<html> <head> <title>Rule 20:06:08:0C Uniform Form for Life Insurance or Annuity 1035 Exchange.</title> <META NAME="Keywords" Content="Administrative Rules 20:06:08:0C"> <META NAME="Description" Content="Administrative Rules 20:06:08:0C Uniform Form for Life Insurance or Annuity 1035 Exchange."> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Generator content="Microsoft Word 14 (filtered)"> <title>DEPARTMENT OF REVENUE AND REGULATION</title> <style> <!-- /* Font Definitions */ @font-face {font-family:Times; panose-1:2 2 6 3 5 4 5 2 3 4;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {margin:0in; margin-bottom:.0001pt; font-size:10.0pt; font-family:"Times","serif";} p.MsoFooter, li.MsoFooter, div.MsoFooter {margin:0in; margin-bottom:.0001pt; font-size:12.0pt; font-family:"Arial","sans-serif";} p.MsoBodyTextIndent2, li.MsoBodyTextIndent2, div.MsoBodyTextIndent2 {margin-top:0in; margin-right:0in; margin-bottom:0in; margin-left:.4in; 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Roman","serif"'>&nbsp;</span></font></p> <p class=MsoFooter><font face="Times New Roman"><span style='font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>DEPARTMENT OF LABOR AND REGULATION</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>DIVISION OF INSURANCE</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>UNIFORM FORM FOR LIFE INSURANCE OR ANNUITY 1035 EXCHANGE</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Chapter 20:06:08</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>APPENDIX C</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>SEE:&nbsp; &#167; 20:06:08:42(3)</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b><span style='font-weight:bold'>Source:</span></b> 29 SDR 84, effective December 15, 2002; 39 SDR 55, effective October 4, 2012.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'><br clear=all style='page-break-before:always'> </span></font> <p class=MsoNormal align=center style='text-align:center'><b><font size=4 face="Times New Roman"><span style='font-size:14.0pt;font-family:"Times New Roman","serif"; font-weight:bold'>Uniform Transaction Form for 1035 Exchange:</span></font></b></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <table class=MsoNormalTable border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;border-collapse:collapse;border:none'> <tr height=33 style='height:25.0pt'> <td width=264 height=33 valign=top style='width:2.75in;border:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt;height:25.0pt'> <p class=MsoNormal style='text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>Name of Insured/Annuitant:</span></font></p> </td> <td width=216 height=33 valign=top style='width:2.25in;border:solid windowtext 1.0pt; border-left:none;padding:0in 5.4pt 0in 5.4pt;height:25.0pt'> <p class=MsoNormal style='text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>Social Security or Taxpayer ID No:</span></font></p> </td> <td width=156 height=33 valign=top style='width:117.0pt;border:solid windowtext 1.0pt; border-left:none;padding:0in 5.4pt 0in 5.4pt;height:25.0pt'> <p class=MsoNormal style='text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>Policy/Contract No:</span></font></p> </td> </tr> <tr height=33 style='height:25.0pt'> <td width=264 height=33 valign=top style='width:2.75in;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt;height:25.0pt'> <p class=MsoNormal style='text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>Joint Insured/Annuitant</span></font></p> </td> <td width=216 height=33 valign=top style='width:2.25in;border-top:none; border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt;height:25.0pt'> <p class=MsoNormal style='text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>Social Security or Taxpayer ID No:</span></font></p> </td> <td width=156 height=33 valign=top style='width:117.0pt;border-top:none; border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt;height:25.0pt'> <p class=MsoNormal style='text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>Daytime Phone No:</span></font></p> </td> </tr> <tr height=33 style='height:25.0pt'> <td width=264 height=33 valign=top style='width:2.75in;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt;height:25.0pt'> <p class=MsoNormal style='text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>Policy Owner (if different than insured):</span></font></p> </td> <td width=216 height=33 valign=top style='width:2.25in;border-top:none; border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt;height:25.0pt'> <p class=MsoNormal style='text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>Social Security or Taxpayer ID No:</span></font></p> </td> <td width=156 height=33 valign=top style='width:117.0pt;border-top:none; border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt;height:25.0pt'> <p class=MsoNormal style='text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>Street Address</span></font></p> </td> </tr> <tr height=33 style='height:25.0pt'> <td width=264 height=33 valign=top style='width:2.75in;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt;height:25.0pt'> <p class=MsoNormal style='text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>Joint Policy Owner (if different than insured):</span></font></p> </td> <td width=216 height=33 valign=top style='width:2.25in;border-top:none; border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt;height:25.0pt'> <p class=MsoNormal style='text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>Social Security or Taxpayer ID No:</span></font></p> </td> <td width=156 height=33 valign=top style='width:117.0pt;border-top:none; border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt;height:25.0pt'> <p class=MsoNormal style='text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>City, State, and Zip Code</span></font></p> </td> </tr> </table> <p class=MsoNormal style='text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font size=2 face="Times New Roman"><span style='font-size: 10.0pt;font-family:"Times New Roman","serif"'>I own the following:&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></font><font face="Times New Roman"><span style='font-family:"Times New Roman","serif"'>&nbsp;Life Insurance Policy </span></font><font face="Times New Roman"><span style='font-family:"Times New Roman","serif"'>&nbsp;Endowment </span></font><font face="Times New Roman"><span style='font-family:"Times New Roman","serif"'>&nbsp;Annuity Contract</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>The existing policy was issued by: _______________________ on _____________.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (Old Company)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (Date)</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>The new policy is being requested for: ____________________ on _____________.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (New Company)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (Date)</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <table class=MsoNormalTable border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;background:#DFDFDF;border-collapse:collapse; border:none'> <tr> <td width=630 valign=top style='width:472.5pt;border:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'><b><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"; font-weight:bold'>1035 Exchange</span></font></b></p> </td> </tr> </table> <p class=MsoNormal style='text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>I (We) the undersigned owner(s) of the above named contract (existing policy), hereby assign and transfer absolutely all rights, title, and interest in the existing policy. I (We) intend this assignment to be part of a tax-free exchange under Internal Revenue Code Section 1035(a). This exchange must be on the life of the same Insured/Annuitant named in the existing policy if approved for the new policy.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>I further represent:</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>1.&nbsp;&nbsp;&nbsp;<b><span style='font-weight:bold'>Ownership of existing policy.</span></b></span></font></p> <p class=MsoBodyTextIndent2 style='margin-left:.25in;text-indent:0in'><font size=2 face="Times New Roman"><span style='font-size:10.0pt'>I (We) am/are the sole owner(s) of the existing policy. No other person or entity has any claim or interest in or against the existing policy, except ________________________________________________.</span></font></p> <p class=MsoBodyTextIndent2 style='margin-left:.7in'><font size=2 face="Times New Roman"><span style='font-size:10.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (collateral assignees, irrevocable beneficiaries, etc.)</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:.4in;text-align:justify;text-indent:-.4in'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>2.&nbsp;&nbsp;&nbsp;<b><span style='font-weight:bold'>Surrender of existing policy.</span></b></span></font></p> <p class=MsoNormal style='margin-left:.25in;text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>I understand and agree:</span></font></p> <p class=MsoNormal style='margin-left:.25in;text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:.25in;text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>Upon approval of my application for the new policy, the new company will request the cash surrender value of my existing policy.</span></font></p> <p class=MsoNormal style='margin-left:.25in;text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoBodyTextIndent3><font size=2 face="Times New Roman"><span style='font-size:10.0pt'>I know that I may take up to six months to receive the cash surrender value of my existing policy. During this time I assume full responsibility for paying any premium payments, which are now due or may become due while the surrender request is pending. I hold both old and new companies harmless from any claim if it lapses because the premiums have not been paid.</span></font></p> <p class=MsoNormal style='margin-left:.25in;text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:.25in;text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>The new company will apply the case surrender value it receives from the existing policy, less any applicable short term charges. The new company will pay me any excess amounts.</span></font></p> <p class=MsoNormal style='margin-left:.25in;text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:.25in;text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>I know that the payment of the cash surrender value ends all legal obligations of the old company issuing my existing policy. Thus, if the insured under this existing policy dies after the cash surrender value has been sent to the new company. I know that NO DEATH BENEFITS will be paid under the existing policy.</span></font></p> <p class=MsoNormal style='margin-left:.25in;text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:.25in;text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>After the cash surrender value of my existing policy has been paid to the new policy, if I choose not to accept the new policy, the only obligation of the new company shall be to pay me the full cash surrender value received for my existing policy. I know that the company issuing the existing policy may not permit me to reinstate it after it has been surrendered.</span></font></p> <p class=MsoNormal style='margin-left:.25in;text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>4.&nbsp;&nbsp;&nbsp;<b><span style='font-weight:bold'>No insurance created by this form.</span></b></span></font></p> <p class=MsoNormal style='margin-left:.25in;text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>I understand that this form creates no insurance.</span></font></p> <p class=MsoNormal style='margin-left:.25in;text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>5.&nbsp;&nbsp;&nbsp;<b><span style='font-weight:bold'>Absolute assignment of existing policy.</span></b></span></font></p> <p class=MsoNormal style='margin-left:.25in;text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>For the purposes and with the agreements set forth above, I hereby assign, irrevocably transfer, and deliver the existing policy described above to the new company together with all right, title, and interest therein and thereto. My copy of this form when signed is my receipt for the existing policy.</span></font></p> <p class=MsoNormal style='margin-left:.4in;text-align:justify;text-indent:-.4in'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoBodyTextIndent2 style='margin-left:.25in;text-indent:-.25in'><font size=2 face="Times New Roman"><span style='font-size:10.0pt'>6.&nbsp;&nbsp;&nbsp;<b><span style='font-weight:bold'>Acknowledgement of responsibility for tax obligations.</span></b> I understand that any tax obligations resulting from this transaction are mine and it may be in my best interest to seek professional tax advice prior to completing this transaction. I assume any and all risk with respect to accomplishment of a valid Section 1035 exchange under the Internal Revenue Code.</span></font></p> <p class=MsoNormal style='margin-left:.4in;text-align:justify;text-indent:-.4in'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:.4in;text-align:justify;text-indent:-.4in'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>_________________________________&nbsp;&nbsp; __________&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; _________________________________&nbsp;&nbsp; __________</span></font></p> <p class=MsoNormal style='margin-left:.4in;text-align:justify;text-indent:-.4in'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp; (Insured/Annuitant)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (Date)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (Insured/Annuitant)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (Date)</span></font></p> <p class=MsoNormal style='margin-left:.4in;text-align:justify;text-indent:-.4in'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:.4in;text-align:justify;text-indent:-.4in'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>_________________________________&nbsp;&nbsp; __________&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; _________________________________&nbsp;&nbsp; __________</span></font></p> <p class=MsoNormal style='margin-left:.4in;text-align:justify;text-indent:-.4in'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp; (Policy Owner Signature)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (Date)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (Policy Owner Signature)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (Date)</span></font></p> <p class=MsoNormal style='margin-left:.4in;text-align:justify;text-indent:-.4in'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:.4in;text-align:justify;text-indent:-.4in'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>_________________________________&nbsp;&nbsp; __________&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; _________________________________&nbsp;&nbsp; __________</span></font></p> <p class=MsoNormal style='margin-left:.4in;text-align:justify;text-indent:-.4in'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp; (Irrevocable Beneficiary or Assignee)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (Date)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (Collateral Assignee and Title)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (Date)</span></font></p> <p class=MsoNormal style='margin-left:.4in;text-align:justify;text-indent:-.4in'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:.4in;text-align:justify;text-indent:-.4in'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>_________________________________&nbsp;&nbsp; __________&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; _________________________________&nbsp;&nbsp; __________</span></font></p> <p class=MsoNormal style='margin-left:.4in;text-align:justify;text-indent:-.4in'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp; (Witness)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;(Date)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (Witness)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (Date)</span></font></p> <p class=MsoNormal><font size=2 face=Times><span style='font-size:10.0pt'>&nbsp;</span></font></p> </div> </body> </html>