETING RESOURCES AND TOOLS. 3) Click on Forms & Applications.

Agent Procedures – • To determine if a replacement exists, prior to taking the application/ticket, review the

Definition of Replacement (LAD-1226-NY) form with the applicant. Definition of Replacement (LAD-1226-NY)

a. This form must be completed and signed by the applicant and agent for every application taken in the state of New York, even when no replacement is involved.

b. Leave a signed copy of the Definition of Replacement form with the applicant for the applicant’s records.

c. This form must be received at Protective with the application, completed and signed on or before the application signature date.

d. If your client answers “Yes” to any of the Definition of Replacement questions, a replacement has occurred or is likely to occur.

• Where a replacement is identified, please provide the following:

1. Notice to Insurer of Proposed Replacement (LAD-1110-NY) a. This form serves as authorization for Protective to obtain the existing policy

information from the existing insurer necessary to complete the Disclosure Statement.

b. List any sales material, including form name and number, and submit a copy of any proposal used in the sale of the proposed life insurance policy or annuity contract.

c. The Notice to Insurer of Proposed Replacement form must be completed and signed by the existing policy/contract owner(s) only when there is existing coverage being replaced.

http://www.myprotective.com/


2. Important Notice Regarding Replacement or Change of Life Insurance Policies orAnnuity Contracts (LAD-1255-NY)

a. The Important Notice form must be completed only when there is existing coveragebeing replaced.

b. This form must be received at Protective with the application, completed and signedby the applicant on or before the application signature date.

c. Leave a signed copy of the Important Notice form with the applicant for theapplicant’s records.

3. Disclosure Statement (LAD-1254-NY)a. This form is only required when there is existing coverage being replaced.b. Protective will provide you with a partially completed Disclosure Statement

containing information received from the existing insurer, along with the proposedpolicy/contract values.

c. Upon receipt of the Disclosure Statement, you must:• Review all pages of the Disclosure Statement for accuracy and completeness• Complete the Agent/Broker’s Statement with detailed responses regarding your

recommendation to replace an existing policy or contract• Verify if sales material was used by checking the appropriate box• Sign and date the form

d. The Disclosure Statement must be received completed and signed prior topolicy/contract issuance. If not, the policy/contract issue will be delayed.

Important Reminders –

✓ Submit to Protective, with the application, a list of all policies/contracts proposed to be replacedalong with a copy of the sales material, including the proposal, used in the sale of the lifeinsurance policy or annuity contract.

✓ Please verify that the items above are received as indicated to avoid policy/contract issue delays.✓ Once completed documents are received, reviewed and processed, the policy/contract and

supporting documents will be sent to you or your client, as prescribed by your firm or thearrangement with Protective.

LAD-1226 (NY) Page 1 of 1 R: 03/2020

Protective Life and Annuity Insurance Company, P.O. Box 10648, Birmingham, AL 35202-0648 Telephone: 1-800-456-6330 Fax: 1-205-268-3151

APPENDIX 11 DEPARTMENT OF FINANCIAL SERVICES OF THE STATE OF NEW YORK

DEFINITION OF REPLACEMENT IN ORDER TO DETERMINE WHETHER YOU ARE REPLACING OR OTHERWISE CHANGING THE STATUS OF EXISTING LIFE INSURANCE POLICIES OR ANNUITY CONTRACTS, AND IN ORDER TO RECEIVE THE VALUABLE INFORMATION NECESSARY TO MAKE A CAREFUL COMPARISON IF YOU ARE CONTEMPLATING REPLACEMENT, THE AGENT OR BROKER IS REQUIRED TO ASK YOU THE FOLLOWING QUESTIONS AND EXPLAIN ANY ITEMS THAT YOU DO NOT UNDERSTAND.

AS PART OF YOUR PURCHASE OF A NEW LIFE INSURANCE POLICY OR A NEW ANNUITY CONTRACT, HAS EXISTING COVERAGE BEEN, OR IS IT LIKELY TO BE:

(1) LAPSED, SURRENDERED, PARTIALLY SURRENDERED, FORFEITED, ASSIGNED TO THEINSURER REPLACING THE LIFE INSURANCE POLICY OR ANNUITY CONTRACT, OROTHERWISE TERMINATED?

YES_____ NO_____ (2) CHANGED OR MODIFIED INTO PAID-UP INSURANCE; CONTINUED AS EXTENDED TERM

INSURANCE OR UNDER ANOTHER FORM OF NONFORFEITURE BENEFIT; OR OTHERWISEREDUCED IN VALUE BY THE USE OF NONFORFEITURE BENEFITS, DIVIDENDACCUMULATIONS, DIVIDEND CASH VALUES OR OTHER CASH VALUES?

YES_____ NO_____ (3) CHANGED OR MODIFIED SO AS TO EFFECT A REDUCTION EITHER IN THE AMOUNT OF THE

EXISTING LIFE INSURANCE OR ANNUITY BENEFIT OR IN THE PERIOD OF TIME THE EXISTINGLIFE INSURANCE OR ANNUITY BENEFIT WILL CONTINUE IN FORCE?

YES_____ NO_____ (4) REISSUED WITH A REDUCTION IN AMOUNT SUCH THAT ANY CASH VALUES ARE RELEASED,

INCLUDING ALL TRANSACTIONS WHEREIN AN AMOUNT OF DIVIDEND ACCUMULATIONS ORPAID-UP ADDITIONS IS TO BE RELEASED ON ONE OR MORE OF THE EXISTING POLICIES?

YES_____ NO_____ (5) ASSIGNED AS COLLATERAL FOR A LOAN OR MADE SUBJECT TO BORROWING OR

WITHDRAWAL OF ANY PORTION OF THE LOAN VALUE, INCLUDING ALL TRANSACTIONSWHEREIN ANY AMOUNT OF DIVIDEND ACCUMULATIONS OR PAID-UP ADDITIONS IS TO BEBORROWED OR WITHDRAWN ON ONE OR MORE EXISTING POLICIES?

YES_____ NO_____ (6) CONTINUED WITH A STOPPAGE OF PREMIUM PAYMENTS OR REDUCTION IN THE AMOUNT OF

PREMIUM PAID?YES_____ NO_____

IF YOU HAVE ANSWERED YES TO ANY OF THE ABOVE QUESTIONS, A REPLACEMENT AS DEFINED BY NEW YORK INSURANCE REGULATION 60 HAS OCCURRED OR IS LIKELY TO OCCUR AND YOUR AGENT OR BROKER IS REQUIRED TO PROVIDE YOU WITH THE IMPORTANT NOTICE REGARDING REPLACEMENT OR CHANGE OF LIFE INSURANCE POLICIES OR ANNUITY CONTRACTS. YOU WILL ALSO RECEIVE A COMPLETED DISCLOSURE STATEMENT NO LATER THAN THE TIME YOUR NEW POLICY OR NEW CONTRACT IS DELIVERED.

Date: ____________ Signature of Applicant: __________________________________________ Date: ____________ Signature of Applicant: __________________________________________ TO THE BEST OF MY KNOWLEDGE, A REPLACEMENT IS INVOLVED IN THIS TRANSACTION:

YES_____ NO_____Date: ____________ Signature of Agent or Broker: _____________________________________

LAD-1110 (NY) Page 1 of 2 R: 03/2020

Protective Life and Annuity Insurance Company P.O. Box 10648, Birmingham, AL 35202-0648

Telephone: 1-800-456-6330 Fax: 1-205-268-3151

NOTICE TO INSURER OF PROPOSED REPLACEMENT - ANNUITY

Date:

EXISTING POLICY/CONTRACT INFORMATION Company Name: (Please complete a separate form for each company)

Policy/Contract Type:

Life Insurance Annuity

Life Insurance Annuity

Life InsuranceAnnuity

Policy/Contract #:

Policy/Contract Owner(s):

Check if this is a Deferred Annuity to Immediate Annuity replacement and indicate thePayout Type/Income Option Selected (for example, Life Income with 10 year period certain)

Payout Type/Income Option: ____________________________________________________

AGENT INFORMATION – PROPOSED POLICY/CONTRACT Name of Agent:

Address: (Street, City, State and Zip Code)

Telephone Number: Fax Number:

SALES MATERIAL List all sales material used in this sale, including form name and form number.

For variable products, list any sales material used in addition to the prospectus. FORM NAME: FORM NUMBER:

PROPOSAL Indicate if a proposal was used in this sale. If Yes, please submit a copy of the proposal with this form.

Yes No

LAD-1110 (NY) Page 2 of 2 R: 03/2020

EXISTING INSURER

1. Please be advised that the policy/contract owner is considering replacing thepolicy(ies)/contract(s) listed above. The policy/contract owner authorizes the insurer torelease the information needed for completing the New York State LICONY DisclosureStatement, LICONY Appendix 10B, attached. In accordance with the New York StateDepartment of Financial Services Regulation 60, it is required that this information befurnished within twenty (20) days to:

- The agent named above

- PROTECTIVE LIFE AND ANNUITY INSURANCE COMPANY

- The agent of record of the existing policy and/or contract

2. PLEASE NOTE:

• If a Deferred Annuity to Immediate Annuity replacement is indicated on page 1 ofthis form, you must provide the information required to complete page 3b of theLICONY Appendix 10B – Disclosure Statement.

• If the existing annuity includes any Guaranteed Living Benefits (GLB’s), you mustinclude the information required to complete page 3a of the LICONY Appendix 10B– Disclosure Statement.

3. Please forward this information to:

PROTECTIVE LIFE AND ANNUITY INSURANCE COMPANY Fax: 1-205-268-3151

or email to [email protected]

This authorization is valid until revoked by the undersigned in writing.

_____________________________________ _______________________________________ Policy/Contract Owner’s Signature Joint Policy/Contract Owner’s Signature

_____________________________________ _______________________________________ Policy/Contract Owner’s Name (Printed) Joint Policy/Contract Owner’s Name (Printed)

_____________________________________ _______________________________________ Street Address Street Address

_____________________________________ _______________________________________ City, State and Zip Code City, State and Zip Code

LAD-1255 (NY) Page 1 of 2 R: 03/2020

Protective Life and Annuity Insurance Company, P.O. Box 10648, Birmingham, AL 35202-0648 Telephone: 1-800-456-6330 Fax: 1-205-268-3151

APPENDIX 10C DEPARTMENT OF FINANCIAL SERVICES OF THE STATE OF NEW YORK

IMPORTANT NOTICE REGARDING REPLACEMENT OR CHANGE OF LIFE INSURANCE POLICIES OR ANNUITY CONTRACTS

THIS NOTICE IS FOR YOUR BENEFIT AND REQUIRED BY 11 NYCRR PART 51 (INSURANCE REGULATION 60)

YOU ARE CONTEMPLATING THE PURCHASE OF A LIFE INSURANCE POLICY OR ANNUITY CONTRACT IN CONNECTION WITH THE SURRENDER, LAPSE OR CHANGE OF EXISTING LIFE INSURANCE POLICIES OR ANNUITY CONTRACTS. THE AGENT OR BROKER IS REQUIRED TO GIVE YOU THIS NOTICE. A SIGNED DISCLOSURE STATEMENT WILL ALSO BE PROVIDED TO YOU CONTAINING THE SUMMARY RESULT COMPARISON FOR THE NEW LIFE INSURANCE POLICY OR ANNUITY CONTRACT AND ANY LIFE INSURANCE POLICIES OR ANNUITY CONTRACTS TO BE CHANGED THAT SETS FORTH THE FACTS OF THE TRANSACTION AND ITS ADVANTAGES AND DISADVANTAGES TO YOU. YOUR DECISION COULD BE A GOOD ONE – OR A MISTAKE – SO MAKE SURE YOU UNDERSTAND THE FACTS. YOU SHOULD:

1. CAREFULLY STUDY THE DISCLOSURE STATEMENT, WHICH INCLUDES A SUMMARYRESULT COMPARISON, UNTIL YOU ARE SURE YOU UNDERSTAND FULLY THE EFFECTOF THE TRANSACTION. THE DISCLOSURE STATEMENT IS REQUIRED TO BE PROVIDEDTO YOU NO LATER THAN UPON DELIVERY OF THE POLICY OR CONTRACT.

2. ASK THE COMPANY, AGENT OR BROKER FROM WHOM YOU BOUGHT YOUR EXISTINGLIFE INSURANCE POLICIES OR ANNUITY CONTRACTS TO REVIEW WITH YOU THETRANSACTION. YOU MAY BE ABLE TO EFFECT THE CHANGES YOU DESIRE MOREADVANTAGEOUSLY WITH THEM.

3. CONSULT YOUR TAX ADVISOR. THERE MAY BE UNFAVORABLE TAX IMPLICATIONSASSOCIATED WITH THE CONTEMPLATED CHANGES TO YOUR EXISTING LIFEINSURANCE POLICIES OR ANNUITY CONTRACTS.

As a general rule, it is often not advantageous to drop or change existing coverage in favor of new coverage, whether issued by the same or a different insurance company. Some of the reasons it may be disadvantageous are:

1. The amount of the annual premium under an existing life insurance policy may be lower than thatcalled for by a new life insurance policy having the same or similar benefits. Any replacement ofthe same type of policy will normally be at a higher premium rate based upon the insured’s thenattained age.

2. Since the initial costs of a life insurance policy are charged against the cash value increases in theearlier life insurance policy years, the replacement of an old life insurance policy by a new oneresults in the policyholder sustaining the burden of these costs twice. Annuity contracts usuallycontain provisions for surrender charges, therefore a replacement involving annuity contracts mayresult in the imposition of surrender charges.

3. The incontestable and suicide clauses begin anew in a new life insurance policy. This could resultin a claim being denied under the new life insurance policy that would have been paid under thelife insurance policy that was replaced.

LAD-1255 (NY) Page 2 of 2 R: 03/2020

4. An existing life insurance policy or annuity contract often has more favorable provisions than anew life insurance policy or annuity contract in areas such as loan interest rate, settlementoptions, disability benefits and tax treatment.

5. There may have been changes in your health since the purchase of the existing coverage.

6. The insurance company with which you have existing coverage can often make a desired changeon terms that would be more favorable than if you replaced existing coverage with new coverage.

YOU HAVE THE RIGHT, WITHIN 60 DAYS FROM THE DATE OF DELIVERY OF A NEW LIFE INSURANCE POLICY OR ANNUITY CONTRACT, TO RETURN IT TO THE INSURER AND RECEIVE AN UNCONDITIONAL FULL REFUND OF ALL PREMIUMS OR CONSIDERATIONS PAID ON IT, OR IN THE CASE OF A VARIABLE OR MARKET VALUE ADJUSTMENT POLICY OR CONTRACT, A PAYMENT OF THE CASH SURRENDER BENEFITS PROVIDED UNDER THE POLICY OR CONTRACT, PLUS THE AMOUNT OF ALL FEES AND OTHER CHARGES DEDUCTED FROM GROSS CONSIDERATIONS OR IMPOSED UNDER THE LIFE INSURANCE POLICY OR ANNUITY CONTRACT, AND MAY HAVE THE RIGHT TO REINSTATE OR RESTORE ANY LIFE INSURANCE POLICIES AND ANNUITY CONTRACTS THAT WERE SURRENDERED, LAPSED OR CHANGED IN THE TRANSACTION TO THEIR FORMER STATUS TO THE EXTENT POSSIBLE AND IN ACCORDANCE WITH THE INSURER’S PUBLISHED REINSTATEMENT RULES TO THE EXTENT SUCH RULES ARE NOT INCONSISTENT WITH THE PROVISIONS OF 11 NYCRR PART 51 (INSURANCE REGULATION 60).

IMPORTANT: THIS RIGHT SHOULD NOT BE VIEWED AS REINSTATING OR RESTORING YOUR LIFE INSURANCE POLICY OR ANNUITY CONTRACT TO THE SAME CONDITION AS IF IT HAD NEVER BEEN REPLACED. THERE MAY BE CONSEQUENCES IN REINSTATING OR RESTORING YOUR LIFE INSURANCE POLICY OR ANNUITY CONTRACT, INCLUDING BUT NOT LIMITED TO:

• THE RIGHT TO REINSTATE OR RESTORE YOUR LIFE INSURANCE POLICY OR ANNUITYCONTRACT APPLIES ONLY TO COMPANIES SUBJECT TO NEW YORK INSURANCE LAWS;

• YOUR LIFE INSURANCE POLICY OR ANNUITY CONTRACT IS SUBJECT TO YOUR SPECIFICCOMPANY’S REINSTATEMENT RULES, WHICH MAY VARY FROM COMPANY TO COMPANY.THESE RULES MAY REQUIRE PAYMENT OF BOTH PREMIUM AND INTEREST; HOWEVER,YOU WILL NOT BE SUBJECT TO EVIDENCE OF INSURABILITY, OR A NEW CONTESTABLEOR SUICIDE PERIOD;

• YOU MAY NOT RECEIVE THE INTEREST OR INVESTMENT PERFORMANCE DURING THEPERIOD THE LIFE INSURANCE POLICY OR ANNUITY CONTRACT WAS REPLACED; AND

• THERE MAY BE UNFAVORABLE FEDERAL INCOME TAX CONSEQUENCES AS A RESULT OFTHE REINSTATEMENT OF YOUR LIFE INSURANCE POLICY OR ANNUITY CONTRACT.

IMPORTANT: IN THE CASE OF A VARIABLE OR MARKET VALUE ADJUSTMENT POLICY OR CONTRACT, THE VALUE OF THE POLICY OR CONTRACT MAY INCREASE OR DECREASE DURING THE 60 DAY PERIOD DEPENDING ON THE PERFORMANCE OF THE UNDERLYING INVESTMENTS, WHICH MAY AFFECT THE VALUE OF THE REFUND YOU RECEIVE.

I HEREBY ACKNOWLEDGE THAT I READ THE ABOVE “IMPORTANT NOTICE” AND HAVE RECEIVED A COPY OF SAME.

Date: ________________ Signature of Applicant: _______________________________________

Date: ________________ Signature of Applicant: _______________________________________



Protective Life and Annuity Insurance CompanyPre-Determined Death Benefit Post Office Box 1928 / Birmingham, AL 35201-1928Payout Election Form Toll Free: 800-456-6330 / Fax: 205-268-6479

Owner's Name: Contract Number:This election is made at the Owner's request. The company reserves the right to modify or disregard an election if necessary to comply with applicable laws and regulations in effect at the time of the Owner's death (or the Annuitant's death if there is a non-natural Owner). After we receive and acknowledge this form, a copy will be returned for the Owner's records. (Other options may be available. Contact us for special cases.)1. Name of Beneficiary to whom this election applies. NOTE: This form does not change your current Beneficiary

designation. The name below must match a Beneficiary designation or this election will have no legal effect.Beneficiary Name: Date of Birth:

Beneficiary Type: Primary Contingent2. The Beneficiary named may take up to ______% as a lump sum withdrawal immediately upon proof of death.

(Whole percentages only) The balance will be paid as designated below.3. Apply this option to the remaining portion of the death benefit payable to the Beneficiary named above:

Payments guaranteed for ______ years. (5 - 30 years)*Payments for a Fixed Amount $ _________. (Fixed amount payments may not be made for less than 5 years ormore than 30 years.* The Company reserves the right to adjust the payment amount to meet these restrictions.)Payments for the Beneficiary's lifetime.Life with Cash Refund (not available with Single Premium Whole Life products)

Life with Installment Refund (not available with Single Premium Whole Life products)

Payments for the Beneficiary's lifetime and guaranteed for ______ years. (5 - 30 years)*

4. Payment Mode (Please select one): Monthly Semi-Annually

Quarterly Annually* Payout period may not exceed the Beneficiary's life expectancy. If the selected payout period exceeds theBeneficiary's life expectancy, we will adjust the payout period to the longest allowable period. (If monthly

payments are less than $50, payments may be made quarterly, semi-annually or annually at the Company's

option.)

SIGNATURES: I / We request and authorize the Company to act on this election. I understand that neither the Beneficiary nor the Company can modify this election except the Company may modify or disregard this election if necessary to comply with any applicable law or regulation in effect at the time of Owner's death.

Owner's Signature Date Spouse or Joint Owner's Signature Date

Registrar Date Recorded

SIGNATURES: I / We hereby cancel the election with respect to the Beneficiary named above. I / We understandthis cancellation removes any pre-determined death benefit payout option election made for this Beneficiary prior tothe date entered next to my / our signature below and that a new election may now be made on a new form.

Owner's Signature Date Spouse or Joint Owner's Signature Date

Registrar Date Recorded1 Not authorized in New York. LAD-1153 R:10/12Page 1 of 1

Address & Telephone No: __________________________________________________________________________Relationship: _____________________ Percentage: ________ Social Security No: _______________________



Protective Life and Annuity Insurance CompanyTelephone Withdrawal Authorization Post Office Box 1928 / Birmingham, AL 35201-1928

Toll Free: 800-456-6330 / Fax: 205-268-6479

Owner's Name: Contract Number:

SECURITY - Checks issued for withdrawals requested over the telephone will always be made payable to the owner and mailed to the owner's address according to our records. Requests on contracts owned jointly may be made by either owner, and will be made payable to both owners, if owners share a common address of record. A party with Power of Attorney (POA) will be allowed to make a request as an owner. Requests on custodial accounts must come from the broker of record, and checks will be made payable to and mailed to the broker / dealer.

We will verify your date of birth and social security (or tax id) number prior to processing a withdrawal request. We may adopt other procedures to confirm that telephone instructions are genuine. We will not be liable for losses or expenses arising from telephone instructions reasonably believed to be genuine.

1. We must receive this signed form before we will honor a telephone withdrawal request.

2. Telephone withdrawals are allowed from fixed, indexed and variable annuities, and may be subject to a surrendercharge and / or a market value adjustment, according to the terms of your contract.

3. The maximum telephone withdrawal is 25% of your current contract value up to $50,000.00. The allowablewithdrawal may be further limited according to the minimum required remaining contract value, if applicable, asdescribed in your contract.

4. Withdrawals from your annuity contract will be taken pro-rata from the investment options unless otherwisespecified.

5. Full surrenders must be requested in writing.

6. Automatic withdrawals must be requested in writing, and may not be available on all products.

7. Brokers / Agents are not authorized to make a telephone withdrawal requests on behalf of an owner unless thebroker / agent is the owner and custodian.

8. For contracts with a SecurePay rider, an Excess Withdrawal during the Benefit Period may significantly reduce oreliminate the value of the SecurePay benefit.

REVOCATION - We reserve the right to modify, suspend, or terminate telephone withdrawal privileges at any time without notice on an individual case basis.

ELECTION: I / We wish to authorize telephone withdrawals. I/we have read and agree to the terms and conditions specified on this form.

I / We wish to revoke telephone withdrawals.

LAD-1155 R:07/18Page 1 of 2

SIGNATURES - By signing below I authorize the Company to act on the instructions indicated above.

Owner's Signature Date Joint Owner's Signature Date

Irrevocable Beneficiary's Signature Date

1 Not authorized in New York. LAD-1155 R:07/18Page 2 of 2

IMPORTANT FOR WITHDRAWAL OR SURRENDER REQUESTS FROM A CONTRACT INVOLVED IN A TAX-FREE PARTIAL EXCHANGE UNDER INTERNAL REVENUE SECTION 1035.

Please consult your tax advisor about whether a withdrawal from, or surrender of, a contract involved in partial exchange could cause the exchange to be treated as a taxable distribution or have other adverse federal income tax consequences.

For Contracts Involved in a Partial Exchange on or after October 24, 2011

Based on our understanding of IRS guidance in Rev. Proc 2011-38, if a contract is involved in a tax-free partial exchange under Internal Revenue Code section 1035 that is completed on or after October 24, 2011, and an amount is withdrawn from or received in surrender of either contract within 180 days of the exchange, the IRS will apply general tax principles to determine the substance, and hence the treatment of the partial exchange and the subsequent withdrawal or surrender. Such a withdrawal or surrender could affect how the partial exchange and the withdrawal or surrender is reported to you and the IRS.

OWNER MUST COMPLETE AND SUBMIT APPROPRIATE TAXPAYER IDENTIFICATION NUMBER AND CERTIFICATION OR W‐8 (Foreign Individual or Entity) WITH REQUEST. SEE BELOW FOR INFORMATION ON WHICH FORM TO COMPLETE

REQUEST FOR TAXPAYER IDENTIFICATION NUMBER AND CERTIFICATION – OWNER IS: • An individual who is a U.S. Citizen or U.S. resident alien• A partnership, corporation, company, or association created or organized in the United States or

under the laws of the United States• An estate (other than a foreign estate), or• A domestic trust (as defined in Regulations section 301.7701‐7)

Other Important Information For U.S. Citizens – If you are a U.S. Citizen and reside outside of the United States, you may not elect out of Federal Withholding. We are required to withhold at least 10% federal withholding on the taxable income of any distribution.

W‐8BEN Certificate of Foreign Status of Beneficial Owner for US Tax Withholding and Reporting – owner is:

• An individual that is not a U.S. citizen or U.S. resident alien and is not required to complete W‐8BEN‐E (for an entity); W‐8ECI, 8233, or W‐8IMY

The Taxpayer Identification Number and Certification has been included with this form request. Taxpayer Identification Number and Certification form and W‐8BEN are also available on our forms site at www.myaccount.protective.com.

For any other applicable forms go to www.irs.gov. Consult your tax professional if neither of these situations pertain to you.

Life and Annuity Division Protective Life Insurance Company 1Protective Life and Annuity Insurance Company

SecurePay Benefit Election

Post Office Box 1928Birmingham, AL 35201-1928

Toll Free: 800-456-6330 / Fax: 205-268-6408

Owner’s Name: ____________________________________________ Contract Number: _____________________

Instructions:

_____ I want to set my Benefit Election Setting the Benefit Election Date will initiate your contract’s Benefit Period. Please refer to your Contract and Rider for details.

_____ I want to start my Partial Automatic Withdrawal

_____ I want to make a change to my existing Withdrawal

_____ I want to cancel my existing Withdrawal

_____ I want to take a One-Time Withdrawal in the amount of $________________

Payout Option: _____ Single Payout (based on the owner’s life only)

If single payout is elected, the covered person will be the single primary owner or the oldest joint owner.

_____ Joint Payout (based on the owner and spouse’s life)

If joint payout is elected please provide:

__________________________ ____________ _________________ Covered Person 1 Date of Birth SSN/Tax ID

__________________________ ____________ _________________ __________________ Covered Person 2 Date of Birth SSN/Tax ID Relationship to Owner If joint payout is elected and the owner is a Custodian, the sole primary beneficiary of the custodial account must be the spouse of the annuitant. Please verify this information before submitting the form.

How much do you want: _____ Send me the maximum annual withdrawal amount allowed _____ Send me only $________________ Any Annual Withdrawal Amount (AWA) not taken during the year is not cumulative from year to year. If you begin taking your AWA at a point between contract anniversary dates, you may request a one-time withdrawal of the amount that is available from the most recent contract anniversary to the first withdrawal scheduled. _____ Please check here if you want a one-time withdrawal of the amount available.

When do you want it:

Select One: _____ Monthly _____ Quarterly _____ Semi-Annually _____ Annually

Beginning Date: ___________________ mm/dd (select a date between the 1st – 28th) The begin date selected will be the date the withdrawal is processed. Please allow 3-5 business days for EFT to be received at your bank.

1 Not authorized in New York Page 1 of 2 LAD-1233-SEC R:10/18

Do you want taxes withheld: (Living Benefit Withdrawals are treated as distributions, NOT transfers. All withdrawals will be processed as gross amount; tax withholding does reduce the amount of the check.)

Federal ______ Do Not Withhold ______ Specify % or Dollar Amount

State ______ *Do Not Withhold ______ **Specify % or Dollar Amount *Some states require mandatory state income tax when federal income tax is withheld. For these states we willwithhold based on the state requirements.

**Some states do not allow state income tax withholding. We will withhold according to your instructions allowed by the state.

I understand that I am responsible for payment of federal income tax on the taxable portion of each withdrawal I receive, even if I choose not to have federal income tax withheld from my withdrawal. I also understand that if I don’t specify the tax withholding I want before my payment date, 10% federal income tax and applicable state income tax will be withheld from the taxable portion of my withdrawals until I make a different election.

I want my funds sent electronically to my bank (EFT):

PLEASE ATTACH A VOIDED CHECK

Routing Number: __________________________ Bank Account Number: ________________________

NOTARY: For your protection, Protective Life requires a Notary Signature for ALL first time electronic fund transfers (EFTs), new bank accounts, changes to your bank account on file, payments to a different address than on file or third party payers. If your request does not include a notarization, we will process your request as a check to the address of record.

NOTARY PUBLIC SEAL STAMP HERE:

_________________________________________ ____________ Notary Public Signature Date

_________________________________________ Title

SIGNATURES:

__________________________________ _______ _______________________________ ________ Owner’s Signature Date Joint Owner’s Signature Date

__________________________________ _______________________________ Owner’s SSN / Tax ID Number Joint Owner’s SSN / Tax ID Number

___________________________________ _______ Annuitant’s Signature (if Custodially Owned) Date

Page 2 of 2 LAD-1233-SEC R:10/18

Life and Annuity Division Protective Life Insurance Company 1Protective Life and Annuity Insurance Company

Post Office Box 1928 / Birmingham, AL 35201-1928Protective Income Manager Withdrawal Form Toll Free: 800-456-6330 / Fax: 205-268-6408

* If you do not wish to begin taking Protective Income Manager Benefit withdrawals within the next 60 daysskip to Section F.

Owner’s Name: ___________________________________________ Contract Number: __________________

Section A: Payout Option – The Joint Life Coverage Option can only be selected if both Owners of the Contract are spouses, OR if there is one Owner and a spouse who is the SOLE Primary Beneficiary. Please choose one and enter Covered Person(s) information in Section B.

Select one: Single Life Coverage Option

Joint Life Coverage Option

Section B: Covered Person(s) Information – Please complete the information below. (If Single Life Coverage Option is elected, Covered Person 1 must be the single Primary Owner or oldest Joint Owner. If Joint Life Coverage Option is elected, Covered Persons 1 and 2 must be spousal Joint Owners or a Single Owner with SOLE spouse Beneficiary.) The Annuitant must be a Covered Person.

_____________________________________ ______________ _________________ Covered Person 1 Date of Birth SSN / Tax ID

_____________________________________ ______________ _________________ __________________ Covered Person 2 (Joint Life Coverage Options Only)

Date of Birth SSN / Tax ID Relationship to Owner

Check here if you have verified that the spouse is the primary beneficiary on the Firm held Custodial Account. Note: Please confirm that this is an available payout option for your Firm’s Custodial Accounts.

(Please continue to Section C for automatic withdrawals, or Section E for a One-Time withdrawal.)

Section C: Withdrawals – All Protective Income Manager withdrawals will be taken on a pro-rata basis from your investment allocations. Withdrawals in excess of your Optimal Withdrawal Amount (OWA) may result in significantly lower OWA in the future. Please refer to your Contract or prospectus for additional information.

*In order for us to process your request you must also complete the “Notice of Federal Tax Withholding onNon-Periodic Distribution” form (LAD-1133.)

*Protective Income Manager withdrawals are not cumulative. Amounts not withdrawn during any contractyear cannot be withdrawn in future years. You may request a withdrawal of any remaining OWA at any timeprior to the next contract anniversary.

*If you need to take an additional amount to satisfy the RMD for this contract, please complete the RMDWithdrawal Service Form (LAD-1163.)

Select one: I wish to set up OWA withdrawals using the Partial Automatic Withdrawal (PAW) program.

I wish to make a change to my existing withdrawal election.

I wish to cancel my existing withdrawal election. (Please continue to Section F)

1 Not authorized in New York Page 1 of 3 LAD-1216 R:10/18

Section C: (Continued) Select one: Please withdraw an amount of $___________ per period based on the frequency selected in

Section D below. (The maximum allowed without causing an excess withdrawal is the OWA remaining for the current contract year / number of modes in a year.) I understand this will be the set payment amount and will not change unless I instruct differently. (Continue to Section D and then Section F.)

Please withdraw the OWA allowable without causing an excess withdrawal and using the PAW program with the amount based on the OWA divided by the frequency selected in Section D below. Remember that the Optimal Withdrawal Amount is calculated from contract anniversary to contract anniversary. Any OWA amount not taken during the year is not cumulative from year to year. If you begin taking your OWA at a point between contract anniversary dates, you may request a one-time withdrawal of the amount that is available from the most recent contract anniversary to the first modal withdrawal scheduled in Section D below.

_____ Please initial here to request this additional amount in a “One-Time” withdrawal.

I wish to withdraw an amount other than the maximum OWA. Please indicate the percentage: _____ % (50%, 75%, etc.) of the OWA.

(Continue to Section D and then Section F.)

Section D: Partial Automatic Withdrawal – All PAWs are taken pro-rata from your investment elections and must be made via Electronic Funds Transfer (EFT). Enclose a voided check with this request. *(Distributions must begin within 60 days of the date this form is signed.) Select one: Monthly Quarterly Semi-Annually Annually

*Beginning Date: ________________________ mm/dd (1st – 28th)

*The “Beginning Date” is the date on which your Partial Automatic Withdrawal will be processed by Protective.Please allow up to 3 days for receipt of funds into your account since acceptance and processing of the funds is atthe discretion of your financial institution.

Section E: “One-Time” Withdrawal I wish to take a “one-time” withdrawal of $________________ from my contract. (Please note

that withdrawals taken in excess of your OWA may result in a significantly lower OWA in the future.) If you are enrolled in the PAW program, your “one-time” withdrawal will terminate your PAW program.

Payment Instructions – If you wish to have your withdrawal sent via EFT, please enclose a voided check with this request.

Select one: Payment to Owner or both Joint Owners

Payment to third party or only one Joint Owner indicated below:

Name: _____________________________________________________________________

Select one: Use address of record.

Use alternate address indicated below:

Mailing Address: __________________________________________________________

__________________________________________________________

Page 2 of 3 LAD-1216 R:10/18

IMPORTANT FOR WITHDRAWAL OR SURRENDER REQUESTS FROM A CONTRACT INVOLVED IN A TAX-FREE PARTIAL EXCHANGE UNDER INTERNAL REVENUE SECTION 1035.

Please consult your tax advisor about whether a withdrawal from, or surrender of, a contract involved in partial exchange could cause the exchange to be treated as a taxable distribution or have other adverse federal income tax consequences.

For Contracts Involved in a Partial Exchange prior to October 24, 2011

Based on our understanding of IRS guidance in Rev. Proc. 2008-24, if a contract is involved in a tax-free exchange under Internal Revenue Code section 1035 that is completed prior to October 24, 2011, and an amount is withdrawn from or received in surrender of either contract involved within 12 months of the exchange, the exchange is to be treated as a taxable distribution unless an exception, such as the occurrence of one of the following events, applies as of the date of the withdrawal or surrender.

Please indicate which, if any, of the following events applies to the taxpayer as of the date of this requested withdrawal or surrender.

Age 59 ½ Disabled Divorced Loss of Employment

NOTE: If none of the above events is checked, and the requested withdrawal or surrender is made within 12 months of a partial exchange involving this contract, the exchange will no longer be treated as a tax-free exchange under Internal Revenue Code section 1035, and the partial exchange may need to be reported to you and the IRS as a taxable distribution from the contract. For Contracts Involved in a Partial Exchange on or after October 24, 2011

Based on our understanding of IRS guidance in Rev. Proc. 2011-38, if a contract is involved in a tax-free partial exchange under Internal Revenue Code section 1035 that is completed on or after October 24, 2011, and an amount is withdrawn from or received in surrender of either contract within 180 days of the exchange, the IRS will apply general tax principles to determine the substance, and hence the treatment of the partial exchange and the subsequent withdrawal or surrender. Such a withdrawal or surrender could affect how the partial exchange and the withdrawal or surrender is reported to you and the IRS.

Section F: Notary For your protection, Protective Life requires a Notary Signature for ALL first time electronic fund transfers (EFTs), new bank accounts, changes to your bank account on file, payments to a different address than on file or third party payers. If your request does not include a notarization, we will process your request as a check to the address of record.

NOTARY PUBLIC SEAL STAMP HERE: _______________________________________ ___________ Notary Public Signature Date

_______________________________________ Title

Section G: SIGNATURES – By signing below I authorize the Company to act on the instructions indicated above.

At this time I do not want the Protective Income Manager Benefit withdrawals to start within the next 60 days.

_____________________________________ _________ _______________________________ _________ Owner’s Signature Date * Joint Owner’s Signature Date *

_____________________________________ _________ Annuitant’s Signature (if Custodial Owned) Date *

Page 3 of 3 LAD-1216 R:10/18

Form W-9 (Rev. October 2018) Department of the Treasury, Internal Revenue Service

Taxpayer Identification Number and Certification Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.

Business name/disregarded entity name, if different from above

Check appropriate box for federal tax classification of the person whose name is entered on the Name line above. Check only one of the following seven boxes:

Exemptions (codes apply only to certain entities, not individuals)

Individual/sole proprietor or C Corporation S Corporation Partnership Trust/estate single-member LLC Exempt payee code (if any) _______

Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) ________________ Note. Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check LLC if

the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that is disregarded from the owner should check the appropriate box for the tax classification of its owner.

Exemption from FATCA reporting

code (if any) __________________

Other (Applies to accounts maintained outside the U.S.)

Address (number, street, and apt, or suite no.) See instructions. Requester’s name and address (optional)

City, State, and ZIP code

List account number(s) here (optional)

Part I Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given on the “Name” line to avoid backup withholding. For individuals, this is generally your social security (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see Part I of the W-9 instructions at website listed below. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on the W-9 instructions at website listed below.

Note. If the account is in more than one name, please refer to the W-9 instructions for guidelines on whose number to enter. Also, see What Name and Number to Give the Requester for guidelines on whose number to enter.

Social security number

- -

Employer identification number

-

Part II Certification

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), 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 (c) the IRS has notified me that I am no longer subject to backup withholding, and

3. I am a U.S. citizen or other U.S. person , and

4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, 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 TIN.

Sign Here

Signature of U.S. person Date

IMPORTANT – if any part of the payment made to you could be subject to backup withholding and we do not receive this completed form, we will do backup withholding of 24% on those amounts.

IRS W-9 form instructions can be used for clarification in completing this form. See www.irs.gov/pub/irs-pdf/fw9.pdf R: 11/2018

Life and Annuity Division Protective Life Insurance Company Annuity New Business ... ·...

Documents

Transcript of Life and Annuity Division Protective Life Insurance Company Annuity New Business ... ·...