Document:

Exhibit

CONTRACT DATA PAGE
	
				
	Product Name:
	[Symetra Trek]

	Product Type: 
	[Non-Qualified Annuity]

	Contract Date:
	[01/01/2019]

	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 [96th] birthday(s).

This is not later than [12/31/2076].

	Delivered in the State of:
	[Any State] and governed by its laws

	Surrender Charge Schedule:
	Contract Year                                  Charge
 [19% of amount withdrawn
  28% of amount withdrawn
  37% of amount withdrawn
  46% of amount withdrawn
  55% of amount withdrawn
  64% of amount withdrawn
After   60% of amount withdrawn]

Please see the “Charges and Taxes” section for a complete explanation of charges.

	Free Withdrawal Percentage:
	[15%]

	
	
	ACCOUNTS AVAILABLE FOR INITIAL INTEREST TERM

	
						
	Index
	Interest Term
	Crediting Method
	Initial Allocation
	Initial Indexed Interest Cap

	[S&P 500 Index
	1 year
	Point to Point with Indexed Interest Buffer:
	10%
	30%
	8.00%

	Russell 2000 Index
	1 year
	Point to Point with Indexed Interest Buffer:
	10%
	0
	8.25%

	NASDAQ-100 Index
	1 year
	Point to Point with Indexed Interest Buffer:
	10%
	0
	8.75%

	MSCI Emerging Markets Index
	1 year
	Point to Point with Indexed Interest Buffer:
	10%
	0
	9.00%

	PIMCO Equity Fusion Index
	1 year
	Point to Point with Indexed Interest Buffer:
	10%
	20%
	9.25%

	 

	S&P 500 Index
	1 year
	Point to Point with Indexed Interest Floor:
	-10%
	30%
	7.00%

	Russell 2000 Index
	1 year
	Point to Point with Indexed Interest Floor:
	-10%
	0
	7.25%

	NASDAQ-100 Index
	1 year
	Point to Point with Indexed Interest Floor:
	-10%
	0
	7.75%

	MSCI Emerging Markets Index
	1 year
	Point to Point with Indexed Interest Floor:
	-10%
	10%
	8.00%

	PIMCO Equity Fusion Index
	1 year
	Point to Point with Indexed Interest Floor:
	-10%
	0
	8.25%]

	Account
	Interest Term
	 
	Initial Allocation
	Initial Interest Rate

	Fixed Account
	[1 year
	10%
	2.50%]

	
		
	[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 and Initial Interest Rate shown above are applicable for the initial Interest Term only. Subsequent Indexed Interest Caps and Interest Rates are subject to change as described in the Contract.

	[Index Return Calculation for the Point to Point Crediting Method:
	 Index Value on the last day of the Interest Term
 Index Value on the first day of the Interest Term  - 1 ]

	Initial Indexed Interest Caps and Initial Interest Rate shown above are applicable for the initial Interest Term only. Subsequent Indexed Interest Caps and Interest Rates are subject to change as described in the Contract.
	If the Index Return is positive or zero:
The Adjusted Index Return will be the lesser of:
the Indexed Interest Cap; or
the Index Return.

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.]

[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 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 LSE Group 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 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.]Exhibit

	
			
	

	 
	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 ]

Annuity APPLICATION
Index Linked Deferred Annuity
[Marketing Name]
	
									
	Owner   All contract Owner correspondence will be sent to this address.

	Maximum issue age [70-95]
	Name (first, middle initial, last) 

	Address
	City
	State
	Zip

	Sex
 M    F
	Birth date 
	SSN/TIN 
	Phone number (include area code)

	Email 
	Citizenship
	Marital status

	Type of Owner (e.g. Individual, Joint, Trust, Corporation, Partnership, Guardianship, Custodian)

	Joint Owner   Only natural-person Owners may have a joint Owner. Optional, nonqualified annuities only.

	Maximum issue age [70-95]
	Name (first, middle initial, last)

	Address
	City
	State
	Zip

	Sex
 M    F
	Birth date 
	SSN/TIN
	Phone number (include area code)

	Email 
	Citizenship
	Relationship to Owner

	Annuitant   Required if Owner is non-natural person. If joint Owners are listed, default Annuitant is the first Owner listed above.

	 
	Name (first, middle initial, last)

	Address
	City
	State
	Zip

	Sex
 M    F
	Birth date 
	SSN/TIN
	Phone number (include area code)

	Email 
	Citizenship
	Relationship to Owner

	Joint Annuitant   Optional, nonqualified annuities only.

	 
	Name (first, middle initial, last)

	Address
	City
	State
	Zip

	Sex
 M    F
	Birth date 
	SSN/TIN
	Phone number (include area code)

	Email 
	Citizenship
	Relationship to Owner

ANNUITY PAYMENTS AND TERMINATION VALUES PROVIDED BY THIS CONTRACT, WHEN BASED ON THE VALUE OF THE INDEX OPTIONS, ARE VARIABLE, MAY INCREASE OR DECREASE, AND ARE NOT GUARANTEED AS TO FIXED DOLLAR AMOUNT. 

	
									
	Owner’s Beneficiary Designation    

[In the event of death of Owner, surviving joint Owner becomes primary beneficiary. Percentages must total 100% for Primary and 100% for Contingent. If Owner is a non-natural person such as a trust or an entity, a primary beneficiary is required. Please attach a separate, signed, dated page for additional beneficiaries.

Do not indicate multiple beneficiaries as a group - e.g. “All Children of Owner.” Do not use “per stirpes” designation].
P - primaryC - contingent

	     P
	Name (first, middle initial, last)
	Date of birth
	Percentage (%)

	Address
	 
	 

	City
	State
	Zip
	Phone number (include area code)

	Relationship to Owner
	SSN/TIN
	Email
	[Citizenship]

	 P

 C
	Name (first, middle initial, last)
	Date of birth
	Percentage (%)

	Address
	 
	 

	City
	State
	Zip
	Phone number (include area code)

	Relationship to Owner
	SSN/TIN
	Email
	[Citizenship]

	 P

 C
	Name (first, middle initial, last)
	Date of birth
	Percentage (%)

	Address
	 
	 

	City
	State
	Zip
	Phone number (include area code)

	Relationship to Owner
	SSN/TIN
	Email
	[Citizenship]

	 P

 C
	Name (first, middle initial, last)
	Date of birth
	Percentage (%)

	Address
	 
	 

	City
	State
	Zip
	Phone number (include area code)

	Relationship to Owner
	SSN/TIN
	Email
	[Citizenship]

	 P

 C
	Name (first, middle initial, last)
	Date of birth
	Percentage (%)

	Address
	 
	 

	City
	State
	Zip
	Phone number (include area code)

	Relationship to Owner
	SSN/TIN
	Email
	[Citizenship]

	 P

 C
	Name (first, middle initial, last)
	Date of birth
	Percentage (%)

	Address
	 
	 

	City
	State
	Zip
	Phone number (include area code)

	Relationship to Owner
	SSN/TIN
	Email
	[Citizenship]

	
									
	Plan Type 

	 
	[ Nonqualified] 
[ IRA]
	 
	[ Roth IRA*]
[*First tax year contribution made: 

	[Contribution: Year]
	Year]

	Transfer Information   If the source of funds for this annuity is a transfer of funds from an existing IRA, qualified retirement plan, or other insurance product, indicate the type of transfer here.

	 
	[ IRC 1035 Exchange]    [ Non-Direct Rollover]    [ Direct Rollover]    [ Direct Transfer]    [ Roth Conversion]

	[Surrender Charge Period   Choice of the Surrender Charge Period under the product.]

	 
	[ 6 Year]    [ 9 Year]   

	Purchase Payment

	 
	Purchase Payment $_______________________(Minimum is [$25,000.00])

	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. 

Specify your allocation (whole percentages only; total allocation must equal 100%):

	 
	Indexed Account Options:
	Initial Allocation(s):
	 
	 

	 
	[Point to Point with Buffer]
[S&P 500® Index][%]
[Russell 2000® Index][%]
[NASDAQ-100® Index][%]
[MSCI Emerging Markets Index] [%]
[PIMCO Equity Fusion Index][%]

[Point to Point with Floor]
[S&P 500® Index][%]
[Russell 2000® Index][%]
[NASDAQ-100® Index][%]
[MSCI Emerging Markets Index] [%]
[PIMCO Equity Fusion Index][%]

Fixed Account%
	 

	[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.  ]

	
		
	[Telephone 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.

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 required to provide the identification information listed below. Confirmation of transfer transaction(s) will be sent to 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. 

Full Name of Authorized Third Party
[Identification Information:   Owner’s mother’s maiden name 
Joint Owner’s mother’s maiden name ]]

	[Optional Rider   [See the Prospectus, or the Contract for complete details. There may be a charge for this rider.]

	 
	                                                                 ]

	[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.]

	
								
	Fraud Warning
	 

	For Residents of the States not listed below: Any person who, with intent to defraud or knowing he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.
	 

	
								
	AL, AR, DC, LA, RI, WV Residents only
	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.
	 

	CO Residents only
	It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.
	 

	FL Residents only
	Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
	 

	KY Residents only
	Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.
	 

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

	NJ Residents only
	Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.
	 

	NM Residents only
	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 civil fines and criminal penalties.
	 

	OK Residents only 
	WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
	 

	ME, TN, VA WA Residents only
	It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
	 

	PA Residents only
	Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance of statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and submits such person to criminal and civil penalties. 
	 

	Owner’s Statement and Signatures

	 
	Do you have any existing life insurance policies or annuity contracts?
 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 
	Contract number

	Company name
	Contract number

	Company name
	Contract number

	Company name
	Contract number

	 
	 
	 

	Owner’s Statement and Signatures   continued

	
								
	 
	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.]

[Minnesota residents only: I have received the MN Annuity Disclosure.]

[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.

The IRS does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.]

	 
	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.

PAYMENTS AND VALUES PROVIDED BY THE CONTRACT FOR WHICH APPLICATION IS MADE ARE VARIABLE AND ARE NOT GUARANTEED AS TO DOLLAR AMOUNT.

	Owner’s signature
	Signed in state
	Date

	Joint Owner’s signature (if applicable)
	Signed in state
	Date

	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.]
[Minnesota residents only: I have delivered the MN 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 government-issued photo identification.]

	Licensed Primary Producer’s signature
	Signed in state
	Date

	Licensed Producer (print name)
	State license number
	Producer number

	Agency name and phone number

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