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LPS APP Annuity – 2009 – MA

Step 1 of 2

FLEXIBLE PREMIUM DEFERRED ANNUITY SUITABILITY QUESTIONNAIRE

Owner Information

Name
Are you actively employed?
Marital Status:

Household Financial Information

The money funding this Annuity comes from: (check all that apply)
After the purchase of this annuity, will you have sufficient income to meet your expenses?
Will you incur a withdrawal or surrender charge on the money used to fund this purchase?
What is your federal income tax bracket?
Do you currently reside in a nursing home or assisted living facility?

Financial Objectives

Why are you considering purchasing this annuity?
Do you expect the contract to be in force for at least 6 years?
When do you expect to start needing income from this annuity?
Which of the following best describes your financial experience?
Describe your risk tolerance
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.
Clear Signature
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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.
I understand that if I withdraw any amount from this annuity during the surrender period, I will incur a surrender charge.
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.
I understand that I may incur a 10% federal tax penalty for withdrawals before age 59½.
I have reviewed the annuity disclosures and I understand the costs and features of the annuity I am purchasing.
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.
I believe that the purchase of this annuity is appropriate to my legal, financial, tax, investment and estate-planning goals and other insurance needs.
Clear Signature
MM slash DD slash YYYY

NOTICE OF INFORMATION PRACTICES 

Thank you for your application. It will be the major source of information about you used to underwrite  your application for insurance. 

We may also: (a) collect or verify information from other sources; and (b) ask a consumer reporting  agency to collect information and submit a report to us. Consumer reports are a usual part of the process  of evaluating risks for life and health insurance.  

You may request in writing to be informed as to whether a consumer report was prepared. The name and  address of the reporting agency that prepared any report will be given to you. You may obtain a copy of  the report from that agency. If information from a consumer report has an adverse effect on our  underwriting decision, we will notify you. We will also furnish the name and address of the reporting  agency. You may discuss the matter with that agency if you wish. 

Information regarding your insurability will be treated as confidential. We or our reinsurers may release  information in our files to other insurance companies to whom you may apply for life or health insurance,  or to whom a claim for benefits may be submitted. Information obtained from a report prepared by an  insurance-support organization may be retained by the insurance-support organization and disclosed to  other persons. 

You have the right of access to certain items of information we have collected about you. You also have  the right to request a correction of any information you feel is inaccurate. In the event of an adverse  underwriting decision, we will either (a) provide you with the specific reason for the adverse underwriting  decision in writing, or (b) advise you that upon written request, you have the right to receive the specific  reason in writing. 

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or  knowingly presents false information in an application for insurance may be subject to fines and  confinement in prison. 

If you wish to have a more detailed description of our information practices, send a written request to our  Home Office at the address shown above. 

NoticePractices MA-2014

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71 South Washington Street | Wilkes-Barre, PA 18701

570-823-3513 | 888-834-6614 (Toll Free)

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