Document:

EX-4.vi

 Exhibit (4)(vi) 

EXHIBIT (4)(vi) 

GUARANTEED MINIMUM DEATH BENEFIT RIDER 

 Transamerica Life Insurance Company 

Cedar Rapids, Iowa 

Contact us at 6400 C Street SW, Cedar Rapids, Iowa 52499 

800-525-6205 

www.transamerica.com 

Guaranteed Minimum Death Benefit Rider 

This Rider is attached to and made part of the policy and is effective upon issuance. All provisions of the policy that do not conflict with this Rider apply
to this Rider. In the event of any conflict between the provisions of this Rider and the provisions of the policy, the provisions of this Rider shall prevail over the provisions of the policy. 

This Rider provides for a guaranteed minimum death benefit as described below. An additional fee may be charged. 

The Death Proceeds Section of the policy to which this Rider is attached is amended to include the addition of the following language: 

The Guaranteed Minimum Death Benefit is equal to [100%] of the Policy Value as of the Rider Date, plus subsequent Premium Payments, less any Adjusted
Withdrawals (as described below), as of the Annuitant’s date of death. 
 A withdrawal will reduce the Guaranteed Minimum Death Benefit by an amount
referred to as the “Adjusted Withdrawal”. The Adjusted Withdrawal may be a different amount than the Gross Withdrawal. If at the time of the withdrawal the Policy Value is equal to the Death Proceeds, the Adjusted Withdrawal will equal the
Gross Withdrawal. If at the time of the withdrawal the Policy Value is less than the Death Proceeds, the Adjusted Withdrawal will be greater than the Gross Withdrawal. 

The Adjusted Withdrawal is equal to the Gross Withdrawal multiplied by the Death Proceeds immediately prior to the withdrawal divided by the Policy Value
immediately prior to the withdrawal. The formula is AW = DP x (GW/PV) where: 
  

	 	AW	 is the Adjusted Withdrawal 

 

	 	DP	 is the Death Proceeds prior to the withdrawal = greater of PV or GMDB 

 

	 	GW	 is the Gross Withdrawal 

 

	 	PV	 is the Policy Value prior to the withdrawal 

 

	 	GMDB	 is the Guaranteed Minimum Death Benefit prior to the withdrawal 

The Rider Fee is calculated and deducted at the end of each Rider Quarter, on the same day of the month as the Rider Date. A Rider Quarter is each
three-month period beginning on the Rider Date. If a day does not exist in a given month, the first day of the following month will be used. A portion of this fee will also be deducted when the rider is terminated. It will be deducted automatically
from all Accounts in which You are invested on a pro rata basis, excluding the Fixed Holding Account, until all other Accounts have been depleted. 
 The
quarterly Rider Fee is calculated as follows: 
 Multiply (A) by (B) divided by 4, where: 

 

	 	(A)	 is the GMDB; and 

  

	 	(B)	 is the Rider Fee Percentage. 

The Rider Fee at rider termination is calculated as follows: 

Multiply (A) by (B) divided by 4 multiplied by (C) where: 
  

	 	(A)	 is the GMDB; 

  

	 	(B)	 is the Rider Fee Percentage; and 

 

	 	(C)	 is the number of days that have elapsed since the previous Rider Quarter divided by the number of days within
the applicable Rider Quarter. 

  
 1 

 If You have an advisor, asset manager or broker/dealer who manages Your policy for a fee, You may elect to
have that fee deducted from Your Policy Value and paid directly to Your advisor, asset manager or broker/dealer. 
 An Advisory Fee Withdrawal is the
Advisory Fee amount You have authorized Us to deduct from Your Policy Value and pay directly to Your advisor, asset manager or broker/dealer on Your behalf. Advisory Fee Withdrawals, as described in Your policy, that are less than or equal to the
Advisory Fee Withdrawal Maximum Percentage shown in Your policy will not be treated as a withdrawal for purposes of calculating the Guaranteed Minimum Death Benefit. Any amount of Advisory Fee Withdrawal in excess of the Advisory Fee Withdrawal
Maximum Percentage is treated as a withdrawal under this Rider and is subject to all withdrawal provisions. 
 The death benefit amount cannot be
withdrawn as a lump sum. 
 While this Rider is in-force, we will not invoke the Involuntary Cashout provision of
the policy to which this Rider is attached if this Rider has a Guaranteed Minimum Death Benefit amount of $2,000 or greater. If the Involuntary Cashout provision is invoked and the policy to which this Rider is attached is terminated, we will pay
the greatest of:     
  

	 	1)	 The Fixed Account and Fixed Holding Account portions of the Minimum Required Cash Value plus the Index
Account(s) portion of the Policy Value; 

  

	 	2)	 The Policy Value; or 

 

	 	3)	 The Guaranteed Minimum Death Benefit amount. 

This Rider is effective on the Rider Date and will terminate upon the earliest of: 
  

	 	1)	 the date the policy to which this Rider is attached terminates; 

 

	 	2)	 the Annuity Commencement Date; 

 

	 	3)	 the date of the Annuitant’s death; or 

 

	 	4)	 the date of the Owner’s death. 

Once terminated, the Rider Fee will also terminate. 
 The amount
of the death benefit will be included in a report sent to You at least once each year until the Annuity Commencement Date as described in Section 3, Reports to Owner provision, in the policy. 

Signed for us at our home office. 
  

									
		  	

	  		  	

	  	
					
		  	              Blake Bostwick	  		  	      Karyn S.W. Polak	  	
		  	              President	  		  	      Secretary	  	

  
 2EX-4.vii

 Exhibit (4)(vii) 

EXHIBIT (4)(vii) 

PERFORMANCE LOCK RIDER 

 Transamerica Life Insurance Company 

Cedar Rapids, Iowa 

Contact us at 6400 C Street SW, Cedar Rapids, Iowa 52499 

800-525-6205 

www.transamerica.com 

Performance Lock Rider 
 This Rider is
attached to and made part of the policy and becomes effective on the date You initially allocate Premium Payments or transfer Policy Value to the Index Account Options available under the Index Account(s) as permitted in the policy. All provisions
of the policy that do not conflict with this Rider apply to this Rider. In the event of any conflict between the provisions of this Rider and the provisions of the policy, the provisions of this Rider shall prevail over the provisions of the policy.

 This Rider allows You to lock in the current Interim Value during the Crediting Period for any available Index Account Option(s). The Interim Value at
the end of a Business Day reflects all applicable remaining fees and charges. 
 RIDER DEFINITIONS: 

Terms used that are not defined in this Rider are defined in Your policy. 

Allocation Anniversary - The twelve-month anniversary of an Index Account Option Allocation Date or any subsequent Allocation Anniversary. 

Performance Lock Account– The Performance Lock Account is a Fixed Account option under Your policy, only available with this Rider. The
Performance Lock Account is an account in which Your locked Interim Value will be held until the next applicable Allocation Anniversary. Interest on the Performance Lock Account will be credited daily and compounded annually, based on a rate
declared by us. The rate will never be less than the Guaranteed Minimum Effective Annual Interest Rate shown in Section 2 – Policy Data. 

Performance Lock Date – The Performance Lock Date is the Business Day in which we calculate and lock in an Interim Value, including any remaining
fees and charges due, for an Index Account Option before the end of the Crediting Period. 
 PERFORMANCE LOCK 

The Owner can request a Performance Lock of the current Interim Value at any time before the end of the Crediting Period for any unlocked Index Account Options
under the available Index Account(s). The Performance Lock will be effective as of the end of the Business Day the request is received in Good Order based on the Interim Value at the end of such Business Day. The Interim Value at the end of a
Business Day reflects all applicable remaining fees and charges. If You exercise a Performance Lock, it is possible to receive less than the full Growth Opportunity Rate, or less than the full Downside Protection Rate than You would have received
had You waited until the end of the Crediting Period. 
 On the Performance Lock Date, after the Performance Lock has been executed, the locked Interim
Value will be transferred to the Performance Lock Account. Interest will be credited until the earliest of the next Allocation Anniversary or the end of the Crediting Period, at which time it will be reallocated according to Your instructions. In
the absence of such instructions, the values will be transferred into the same Index Account Option and Crediting Period as the locked Interim Value Index Account Option; if that option is not available, the values will be transferred into the Fixed
Account. 

  
 1 

 TERMINATION 

This Rider terminates upon termination of the policy to which this Rider is attached. 

 

							
		 	Signed for us at our home office.
				
		 	

	  	

	 	
		 	            Blake Bostwick	  	        Karyn S.W. Polak	 	
		 	            President          	  	        Secretary              	 	

  
 2EX-4.viii

 Exhibit (4)(viii) 

EXHIBIT (4)(viii) 

APPLICATION 

 Exhibit (4)(viii) 

 

					
	 TRANSAMERICA LIFE INSURANCE COMPANY

Individual Flexible Premium Deferred Annuity
  
	  	 	

	 

  
  

Home Office: 6400 C Street SW, Cedar Rapids, IA 52499 

“Company’, “we”, “our”, and “us” all refer to Transamerica. Unless otherwise stated, “You” refers to the
Owner 
  

			
	  
 

	  	  

By providing an email address below, I consent to receive an email that will initiate the process of receiving electronic documents and
notices applicable to the Eligible Policy/ Policies accessed through the Company website. A link within the email will direct you to the Company e-delivery terms and conditions as well as our registration and
consent process. I have access to the Internet for the purpose of accepting electronic delivery of documents.

			
	 	 
	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.
  

  
  

1. PRODUCT INFORMATION 
 Product: Transamerica Structured
Index AdvantageSM Annuity 
  
  

2. OWNER INFORMATION 
 Type of Owner: If the Type of
Owner is an Individual, there must be an immediate (self, spouse, civil union, domestic partner, parent, child, grandparent, grandchild or sibling) familial relationship between the Owner(s) and the Annuitant. Unless otherwise requested, the Owner
will receive any policy correspondence and tax forms. 
  

					
	¡  Individual	  	¡  Trust1 	  	¡  Qualified Custodial Account
			
	¡  Entity2 	  	¡  Company Qualified Plan3 	  	¡  UGMA/UTMA

  

									
	Relationship to Annuitant:	 	 	 	 	 	 	 	 
					
	Complete Legal Name:	 	 	 	 	 	 	 	 
					
	Residential Address:	 	 	 	 	 	 	 	 
	(Cannot be a P.O. Box)	 	 Street Address
  
	 		 		 	
		 	 City
  
	 	 State
  
	 	 Zip Code
  
	 	 Country
  

		 	Telephone	 	 	 	 	 	 
					
	Mailing Address:	 		 		 		 	
		 	 Street Address
  
	 	 	 	 	 	 
		 	City	 	State	 	Zip Code	 	Country

  

							
	SSN/TIN:  
                                    	 	Date of Birth:                                 
      	 	¡  Male	 	¡  Female
				
	Citizenship:  ¡  U.S. Citizen/Entity	 	¡  Non-U.S. Citizen/Entity-Country:	 	 	 	 
				
		 	¡  Resident Alien	 	¡  Non-Resident Alien	 	

  

	1 	 Trustee Certification Form is Required. 

	2 	 Entity Certification Form is Required. 

	3 	 Profit Sharing Plan, Pension Plan, 401(k), etc. Qualified Plan Certification Form is Required. The Company
must be the Beneficiary listed in Section 5. 

  

							
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3. JOINT OWNER INFORMATION 
 If no Joint Owner is listed,
the Company will issue the policy with the Owner listed in Section 2. 
 If Type of Owner in Section 2 is an Individual; there must be an immediate
(self, spouse, civil union, domestic partner, parent, child, grandparent, grandchild or sibling) familial relationship between the Owner(s) and the Annuitant. 

¡   Check here if the Joint Owner’s Address is the same as the Owner’s Address listed in Section 2. 

 

									
	Relationship to Annuitant:	 	 	 	 	 	 	 	 
					
	Complete Legal Name:	 	 	 	 	 	 	 	 
					
	Residential Address:	 	 	 	 	 	 	 	 
	(Cannot be a P.O. Box)	 	 Street Address
  
	 		 		 	
		 	 City
  
	 	 State
  
	 	 Zip Code
  
	 	 Country
  

		 	Telephone	 	 	 	 	 	 
					
	Mailing Address:	 		 		 		 	
		 	 Street Address
  
	 	 	 	 	 	 
		 	City	 	State	 	Zip Code	 	Country

  

							
	SSN/TIN:                                     
              	  	Date of Birth:                                 
      	    	¡  Male	 	¡  Female
				
	Citizenship:  ¡  U.S. Citizen/Entity	  	¡  Non-U.S. Citizen/Entity-Country:	    	 	 	 
			
		  	¡  Resident Alien                ¡  Non-Resident Alien	 	

  
  

4. ANNUITANT INFORMATION 
 If no Annuitant is listed, the
Company will issue the policy with the Owner and Annuitant as the same. 
 If Type of Owner in Section 2 is an Individual; there must be an immediate
(self, spouse, civil union, domestic partner, parent, child, grandparent, grandchild or sibling) familial relationship between the Owner(s) and the Annuitant. 

¡   Check here if the Annuitant’s Address is the same as the Owner’s Address listed in Section 2. 

 

									
	Complete Legal Name:	 	 	 	 	 	 	 	 
					
	Residential Address:	 	 	 	 	 	 	 	 
	(Cannot be a P.O. Box)	 	 Street Address
  
	 		 		 	
		 	 City
  
	 	 State
  
	 	 Zip Code
  
	 	 Country
  

		 	Telephone	 	 	 	 	 	 
					
	Mailing Address:	 		 		 		 	
		 	 Street Address
  
	 	 	 	 	 	 
		 	City	 	State	 	Zip Code	 	Country

  

							
	SSN/TIN:                                     
              	  	Date of Birth:                                 
      	    	¡  Male	 	¡  Female
				
	Citizenship:  ¡  U.S. Citizen/Entity	  	¡  Non-U.S. Citizen/Entity-Country:	    	 	 	 
			
		  	¡  Resident Alien                ¡  Non-Resident Alien	 	

  

							
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5. BENEFICIARY DESIGNATION 
 The percentages assigned must
be whole percentages and total 100% for each beneficiary type (primary and/or contingent). If the percentages do not total 100%, we will consider this designation incomplete until sufficient beneficiary information is received. If a designation is
incomplete or there are no surviving beneficiaries at the time a claim is processed, proceeds will be payable per the terms of the policy. 
  

													
	 •  If the Beneficiary is to be restricted, the Beneficiary
Designation with Restricted Payout Form must be received.

				
	
¡  Primary
	 		  	 Allocation Percentage:
            %
	  	
Is this an Irrevocable Beneficiary?   ¡  Yes     ¡  No

  

									
	Relationship to Annuitant:	 	 	 	 	 	 	 	 
					
	Complete Legal Name:	 	 	 	 	 	 	 	 
					
	Residential Address:	 	 	 	 	 	 	 	 
	(Cannot be a P.O. Box)	 	 Street Address
  
	 		 		 	
		 	City	 	State	 	Zip Code	 	Country

  

							
	SSN/TIN:  
                                    	 	Date of Birth:                                
       	 	Telephone:                                 
                                         
                                 
				
	Citizenship:  ¡  U.S. Citizen/Entity	 	¡  Non-U.S. Citizen/Entity-Country:	 	 	 	 
				
		 	¡  Resident Alien	 	¡  Non-Resident Alien	 	

  
  

 

													
	
¡  Primary
	 	
¡  Contingent
	  	 Allocation Percentage:
            %
	  	
Is this an Irrevocable Beneficiary?   ¡  Yes     ¡  No

  

									
	Relationship to Annuitant:	 	 	 	 	 	 	 	 
					
	Complete Legal Name:	 	 	 	 	 	 	 	 
					
	Residential Address:	 	 	 	 	 	 	 	 
	(Cannot be a P.O. Box)	 	 Street Address
  
	 		 		 	
		 	City	 	State	 	Zip Code	 	Country

  

							
	SSN/TIN:  
                                    	 	Date of Birth:                                
       	 	
Telephone:                        
                                         
                                         
 

				
	Citizenship:  ¡  U.S. Citizen/Entity	 	¡  Non-U.S. Citizen/Entity-Country:	 	 	 	 
				
		 	¡  Resident Alien	 	¡  Non-Resident Alien	 	

  
  

 

													
	
¡  Primary
	 	
¡  Contingent
	  	 Allocation Percentage:
            %
	  	
Is this an Irrevocable Beneficiary?   ¡  Yes     ¡  No

  

									
	Relationship to Annuitant:	 	 	 	 	 	 	 	 
					
	Complete Legal Name:	 	 	 	 	 	 	 	 
					
	Residential Address:	 	 	 	 	 	 	 	 
	(Cannot be a P.O. Box)	 	 Street Address
  
	 		 		 	
		 	City	 	State	 	Zip Code	 	Country

  

							
	SSN/TIN:  
                                    	 	Date of Birth:                                
       	 	
Telephone:                        
                                         
                                         
 

				
	Citizenship:  ¡  U.S. Citizen/Entity	 	¡  Non-U.S. Citizen/Entity-Country:	 	 	 	 
				
		 	¡  Resident Alien	 	¡  Non-Resident Alien	 	

  
  

 

	
	
¡  Check if there
are more Beneficiaries and complete the Additional Beneficiary Form and return with the application

  

							
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6. PURCHASE PAYMENT INFORMATION 
 Type of Annuity
Applying for (select only one): If applying for a Qualified Plan (Profit Sharing Plan, Pension Plan, 401(k), or other), the Qualified Plan Certification and Acknowledgement Form and Plan Investment and Services Agreement is required. If the
Beneficiary is to be restricted, the Beneficiary Designation with Restricted Payout Form must be received. 
  

									
	¡   Non-Qualified	  	¡   Traditional IRA	  	¡   Roth IRA	  	¡   SEP IRA	  	¡   SIMPLE IRA
				
	¡   Profit Sharing Plan	  	¡   Pension Plan	  	¡   401(k)	  	¡   Other                 
                         

  

			
	¡   Qualified Stretch - Deceased
Name:                                        
                                  	  	Date of Death:                                 
                     
		
	¡   Non-Qualified Stretch - Deceased
Name:                                        
                          	  	Date of Death:                                 
                 
		
	¡   10 Year Delay - Deceased
Name:                                        
                                      	  	Date of Death:                                 
                 

 Funding Options: 
 ¡   Check 

¡   Enclosed 
 ¡   Wire 
 ¡   Financial Professional/Client to request release of funds 

 

	¡  	 The Company to request release of funds. The 1035 Exchange, Rollover or Transfer Request Form is
required. Submit the appropriate state replacement form(s) if the Applicant has existing life insurance policies or annuity contracts. 

Source of Funds: 
  

			
	
¡   New Money /
Contribution Money $
                                         
                        if Qualified Plan - Tax
Year:                                  

	
	
¡   Non-Qualified 1035 Exchange - Anticipated Premium Amount
$                                         
                                         
                   

	
	
¡   CD/Mutual Fund
Redemption - Anticipated Premium Amount
$                                         
                                         
                                        

	
	
¡   Direct Transfer -
Anticipated Premium Amount
$                                         
                                         
                                         
                               

	
	
¡   Rollover -
Anticipated Premium Amount
$                                         
                                         
                                         
                                     

  
  

7. ELECTIONS - DEATH BENEFIT 
 You must select only
one Death Benefit option. Your selection cannot be changed after the policy has been issued. 
 ¡   Policy Value Death Benefit 

¡   Return of Premium Death Benefit 
  

							
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8. PREMIUM ALLOCATIONS 
 The percentages assigned must be
whole percentages and total 100%. 
  

											
	 
	FIXED ACCOUNT OPTION
	 	 	 	 	 	 
	        %  	  	Fixed Account	 	 	 	 	 	 	 	 
	 
	BEST ENTRY INDEX ACCOUNT
OPTIONS
	 	 	 	 	 	 
	  	  	Index	 	Crediting
Period	 	Growth Opportunity	 	Downside Protection	 	Credit
Advantage*
	 	 	 	 	 	 
	        %	  	Fidelity World Factor Leaders IndexSM 	 	6 Year	 	Cap	 	Buffer 10%	 	

	 	 	 	 	 	 
	        %	  	S&P 500®	 	6 Year	 	Cap	 	Buffer 10%	 	

	 
	BASIC INDEX ACCOUNT
OPTIONS
	 	 	 	 	 	 
	  	  	Index	 	  Crediting  
Period	 	Growth Opportunity	 	Downside Protection	 	Credit
Advantage*
	 	 	 	 	 	 
	        %	  	Fidelity World Factor Leaders IndexSM 	 	1 Year	 	Cap	 	Buffer 10%	 	 
	 	 	 	 	 	 
	        %	  	Fidelity World Factor Leaders IndexSM 	 	2 Year	 	Cap	 	Buffer 10%	 	 
	 	 	 	 	 	 
	        %	  	Fidelity World Factor Leaders IndexSM 	 	2 Year	 	Cap	 	Buffer 15%	 	 
	 	 	 	 	 	 
	        %	  	Fidelity World Factor Leaders IndexSM 	 	2 Year	 	Cap	 	Buffer 15%	 	

	 	 	 	 	 	 
	        %	  	Fidelity World Factor Leaders IndexSM 	 	6 Year	 	Cap	 	Buffer 10%	 	 
	 	 	 	 	 	 
	        %	  	Fidelity World Factor Leaders IndexSM 	 	6 Year	 	Cap	 	Buffer 20%	 	 
	 	 	 	 	 	 
	        %	  	iShares® Russell 2000 ETF	 	1 Year	 	Cap	 	Buffer 10%	 	 
	 	 	 	 	 	 
	        %	  	iShares® Russell 2000 ETF	 	2 Year	 	Cap	 	Buffer 10%	 	 
	 	 	 	 	 	 
	        %	  	iShares® Russell 2000 ETF	 	2 Year	 	Cap	 	Buffer 15%	 	 
	 	 	 	 	 	 
	        %	  	iShares® Russell 2000 ETF	 	2 Year	 	Cap	 	Buffer 15%	 	

	 	 	 	 	 	 
	        %	  	iShares® U.S. Technology ETF	 	1 Year	 	Cap	 	Buffer 10%	 	 
	 	 	 	 	 	 
	        %	  	iShares® U.S. Technology ETF	 	2 Year	 	Cap	 	Buffer 10%	 	 
	 	 	 	 	 	 
	        %	  	iShares® U.S. Technology ETF	 	2 Year	 	Cap	 	Buffer 15%	 	 
	 	 	 	 	 	 
	        %	  	iShares® U.S. Technology ETF	 	2 Year	 	Cap	 	Buffer 15%	 	

	 	 	 	 	 	 
	        %	  	S&P 500®	 	1 Year	 	Cap	 	Buffer 10%	 	 
	 	 	 	 	 	 
	        %	  	S&P 500®	 	2 Year	 	Cap	 	Buffer 10%	 	 
	 	 	 	 	 	 
	        %	  	S&P 500®	 	2 Year	 	Cap	 	Buffer 15%	 	 
	 	 	 	 	 	 
	        %	  	S&P 500®	 	2 Year	 	Cap	 	Buffer 15%	 	

	 	 	 	 	 	 
	        %	  	S&P 500®	 	6 Year	 	Cap	 	Buffer 10%	 	 
	 	 	 	 	 	 
	        %	  	S&P 500®	 	6 Year	 	Cap	 	Buffer 20%	 	 
	 
	 
	        %	  	Total Allocation (Sum of all Account Options [including the Fixed Account Option] must total
100%)

  

	*	 Index Account Options with Credit Advantage include an additional fee. 

 

							
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9. OWNER & FINANCIAL PROFESSIONAL - REPLACEMENT INFORMATION 

Both the Owner Response and the Financial Professional Response columns must be completed. 

Submit the appropriate state replacement form(s) if the Applicant has existing life insurance policies or annuity contracts. 

 

	¡	 Check here if there are more than three (3) replacement policies, complete the Additional Replacement
Policy Form and return with the application. 

  

													
	 	 	 
	Replacement Questions	  	    Owner Response    	 	  	Financial Professional Response
	 	 	 
	Did the Financial Professional present and leave only insurer-approved sales material with the Owner?	  	 	
Not Applicable
	 	  	¡ No    ¡ Yes
	 	 	 	 
	Does the Owner have any existing life insurance policies or annuity contracts?	  	 	¡ No	 	 	 	¡ Yes	 	  	¡ No    ¡ Yes
	 	 	 	 
	Will this annuity replace, discontinue or change any existing life insurance policies or annuity contracts?	  	 	¡ No	 	 	 	¡ Yes	 	  	¡ No    ¡ Yes
	 		 	 	 
	
If yes - Company:
	 	
                   
                                         
                            
	  				 			 	  	 
	 Policy#:
	 	
                   
                                         
                            
	  				 			 	  	 
	 		 	 	 
	 Company:
	 	
                   
                                         
                            
	  				 			 	  	 
	 Policy#:
	 	
                   
                                         
                            
	  				 			 	  	 
	 		 	 	 
	 Company:
	 	
                   
                                         
                            
	  				 			 	  	 
	
Policy#:
	 	
                   
                                         
                            
	  	 	 	 	 	 	 	 	  	 

  
  

10. TELEPHONE/ELECTRONIC AUTHORIZATION 
 As the Owner, you
will receive this privilege automatically. If a policy has Joint Owners, each Owner may individually make telephone and/or electronic requests. If no option is selected, the authorization will default to Owner(s) only. 

 

	¡	 Yes 

By checking “Yes,” I am authorizing and directing the Company to act on telephone or electronic instructions from my Financial
Professional(s), Servicing Representative(s) or their Support Staff. This may include fund transfers, allocation changes and any other changes approved by the Company. The Company will use reasonable procedures to confirm that these instructions are
authorized and genuine. As long as these procedures are followed, the Company and its affiliates and their Directors, Officers, Employees, and Financial Professionals will be held harmless for any claim, liability, loss or cost. 

 

	¡	 No 

By checking “No”, I am not authorizing and directing the Company to act on telephone or electronic instructions from my
Financial Professionals of record, Servicing Representative(s) or their Support Staff. 
  
  

							
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11. OWNER & ANNUITANT SIGNATURES AND ACKNOWLEDGEMENTS 
  

	•	 	 I understand this policy is a Registered Index-Linked Annuity and have been reasonably informed of various
features of the annuity. While values of the policy may be affected by an external index, the policy does not directly participate in any equity investment. 

  

	•	 	 Unless I have notified the Company of a community or marital property interest in this policy, the Company will
rely on good faith belief that 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 application are correct and
true. 

  

	•	 	 This application is subject to acceptance by the Company. If this application is rejected for any reason, the
Company will be liable only for return of purchase payment paid. 

  

	•	 	 I understand that 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. 

 

	•	 	 All statements in this application made by or under the authority of the applicant are representations and not
warranties. 

 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. 
 Account values when allocated to any of the options in Section 8 are not guaranteed as to fixed dollar
amount and will increase or decrease with investment performance. 
 If the individuals signing below are signing as a Power of Attorney, Guardian,
Conservator, Authorized Representative, or Trustee, additional information is required. 
  

							
	Signed at:	 	 
		 	 City
	 	 State
	 	
				
	Date:	 	 	 	 Linking Number:
	 	 

  

											
	 

 Owner(s) Signature:
	 	 	  	 	  	 	  	 	  	 

											
	 I am signing as:
	  	¡  Power of Attorney	  	¡  Guardian	  	¡  Conservator	  	¡  Authorized Representative	  	¡  Trustee

											
						
	

  Joint Owner(s) Signature:	 	 	  	 	  	 	  	 	  	 

											
	 I am signing as:
	  	¡  Power of Attorney	  	¡  Guardian	  	¡  Conservator	  	¡  Authorized Representative	  	¡  Trustee

			
		
	

  Annuitant Signature (if not Owner):	 	 

  

							
	 ICC21
T-AP-VIA1400-0121
	  	 Incomplete without all pages
	  	 	81605509 05/22	 

  
 7 

  

12. FINANCIAL PROFESSIONAL ACKNOWLEDGEMENTS & SIGNATURES 

I certify that I have truly and accurately recorded on the application the information that was provided to me by the applicant. 

I HAVE MADE REASONABLE EFFORTS TO OBTAIN INFORMATION CONCERNING THE APPLICANT’S FINANCIAL STATUS, TAX STATUS, INVESTMENT OBJECTIVES AND SUCH OTHER
INFORMATION USED OR CONSIDERED TO BE REASONABLE IN MAKING THE ANNUITY RECOMMENDATION AND FIND THE ANNUITY BEING APPLIED FOR APPROPRIATE FOR HIS/ HER NEEDS. 

If this is a replacement transaction, I confirm that I have reviewed the Company’s written standard regarding the acceptability of replacements and that
it meets the Company’s standard. 
 Primary Registered Financial Professional 

 

			
	 Print Full Name:
	 	 

			
		
	 Financial Professional ID Number:
	 	 

									
				
	 Email Address (Optional):
	 	 	  	 	Phone Number:	 	 	 

			
		
	 Firm Name:
	 	 
		
	 Firm Address:
	 	 
	
	 Commission Split:1
          %

  

			
	 

  Signature:
	 	 

  
  

							
	For Financial Professional Use Only - Contact your home office for program information.
	
	Commission options below are based on the product and rider(s) selected.
				
	
¡  Option A
	 	¡  Option B	 	¡  Option C	 	
¡  Option 
D

	
	 (Once selected, program cannot be changed)

  
  

Additional Financial Professional(s) 
 The following Servicing
Financial Professional(s) must also meet all licensing, appointment and training required to solicit this policy. As a Servicing Financial Professional the individual(s) listed below will have the same independent rights to access policy information
and submit instructions as are granted to the Primary Financial Professional of Record. 
  

			
	Print Full Name:	  	 

									
				
	 Financial Professional ID Number:
	 	 	  	 	Commission Split:	1 	 	                %

			
		
	Print Full Name:	  	 

									
				
	 Financial Professional ID Number:
	 	 	  	 	Commission Split:	1 	 	                %

			
		
	Print Full Name:	  	 

									
				
	 Financial Professional ID Number:
	 	 	  	 	Commission Split:	1 	 	                %

  

	¡	 Check here if there are more than four (4) Financial Professionals. If so, please complete the
Additional Financial Professional Form. 

 1 Must be in whole percentages. The
sum of the Commission Split for the Primary Registered Financial Professional and Additional Financial Professionals must equal 100%. 
  

							
	 ICC21
T-AP-VIA1400-0121
	  	 Incomplete without all pages
	  	 	81605509 05/22	 

  
 8

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