LPS APP Annuity – 2009 – MI | Ladies Pennsylvania Slovak Catholic Union

LPS APP Annuity – 2009 – MI

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50%

FLEXIBLE PREMIUM DEFERRED ANNUITY SUITABILITY QUESTIONNAIRE

Owner Information

Name

First Middle Last

Age

Are you actively employed?

Yes

Occupation

Marital Status:

Single

Married

Widowed

Divorced

Household Financial Information

The money funding this Annuity comes from: (check all that apply)

Other Annuities

Life Insurance

Stocks/Bonds/Mutual Funds

Money Market

Certificates of Deposit

Savings/Checking

IRA or Retirement Plan

Loan

Household Annual Gross Income:

Estimated Net Worth: (Total)

Liquid Net Worth (Includes: Savings/Checking/CDs, Stocks/Bonds/Mutual Funds, Life Insurance, Retirement Plan Funds, Cash Value of Annuities :

After the purchase of this annuity, will you have sufficient income to meet your expenses?

Yes

If No, please explain:

Will you incur a withdrawal or surrender charge on the money used to fund this purchase?

Yes

What is your federal income tax bracket?

0 to 10%

Greater than 10%

Do you currently reside in a nursing home or assisted living facility?

Yes

Financial Objectives

Why are you considering purchasing this annuity?

Immediate Income

Future Income

Tax Deferral

Liquidity

Assets for Beneficiaries

Estate Planning

Retirement

Long-Term Care

Preservation of Capital

Other

If other, please explain:

Do you expect the contract to be in force for at least 6 years?

Yes

If no, why?

When do you expect to start needing income from this annuity?

Never (money for charity/inheritance)

Less than 1 Year

1 Year

2-6 Years

More than 6 Years

If needed for other reason (e.g., long term care)

Which of the following best describes your financial experience?

Very experienced

Moderate experience

Limited experience

Describe your risk tolerance

Low (Conservative)

Moderate

High (aggressive)

General Information

1. The purpose of this questionnaire is to help the Society determine if the annuity product you are purchasing is suitable based on your financial situation and goals. You must complete this profile in its entirety and submit it with your application for the Society to proceed with your purchase.

2. Representatives of the Society may be paid a commission. Commissions are not paid by members. Commissions are not deducted from your account value. All contributions received from you are credited to your account at 100%.

INSURANCE AGENT DECLARATIONS AND ACKNOWLEDGMENT

I acknowledge that I have obtained the above information from the Owner concerning the Owner’s financial status, tax status, investment objectives, and other information considered reasonable. It is my belief that, based on the information provided by the Owner and based on the circumstances known to me at the time the recommendation was made, the annuity being applied for, based on my recommendation, is suitable for the Owner’s insurance needs and/or financial objectives.

Agent/Society’s Representative Signature:

Date

MM slash DD slash YYYY

Agent’s State License Number:

State Licensed In:

OWNER DECLARATIONS AND ACKNOWLEDGMENT

I hereby acknowledge:

I represent that all statements and information provided herein are true and complete to the best of my knowledge and belief.

Yes

I understand that should I provide incomplete or inaccurate information, I will limit protection afforded to me by law regarding the suitability of this purchase.

Yes

I understand that if I withdraw any amount from this annuity during the surrender period, I will incur a surrender charge.

Yes

I understand that I may incur a 10% federal tax penalty for withdrawals before age 59½.

Yes

I have reviewed the annuity disclosures and I understand the costs and features of the annuity I am purchasing.

Yes

I acknowledge that the Society and its representative do not offer legal, financial, tax, investment or estate-planning advice and I have had the opportunity to seek such advice from the proper sources before purchasing this annuity.

Yes

I believe that the purchase of this annuity is appropriate to my legal, financial, tax, investment and estate-planning goals and other insurance needs.

Yes

Owner Signature:

Date

MM slash DD slash YYYY

APPLICATION FOR DEFERRED ANNUITY

Proposed Annuitant

First Last

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone

Social Security Number

Date of Birth

MM slash DD slash YYYY

Age

Place of Birth

Gender

Male

Female

Applicant (if other than Annuitant)

First Last

Relationship

Social Security Number

Address

Street Address City State / Province / Region ZIP / Postal Code

Mail Reminder Notice to:

Proposed Annuitant

Applicant

Plan Type:

Maturity Date:

Initial Deposit: $

Beneficiary
(If more than one, then benefit paid equally to the survivors unless otherwise indicated. List additional beneficiaries in REMARKS)

Primary Beneficiary:

First Last

Relationship to Annuitant

Contingent Beneficiary:

First Last

Relationship to Annuitant

Will the insurance being applied for replace or change any existing life insurance or annuities in this or any other company? If Yes, give details and name of companies in REMARKS.

Yes

Dividend Option:

Add to Account Value

Cash

Marital Status:

Single, Widowed or Divorced

Married

Is the Proposed Annuitant a member of the Society? If not, please apply for membership.

Yes

Optional Secondary Addressee
(for notification of a past due premium or possible lapse of coverage)

Name

First Last

Address

Street Address City State / Province / Region ZIP / Postal Code

If Annuitant wishes to be reminded to make regular payments, indicate amount and frequency:

Frequency:

Annually

Semiannually

Quarterly

Monthly

Amount:

REMARKS:

NOTE: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

AnnuityAPP-2015-IL LADIES PENNSYLVANIA SLOVAK CATHOLIC UNION

PROPOSED ANNUITANT/APPLICANT STATEMENT

I declare that the statements and answers given in this application are true, complete and correctly recorded to the best of my knowledge and belief. I agree that this application shall be the basis for and a part of any contract issued. I understand that coverage will not be effective until the initial deposit has been paid and the contract has been delivered.

THE LADIES PENNSYLVANIA SLOVAK CATHOLIC UNION IS LICENSED TO DO BUSINESS IN THE STATE OF ILLINOIS AS A FRATERNAL BENEFIT SOCIETY. AS SUCH, IT IS NOT INCLUDED IN THE ILLINOIS LIFE AND HEALTH GUARANTY ASSOCIATION (OTHERWISE KNOWN AS THE GUARANTY ASSOCIATION). THIS MEANS THAT FRATERNAL BENEFIT SOCIETIES CANNOT BE ASSESSED FOR THE INSOLVENCY OF OTHER LIFE INSURERS OR OTHER FRATERNAL BENEFIT SOCIETIES. BY LAW, A FRATERNAL BENEFIT SOCIETY IS RESPONSIBLE FOR ITS OWN SOLVENCY. IF THERE IS AN IMPAIRMENT OF RESERVES, A CERTIFICATE HOLDER MAY BE ASSESSED A PROPORTIONATE SHARE OF THE IMPAIRMENT. THIS PROCESS IS DESCRIBED IN THE CERTIFICATE ISSUED BY THE SOCIETY.

Signature of Proposed Annuitant Date Signed by Proposed Annuitant

Signature of Applicant (if other than Date Signed by Applicant Proposed Annuitant)

RECOMMENDER’S STATEMENT

Was this insurance applied for to replace or change any existing life insurance or annuity contract? If Yes, provide required disclosure notices to the Proposed Insured/Applicant.

Yes

This signature will be requested directly by LPSCU after the form is submitted.

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