revocable beneficiary single premium … · show full names, relationship to owner, and percentage...

916 Sherwood Drive Lake Bluff, Illinois 60044-2285 847-295-6000 800-321-ELCO

REVOCABLE BENEFICIARY SINGLE PREMIUM IMMEDIATE ANNUITY APPLICATION INSTRUCTIONS

General Information

Annuity Applications -- Print all information in dark ink. Minimum Premium: $5,000 Maximum Policy Premium: $500,000 without H.O. approval Maximum Policy Premium: $5,000,000 per family limit. Application Information

Section1. Must be completed on every application. Proposed Annuitant must be a living person (not an entity or trust). Section 2. Not applicable to the Revocable Single Premium Immediate Annuity. Section 3. Complete only if the owner is to be someone other than the annuitant. Remember, with this type of policy we only

allow for a Trust with a direct relationship to the annuitant (Grantor of trust). If the trust is the owner we will pay the death benefit at the death of the annuitant.

Section 4. Be sure to mark the correct box for plan type. A. Make sure the tax qualification box in section 4 is appropriately checked. If the selection is incorrectly marked

this will cause tax problems for the client. If the case is an IRA Rollover, please keep RMD requirements in mind, Interest Plus (Balloon Style) Annuities do not meet RMD requirements. We require proof that the funds are qualified, qualification must be indicated somewhere other than the application. Whether that is the check, the suitability form, and/or a letter of instruction is up to the agent but we must have proof before issuing the policy. Make sure the correct box is marked for Commencement Date. If requesting an Annuity Due (first check with policy) do not mark Annuity Commencement Date.

Section 5. Show full names, relationship to owner, and percentage (%) of benefit to be paid to each beneficiary. We do

not accept “per stirpes” beneficiary designations. Descendants to be beneficiaries must be fully named on the application. Beneficiaries must be 18 or over. If a trust is to be a beneficiary you must provide a copy of the trust.

Section 6. Mark how dividends, if any, are to be distributed. Section 7. Answer questions (yes or no). If replacement, submit completed Form RNLIA and 1035 fact sheet.

Remember, it’s still a replacement if old policy was terminated in advance of application-we need for RNLIA. Remarks Section: Use for any additional information including requests for a specific date or immediate due

designation (first check will be sent with policy). Signatures. Get signature(s) of annuitant(s) and owner (if other than annuitant). Complete all agent information and

sign and date the application. Signatures must be originals. Proxies. As a mutual company, owned by our policyholders, we want the proxies signed, preferably answered YES to

continue operations of our company in our policyholder’s best interest.

REVOCABLE BENEFICIARY SINGLE PREMIUM IMMEDIATE ANNUITY APPLICATION INSTRUCTIONS CONTINUED… Submit the following signed and completed forms with each annuity application:

Check(s) made payable to: ELCO Mutual Life & Annuity. Make sure the checks numerical and written $ amount match and the date is correct before you send it in with the

application. Remember we do NOT accept third party checks on non-qualified funds. Completed Annuity Sale Suitability Disclosure ASD form for all applicants. (If clients choose not to divulge their financial information, complete the form appropriately.) Be sure form is

signed. Florida applications require Annuity Suitability Questionnaire DFS-H1-1980. Complete Annuity Sales Disclosure Form IASD13 If a “power-of-attorney” has signed the application in someone’s stead, be sure the POA designation is listed next to the

signature and submit a copy of the POA papers. If beneficiary is to be a trust, submit a trust “abstract” or a copy of the trust declaration page of the trust. Complete the Community Property Form CPS13 in AZ, CA, ID, LA, NM, NV, TX and WI. Complete REQUIRED IRS Form W4P and return with each SPIA application. Please note: ELCO only withholds FEDERAL taxes Complete REQUIRED IRS Form W9 and return with each application. Complete IRA / ROTH IRA Fact Sheet (MUST BE COMPLETED and submitted with each IRA / Roth IRA Application)

Additional Information ELCO does not allow the use of white-out or “strike overs” on the application. If an error occurs during the writing of an application please correct and have the client initial the change. Use of white-out or “strike overs” to the application will result in an amendment to the application which will require the applicant to sign the amendment at delivery. If the owner and/or the beneficiary of the policy is a revocable trust the client must change the owner and/or beneficiary before submitting a request for a Letter of Irrevocability.

We recommend sending applications to the home office by -or- shipping to insure delivery. NOTICE: IF there are errors, strikeovers or white out used on the application (without the client having initialed the changes) we may send the application back to the agent. Effective policy dates are given based on all paperwork and premium funds being received at the home office.

http://www.irs.gov/pub/irs-pdf/fw4p.pdf

http://www.irs.gov/pub/irs-pdf/fw9.pdf

Single Premium Individual 916 Sherwood Drive Lake Bluff, Illinois 60044-2285 Immediate Annuity Application 1-800-321-ELCO Please print in dark ink.

1. Proposed Annuitant:

Name: _________________________________________________________________ Date of Birth: _______________________________________

Sex: ________ Social Security #: ___________________________________________ Phone: ____________________________________________

Address: __________________________________________________________________________________________________________________

2. Proposed Co-Annuitant: (if any) MUST BE SPOUSE OF ANNUITANT

Name: _________________________________________________________________ Date of Birth: _______________________________________

Sex: ________ Social Security #: ___________________________________________ Phone: ____________________________________________

Address: _________________________________________________________________________________________________________________

3. Owner: If other than Annuitants.

Name : _______________________________________________ Date of Birth: _____________________ Phone: ____________________________

T.I.N./ S.S.#: __________________________________________ Relationship to proposed annuitant(s): ____________________________________

Address: __________________________________________________________________________________________________________________

4. Plan: Single Premium Individual Immediate Annuity 1 . Single Life: Life Only Life with Period Certain _______ Years (Options: 5, 10, 15, 20 years.)

2. Single Life-Fixed Benefit: Level Benefit Balloon Style Benefit Period ________ Months Years

3. Joint Life: Joint Life Only Joint Life with Period Certain ________Years (Options: 5, 10, 15, 20 years.)

4. Joint Life-Fixed Benefit: Level Benefit Benefit Period ________ Months Years Percent to Survivor_________%

Mode of Annuity Payments: Monthly Annual (For annual mode, benefit period must be in whole years.)

Annuity Commencement Date: 1 month, 1 year_____, after Effective Date

Annuity Due (first annuity payment check accompanies the contract.)

Plan Qualification: Non-Qualified Tax–Deferred IRA Tax-Deferred Roth IRA (The company will not accept tax-qualified joint-life plans other than with spouses.)

Single Premium submitted with this application: $_____________________________*

* Make Checks Payable to: ELCO MUTUAL LIFE AND ANNUITY. Do NOT pay to agent or leave payee blank. 5. Beneficiary: List name, address and relationship .

Primary: __________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________ Contingent: ________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

6. Dividends if any:

Lump Sum cash; Increase Annuity Payments.

ICC11-App. SPIA11 Ed. 11/10 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Application continues on reverse side.

Single Premium Individual Immediate Annuity Application (Continued)

7. Replacement: (If other policies/certificates exist, list name of company(s) and policy number(s) in Remarks Section.)

Does the Annuitant or Co-Annuitant, if any, have an existing life insurance or annuity contract? Yes No. Will the plan now applied for replace or change any existing life insurance or annuity contract? Yes No.

8. Remarks: ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________

FRAUD NOTICE WARNING

Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law. The undersigned: (1) REPRESENT that the information shown in this application is, to the best of their knowledge and belief, complete and true; (2) AGREE that this application shall be the basis for and a part of any contract issued; and (3) UNDERSTAND that: (A) the contract will be effective on the date the Company approves issue of the contract or the date of its receipt of the premium for the contract; and (B) only an officer of the Company may, in writing: (a) make or modify contracts; or (b) waive any of the Company’s rights or requirements.

Annuitant’s Signature: _______________________________________________________ Date: __________________________________

Co-Annuitant’s Signature: ____________________________________________________ Date: ______________________________

Agent Information:

Does the proposed annuitant have existing life insurance or annuity contracts? Yes. No. Do you have knowledge or reason to believe that replacement of existing life insurance or annuity contracts may be involved? Yes. No. I Attest that I have witnessed all signatures. Application signed at (City/State): ___________________________________________________________

Agent’s Signature: _______________________________________________________ Date: ______________________________________

Agent’s printed name: _________________________________________________________ Agent Code #: ________________________________

Agent’s phone #: _________________________________________________ Agent’s Fax #: ____________________________________________ Agent’s Email Address: ______________________________________________ Agent’s Florida Lic. # (if applicable): ___________________________ ICC11-App. SPIA11 Ed. 06/11 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

PROXY Do you hereby constitute and appoint the proxy committee of ELCO Mutual Life and Annuity, as established in the bylaws, as your lawful attorney and proxy and in your name and stead hereby authorize and empower it to cast your vote at any meeting of the policyholders of the company? This proxy shall continue in force except when you are present in person or revoke it by giving the company written notice in accordance with the ELCO Mutual Life and Annuity bylaws. Answer: Yes. No. _______________________________________ ____________________________________ Proposed Owner’s Signature Date

PROXY 2002

Owner’s Signature, if other than annuitant(s):_____________________________________ Date: ______________________________

916 Sherwood Drive

Lake Bluff, Illinois 60044-2285

847-295-6000

800-321-ELCO

INSTRUCTION FOR REPLACEMENT FORM

Our life insurance and annuity applications contain two replacement questions for both the applicant and the producer.

The first question asks whether the applicant has any existing life insurance or annuity contracts.

If the answer to this question is “NO”, the Replacement Form is NOT required.

If the answer to this question is “YES”, the Replacement Form IS required.

Regardless of how the second question in answered, let the answer to the first question be your guide in determining

whether to complete a Replacement Form.

This requirement applies to all states in which ELCO is authorized to do business. If you have any questions, please

contact ELCO’s new business department at (888) 872-7954.

916 Sherwood Drive Lake Bluff, Illinois 60044-2285 888-872-7954

Page 1 of 3 Applicant Copy Form RNLIA ED 1/2014

IMPORTANT NOTICE REPLACEMENT OF LIFE INSURANCE OR ANNUITIES This document must be signed by the applicant and the agent, if there is one, and a copy left with the applicant You are contemplating the purchase of a life insurance policy or annuity contract. In some cases this purchase may involve discontinuing or changing an existing policy or contract. If so, a replacement is occurring. Financed purchases are also considered replacements. A replacement occurs when a new policy or contract is purchased and, in connection with the sale, you discontinue making premium payments on the existing policy or contract, or an existing policy or contract is surrendered, forfeited, assigned to the replacing insurer, or otherwise terminated or used in a financed purchase. A financed purchase occurs when the purchase of a new life insurance policy involves the use of funds obtained by the withdrawal or surrender of or by borrowing some or all of the policy values, including accumulated dividends, of an existing policy, to pay all or part of any premium or payment due on the new policy. A financed purchase is a replacement. You should carefully consider whether a replacement is in your best interest. You will pay acquisition costs and there may be surrender costs deducted from your policy or contract. You may be able to make changes to your existing policy or contract to meet your insurance needs at less cost. A financed purchase will reduce the value of your existing policy and may reduce the amount paid upon the death of the insured. We want you to understand the effects of replacements before you make your purchase decision and ask that you answer the following questions and consider the questions in this form. 1. Are you considering discontinuing making premium payments, surrendering, forfeiting, assigning to the insurer, or

otherwise terminating your existing policy or contract? ________YES ________NO 2. Are you considering using funds from your existing policies or contracts to pay premiums due on the new policy or

contract? ________YES ________NO

If you answered “Yes” to either of the above questions, list each existing policy or contract you are contemplating replacing (including the name of the insurer, the contract or policy number, if available, the insured or annuitant name) and whether each policy or contract will be replaced or used as a source to finance the new ELCO policy:

INSURER CONTRACT OR INSURED OR REPLACED (R) OR NAME POLICY # ANNUITANT NAME FINANCING (F)

1. _________________________________________________________________________________________________________

2. _________________________________________________________________________________________________________

3. _________________________________________________________________________________________________________



Make sure you know the facts. Contact your existing company or its agent for information about the old policy or contract. If you request one, an in-force illustration, policy summary or available disclosure documents must be sent to you by the existing insurer. Ask for and retain all sales material used by the agent in the sale presentation. Be sure that you are making an informed decision. The existing policy or contract is being replaced because: ________________________________________________________ I certify that the responses herein are, to the best of my knowledge, accurate: Applicant’s Signature and Printed Name Date Telephone Number Agent’s Signature and Printed Name Date

I do not want this notice read aloud to me. ____________________________________________________________________

(Applicant must initial only if they do not want notice read aloud.) A replacement may not be in your best interest, or your decision could be a good one. You should make a careful comparison of the costs and benefits of your existing policy or contract and the proposed policy or contract. One way to do this is to ask the company or agent that sold you your existing policy or contract to provide you with information concerning your existing policy or contract. This may include an illustration of how your existing policy or contract is working now and how it would perform in the future based on certain assumptions. Illustrations should not, however, be used as a sole basis to compare policies or contracts. You should discuss the following with your agent to determine whether replacement or financing your purchase makes sense:

PREMIUMS:

Are they affordable? Could they change? You’re older – are premiums higher for the proposed new policy?

How long will you have to pay premiums on the new policy? On the old policy?

POLICY VALUES:

New policies usually take longer to build cash values and to pay dividends.

Acquisition costs for the old policy may have been paid; you will incur costs for the new one.

What surrender charges do the policies have?

What expense and sales charges will you pay on the new policy? Does the new policy provide more insurance coverage?



INSURABILITY: If your health has changed since you bought your old policy, the new one could cost you more, or you could be turned down. You may need a medical exam for a new policy. (Claims on most new policies for up to the first two years can be denied based on inaccurate statements. Suicide limitations may begin anew on the new coverage.) IF YOU ARE KEEPING THE OLD POLICY AS WELL AS THE NEW POLICY:

How are premiums for both policies being paid?

How will the premiums on your existing policy be affected? Will a loan be deducted from death benefits?

What values from the old policy are being used to pay premiums? IF YOU ARE SURRENDERING AN ANNUITY OR INTEREST SENSITIVE LIFE PRODUCT:

Will you pay surrender charges on your old contract?

What are the interest rate guarantees for the new contract?

Have you compared the contract charges or other policy expenses? OTHER ISSUES TO CONSIDER FOR ALL TRANSACTIONS:

What are the tax consequences of buying the new policy?

Is this a tax-free exchange? (See your tax advisor.)

Is there a benefit from favorable “grand fathered” treatment of the old policy under the federal tax code?

Will the existing insurer be willing to modify the old policy?

How does the quality and financial stability of the new company compare with your existing company?


Page 1 of 3 Home Office Copy – Return This Copy to ELCO Form RNLIA ED 1/2014

IMPORTANT NOTICE REPLACEMENT OF LIFE INSURANCE OR ANNUITIES This document must be signed by the applicant and the agent, if there is one, and a copy left with the applicant You are contemplating the purchase of a life insurance policy or annuity contract. In some cases this purchase may involve discontinuing or changing an existing policy or contract. If so, a replacement is occurring. Financed purchases are also considered replacements. A replacement occurs when a new policy or contract is purchased and, in connection with the sale, you discontinue making premium payments on the existing policy or contract, or an existing policy or contract is surrendered, forfeited, assigned to the replacing insurer, or otherwise terminated or used in a financed purchase. A financed purchase occurs when the purchase of a new life insurance policy involves the use of funds obtained by the withdrawal or surrender of or by borrowing some or all of the policy values, including accumulated dividends, of an existing policy, to pay all or part of any premium or payment due on the new policy. A financed purchase is a replacement. You should carefully consider whether a replacement is in your best interest. You will pay acquisition costs and there may be surrender costs deducted from your policy or contract. You may be able to make changes to your existing policy or contract to meet your insurance needs at less cost. A financed purchase will reduce the value of your existing policy and may reduce the amount paid upon the death of the insured. We want you to understand the effects of replacements before you make your purchase decision and ask that you answer the following questions and consider the questions in this form. 1. Are you considering discontinuing making premium payments, surrendering, forfeiting, assigning to the insurer, or

otherwise terminating your existing policy or contract? ________YES ________NO 2. Are you considering using funds from your existing policies or contracts to pay premiums due on the new policy or

contract? ________YES ________NO

If you answered “Yes” to either of the above questions, list each existing policy or contract you are contemplating replacing (including the name of the insurer, the contract or policy number, if available, the insured or annuitant name) and whether each policy or contract will be replaced or used as a source to finance the new ELCO policy:

INSURER CONTRACT OR INSURED OR REPLACED (R) OR NAME POLICY # ANNUITANT NAME FINANCING (F)

1. _________________________________________________________________________________________________________

2. _________________________________________________________________________________________________________

3. _________________________________________________________________________________________________________



Make sure you know the facts. Contact your existing company or its agent for information about the old policy or contract. If you request one, an in-force illustration, policy summary or available disclosure documents must be sent to you by the existing insurer. Ask for and retain all sales material used by the agent in the sale presentation. Be sure that you are making an informed decision. The existing policy or contract is being replaced because: ________________________________________________________ I certify that the responses herein are, to the best of my knowledge, accurate: Applicant’s Signature and Printed Name Date Telephone Number Agent’s Signature and Printed Name Date

I do not want this notice read aloud to me. ____________________________________________________________________

(Applicant must initial only if they do not want notice read aloud.) A replacement may not be in your best interest, or your decision could be a good one. You should make a careful comparison of the costs and benefits of your existing policy or contract and the proposed policy or contract. One way to do this is to ask the company or agent that sold you your existing policy or contract to provide you with information concerning your existing policy or contract. This may include an illustration of how your existing policy or contract is working now and how it would perform in the future based on certain assumptions. Illustrations should not, however, be used as a sole basis to compare policies or contracts. You should discuss the following with your agent to determine whether replacement or financing your purchase makes sense:

PREMIUMS:

Are they affordable? Could they change? You’re older – are premiums higher for the proposed new policy?

How long will you have to pay premiums on the new policy? On the old policy?

POLICY VALUES:

New policies usually take longer to build cash values and to pay dividends.

Acquisition costs for the old policy may have been paid; you will incur costs for the new one.

What surrender charges do the policies have?

What expense and sales charges will you pay on the new policy? Does the new policy provide more insurance coverage?



INSURABILITY: If your health has changed since you bought your old policy, the new one could cost you more, or you could be turned down. You may need a medical exam for a new policy. (Claims on most new policies for up to the first two years can be denied based on inaccurate statements. Suicide limitations may begin anew on the new coverage.) IF YOU ARE KEEPING THE OLD POLICY AS WELL AS THE NEW POLICY:

How are premiums for both policies being paid?

How will the premiums on your existing policy be affected? Will a loan be deducted from death benefits?

What values from the old policy are being used to pay premiums? IF YOU ARE SURRENDERING AN ANNUITY OR INTEREST SENSITIVE LIFE PRODUCT:

Will you pay surrender charges on your old contract?

What are the interest rate guarantees for the new contract?

Have you compared the contract charges or other policy expenses? OTHER ISSUES TO CONSIDER FOR ALL TRANSACTIONS:

What are the tax consequences of buying the new policy?

Is this a tax-free exchange? (See your tax advisor.)

Is there a benefit from favorable “grand fathered” treatment of the old policy under the federal tax code?

Will the existing insurer be willing to modify the old policy?

How does the quality and financial stability of the new company compare with your existing company?

916 Sherwood Drive Lake Bluff, Illinois 60044 847-295-6000 800-321-ELCO

ANNUITY SALE SUITABILITY DISCLOSURE TO BE COMPLETED BY THE CLIENT

ASD-05-16 Page 1 of 2 NOT COMPLETE WITHOUT BOTH PAGES

Your state law requires that any person who may be considering the purchase of an annuity contract must be given the opportunity to provide information concerning his or her financial condition to the agent selling the contract. The information given will be used to determine if the proposed annuity contract is appropriate for your financial circumstances. You may decline to provide this information, but in so doing, you take full responsibility in determining whether the proposed annuity contract is suitable for you. By signing, you acknowledge your understanding that an annuity is generally a long-term investment and that withdrawals may be subject to charges.

YES, I agree to answer the questions below and I understand that any recommendations assume the information provided

is both current and accurate. Please answer questions 1 - 15, sign and date the form below.

NO, I will not answer the questions below and I take full responsibility for determining whether the proposed annuity is

suitable for me. Please sign and date this form below.

GENERAL INFORMATION

Owner/Applicant Full Name Social Security # Date of Birth Age

Joint Owner/Applicant Full Name Social Security # Date of Birth Age

1. Source Of Funds: Indicate the source(s) of funds to be used for the purchase of this annuity

⃞ Life Ins. Policy ⃞ Annuity ⃞ Stocks/Bonds/Mutual Funds ⃞ CD ⃞ Savings/Checking ⃞ Other

2. What is the purpose of the annuity you are applying for?

3. In order to determine the suitability of the annuity applied for, please provide the following information to the best of your ability. If the annuity will be owned by a trust, please provide only the assets of the trust:

Annual Household Income: per year Source of Income:

Annual Household Expenses: per year Liquid Assets*:

*Liquid Assets includes the value of financial assets that can readily be converted into their cash equivalent without loss of principal, such as checking/savings accounts, stocks, bonds or CDs. It does NOT include real estate, or the funds used to purchase this annuity.

Net Worth: (Assets – Liabilities = Net Worth)

4. Are you aware that the fixed annuity contract for which you are applying may be a long-term contract with substantial penalties for early withdrawal? ⃞ Yes ⃞ No ⃞ N/A – Applying for Immediate Annuity

5. Do you have a reverse mortgage on your primary residence? ⃞ Yes ⃞ No

6. Do you have an emergency fund for unexpected expenses? ⃞ Yes ⃞ No

7. Considering your financial and tax status, why are you considering purchasing this annuity? (Check all that apply)

⃞ Estate Planning ⃞ Potential Growth ⃞ Tax Deferral ⃞ Flexible Income Options ⃞ Other:

8. Indicate your willingness to accept financial risk: ⃞ Conservative ⃞ Moderate ⃞ Aggressive

ANNUITY SALE SUITABILITY DISCLOSURE (CONTINUED)

ASD-05-16 Page 2 of 2 NOT COMPLETE WITHOUT BOTH PAGES

9. What is your financial experience? ⃞ 0-5 years ⃞ 6-10 years ⃞ 11-20 years ⃞ Over 20 years

10. Types of current assets (Check all that apply)

⃞ Stocks/Bonds ⃞ Life Insurance/Annuities ⃞ CDs/Money Market

⃞ Real Estate ⃞ Mutual Funds ⃞ 401k/Pension

⃞ Cash/Savings ⃞ Other (provide details)

11. Combined state and federal tax bracket: ⃞ 10-20% ⃞ 21-30% ⃞ 31-40% ⃞ 41-50%

If purchasing an Immediate Annuity, do not answer questions 12, 13 or 14, and go to Signatures Section (below). For Deferred Annuities, continue to question 12.

12. Do you anticipate material changes in your annual income, financial situation and needs, existing assets, liquidity needs, or liquid net worth? ⃞ Yes ⃞ No

If yes, please explain

13. Will you need access to these funds during your lifetime? ⃞ Yes ⃞ No If you answered “No” to item 13, skip items 14 and 15, and go to Signatures Section (below).

14. When will you need access to these funds? ⃞ Less than 1 year ⃞ 1 to 5 years ⃞ 6 to 10 years ⃞ Over 10 years

15. How do you anticipate accessing funds from this annuity? (Check all that apply) ⃞ Penalty-free withdrawals ⃞ Required minimum distributions (qualified only) ⃞ Annuitize

⃞ Other, please explain:

Signatures

By signing below, I acknowledge that I have read and reviewed the product specific Disclosure Statement with my agent, in addition to the financial factors listed above, and have determined that the product meets my needs and objectives.

Signature of Owner/Applicant Date Printed Name of Owner/Applicant

Signature of Joint Owner/Applicant Date Printed Name of Joint Owner/Applicant

By signing below I acknowledge that I have made a reasonable effort to obtain information concerning the financial and tax

status, investment objectives and other information considered reasonable for this purchase. It is my belief that based on this

information and all circumstances known to me at this time, the annuity being applied for meets the financial needs and objectives

provided by my clients. In addition, I have verified identity, believe the information provided to me is true and accurate and I

understand the Company may contact my client directly for additional information, if necessary.

Signature of Agent Date Printed Name of Agent Agent Number


Annuity Sale Disclosure

This acknowledges that on the date shown below an application has been completed for an annuity contract with

ELCO Mutual Life and Annuity. I understand the following items pertinent to the proposed contract:

The proposed Owner should initial all items

For Single Premium Immediate Annuities: _________ It is understood that this policy will provide periodic payments for one of the following options Initial as applied for: a) the annuitant’s lifetime with or without a certain number of payments guaranteed; b)

the joint lifetime of the annuitant and co-annuitant with or without a certain number of payments guaranteed; or c) a specified fixed period. Payment amounts will be specified in the policy.

_________ It is understood that once payments have begun, no cash surrender of the policy is possible. Initial _________ It is understood that any guaranteed periodic payments remaining unpaid at the annuitant’s death will Initial continue to the beneficiary(s) listed in the application. Signed at _______________________________________ on __________________________________________ City, State Date

________________________________________________ ____________________________________________

Proposed Owner’s Printed Name Signature

Witness: _________________________________________ Agent Code Number: __________________________ Agent’s Signature Form IASD13 Ed. 11/13


COMMUNITY PROPERTY STATE COMPLETION FORM

The proposed contract owner (s), _______________________________________, live(s) in a Community Property State. To be compliant with the mandatory state regulations pertaining to community property spouses, please complete the form below as directed. Please check the one appropriate box: 1. The proposed contract owner is either single or divorced and community property issues

do not apply. 2. The proposed contract owner is married and the primary beneficiary designation is the

spouse. 3. Joint owners (husband and wife) exist. 4. The proposed contract owner is married and the primary beneficiary designation is

someone other than the spouse. This requires the signature of the proposed contract owner and the community property spouse.

If either box 1 or 2 is checked, only the Proposed Contract Owner’s signature is required: _________________________________________________ _____________________ Proposed Contract Owner’s Signature Date If box 3 or 4 is checked, the Community Property Spouse’s signature is also required: _________________________________________________ _____________________ Community Property Spouse’s Signature Date _________________________________________________ _____________________ Agent/Witness Signature Date CPS13


REQUIRED DOCUMENTATION FROM THE INTERNAL REVENUE SERVICE

CLICK HERE FOR IRS FORM W4P

CLICK HERE FOR IRS FORM W9

http://www.irs.gov/pub/irs-pdf/fw4p.pdf

http://www.irs.gov/pub/irs-pdf/fw9.pdf


IRA / ROTH IRA Fact Sheet

(MUST BE COMPLETED and submitted with each IRA / Roth IRA Application)

The proposed contract owner, __________________________________________________, has applied for an ELCO Annuity Contract. To ensure that the correct IRS qualification is applied to the annuity contract the following information is required for all IRA and all Roth IRA Annuity applications.

1. Qualification

The annuity applied for is (please check one appropriate box):

a. Traditional IRA (Individual Retirement Account). Complete Sections 2 and 3 b. Roth IRA. Complete information regarding Roth account and Sections 2 and 3. Date of existing ROTH IRA Inception: Create new ROTH IRA

2. Source Of Funds

`

Current Year Contribution Transfer From Another Company Rollover Prior Year Contribution (For contributions made Jan 1st-April 15th)

3. Signature and Acknowledgement

The above statements are true to the best of my knowledge and belief.

Printed Name of Annuitant/Owner

Signature of Annuitant/Owner Date

916 SHERWOOD DRIVE • LAKE BLUFF, ILLINOIS 60044-2285 • (847) 295-6000 • (800) 321-3526 • FAX (847) 295-1145

TAX ID NUMBER: 36-2123818

DIRECT DEPOSIT FORM

This is an authorization agreement for automatic deposit (ACH Credits). I hereby authorize ELCO Mutual Life and Annuity to initiate credit entries directly into my account identified below at the depository financial institution. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. Checking Account Savings Account (Bank must be a member of ACH) Bank Name: Routing Number: Account Number:

If monies to which I am not entitled are deposited to my account, I authorize ELCO Mutual Life and Annuity to direct the financial institution to return said funds. This authority will remain in effect until I have filed a new authorization, or until revoked by me in writing or upon termination of my contract with ELCO Mutual Life and Annuity.

Print Name: ELCO Policy Number:

Signature:

Date:

Staple, in this box, a VOIDED check for the account indicated above.

Return this completed form to ELCO Mutual Life and Annuity

revocable beneficiary single premium … · show full names, relationship to owner, and percentage...

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