Exhibit 4(a)

 

INDIVIDUAL ANNUITY APPLICATION

 

 

	
 
    	
Send Applications to:
    
	
Protective Life Insurance   Company
    	
[ Overnight:  2801 Hwy 280 South, Birmingham, Alabama  35223
    
	
 
    	
U. S. Mail:   P. O. Box 10648, Birmingham, Alabama  35202-0648
    
	
Select Product:  
    	
[ o   Protective Market Defender II ]

 
    	
(800) 456-6330 ]
    
	
 
    	
A Single Premium Registered Index-Linked Deferred Annuity
    
			


 

	
 
    	
Contract #                                                           
    


 

 

PRIMARY OWNER  (If mailing address is a P.O. Box, please provide a physical address in the ‘Remarks’ area.)

 

	
Name: 
    	
 
    	
Daytime   Phone:
    	
 
    
	
 
    	
 
    
	
Address: 
    	
 
    	
 
    	
City:
    	
 
    	
 
    	
State: 
    	
 
    	
 
    	
Zip:
    	
 
    
	
 
    	
 
    	
 
    	
 
    	
 
    	
 
    	
 
    
	
SSN/Tax   ID:
    	
 
    	
 
    	
DOB:
    	
 
    	
 
    	
oM  oF   Email:
    	
 
    
																	


 

JOINT OWNER  (If applicable.)

 

	
Name: 
    	
 
    	
Daytime   Phone:
    	
 
    
	
 
    	
 
    
	
Address: 
    	
 
    	
 
    	
City:
    	
 
    	
 
    	
State: 
    	
 
    	
 
    	
Zip:
    	
 
    
	
 
    	
 
    	
 
    	
 
    	
 
    	
 
    	
 
    
	
SSN/Tax   ID:
    	
 
    	
 
    	
DOB:
    	
 
    	
 
    	
oM  oF   Email:
    	
 
    
																	


 

ANNUITANT  (If different from Primary Owner.  Must be a living person.)

 

	
Name: 
    	
 
    	
Daytime   Phone:
    	
 
    
	
 
    	
 
    
	
Address: 
    	
 
    	
 
    	
City:
    	
 
    	
 
    	
State: 
    	
 
    	
 
    	
Zip:
    	
 
    
	
 
    	
 
    	
 
    	
 
    	
 
    	
 
    	
 
    
	
SSN/Tax   ID:
    	
 
    	
 
    	
DOB:
    	
 
    	
 
    	
oM  oF   Email:
    	
 
    
																	


 

	
PLAN TYPE:
    	
o Non-Qualified
    	
o Traditional IRA
    	
o Roth IRA
    	
o Other
    	
 
    
	
(Please choose one.)
    	
 
    	
 
    	
 
    	
 
    	
 
    


 

	
PURCHASE PAYMENT:  $
    	
 
    	
 
    
	
 
    	
[ (Minimum: $25,000) ]
    	
 
    


 

	
FUNDING SOURCE:
    	
o Transfer - $
    	
o Cash - $
    
	
(Please check all that   apply.)
    	
o Rollover - $
    	
o 1035 Exchange - $
    
	
 
    	
o IRA or Roth IRA Contribution - $                                for Tax Year
    


 

ALLOCATION INSTRUCTIONS:   Use whole percentages to allocate your purchase payment.  Must equal 100%.  Must result in minimum [ $5,000 ] per Strategy selected.

 

Indexed Strateg[y][ies]:

 

	
[ S&P   500®
    	
[ MSCI   EAFE®
    
	
%
    	
  1-Year Term,  0% Floor
    	
%
    	
  1-Year Term,  0% Floor
    
	
%
    	
  [ 1-Year Term,  -5%   Floor ]
    	
%
    	
  [ 1-Year Term,  -5%   Floor ]
    
	
%
    	
  [ 1-Year Term, -10% Floor ]
    	
%
    	
  [ 1-Year Term, -10% Floor ]
    
	
%
    	
  [ 1-Year Term, -20% Floor ]
    	
%
    	
  [ 1-Year Term, -20% Floor ]
    
	
%
    	
  [ 1-Year Term, -15% Buffer ] ]
    	
%
    	
  [ 1-Year Term, -15% Buffer ] ]
    


 

	
Automatic Annual Rebalance:
    	
o
    	
Rebalance my Contract Value on each Anniversary   using the allocation instructions in effect at that time.  (I understand I may cancel this rebalance   instruction at any time.)
    


 

[ OPTIONAL RETURN OF PURCHASE PAYMENT DEATH BENEFIT

 

               I elect the optional Return of Purchase Payment Death Benefit for an additional charge. ]

 

An annuity contract is not a deposit or obligation of, or guaranteed by any bank or financial institution.

It is not insured by the Federal Deposit Insurance Corporation or any other government agency.

 


	
SG-RILA-P-1011
    	
 
    	
[ Protective   Market Defender II       4/20 ]
    




 











 

[ IMPORTANT NOTICE

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. ]

 

 

REPLACEMENT:

 

	
·       Will this annuity change or replace an existing life insurance   policy or annuity contract?
    	
o NO     o YES
    
	
·       Do you currently have a life insurance policy or annuity   contract?
    	
o NO     o YES
    
	
(If ‘YES’, please provide the company name and policy or contract   number below.)
    	
 
    


 

	
Company -
    	
Policy or   Contract #
    
	
Company -
    	
Policy or   Contract #
    
	
Company -
    	
Policy or   Contract #
    
	
 
    	
 
    


 

REMARKS:

 

 

 

 

NOT INSURED BY ANY GOVERNMENT AGENCY     ·     NO BANK GUARANTEE     ·    NOT A DEPOSIT

 

 

I understand this application will become part of my annuity contract.  I have read the completed application and confirm  the information it contains is true and correct, to the best of my knowledge and belief.  However, these statements are representations and not warranties.  If this application has a Joint Owner, Protective Life may accept instructions from either Owner on behalf of both Owners.

 

I acknowledge receipt of an “Annuity Buyer’s Guide” and a prospectus describing the [Protective Market Defender II Annuity].

 

I understand this annuity includes index-linked Strategies and an unlimited market value adjustment.  Strategy gains and losses depend upon the performance of an independent Reference Index, and the Strategy’s Crediting Elements and Downside Protection, but the Contract does not participate directly in any index or stock investment.  I understand that during the withdrawal charge period, withdrawals from the contract that exceed any available free-withdrawal amount are subject to a withdrawal charge.

 

	
Application   signed at: 
    	
 
    	
 
    	
on
    	
 
    
	
 
    	
(City and State)
    	
 
    	
 
    	
(Date)
    


 

	
 
    	
 
    	
 
    	
 
    	
 
    
	
Owner’s Signature
    	
 
    	
Joint Owner’s Signature (if applicable)
    	
 
    	
Annuitant’s   Signature (if not an Owner)
    


 

Federal law requires the following notice:  We may request or obtain additional information to establish or verify your identity.

 

Use Administrative Form [ LAD-1225 ] to name or change a beneficiary any time before the death of an owner.

 

PRODUCER REPORT:

(To prevent delays processing this application, please complete all questions in this section.)

 

To the best of your knowledge and belief:

 

	
·       Does this annuity purchase change or replace any existing life   insurance policy or annuity contract?
    	
o NO     o YES
    
	
·       Does the applicant have any existing life insurance   policy(s) or annuity contract(s)?
    	
o NO     o YES
    


 

	
Type of unexpired government issued photo I.D. used to verify   the applicant’s identity?
    	
 
    
	
 
    	
(Type)
    	
(Number)
    


 

I determined the suitability of this annuity to the applicant’s current financial needs, goals, and situation by asking about the applicant’s financial status, tax status, financial goals and objectives, and other relevant information.

 

I have accurately recorded the information provided by the applicant(s).  I have not used any written sales materials other than those approved by Protective Life.  I have reasonable grounds to believe the purchase of this annuity is suitable for the applicant(s).

 

	
Producer 1 Signature
    	
 
    	
 
    	
Producer   1 #
    	
 
    	
 
    	
Share
    	
 
    	
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Producer 1 Printed Name
    	
 
    	
 
    	
Producer 1 Florida Lic. # (if applicable)
    	
 
    
	
Broker/Agency Name 
    	
 
    	
 
    	
Phone #
    	
 
    	
 
    	
Email
    	
 
    
	
Producer 2 Printed Name
    	
 
    	
 
    	
Producer   2 #
    	
 
    	
 
    	
Share
    	
 
    	
%
    
													


 


	
  SG-RILA-P-1011
    	
 
    	
Select Commission   Option:   A   B   C
    	
 
    	
[ Protective   Market Defender II    4/20 ]