Document:

ex4iiplusdatapage

RSC-0559 D 3/21 [-1a-] [RSC-0539/D/v1 5/21] CONTRACT DATA PAGE Product Name: [Symetra Trek Plus] Product Type: [Non-Qualified Annuity] Contract Date: [12/01/2020] Allocation Date: [12/07/2020] Contract Number: [000000000] Purchase Payment: [$25,000] Separate Account: [Symetra Separate Account RINA] Owner: [John Doe] [[Date of Birth: [12/12/1959] Age at issue: [59] Sex: [Male]] [Joint Owner: [Jane Doe] Date of Birth: [11/12/1959] Age at issue: [59] Sex: [Female]] Annuitant: [John Doe] Date of Birth: [12/12/1959] Age at issue: [59] Sex: [Male] [Joint Annuitant: [Jane Doe] Date of Birth: [11/12/1959] Age at issue: [59] Sex: [Female]] Maximum Issue Age: [80]. The Contract Date must be prior to the Owner's and Annuitant's [81st] birthday(s). Maximum Annuitization Age: [95]. Annuity Payments must begin prior to the Annuitant's [96]th birthday(s). This is not later than [12/13/2076]. Delivered in the State of: [Any State] and governed by its laws. Surrender Charge Schedule: Contract Year Charge [1 9% of amount withdrawn 2 8% of amount withdrawn 3 7% of amount withdrawn 4 6% of amount withdrawn 5 5% of amount withdrawn 6 4% of amount withdrawn After 6 0% of amount withdrawn] Please see the "Charges and Taxes" section for a complete explanation of charges. Free Withdrawal Percentage: [15%] Minimum Withdrawal Amount: [$500] Transfer Notice Deadline: [2 business days] 

 

RSC-0559 D 3/21 [-1b-] ACCOUNTS AVAILABLE FOR INITIAL INTEREST TERM Initial Indexed Interest Index and Crediting Method Interest Term Initial Allocation Charge Rate Cap Participation Rate Trigger Rate [S&P 500 Index Point-to-Point with Indexed Interest Buffer: 10% 1 year 20% - 13.50% 100% - Russell 2000 Index Point-to-Point with Indexed Interest Buffer: 10% 1 year - - - - - NASDAQ-100 Index Point-to-Point with Indexed Interest Buffer: 10% 1 year - - - - - MSCI Emerging Markets Index Point-to-Point with Indexed Interest Buffer: 10% 1 year - - - - - PIMCO Equity Fusion IndexTM Point-to-Point with Indexed Interest Buffer: 10% 1 year 10% - 14.00% 100% - S&P 500 Index Point-to-Point with Indexed Interest Floor: -10% 1 year - - - - - Russell 2000 Index Point-to-Point with Indexed Interest Floor: -10% 1 year - - - - - NASDAQ-100 Index Point-to-Point with Indexed Interest Floor: -10% 1 year - - - - - MSCI Emerging Markets Index Point-to-Point with Indexed Interest Floor: -10% 1 year - - - - - PIMCO Equity Fusion IndexTM Point-to-Point with Indexed Interest Floor: -10% 1 year - - - - - S&P 500 Index Point-to-Point with Indexed Interest Floor: -10% 1 year 10% - - - 5.75% S&P 500 Index Point-to-Point with Indexed Interest Barrier: -15% 1 year - - - - - S&P 500 Index Point-to-Point with Indexed Interest Buffer: 10% 2 year 10% - 27.00% 100% - Russell 2000 Index Point-to-Point with Indexed Interest Buffer: 10% 2 year - - - - - NASDAQ-100 Index Point-to-Point with Indexed Interest Buffer: 10% 2 year - - - - - MSCI Emerging Markets Index Point-to-Point with Indexed Interest Buffer: 10% 2 year - - - - - PIMCO Equity Fusion IndexTM Point-to-Point with Indexed Interest Buffer: 10% 2 year - - - - - S&P 500 Index Point-to-Point with Indexed Interest Buffer: 10% 2 year - 1% - - - Russell 2000 Index Point-to-Point with Indexed Interest Buffer: 10% 2 year - 1% - - - NASDAQ-100 Index Point-to-Point with Indexed Interest Buffer: 10% 2 year - 1% - - - MSCI Emerging Markets Index Point-to-Point with Indexed Interest Buffer: 10% 2 year - 1% - - - 

 

RSC-0559 D 3/21 [-1c-] ACCOUNTS AVAILABLE FOR INITIAL INTEREST TERM (continued) Initial Indexed Interest Index and Crediting Method Interest Term Initial Allocation Charge Rate Cap Participation Rate Trigger Rate PIMCO Equity Fusion IndexTM Point-to-Point with Indexed Interest Buffer: 10% 2 year - 1% - - - S&P 500 Index Point-to-Point with Indexed Interest Buffer: 10% 6 year 15% - - 100% - Russell 2000 Index Point-to-Point with Indexed Interest Buffer: 10% 6 year - - - - - S&P 500 Index Point-to-Point with Indexed Interest Buffer: 10% 6 year 5% 1% - 130% - Russell 2000 Index Point-to-Point with Indexed Interest Buffer: 10% 6 year - 1% - - - S&P 500 Index Point-to-Point with Indexed Interest Buffer: 20% 6 year - - - - - Russell 2000 Index Point-to-Point with Indexed Interest Buffer: 20% 6 year - - - - - S&P 500 Index Point-to-Point with Indexed Interest Buffer: 20% 6 year 10% 1% - 110% - Russell 2000 Index Point-to-Point with Indexed Interest Buffer: 20% 6 year 10% 1% 105.00% 100% -] Account Interest Term Initial Allocation Initial Interest Rate Fixed Account [1 year 10% 1.00%] [An Index does not include the payment or reinvestment of dividends in the calculation of its performance and is not available for direct investment.] [Initial Indexed Interest Caps, Indexed Interest Participation Rates, Indexed Interest Trigger Rates, and] Initial Interest Rate shown above are applicable for the initial Interest Term only. Subsequent [Indexed Interest Caps, Indexed Interest Participation Rates, Indexed Interest Trigger Rates and] Interest Rates are subject to change as described in the Contract. 1 Point to Point Index Return Calculation: Index Value on the last day of the Interest Term Index Value on the first day of the Interest Term [Adjusted Index Return Calculation with an Indexed Interest Buffer: If the Index Return is positive or zero : For indexed accounts with a Trigger Rate, the Adjusted Index Return will equal the Trigger Rate. For accounts with the Cap and Participation Rate, the Adjusted Index Return will be the lesser of: • the Indexed Interest Cap; or • the Index Return multiplied by the Indexed Interest Participation Rate. 

 

RSC-0559 D 3/21 [-1d-] If the Index Return is negative : If the negative Index Return is within the Indexed Interest Buffer, the Adjusted Indexed Return will equal zero. If the negative Index Return is beyond the Indexed Interest Buffer, the Adjusted Index Return will equal the amount by which the negative Indexed Return exceeds the Indexed Interest Buffer.] [Adjusted Index Return Calculation with an Indexed Interest Floor: If the Index Return is positive or zero : For indexed accounts with a Trigger Rate, the Adjusted Index Return will equal the Trigger Rate. For accounts with a Cap and Participation Rate, the Adjusted Index Return will be the lesser of: • the Indexed Interest Cap; or • the Index Return multiplied by the Indexed Interest Participation Rate. If the Index Return is negative : The Adjusted Index Return will be the greater of: • the Index Return; or • the Indexed Interest Floor] [Adjusted Index Return Calculation with an Indexed Interest Barrier: If the Index Return is positive or zero : For indexed accounts with a Trigger Rate, the Adjusted Index Return will equal the Trigger Rate. For accounts with a Cap and Participation Rate, the Adjusted Index Return will be the lesser of: • the Indexed Interest Cap; or • the Index Return multiplied by the Indexed Interest Participation Rate. If the Index Return is negative : If the negative Index Return is within the Indexed Interest Barrier, the Adjusted Indexed Return will equal zero. If the negative Index Return is beyond the Indexed Interest Barrier, the Adjusted Index Return will equal the Index Return.] Fixed Account Guaranteed Minimum Interest Rate: [1.00%] Guaranteed Minimum Indexed Interest Cap: [[1.00%] while the surrender charge percentage exceeds 0%, [1.00%] thereafter.] Guaranteed Minimum Indexed Interest Participation Rate: [[100%] while the surrender charge percentage exceeds 0%, [100%] thereafter.] Guaranteed Minimum Indexed Interest Trigger Rate: [[1.00%] while the surrender charge percentage exceeds 0%, [1.00%] thereafter.] Annuity Payments Table: [Annuity Reserve 2012 mortality table with mortality improvement scale G2, with age setback of five years], and an interest rate of [1%]. [Premium Taxes: [0.00%] 

 

RSC-0559 D 3/21 [-1e-] ANNUITY SERVICE OFFICE: Home Office: Symetra Life Insurance Company [777 108th Ave. NE, Suite 1200 Bellevue, Washington 98004] Telephone: [ 1-800-796-3872] Mailing Address: Symetra Life Insurance Company [PO Box 305156 Nashville, Tennessee 37230-5156] Fax: [ 1-866-532-1356] 

 

RSC-0559 D 3/21 [-1f-] [The “S&P 500 Index” is a product of S&P Dow Jones Indices LLC, a division of S&P Global, or its affiliates (“SPDJI”), and has been licensed for use by Symetra Life Insurance Company (“Symetra”). Standard & Poor’s® and S&P® are registered trademarks of Standard & Poor’s Financial Services LLC, a division of S&P Global (“S&P”); Dow Jones® is a registered trademark of Dow Jones Trademark Holdings LLC (“Dow Jones”); and these trademarks have been licensed for use by SPDJI and sublicensed for certain purposes by Symetra Life Insurance Company. It is not possible to invest directly in an index. Symetra’s products are not sponsored, endorsed, sold or promoted by SPDJI, Dow Jones, S&P, any of their respective affiliates (collectively, “S&P Dow Jones Indices”). S&P Dow Jones Indices does not make any representation or warranty, express or implied, to the owners of Symetra’s products or any member of the public regarding the advisability of investing in securities generally or Symetra’s products particularly or the ability of the S&P 500 Index to track general market performance. Past performance of an index is not an indication or guarantee of future results. S&P Dow Jones Indices’ only relationship to Symetra with respect to the S&P 500 Index is the licensing of the Index and certain trademarks, service marks and/or trade names of S&P Dow Jones Indices and/or its licensors. The S&P 500 Index is determined, composed and calculated by S&P Dow Jones Indices without regard to Symetra or Symetra’s products. S&P Dow Jones Indices has no obligation to take the needs of Symetra or the owners of Symetra’s products into consideration in determining, composing or calculating the S&P 500 Index. S&P Dow Jones Indices is not responsible for and has not participated in the determination of the prices, and amount of Symetra’s products or the timing of the issuance or sale of Symetra’s products or in the determination or calculation of the equation by which Symetra’s products are to be converted into cash, surrendered or redeemed, as the case may be. S&P Dow Jones Indices has no obligation or liability in connection with the administration, marketing or trading of Symetra’s products. There is no assurance that investment products based on the S&P 500 Index will accurately track index performance or provide positive investment returns. S&P Dow Jones Indices LLC is not an investment or tax advisor. A tax advisor should be consulted to evaluate the impact of any tax-exempt securities on portfolios and the tax consequences of making any particular investment decision. Inclusion of a security within an index is not a recommendation by S&P Dow Jones Indices to buy, sell, or hold such security, nor is it considered to be investment advice. S&P DOW JONES INDICES DOES NOT GUARANTEE THE ADEQUACY, ACCURACY, TIMELINESS AND/OR THE COMPLETENESS OF THE S&P 500 INDEX OR ANY DATA RELATED THERETO OR ANY COMMUNICATION, INCLUDING BUT NOT LIMITED TO, ORAL OR WRITTEN COMMUNICATION (INCLUDING ELECTRONIC COMMUNICATIONS) WITH RESPECT THERETO. S&P DOW JONES INDICES SHALL NOT BE SUBJECT TO ANY DAMAGES OR LIABILITY FOR ANY ERRORS, OMISSIONS, OR DELAYS THEREIN. S&P DOW JONES INDICES MAKES NO EXPRESS OR IMPLIED WARRANTIES, AND EXPRESSLY DISCLAIMS ALL WARRANTIES, OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE OR USE OR AS TO RESULTS TO BE OBTAINED BY SYMETRA, OWNERS OF SYMETRA’S PRODUCTS, OR ANY OTHER PERSON OR ENTITY FROM THE USE OF THE S&P 500 INDEX OR WITH RESPECT TO ANY DATA RELATED THERETO. WITHOUT LIMITING ANY OF THE FOREGOING, IN NO EVENT WHATSOEVER SHALL S&P DOW JONES INDICES BE LIABLE FOR ANY INDIRECT, SPECIAL, INCIDENTAL, PUNITIVE, OR CONSEQUENTIAL DAMAGES INCLUDING BUT NOT LIMITED TO, LOSS OF PROFITS, TRADING LOSSES, LOST TIME OR GOODWILL, EVEN IF THEY HAVE BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES, WHETHER IN CONTRACT, TORT, STRICT LIABILITY, OR OTHERWISE. THERE ARE NO THIRD PARTY BENEFICIARIES OF ANY AGREEMENTS OR ARRANGEMENTS BETWEEN S&P DOW JONES INDICES AND SYMETRA, OTHER THAN THE LICENSORS OF S&P DOW JONES INDICES.] [THIS PRODUCT IS NOT SPONSORED, ENDORSED, SOLD OR PROMOTED BY MSCI INC. ("MSCI"), ANY OF ITS AFFILIATES, ANY OF ITS INFORMATION PROVIDERS OR ANY OTHER THIRD PARTY INVOLVED IN, OR RELATED TO, COMPILING, COMPUTING OR CREATING ANY MSCI INDEX (COLLECTIVELY, THE "MSCI PARTIES"). THE MSCI INDEXES ARE THE EXCLUSIVE PROPERTY OF MSCI. MSCI AND THE MSCI INDEX NAMES ARE SERVICE MARK(S) OF MSCI OR ITS AFFILIATES AND HAVE BEEN LICENSED FOR USE FOR CERTAIN PURPOSES BY SYMETRA LIFE INSURANCE COMPANY. NONE OF THE MSCI PARTIES MAKES ANY REPRESENTATION OR WARRANTY, EXPRESS OR IMPLIED, TO THE ISSUER OR OWNERS OF THIS PRODUCT OR ANY OTHER PERSON OR ENTITY REGARDING THE ADVISABILITY OF INVESTING IN PRODUCTS GENERALLY OR IN THIS PRODUCT PARTICULARLY OR THE ABILITY OF ANY MSCI INDEX TO TRACK CORRESPONDING STOCK MARKET PERFORMANCE. MSCI OR ITS AFFILIATES ARE THE LICENSORS OF CERTAIN TRADEMARKS, SERVICE MARKS AND TRADE NAMES AND OF THE MSCI INDEXES WHICH ARE DETERMINED, COMPOSED AND CALCULATED BY MSCI WITHOUT REGARD TO THIS PRODUCT OR THE ISSUER OR OWNERS OF THIS PRODUCT OR ANY OTHER PERSON OR ENTITY. NONE OF THE MSCI PARTIES HAS ANY OBLIGATION TO TAKE THE NEEDS OF THE ISSUER OR OWNERS OF THIS PRODUCT OR ANY OTHER PERSON OR ENTITY INTO CONSIDERATION IN DETERMINING, COMPOSING OR CALCULATING THE MSCI INDEXES. NONE OF 

 

RSC-0559 D 3/21 [-1g-] THE MSCI PARTIES IS RESPONSIBLE FOR OR HAS PARTICIPATED IN THE DETERMINATION OF THE TIMING OF, PRICES AT, OR QUANTITIES OF THIS PRODUCT TO BE ISSUED OR IN THE DETERMINATION OR CALCULATION OF THE EQUATION BY OR THE CONSIDERATION INTO WHICH THIS PRODUCT IS REDEEMABLE. FURTHER, NONE OF THE MSCI PARTIES HAS ANY OBLIGATION OR LIABILITY TO THE ISSUER OR OWNERS OF THIS PRODUCT OR ANY OTHER PERSON OR ENTITY IN CONNECTION WITH THE ADMINISTRATION, MARKETING OR OFFERING OF THIS PRODUCT. ALTHOUGH MSCI SHALL OBTAIN INFORMATION FOR INCLUSION IN OR FOR USE IN THE CALCULATION OF THE MSCI INDEXES FROM SOURCES THAT MSCI CONSIDERS RELIABLE, NONE OF THE MSCI PARTIES WARRANTS OR GUARANTEES THE ORIGINALITY, ACCURACY AND/OR THE COMPLETENESS OF ANY MSCI INDEX OR ANY DATA INCLUDED THEREIN. NONE OF THE MSCI PARTIES MAKES ANY WARRANTY, EXPRESS OR IMPLIED, AS TO RESULTS TO BE OBTAINED BY THE ISSUER OF THE PRODUCT, OWNERS OF THE PRODUCT, OR ANY OTHER PERSON OR ENTITY, FROM THE USE OF ANY MSCI INDEX OR ANY DATA INCLUDED THEREIN. NONE OF THE MSCI PARTIES SHALL HAVE ANY LIABILITY FOR ANY ERRORS, OMISSIONS OR INTERRUPTIONS OF OR IN CONNECTION WITH ANY MSCI INDEX OR ANY DATA INCLUDED THEREIN. FURTHER, NONE OF THE MSCI PARTIES MAKES ANY EXPRESS OR IMPLIED WARRANTIES OF ANY KIND, AND THE MSCI PARTIES HEREBY EXPRESSLY DISCLAIM ALL WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE, WITH RESPECT TO EACH MSCI INDEX AND ANY DATA INCLUDED THEREIN. WITHOUT LIMITING ANY OF THE FOREGOING, IN NO EVENT SHALL ANY OF THE MSCI PARTIES HAVE ANY LIABILITY FOR ANY DIRECT, INDIRECT, SPECIAL, PUNITIVE, CONSEQUENTIAL OR ANY OTHER DAMAGES (INCLUDING LOST PROFITS) EVEN IF NOTIFIED OF THE POSSIBILITY OF SUCH DAMAGES.] [The Product has been developed solely by Symetra Life Insurance Company and is not in any way connected to or sponsored, endorsed, sold or promoted by the London Stock Exchange Group plc and its group undertakings (collectively, the “LSE Group”). FTSE Russell is a trading name of certain of the LSE Group companies. All rights in the “Russell 2000® Index” (the “Index”) vest in the relevant LSE Group company which owns the Index. “Russell®”, “FTSE Russell®”, and “Russell 2000® Index” are trademarks of the relevant LSE Group company and are used by any other LSE Group company under license. The Index is calculated by or on behalf of FTSE International Limited or its affiliate, agent or partner. The LSE Group does not accept any liability whatsoever to any person arising out of (a) the use of, reliance on or any error in the Index or (b) investment in or operation of the Product. The LSE Group makes no claim, prediction, warranty or representation either as to the results to be obtained from the Product or the suitability of the Index for the purpose to which it is being put by Symetra Life Insurance Company. The Product is not in any way connected to or sponsored, endorsed, sold or promoted by the London Stock Exchange Group plc and its group undertakings (collectively, the “LSE Group”). The LSE Group does not accept any liability whatsoever to any person arising out of the use of the Product or the underlying data.] [The Product(s) is not sponsored, endorsed, sold or promoted by Nasdaq, Inc. or its affiliates (Nasdaq, with its affiliates, are referred to as the “Corporations”). The Corporations have not passed on the legality or suitability of, or the accuracy or adequacy of descriptions and disclosures relating to, the Product(s). The Corporations make no representation or warranty, express or implied to the owners of the Product(s) or any member of the public regarding the advisability of investing in securities generally or in the Product(s) particularly, or the ability of the Nasdaq-100 Index® to track general stock market performance. The Corporations' only relationship to Symetra Life Insurance Company (“Licensee”) is in the licensing of the Nasdaq®, Nasdaq-100®, Nasdaq-100 Index®, and certain trade names of the Corporations and the use of the Nasdaq-100 Index® which is determined, composed and calculated by Nasdaq without regard to Licensee or the Product(s). Nasdaq has no obligation to take the needs of the Licensee or the owners of the Product(s) into consideration in determining, composing or calculating the Nasdaq-100 Index®. The Corporations are not responsible for and have not participated in the determination of the timing of, prices at, or quantities of the Product(s) to be issued or in the determination or calculation of the equation by which the Product(s) is to be converted into cash. The Corporations have no liability in connection with the administration, marketing or trading of the Product(s). The Corporations do not guarantee the accuracy and/or uninterrupted calculation of Nasdaq-100 Index ® or any data included therein. The Corporations make no warranty, express or implied, as to results to be obtained by Licensee, owners of the product(s), or any other person or entity from the use of the Nasdaq-100 Index ® or any data included therein. The Corporations make no express or implied warranties, and expressly disclaim all warranties of merchantability or fitness for a particular purpose or use with respect to the Nasdaq-100 Index ® or any data included therein. Without limiting any of the foregoing, in no event shall the 

 

RSC-0559 D 3/21 [-1h-] Corporations have any liability for any lost profits or special, incidental, punitive, indirect, or consequential damages, even if notified of the possibility of such damages.] [The PIMCO Equity Fusion IndexTM (the "Index") is an equity index that allocates to exchange-traded funds tracking four major equity markets: U.S. large-capitalization equities, U.S. small-capitalization equities, technology-focused equities, and emerging markets equities. On a quarterly basis, the index adjusts its allocation to the Constituents according to a predefined set of rules based on contrarian signals. The Index is a trademark of Pacific Investment Management Company LLC ("PIMCO") and has been licensed for use for certain purposes by Symetra Life Insurance Company (“Symetra”) on behalf of the annuity. The Index is the exclusive property of PIMCO and is made and compiled without regard to the needs, including, but not limited to, the suitability needs, of Symetra, the annuity, or the annuity contract owners. The annuity is not sold, sponsored, endorsed or promoted by PIMCO or any other party involved in, or related to, making or compiling the Index. PIMCO does not make any warranty or representation as to the accuracy, completeness, or availability of the Index or information included in the Index and shall have no responsibility or liability for the impact of any inaccuracy, incompleteness, or unavailability of the Index or such information. Neither PIMCO nor any other party involved in, or related to, making or compiling the Index makes any representation or warranty, express or implied, to the annuity contract owner, Symetra, or any member of the public regarding the advisability of purchasing annuities generally or the annuity particularly, the legality of the annuity under applicable federal securities, state insurance and tax laws, the ability of the annuity to track the performance of the Index, any other index or benchmark or general fixed income market or other asset class performance, or the results, including, but not limited to, performance results, to be obtained by Symetra, the annuity, annuity contract owners, or any other person or entity. PIMCO does not provide investment advice to Symetra with respect to the annuity, to the annuity, or to annuity contract owners. Neither PIMCO nor any other party involved in, or related to, making or compiling the Index has any obligation to continue to provide the Index to Symetra with respect to the annuity. In the event that the Index is no longer available to the annuity or annuity contract owners, Symetra may seek to replace the Index with another suitable index, although there can be no assurance that one will be available. PIMCO disclaims all warranties, express or implied, including all warranties of merchantability or fitness for a particular purpose or use. PIMCO shall have no responsibility or liability with respect to the annuity. The Index is comprised of a number of constituents, some of which are owned by entities other than PIMCO. The Index replies on a variety of publicly available data and information and licensable equity and fixed income sub-indices. All disclaimers referenced in the Agreement relative to PIMCO also apply separately to those entities that are owners of the constituents of the Index.] SPDR® S&P 500® ETF Trust (SPY ETF), IWM (iShares Russell 2000 ETF), QQQ (Invesco QQQ Trust Series 1) and EEM (iShares MSCI Emerging Markets ETF) are each a constituent of the PIMCO Equity Fusion IndexTM. S&P® and SPDR® are registered trademarks of Standard & Poor’s Financial Services LLC (S&P), iShares® is a registered trademark of BlackRock Fund Advisors or BlackRock, Inc. and its subsidiaries, and “Russell” and Russell 2000® are registered trademarks of FTSE Russell, each an “ETF Trademark Owner” and collectively, the “ETF Trademark Owners”. The PIMCO Equity Fusion Index is not sponsored, endorsed, sold, or promoted by any of the ETF Trademark Owners. The ETF Trademark Owners make no representations or warranties to the owners of products utilizing the PIMCO Equity Fusion Index or any member of the public regarding the advisability of purchasing a product utilizing the PIMCO Equity Fusion Index. None of the ETF Trademark Owners has any obligation or liability in connection with the operation, marketing, trading or sale of the PIMCO Equity Fusion Index. ]ex4iiiplusapp

ICC21_RA1 Page[ 1 of 7] [RSA-0098 5/21]     Symetra Life Insurance Company  [777 108th Avenue NE, Suite 1200 | Bellevue, WA 98004-5135  Mail to: PO Box 305154 | Nashville, TN 37230-5154  Overnight to: 100 Centerview Drive, Suite 100 | Nashville, TN 37214-3439  Phone 1-800-796-3872]  INDIVIDUAL SINGLE PREMIUM ANNUITY APPLICATION  [Index Linked Deferred Annuity]  Product: _______________________________________________________________________________________  Surrender Charge Period: _________________________________________________________________________  Plan Type: _____________________________________________________________________________________  Owner    Name     Residential address     Mailing address     Sex   M    F  Date of birth  SSN/TIN  Mobile phone  Other phone   Email  Citizenship    Joint Owner      Name     Residential address     Mailing address     Sex   M    F  Date of birth  SSN/TIN Mobile phone  Other phone   Email  Citizenship Relationship to Owner  Annuitant     Name     Residential address     Mailing address     Sex   M    F  Date of birth  SSN/TIN Mobile phone  Other phone   Email  Citizenship    Relationship to Owner  Joint Annuitant     Name     Residential address     Mailing address     Sex   M    F  Date of birth  SSN/TIN Mobile phone  Other phone  Email  Citizenship Relationship to Owner  

 

ICC21_RA1 Page[ 2 of 7]   [For Beneficiary/Inherited Accounts Only]    [Decedent’s date of death Relationship of decedent to owner  Previous year-end balance of existing account Has the RMD been taken?   Yes    No  Exact title of owner at the existing carrier]  Beneficiaries    Primary     Contingent      Beneficiary name       Address      Relationship SSN/TIN Mobile phone Other phone  Birth/Trust date [Citizenship] Email Beneficiary %   Primary     Contingent  Beneficiary name       Address      Relationship SSN/TIN Mobile phone Other phone  Birth/Trust date [Citizenship] Email Beneficiary %   Primary     Contingent  Beneficiary name       Address      Relationship SSN/TIN Mobile phone Other phone  Birth/Trust date [Citizenship] Email Beneficiary %   Primary     Contingent  Beneficiary name       Address      Relationship SSN/TIN Mobile phone Other phone  Birth/Trust date [Citizenship] Email Beneficiary %   Primary     Contingent                  Beneficiary name       Address      Relationship SSN/TIN Mobile phone  Other phone  Birth/Trust date [Citizenship] Email Beneficiary %  Payment   Amount  [Roth IRA first tax year contribution made:   Year __________ ]   

 

ICC21_RA1 Page[ 3 of 7]   Initial Allocation   Allocate your Purchase Payment to the options below. The minimum allocation to any account is [$2,000]. Your  initial funds will be automatically allocated according to the selections made below on the first available Allocation  Date after the Contract Date.     [If you are purchasing a product with an indexed account option that has a charge, you acknowledge and understand  that these indexed accounts incur a charge that will reduce the contract value, and do NOT guarantee performance  any greater than the indexed account options that have no charge.]    Specify your allocation (whole percentages only; total allocation must equal 100%):     Account Options: Initial Allocation(s):      [Allocations]                                                                                                 

 

ICC21_RA1 Page[ 4 of 7]   [Rebalancing Authorization    I/we have read the information in the prospectus about the option to rebalance [annually,] and would like to  elect to rebalance the portion of my contract value allocated as listed in the “Initial Allocation” section.  ]  [Features   [See the Prospectus, or the Contract for complete details. There may be a charge for this feature.]]                                                                        ]  [Transfer Authorization    I/we hereby authorize Symetra to accept and act on telephone instructions from me or any person(s) listed  below regarding the transfer of funds between the account options of my annuity contract or to exercise the  Return Lock. This authorization will remain in effect until Symetra receives written revocation from me.    Please check all that apply: If no option is selected, we will default to you as owner and joint owner (if applicable)   My Insurance Producer(s) (as on file with Symetra and includes members of their staff)   The authorized third-party listed below. Please clearly print their full name(s) below.   Authorized third party name(s):   __________________________________________________________________________________________    Relationship to owner(s):  Spouse    Child   Other (specify):  _____________________________________    Symetra will employ reasonable procedures to confirm that instructions communicated by telephone are genuine.  Symetra reserves the right to refuse telephone instructions from any caller when unable to confirm to Symetra’s  satisfaction that the caller is authorized to give those instructions.    To transfer by telephone, call Symetra at [1-800-SYMETRA (1-800-796-3872)]. All telephone transfer calls will be  recorded. You will be recorded. Confirmation of transfer transaction(s) will be sent to you. Instructions may also be  submitted online, if available, provided you or your authorized party are able to log in with certain identification  information, such as a password or personal identification information. You should protect your login information,  because internet access will be available to anyone who provides your information. We will not be able to verify  that the person logging into your account and providing instructions is you or a person authorized by you.    Unless otherwise indicated, this form does not permit anyone else to exercise discretionary authority to effect  transactions on your behalf without obtaining your prior authorization.]  

 

ICC21_RA1 Page[ 5 of 7]   [Electronic Delivery    I would like to receive prospectus updates and other documents pertaining to my contract over the Internet by  accessing Symetra’s website, www.symetra.com. I understand that I will receive notice that the documents are  available on the website by an e-mail message sent to me.    Important Information Concerning Electronic Delivery:   Documents currently delivered electronically include prospectuses and any prospectus supplements. Other  documents may be available for electronic delivery in the future.   If Symetra is unable to confirm an email address or has reasonable suspicion that an email address is  incorrect, electronic delivery will not be activated and paper documents will be sent.   You should update your email filters to allow email notifications from Symetra.  If emails are returned as not deliverable, electronic delivery will be cancelled and documents will be  provided by mail.    There is no charge to you for electronic delivery, although your Internet provider may charge service  provider fees. To view the documents, you must have internet access.    The disclosure documents will be in PDF format; if you do not have Adobe Acrobat, download it for free  from www.adobe.com.    Symetra may, without prior notice to you, deliver paper documents by mail instead of electronic delivery  at any time.   Paper copies of the information may be requested at any time for no charge by calling us.   For jointly owned contracts, both owners consent to have information sent to the email address listed.   To revoke your consent, update your email address, or receive a paper copy of any document in the mail,  call us at [1-800-796-3872], submit a written notice or applicable form, or update your delivery option on  our website. This consent to receive electronic delivery of disclosure documents will remain in effect until  revoked.    EMAIL ADDRESS FOR ELECTRONIC DELIVERY:  ______________________________________________  Electronic delivery document notifications will be provided to only one email address. The email address provided  above will override any existing email address, if applicable. If no email address is listed here, the email address  listed under the Owner section of this application will be used for electronic delivery purposes.]  

 

ICC21_RA1 Page[ 6 of 7]     Owner’s Statement and Signatures   Do you have any existing life insurance policies or annuity contracts with this or any other company?   Yes (complete any state specific replacement forms, if required)     No      Is this contract intended to replace or change any in-force life insurance or annuity contract with this or any other  company?    Yes (complete the following and submit state specific replacement forms, if required)     No  Company Name  Existing Contract Number  Company Name Existing Contract Number  Company Name Existing Contract Number  Company Name Existing Contract Number   There are additional replacements involved.    I understand this annuity is not federally insured. On behalf of myself and any person who may claim any interest  under this contract, I declare that the statements and answers on this application are full, complete and true to the  best of my knowledge and belief and shall form a part of the annuity contract issued hereon. I understand that I am  purchasing an annuity contract. I believe that this contract is consistent with my financial needs. I have read and  understand the important disclosures located below.    I have received the Annuity Buyer’s Guide, in applicable states. I have received a current prospectus.     [Connecticut residents only: I have received the CT Annuity Disclosure.]      [W-9 Certification: Under penalties of perjury, I certify that the number shown on this form is my correct Social  Security or Tax Identification Number, I am a U.S. citizen or other U.S. person, and I am not subject to backup  withholding due to failure to report all interest or dividends.       Check this box if you have received a notification from the IRS that you are subject to backup withholding.    Check this box if you are claiming Non-U.S. status and submitting an appropriate withholding certificate  (usually a signed IRS Form W-8 or IRS Form 8233) instead of agreeing to this certification. ]    Fraud 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.    I understand that withdrawals from an Indexed Account prior to the end of the Interest Term will not receive indexed  interest. Any indexed interest is only credited at the end of each Interest Term.     I UNDERSTAND THAT I AM PURCHASING A REGISTERED INDEX LINKED DEFERRED ANNUITY  CONTRACT AND THAT WHILE THE VALUE OF THE CONTRACT MAY BE AFFECTED BY AN  EXTERNAL INDEX, THE CONTRACT DOES NOT DIRECTLY PARTICIPATE IN ANY STOCK, EQUITY OR  COMMODITY INVESTMENTS.    The contract values that are based on the index linked account options are not guaranteed and will decrease  or increase with experience.    [The IRS does not require your consent to any provision of this document other than the certifications  required to avoid backup withholding.]    Owner’s signature Signed in state Date  Joint Owner’s signature (if applicable) Signed in state Date  

 

[Symetra® is a registered service mark of Symetra Life Insurance Company.]  ICC21_RA1 Page[ 7 of 7]   Agency Statement      To the best of your knowledge, does the Owner(s) have any existing life insurance policies or annuity contracts?   Yes (complete any state specific replacement forms, if required)     No    Do you have any reason to believe the annuity applied for will replace or change any existing life insurance  policies or annuity contracts?   Yes (complete any state specific replacement forms, if required)     No    I have reviewed the applicant’s financial status and objectives and find this coverage is appropriate for his/her  needs.    I have delivered the Annuity Buyer’s Guide, if applicable in my state. I have delivered the current prospectus.     [Connecticut residents only: I have delivered the CT Annuity Disclosure.]    I certify that I have truly and accurately recorded on the application the information provided by the applicant(s).    [I certify that I have verified the identity of each Owner/Annuitant by reviewing a valid government-issued photo  identification.]  Licensed Primary Insurance Producer’s signature Signed in State Date  Licensed Insurance Producer (print name) State license number Insurance Producer number  Agency name  Mobile phone Other phone  Insurance Producer/Representative    More than 4 producers      Insurance Producer/Representative printed name     State license number Split %  Insurance Producer/Representative printed name     State license number Split %  Insurance Producer/Representative printed name     State license number Split %  Insurance Producer/Representative printed name     State license number Split %    FOR INTERNAL USE ONLY   Submitted  __________________________________

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