EX-4.(b)






			
	16(4)(b)	  	Form of Application for Group Contingent Deferred Annuity Certificate

 CONSTANCE CONTINGENT DEFERRED ANNUITY ENROLLMENT 

MIDLAND LIFE INSURANCE COMPANY 
 Home
Office: (Midland address) Telephone: (877) 575-2742 
 Mailing
Address: RetireOne, First Jefferson Centre, 222 South 1st Street, Suite 600, Louisville, KY 40202 
  

 
  

	1.	 COVERAGE PLAN 



☐ Core                ☐
CorePlus                ☐ CorePlus X 
  

 

	2.	 PRIMARY CERTIFICATE OWNER/COVERED PERSON 



If the Primary Certificate Owner is a non-natural person/custodian, information in this section is for
the Covered Person and Section 3 must be completed for the Certificate Owner. 
 Type of Owner: ☐
Individual    ☐ Non-Natural (1) ☐ Custodial (1) 

Complete Legal Name: _____________________________________________________________________ 

Residential Address (2): ____________________________________________________________________ 

Mailing Address: _________________________________________________________________________ 

SSN: _______________ Date of Birth: ______________ Telephone: ______________ Mobile Phone:_____ 

Gender:     ☐ Male     ☐ Female 

Citizenship: ☐ U.S. Citizen    ☐ Resident Alien (Country of Citizenship:
_____________) 
 ☐ Non-Resident Alien (Country of Citizenship:
____________)                 
  

 
  

	3.	 JOINT CERTIFICATE OWNER/COVERED PERSON (if applicable) 



If no Joint Owner is listed, Midland Life Insurance Company will issue with the Owner listed in is a
non-natural Section 1 and Section 3 as applicable. 
 Complete Legal Name:
_____________________________________________________________________ 
 Residential Address (2):
____________________________________________________________________ 
 Mailing Address:
_________________________________________________________________________ 
 SSN/TIN (3) : _____________ Date of Birth: ____________
Telephone: _____________ 
 Mobile Phone: _____________ 

Gender:     ☐ Male     ☐ Female 

Citizenship: ☐ U.S. Citizen    ☐ Resident Alien (Country of Citizenship:
____________)    ☐ Non-Resident Alien (Country of Citizenship: ____________) 
  

 

  
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	4.	 CERTIFICATE OWNER (for non-natural owner) (1) 



Complete Legal Name: _____________________________________________________________________ 

Residential Address (2): ____________________________________________________________________ 

Mailing Address: _________________________________________________________________________ 

TIN(3) : _____________ Date of Formation:______________ 

Citizenship: ☐ U.S. Entity    ☐ Non-U.S. Entity (Country of Formation:
_____________) 
 Will the contract be held within a Qualified Plan? ☐ Yes    ☐ No 

(1) A Certification Form must be submitted if a non-natural
person is named as the Certificate Owner. 
 (2) A Residential Address must be completed and cannot be a
P.O. Box. 
 (3) Social Security Number (SSN)/Tax Identification Number (TIN) 

 

	5.	 COVERED ASSET INFORMATION 



Type of Covered Asset: ☐ Non-Qualified    ☐ Qualified – Type of
Account: _________________________ 
 Financial Institution Name: _________________________________________________________________ 

Financial Institution Account Number: ________________________________________________________ 

Name on Account: ________________________________________________________________________ 

Tax ID on Account: ________________________________________________________________ 

Investment Profile or Strategy: ☐ A    ☐ B    ☐ C     ☐
Strategy: _________________________ 
 Fee Option: ☐ No Deduction ☐ Deduction of Advisor Fees 

 

	6.	 ELECTRONIC DOCUMENT DELIVERY 



By providing an email address, I consent to initiate the process of receiving electronic documents and notices applicable to the Eligible
Policy/Policies accessed through the Company website. These include, but are not limited to, prospectuses, prospectus supplements, periodic reports or statements, privacy notices and other notices and documentation in electronic format when
available instead of receiving paper copies of these documents by U.S. mail. I consent to receive in electronic format any documents added in the future. 

Important Information Concerning Electronic Document Delivery: 
  

	 	•	 	 There is no charge for electronic delivery, although an internet provider may charge for internet access.



  

	 	•	 	 You are confirming you have access to a computer with internet capabilities and an active email account to
receive information electronically. 


  

	 	•	 	 This Electronic Document Delivery applies only to Eligible Policies accessible through our websites.



  

	 	•	 	 After subscribing to Electronic Document Delivery, Midland Life Insurance Company or their administrator
RetireOne will send an email to confirm the provided email address is correct. If Midland Life Insurance Company or their administrator RetireOne is not able to confirm an email address or has reasonable suspicion that an email address is incorrect,
Midland Life Insurance Company or their administrator RetireOen will not be able to activate the subscription for electronic delivery, in which case paper copy documents will be sent. 



 

	 	•	 	 Email filters must be updated which may prevent email notifications from Midland Life Insurance Company or their
administrator RetireOne to be received. 


  

	 	•	 	 Not all contract documentation and notifications may currently be available in electronic format.



  

	 	•	 	 Paper copies of the information may be requested at any time for no charge. 



  
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	 	•	 	 For jointly owned policies both owners are consenting to have information sent to the email address listed below.



  

	 	•	 	 If the email address changes after the subscription process, notification must be sent to Midland Life Insurance
Company or their administrator. 


  

	 	•	 	 Electronic delivery will be cancelled if emails are returned undeliverable. 



 

	 	•	 	 This consent will remain in effect until revoked. 



Please call (877) 575-2742 or visit the Company website if you would like to revoke your consent, wish
to receive a paper copy of the information above, or need to update your email address. 

Email Address:                   
                                         
                                         
                                         
                                         

Electronic Delivery Document notifications will be provided to only one email address. Any email provided above will override any existing
email address, if applicable. 
  

	7.	 REPLACEMENT INFORMATION 



All questions in this section must be answered. 

☐ No    ☐ Yes    Did the Representative/Insurance Producer present and leave the applicant
sales material? 
 ☐ No    ☐ Yes    Do you have any existing life insurance policies or
annuity contracts? 
 ☐ No    ☐ Yes    Will this annuity replace or change any existing
life insurance policies or annuity contracts? 
 If yes—Company: ________________________________ Policy
#:______________                 
  

	8.	 FRAUD AND DISCLOSURE STATEMENTS 



For Applicants in AL - Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or
who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof. 

For Applicants in AR - 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 is guilty of a crime and may be subject to fines and confinement in prison. 

For Applicants in CA 65 and Older - I have been advised that the sale or liquidation of any stock, bond, IRA, certificate of deposit,
mutual fund, annuity or other asset used to fund the purchase of a life or annuity product may involve tax consequences, early withdrawal penalties, or other costs or penalties associated with the sale or liquidation of the
asset.    I have also been advised to obtain the advice of independent legal or financial counsel before selling any assets and before purchasing the life or annuity product. 

For Applicants in DC - WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of
defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. 

For all other states - 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.                 
  

	9.	 REPLACEMENT INFORMATION 



 

	 	•	 	 Unless I have notified Midland Life Insurance Company or their administrator of a community or marital



  

	 	o	 property interest in this certificate, Midland Life Insurance Company will rely on good faith belief no such
interest exists and will assume no responsibility for inquiry. 


  

	 	•	 	 To the best of my knowledge and belief, all of my statements and answers on this form are correct and true.



  

	 	•	 	 This enrollment form is subject to acceptance by Midland Life Insurance Company. 



  
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	 	•	 	 I understand federal law requires all financial institutions to obtain customer information, including the name,
residential address, date of birth, Social Security Number or Taxpayer Identification Number and any other information necessary to sufficiently identify each customer. I understand failure to provide this information could result in the annuity
certificate not being issued, delayed or unprocessed transactions, or annuity certificate termination. 


 I have read the Fraud and
Disclosure Statements listed in this enrollment form. 
 Signed at:
                                         
                                         
                                         
                                         
                                 

                     
           City                              
                  
State                                        
                        Date 

Owner/Covered Person’s Signature:
X                                         
                                         
                                         
                          

Joint Owner/Covered Person’s Signature:
X                                      
                                         
                                         
                         
 Non-Natural Signature (Authorized Representative/Trustee):
X                                        
                                         
                                

Non-Natural Signature (Authorized Representative/Trustee):
X                                       
                                         
                                   

 

	10.	 AGENT/REPRESENTATIVE INFORMATION 



All questions in this section must be answered. 

☐ No    ☐ Yes    Did you present and leave the applicant insurer-approved sales material?

 ☐ No    ☐ Yes    Does the applicant have any existing life insurance policies or
annuity contracts? 
 ☐ No    ☐ Yes    Do you have any reason to believe the annuity
applied for will replace or change any existing annuity insurance? 
 I certify that I have truly and accurately recorded on the application
the information that was provided to me by the applicant. 
 Agent/Representative Full Name:
                                        
                                         
                                         
                             

ID
Number:                                        
                                    Phone Number:
                                        
                                         
  
 Email Address (Optional):
                                        
                                         
                                         
                                         
  
 Signature:
X                                      
                                         
                                         
                                         
                           

  
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