Document:

Exhibit
10.3

 

 U.S.
Energy Corp.

4643
S. Ulster Street, Suite 970

Denver,
Colorado 80237

 

October
2, 2017

 

APEG
Energy II, L.P.

Attn:
Messrs. Haarman and Duke

 

Re:      U.S.
Energy Corp. – Debt Equity Swap

 

Dear
Messrs. Haarman and Duke:

 

Reference
is made to that certain Exchange Agreement by and among U.S. Energy Corp. (the “Company”), Energy One LLC (“Energy
One”) and APEG Energy II, L.P. (“APEG”) dated September 28, 2017 and that certain Standstill Agreement by and
between the Company and APEG dated September 28, 2017.

 

The
Exchange Agreement and the Standstill Agreement are subject to approval by the Company’s Board of Directors and shall not
become effective until the Company’s Board provided such approval.

 

Furthermore,
closing of the Exchange Agreement is subject to NASDAQ approval and approval by the shareholders at a special meeting of the Company
and such closing shall not take place until those approvals are received.

 

By
executing below APEG acknowledges that the Exchange Agreement and the Standstill Agreement shall not be effective until approved
by the Company’s Board of Directors and the closing of the Exchange Agreement shall not take place until the Company receives
NASDAQ and shareholder approval.

 

[signature
and acknowledgment follows]

 

     

     

    

 

	 	Sincerely,
	 	 
	 	U.S. ENERGY CORP.
	 	 	 
	 	By:	/s/David Veltri
	 	Name: 	David Veltri
	 	Title:	President and Chief Executive Officer

 

Agreed
and accepted on this 2 day of October, 2017

 

APEG
Energy II, L.P.

	 	 	 
	By: 	/s/Patrick
    Duke	 
	Name: Patrick Duke	 
	Title: Managing Partner	 

 

APEG
Energy II, L.P.

	 	 	 
	By: 	/s/Paul
    Haarman	 
	Name: Paul Haarman	 
	Title: Managing PartnerBlueprint

 

Exhibit 10.1

 

AMENDMENT

TO

AMENDED AND RESTATED STOCKHOLDERS’ AGREEMENT

OF

RUMBLEON, INC.

 

 

Reference is made
to that certain Amended and Restated Stockholders’ Agreement,
dated February 8, 2017 (the “Agreement”) by and among
(i) RumbleOn, Inc. (f/k/a Smart Server, Inc.) (the
“Corporation”) (ii)
Berrard Holdings Limited Partnership, a Delaware limited
partnership (“BHLP”), (iii) Steven R.
Berrard (“Berrard”), (iv) Marshall
Chesrown (“Chesrown”), and (v) the
other stockholders of the Company listed on the signature page (the
“Other
Stockholders”) (each of the Company, Berrard,
Chesrown, and the Other Stockholders is a “Party” and collectively
are referred to in this Amendment as the “Parties”). This Amendment
to the Agreement (the “Amendment”) is entered
into as of September 29, 2017, by and among the
Parties.

 

RECITALS:

 

WHEREAS, the Nominating and Corporate
Governance Committee (the “Committee”), pursuant to
the its authority under the Committee's Charter, recommended an
increase in the size of the Board of Directors of the Corporation
(the “Board”) from six members
to seven members;

 

WHEREAS, the Board, pursuant to the its
authority under Article III of the Corporation's Amended Bylaws,
has approved the increase in the size of the Board from six members
to seven members, effective October 1, 2017;

 

WHEREAS, the Parties desire to amend the
Agreement in order to increase size of the Board.

 

AGREEMENT:

 

NOW, THEREFORE, in consideration of the
foregoing premises, and other good and valuable consideration the
Parties hereto acknowledge, the Parties agree as
follows:

 

Article
II, Section 2.1 (a) of the Agreement is hereby amended and
restated in its entirety as follows:

 

“As of the
date hereof, the Board shall be comprised of seven (7) directors.
From and after the date hereof and for so long as Chesrown, or an
Affiliate of Chesrown beneficially owns, in the aggregate, at least
1,000,000 shares of the issued and outstanding Common Stock (the
“Minimum Threshold”), the Board shall be comprised of
no more than seven (7) directors, and Chesrown shall be entitled to
(i) nominate three (3) individuals to the Board (such individuals,
including their respective successors, the “Chesrown
Directors”), to serve as members of the Board until their
respective successors are elected and qualified, (ii) nominate any
successor to each Chesrown Director, and (iii) direct the removal
from the Board of any Chesrown Director; provided, that at least two of the
Chesrown Directors shall be “independent” as defined by
the applicable rules and regulations of the SEC and the NASDAQ
stock market. The Chesrown Directors shall initially be Marshall
Chesrown, Mitch Pierce, and Kevin Westfall.”

 

 

1

 

 

Article
II, Section 2.1 (d) of the Agreement is hereby amended and
restated in its entirety as follows:

 

“From and
after the date hereof and for so long as Berrard, or an Affiliate
of Berrard beneficially owns, in the aggregate, at least the
Minimum Threshold, the Board shall be comprised of no more than
seven (7) directors, and Berrard shall be entitled to (i) nominate
one individual to the Board (such individual, including such
individual's successor, the “Berrard Director”), to
serve as a member of the Board until the Berrard Director's
successor is elected and qualified, (ii) nominate any successor to
the Berrard Director, and (iii) direct the removal from the Board
of the Berrard Director. The Berrard Director shall initially be
Steven R. Berrard.”

 

Other
than as expressly set forth above, the Agreement shall remain in
full force and effect.

 

 

 

 

 

2

 

 

IN WITNESS WHEREOF, each of the
undersigned has signed this Amendment as of the date first above
written.

 

RumbleOn,
Inc.

 

By:
/s/ Steven R.
Berrard

Name:
Steven R. Berrard

Title:
Chief Financial Officer

 

Berrard
Holdings Limited Partnership

Berrard
Holdings, LLC, its general partner

 

By:
/s/ Steven R.
Berrard

Name:
Steven R. Berrard

Title:
Sole Member

 

/s/ Steven R. Berrard

Steven
R. Berrard

 

/s/ Marshall Chesrown

Marshall
Chesrown

 

/s/ Lori Sue Chesrown

Lori
Sue Chesrown

 

/s/ Thomas Aucamp

Thomas
Aucamp

 

/s/ Beverly Rath

Beverly
Rath

 

 

 

[Signature
Page to the Amendment to the Amended and Restated
Stockholders’ Agreement of RumbleOn, Inc.]

3

 

 

 

IN WITNESS WHEREOF, each of the
undersigned has signed this Amendment as of the date first above
written.

 

 

Blue
Flame Capital, LLC.

 

By:/s/
Denmar Dixon

Name:
Denmar Dixon

Title:
Managing Partner

 

NextGen
Dealer Solutions, LLC.

 

By:/s/
Kartik Kakarala

Name:
Kartik Kakarala

Title:
President

 

/s/ Kartik Kakarala

Kartik
Kakarala

 

/s/ Jay Goodart

Jay
Goodart

 

/s/ Jeffrey Cheek

Jeffrey
Cheek

 

/s/ Jack Lynn

Jack
Lynn

 

/s/ Thomas Byrne

Thomas
Byrne

 

/s/ Ralph Wegis

Ralph
Wegis

 

[Signature
Page to the Amendment to the Amended and Restated
Stockholders’ Agreement of RumbleOn, Inc.]

 

4Exhibit

FLEXIBLE PREMIUM DEFERRED 
VARIABLE ANNUITY CONTRACT
Glenbrook Life and Annuity Company, A Stock Company, Home Office:
 
Allstate Plaza, Northbrook, Illinois 60062
This Contract is issued in consideration of the initial purchase payment and any application. Glenbrook Life and Annuity Company will pay the benefits of this Contract, subject to its terms and conditions.
Throughout this Contract, "you" and "your" refer to the Contract owner(s). "We", "us" and "our" refer to Glenbrook Life and Annuity Company.
This flexible premium deferred variable annuity provides a cash withdrawal benefit, a death benefit, and a settlement value during the Accumulation Phase and periodic income payments beginning on the Payout Start Date during the Payout Phase.
The dollar amount of income payments or other values provided by this Contract, when based on the investment experience of the Variable Account, varies to reflect the performance of the Variable Account. For amounts in the Guaranteed Maturity Fixed Account, the withdrawal benefit, the death benefit, the settlement value, transfers to other sub-accounts and any periodic income payments may be subject to a Market Value Adjustment which may result in an upward or downward adjustment of the amount distributed.
This Contract does not pay dividends.
The tax status of this Contract as it applies to the owner should be reviewed each year.
PLEASE READ YOUR CONTRACT CAREFULLY.
This is a legal Contract between the Contract owner(s) and Glenbrook Life and Annuity Company.
RETURN PRIVILEGE
If you are not satisfied with this Contract for any reason, you may return it to us or our agent within 20 days after you receive it. We will refund any purchase payments allocated to the Variable Account, adjusted to reflect investment gain or loss from the date of allocation to the date of cancellation, plus any purchase payments allocated to the fixed account. if this contract is qualified under section section 408 of the Internal Revenue Code, we will refund the greater of any purchase payments or the Contract Value.
If you have any questions about your Glenbrook Life variable annuity, please contact Glenbrook Life at (800) 755-5275.
Secretary Chief Executive Officer
FLEXIBLE PREMIUM DEFERRED VARIABLE ANNUITY
Page 1

	
	
	TABLE OF CONTENTS 
 
THE PERSONS INVOLVED  . . . . . . . . . . . . . . . . . . . . . . .  3 
 
ACCUMULATION PHASE  . . . . . . . . . . . . . . . . . . . . . . . .  4 
 
PAYOUT PHASE  . . . . . . . . . . . . . . . . . . . . . . . . . . .  9 
 
INCOME PAYMENT TABLES . . . . . . . . . . . . . . . . . . . . . . . 11 
 
GENERAL PROVISIONS  . . . . . . . . . . . . . . . . . . . . . . . . 12 
 
                                Page 2

	
	
	ANNUITY DATA 
 
CONTRACT NUMBER:  . . . . . . . . . . . . . . . . . . . . 444444444 
 
ISSUE DATE: . . . . . . . . . . . . . . . . . . . . . . . July 1, 1994 
 
INITIAL PURCHASE PAYMENT: . . . . . . . . . . . . . . . . $10,000.00 
                                                              IRA

INITIAL ALLOCATION OF PURCHASE PAYMENT: 
ALLOCATED 
AMOUNT (%) 
VARIABLE ACCOUNT

	
	
	Fund Manager sub-account a                10% 
    Fund Manager sub-account b                10% 
    Fund Manager sub-account c                10% 
    Fund Manager sub-account d                10% 
    Fund Manager sub-account e                10% 
    Fund Manager sub-account f                10% 
                                                             RATE 
                                   ALLOCATED  GUARANTEED     GUARANTEED 
                                   AMOUNT (%) INTEREST RATE  THROUGH 
GUARANTEED MATURITY FIXED ACCOUNT 
    1 Year Guarantee Period          10%          5.00%      06/30/1995 
    3 Year Guarantee Period          10%          6.40%      06/30/1997 
    5 Year Guarantee Period           5%          7.00%      06/30/1999 
    7 Year Guarantee Period           5%          7.20%      06/30/2001 
    10 Year Guarantee Period          5%          7.35%      06/30/2004 
 
DOLLAR COST AVERAGING FIXED ACCOUNT 
    1 Year Guarantee Period           5%          5.00%      06/30/1995

MINIMUM GUARANTEED RATE

	
	
	Dollar Cost Averaging Fixed Account:  . . . . . . . . . . . . 3.00% 
 
PAYOUT START DATE:  . . . . . . . . . . . . . . . . . . .  July 1, 2049 
    (The latest date on which Income Payments must begin) 
OWNER:  . . . . . . . . . . . . . . . . . . . . . . . . . . .  John Doe 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Jane Doe 
 
ANNUITANT:  . . . . . . . . . . . . . . . . . . . . . . . . .  John Doe 
    AGE AT ISSUE: . . . . . . . . . . . . . . . . . . . . . . . . .  35 
    SEX:  . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Male 
 
BENEFICIARY              RELATIONSHIP  TO OWNER           PERCENTAGE 
Jane Doe                        Wife                         100% 
 
CONTINGENT BENEFICIARY   RELATIONSHIP TO OWNER            PERCENTAGE 
June Doe                       Daughter                       100%

Page 3

THE PERSONS INVOLVED
OWNER. The person named at the time of application is the owner of this Contract unless subsequently changed. As owner, you will receive any periodic income payments, unless you have directed us to pay them to someone else. The Contract cannot be jointly owned by both a non-natural person and a natural person.
You may exercise all rights stated in this Contract, subject to the rights of any irrevocable beneficiary.
You may change the owner or beneficiary at any time. If the owner is a natural person, you may change the annuitant prior to the Payout Start Date. Once we have received a satisfactory written request for an owner, beneficiary or annuitant change, the change will take effect as of the date you signed it. We are not liable for any payment we make or other action we take before receiving any written request for a change from you.
You may not assign an interest in this Contract as collateral or security for a loan. However, you may assign periodic income payments under this Contract prior to the Payout Start Date. We are bound by an assignment only if it is signed by the assignor and filed with us. We are not responsible for the validity of an assignment.
If the sole surviving owner dies prior to the Payout Start Date, the beneficiary becomes the new owner. If the sole surviving owner dies after the Payout Start Date, the beneficiary becomes the new owner and will receive any subsequent guaranteed income payments.
If more than one person is designated as owner:
- owner as used in this contract refers to all people named as owners, unless otherwise indicated;
- any request to exercise ownership rights must be signed by all owners; and
- on the death of any person who is an owner, the surviving person(s) named as owner will continue as owner.
ANNUITANT. The annuitant is the person named on the Annuity Data Page, but may be changed by the owner, as described above. The annuitant must be a natural person. If the annuitant dies prior to the Payout Start Date, the new annuitant will be:
- the youngest owner; otherwise,
- the youngest beneficiary.
BENEFICIARY. The beneficiary is the person(s) named on the Annuity Data Page, but may be changed by the owner, as described above. We will determine the beneficiary from the most recent written request we have received from you. If you do not name a beneficiary or if the beneficiary named is no longer living, the beneficiary will be:
- your spouse if living; otherwise
- your children equally if living; otherwise
- your estate.
The beneficiary may become the owner under the circumstances described above.
The beneficiary may assign benefits under the Contract, as described above, once they are payable to the beneficiary. We are bound by an assignment only if it is signed by the assignor and filed with us. We are not responsible for the validity of an assignment.
Page 4

ACCUMULATION PHASE
ACCUMULATION PHASE DEFINED. The "Accumulation Phase" is the first of two phases during your Contract. The Accumulation Phase begins on the issue date stated on the Annuity Data Page. 
This phase will continue until the Payout Start Date unless the Contract is terminated before that date.
CONTRACT YEAR. The one year period beginning on the issue date and on each anniversary of the issue date.
PURCHASE PAYMENTS. You may make subsequent purchase payments during the Accumulation Phase. The minimum subsequent purchase payment amount is $50. We reserve the right to reduce the minimum purchase payment. We may limit the maximum amount of purchase payments we will accept. We may limit your ability to make subsequent purchase payments in order to comply with the laws of the state where this Contract is delivered.
We will invest the purchase payments in the Investment Alternatives you select. You may allocate any portion of your purchase payment in whole percents from 0% to 100% or in exact dollar amounts to any of the Investment Alternatives. The total allocation must equal 100% or the total dollar amount of your purchase payment. For each purchase payment, the minimum amount that may be allocated to any Fixed Account option is $50.
The allocation of the initial purchase payment is shown on the Annuity Data Page. Allocation of each subsequent purchase payment will be the same as for the most recent purchase payment unless you change the allocation. You may change the allocation of subsequent purchase payments at any time, without charge, simply by giving us written notice. Any change will be effective at the time we receive the notice.
INITIAL PURCHASE PAYMENT ALLOCATION. If the Return Privilege provision requires us to refund purchase payments, then during the Return Privilege period, we reserve the right to invest any purchase payments you allocated to the Variable Account to a money market portfolio available under this Contract. We will notify you if we do so. At the end of the Return Privilege period, the amount in the money market portfolio may be allocated to the Variable Account. This allocation will not be considered a transfer.
INVESTMENT ALTERNATIVES. Investment Alternatives are the Sub-accounts of the Variable Account, the Dollar Cost Averaging Fixed Account, and the Sub-accounts of the Guaranteed Maturity Fixed Account shown on the Application.
VARIABLE ACCOUNT. The "Variable Account" for this Contract is the Glenbrook Life Multi-Manager Variable Account. This account is a separate investment account to which we allocate assets contributed under this and certain other contracts. The income, gains and losses, realized or unrealized, from assets allocated to the Variable Account are credited to or charged against the account without regard to our other income, gains or losses.
VARIABLE SUB-ACCOUNTS. The Variable Account is divided into Sub-accounts. Each Sub-account invests solely in the shares of the mutual fund underlying that Sub-account.
FIXED ACCOUNT OPTIONS. The Fixed Account options are the Dollar Cost Averaging Fixed Account and the Sub-accounts of the Guaranteed Maturity Fixed Account.
DOLLAR COST AVERAGING FIXED ACCOUNT. Money in the Dollar Cost Averaging Fixed Account will earn interest for one year at the current rate in effect at the time of allocation to the Dollar Cost Averaging Fixed Account. After one year, a one year renewal rate will be declared. Subsequent renewal dates will be on anniversaries of the first renewal date.
GUARANTEED MATURITY FIXED ACCOUNT. The Guaranteed Maturity Fixed Account is divided into Sub-accounts. A Sub-account is identified by its Guarantee Period and the date the Guarantee Period begins. You create a Sub-account when:
Page 5

- you make a purchase payment and allocate part or all of that purchase payment to the Sub-account; or
- you select a new Guarantee Period when a Sub-account expires; or
- you transfer to the Sub-account an amount from an existing Sub-account of the Variable Account or from another Sub-account of the Guaranteed Maturity Fixed Account.
A Sub-account continues until the end of its Guarantee Period.
You must select a Guarantee Period for all purchase payments and transfers allocated to a Sub-account of the Guaranteed Maturity Fixed Account. If you do not select a Guarantee Period for a purchase payment or transfer, we will assign the same period(s) you selected for your most recent purchase payment. Guarantee Periods are offered at our discretion and may range from one to ten years. We may change the Guarantee Periods available for future purchase payments or transfers allocated to the Guaranteed Maturity Fixed Account.
We will mail you a notice prior to the expiration of the Guarantee Period of each Sub-account outlining the options available at the end of the Guarantee Period. During the 30 day period after a Guarantee Period expires you may:
- take no action and we will automatically renew the Sub- account value to a Guarantee Period of the same duration to be established as of the day the previous Guarantee Period expired; or
- notify us to apply the Sub-account value to a new Guarantee Period(s) to be established as of the day the previous Guarantee Period expired; or
- notify us to apply the Sub-account value to any Sub-account of the Variable Account on the day we receive the notification; or
- receive the entire Sub-account value through a partial or full withdrawal that is not subject to a Market Value Adjustment. In this case, the Sub-account will be deemed to have been renewed at the shortest Guarantee Period then being offered with current interest credited from the date the Guarantee Period expired.
The minimum amount that can be allocated to a new Sub-account is $50.
CREDITING INTEREST. We credit interest daily to money allocated to the Fixed Account(s) at a rate which compounds over one year to the interest rate we guaranteed when the money was allocated. We will credit interest to the initial purchase payment from the issue date. We will credit interest to subsequent purchase payments from the date we receive them. We will credit interest to transfers from the date the transfer is made. The interest rate for the Dollar Cost Averaging Fixed Account will never be less than the minimum guaranteed rate shown on the Annuity Data Page.
TRANSFERS. Prior to the Payout Start Date, you may transfer amounts between Investment Alternatives. You may make 12 transfers per Contract Year without charge. Each transfer after the 12th transfer in any Contract Year may be assessed a $10 transfer fee. Transfers are subject to the following restrictions.
- The minimum amount that may be transferred into a Sub- account of the Guaranteed Maturity Fixed Account is $50.
- Any transfer from a Sub-account of the Guaranteed Maturity Fixed Account at a time other than during the 30 day period after a Guarantee Period expires will be subject to a Market Value Adjustment.
- At the end of 36 months from the date of a purchase payment allocation to the Dollar Cost Averaging Fixed Account, any remaining portion of the purchase payment and interest in the Dollar Cost Averaging Fixed Account will be transferred to the Variable Account Money Market Sub-account.
Page 6

- No amount may be transferred into the Dollar Cost Averaging Fixed Account.
We reserve the right to waive the transfer fees and restrictions contained in this Contract.
CONTRACT VALUE. Your "Contract Value" is equal to the sum of:
- the number of Accumulation Units you hold in each Sub- account of the Variable Account multiplied by the Accumulation Unit Value for that Sub-account on the most recent Valuation Date; plus
- the total value you have in the Dollar Cost Averaging Fixed Account; plus
- the sum of Sub-account values in the Guaranteed Maturity Fixed Account.
ACCUMULATION UNITS AND ACCUMULATION UNIT VALUE. Amounts which you allocate to a Sub-account of the Variable Account are used to purchase Accumulation Units in that Sub-account. The Accumulation Unit Value for each Sub-account at the end of any Valuation Period is calculated by multiplying the Accumulation Unit Value at the end of the immediately preceding Valuation Period by the Sub-account's Net Investment Factor for the Valuation Period. The Accumulation Unit Values may go up or down. Additions or transfers to a Sub-account of the Variable Account will increase the number of Accumulation Units for that Sub-account. Withdrawals or transfers from a Sub-account of the Variable Account will decrease the number of Accumulation Units for that Sub-account.
VALUATION PERIOD AND VALUATION DATE. A "Valuation Period" is the time interval between the closing of the New York Stock Exchange on consecutive Valuation Dates. A "Valuation Date" is any date the New York Stock Exchange is open for trading.
NET INVESTMENT FACTOR. For each Sub-account of the Variable Account, the "Net Investment Factor" for a Valuation Period is (A) divided by (B), minus (C) where: 
(A) is the sum of:
(1) the net asset value per share of the mutual fund underlying the Sub-account determined as of the end of the current Valuation Period, plus
(2) the per share amount of any dividend or capital gain distributions made by the mutual fund underlying the Sub-account during the current Valuation Period.
(B) is the net asset value per share of the mutual fund underlying the Sub-account determined as of the end of the immediately preceding Valuation Period.
(C) is the sum of the annualized Administrative Expense Charge and the annualized Mortality and Expense Risk Charge divided by 365 and then multiplied by the number of calendar days in the current Valuation Period.
CHARGES. The charges for this Contract include Administrative Expense Charges, Mortality and Expense Risk Charges, Contract Maintenance Charges, transfer charges, and taxes. If withdrawals are made, the Contract may also be subject to Withdrawal Charges and Market Value Adjustments.
ADMINISTRATIVE EXPENSE CHARGE. The annualized Administrative Expense Charge will never be greater than 0.10%. (See Net Investment Factor for a description of how this charge is applied.)
MORTALITY AND EXPENSE RISK CHARGE. The annualized Mortality and Expense Risk Charge will never be greater than 1.25%. (See Net Investment Factor for a description of how this charge is applied.)
Our actual mortality and expense experience will not adversely affect the dollar amount of variable benefits or other contractual payments or values under this Contract.
Page 7

CONTRACT MAINTENANCE CHARGE. Prior to the Payout Start Date, a Contract Maintenance Charge will be deducted from your Contract Value on each contract anniversary. The charge will be deducted on a pro- rata basis from each Sub-account of the Variable Account in the proportion that your value in each bears to your total value in all Sub-accounts of the Variable Account. A reduced Contract Maintenance Charge proportional to the part of the Contract Year elapsed will also be deducted if the Contract is terminated on any date other than a contract anniversary. After the Payout Start Date the Contract Maintenance Charge will be deducted in equal parts from each income payment. The annualized charge will never be greater than $35 per contract year. The Contract Maintenance Charge will be waived if, on the contract anniversary, total purchase payments are $50,000 or more or if all money is allocated to the Fixed Account(s) on the contract anniversary.
TAXES. Any premium tax or income tax withholding relating to this Contract may be deducted from purchase payments or the Contract Value when the tax is incurred or at a later time.
WITHDRAWAL. You have the right, subject to the restrictions and charges described in this Contract, to withdraw part or all of your Contract Value at any time during the Accumulation Phase. A withdrawal must be at least $50. If any withdrawal reduces the Contract Value to less than $2,000, we will treat the request as a withdrawal of the entire Contract Value. If you withdraw the entire Contract Value, the Contract will terminate.
You must specify the Investment Alternative(s) from which you wish to make a withdrawal. When you make a withdrawal, your Contract Value will be reduced by a withdrawal amount equal to the amount paid to you and any applicable Withdrawal Charge, Market Value Adjustment, and taxes.
Any Withdrawal Charge will be waived on withdrawals taken to satisfy IRS minimum distribution rules. This waiver is permitted only for withdrawals which satisfy distributions resulting from this Contract.
FREE WITHDRAWAL AMOUNT. Each Contract Year the Free Withdrawal Amount is equal to 15% of the amount of purchase payments. Each Contract Year you may withdraw the Free Withdrawal Amount without any Withdrawal Charge or Market Value Adjustment. Each Contract Year begins on the anniversary of the date the Contract was established. Any Free Withdrawal Amount which is not withdrawn in a year may not be carried over to increase the Free Withdrawal Amount in a subsequent year.
WITHDRAWAL CHARGE. To determine the Withdrawal Charge, we assume that purchase payments are withdrawn first, beginning with the oldest payment. When all purchase payments have been withdrawn, additional withdrawals will not be assessed a Withdrawal Charge.
Withdrawals in excess of the Free Withdrawal Amount will be subject to a Withdrawal Charge as follows:
Payment Year: 1 2 3 4 5 6 7 and Later
Percentage: 6% 6% 5% 5% 4% 3% 0%
For each purchase payment withdrawal, the "Payment Year" in the table is measured from the date we received the purchase payment. The Withdrawal Charge is determined by multiplying the percentage corresponding to the Payment Year times that part of each purchase payment withdrawal that is in excess of the Free Withdrawal Amount.
MARKET VALUE ADJUSTMENT. Withdrawals in excess of the Free Withdrawal Amount, transfers, death benefits, and amounts applied to an income plan from a Sub-account of the Guaranteed Maturity Fixed Account other than during the 30 day period after a Guarantee Period expires are subject to a Market Value Adjustment. A Market Value Adjustment is an increase or decrease in the amount reflecting changes in the level of interest rates since the Sub-account was established. As used in this provision, "Treasury Rate" means the U. S. Treasury Note Constant Maturity yield as reported in Federal Reserve Bulletin Release H.15. The Market Value Adjustment is based on the following:
Page 8

I = the Treasury Rate for a maturity equal to the Sub-account's Guarantee Period for the week preceding the establishment of the Sub-account;
N = the number of whole and partial years from the date we receive the withdrawal, transfer, or death benefit request, or from the Payout Start Date, to the end of the Sub-account's Guarantee Period;
J = the Treasury Rate for a maturity equal to the Sub-account's Guarantee Period for the week preceding the receipt of the withdrawal request, transfer request, death benefit request, or Income Payment request.
An adjustment factor is determined from the following formula:
.9 x (I - J) x N
The amount subject to a Market Value Adjustment that is deducted from a Sub-account of the Guaranteed Maturity Fixed Account is multiplied by the adjustment factor to determine the amount of the Market Value Adjustment. The amount deducted from the Sub-account includes the transfer amount or the amount we pay you, income tax we withhold for you, the Withdrawal Charge, any applicable premium tax charge, and the Market Value Adjustment.
DEATH OF OWNER OR ANNUITANT. A benefit may be paid to the owner determined immediately after the death if, prior to the Payout Start Date:
- any owner dies; or
- the annuitant dies and the owner is not a natural person.
If the owner eligible to receive the death benefit is not a natural person, the owner may elect to receive the benefit in one or more distributions. Otherwise, if the owner is a natural person, the owner may elect to receive a benefit either in one or more distributions or by periodic payments through an Income Plan.
A Death Benefit will be paid: 1) if the owner elects to receive the Death Benefit distributed in a single payment within 180 days of the date of death, and 2) if the Death Benefit is paid as of the day the value of the Death Benefit is determined. Otherwise, the Settlement Value will be paid. In any event, the entire value of the Contract must be distributed within five (5) years after the date of death unless an Income Plan is elected or a surviving spouse continues the Contract in accordance with the following provisions.
Payments from the Income Plan must begin within one year of the date of death and must be payable throughout:
- the life of the owner; or
- a period not to exceed the life expectancy of the owner; or
- the life of the owner with payments guaranteed for a period not to exceed the life expectancy of the owner.
If the surviving spouse of the deceased owner is the new owner, then the spouse may elect one of the options listed above or may continue the Contract in the Accumulation Phase as if the death had not occurred. If the Contract is continued in the Accumulation Phase, the surviving spouse may make a single withdrawal of any amount within one year of the date of death without incurring a Withdrawal Charge. However, any applicable Market Value Adjustment, determined as of the date of the withdrawal, will apply.
Page 9

DEATH BENEFIT. Prior to the Payout Start Date, the death benefit is equal to the greatest of:
- the Contract Value as of the date we determine the death benefit; or
- the Settlement Value on the date we determine the death benefit; or
- the Contract Value on each Death Benefit Anniversary prior to the date we determine the death benefit, increased by purchase payments made since that Death Benefit Anniversary and reduced by an adjustment for any partial withdrawals since that Death Benefit Anniversary.
The adjustment is equal to (A) divided by (B) and the result multiplied by (C) where:
(A) is the withdrawal amount. 
(B) is the Contract Value immediately prior to the withdrawal. 
(C) is the Contract Value on the Death Benefit Anniversary adjusted by any prior purchase payments or withdrawals made since that Anniversary.
The first Death Benefit Anniversary is the issue date. Subsequent Death Benefit Anniversaries are those contract anniversaries that are multiples of 7 Contract Years, beginning with the 7th contract anniversary. For example, the issue date, 7th, and 14th contract anniversaries are the first three Death Benefit anniversaries.
We will determine the value of the death benefit as of the end of the Valuation Period during which we receive a complete request for payment of the death benefit. A complete request includes due proof of death.
SETTLEMENT VALUE. The Settlement Value is the same amount that would be paid in the event of withdrawal of the Contract Value. We will calculate the Settlement Value at the end of the Valuation Period coinciding with the requested distribution date for payment or on the mandatory distribution date of 5 years after the date of death.
Page 10

PAYOUT PHASE
PAYOUT PHASE DEFINED. The "Payout Phase" is the second of the two phases during your Contract. During this phase the Contract Value adjusted by any Market Value Adjustment and less any applicable taxes is applied to the Income Plan you choose and is paid out as provided in that plan.
The Payout Phase begins on the Payout Start Date. It continues until we make the last payment as provided by the Income Plan chosen.
PAYOUT START DATE. The "Payout Start Date" is the date the Contract Value adjusted by any Market Value Adjustment and less any applicable taxes is applied to an Income Plan. The anticipated Payout Start Date is shown on the Annuity Data Page. You may change the Payout Start Date by writing to us at least 30 days prior to this date.
The Payout Start Date must be on or before the later of:
- the annuitant's 90th birthday; or
- the 10th anniversary of this Contract's issue date.
INCOME PLANS. An "Income Plan" is a series of payments on a scheduled basis to you or to another person designated by you. The Contract Value on the Payout Start Date adjusted by any Market Value Adjustment and less any applicable taxes, will be applied to your Income Plan choice from the following list:
1. LIFE INCOME WITH GUARANTEED PAYMENTS. We will make payments for as long as the annuitant lives. If the annuitant dies before the selected number of guaranteed payments have been made, we will continue to pay the remainder of the guaranteed payments.
2. JOINT AND SURVIVOR LIFE INCOME WITH GUARANTEED PAYMENTS. We will make payments for as long as either the annuitant or joint annuitant, named at the time of Income Plan selection, lives. If both the annuitant and the joint annuitant die before the selected number of guaranteed payments have been made, we will continue to pay the remainder of the guaranteed payments.
3. GUARANTEED NUMBER OF PAYMENTS. We will make payments for a specified number of months beginning on the Payout Start Date. These payments do not depend on the annuitant's life. The number of months guaranteed may be from 60 to 360.
We reserve the right to make available other Income Plans.
INCOME PAYMENTS. Income payment amounts may vary based on any Sub- account of the Variable Account and/or may be fixed for the duration of the Income Plan. The method of calculating the initial payment is different for Variable Amount Income Payments and Fixed Amount Income Payments. The Contract Maintenance Charge will be deducted in equal payments from each income payment. The Contract Maintenance Charge will be waived if total Purchase Payments are $50,000 or more as of the Payout Start Date.
VARIABLE AMOUNT INCOME PAYMENTS. The initial income payment based upon the Variable Account is calculated by applying the portion of the Contract Value in the Variable Account on the Payout Start Date, less any applicable premium tax, to the appropriate value from the Income Payment Table selected. Subsequent income payments will vary depending upon the changes in the Annuity Unit Values for the Sub- accounts upon which the income payments are based.
The portion of the initial income payment based upon a particular Variable Sub-account is determined by applying the amount of the Contract Value in that Sub-account on the Payout Start Date, less any applicable premium tax, to the appropriate value from the Income Payment Table. This portion of the initial income payment is divided by the Annuity Unit Value on the Payout Start Date for that Variable Sub-account to determine the number of Annuity Units from that Sub- account which will be used to determine subsequent income payments. Unless Annuity Transfers are made between Sub-accounts, each subsequent income payment from that Sub-account will be that number of Annuity Units times the Annuity Unit Value for the Sub-account for the Valuation Date on which the income payment is made.
Page 11

ANNUITY UNIT VALUE. The Annuity Unit Value for each Sub-account of the Variable Account at the end of any Valuation Period is calculated by:
- multiplying the Annuity Unit Value at the end of the immediately preceding Valuation Period by the Sub-account's Net Investment Factor during the period; and then
- dividing the result by 1.000 plus the assumed investment rate for the period. The assumed investment rate is an effective annual rate of 3%.
FIXED AMOUNT INCOME PAYMENTS. The income payment amount derived from any monies allocated to the Dollar Cost Averaging Fixed Account or Sub-accounts of the Guaranteed Maturity Fixed Account during the Accumulation Phase are fixed for the duration of the Income Plan. The Fixed Amount Income Payment is calculated by applying the portion of the Contract Value in the Fixed Account(s) on the Payout Start Date, adjusted by any Market Value Adjustment plus any amount from the Variable Account that the owner elects to apply to a Fixed Amount Income Payment and less any applicable premium tax, to the greater of the appropriate value from the Income Payment Table selected or such other value as we are offering at that time.
ANNUITY TRANSFERS. After the Payout Start Date, no transfers may be made from the Fixed Amount Income Payment. If you choose an Income Plan which depends on any person's life, transfers between Variable Sub-accounts or from the Variable Amount Income Payment to the Fixed Amount Income Payment may not be made for six months after the Payout Start Date. Annuity transfers may be made once every six months thereafter. If you choose an Income Plan which does not depend on any person's life, transfers between Variable Sub-accounts are from the Variable Amount Income Payment to the Fixed Amount Income Payment are permitted immediately.
PAYOUT TERMS AND CONDITIONS. The income payments are subject to the following terms and conditions:
- If the Contract Value is less than $2,000, or not enough to provide an initial payment of at least $20, we reserve the right to:
- change the payment frequency to make the payment at least $20; or
- terminate the Contract and pay you the Contract Value adjusted by any Market Value Adjustment and less any applicable taxes in a lump sum.
- If we do not receive a written choice of an Income Plan from you at least 30 days before the Payout Start Date, the Income Plan will be life income with guaranteed payments for 120 months.
- If you choose an Income Plan which depends on any person's life, we may require:
- proof of age and sex before income payments begin; and
- proof that the annuitant or joint annuitant is still alive before we make each payment.
- After the Payout Start Date, the Income Plan cannot be changed and withdrawals cannot be made unless income payments are being made from the Variable Account under Income Plan 3. You may terminate the income payments being made from the Variable Account under Income Plan 3 at any time and withdraw their value, subject to Withdrawal Charges.
- If any owner dies during the Payout Phase, the remaining income payments will be paid to the successor owner as scheduled.
Page 12

INCOME PAYMENT TABLES
The initial income payment will be at least the amount based on the adjusted age of the annuitant(s) and the tables below, less any federal income taxes which are withheld. The adjusted age is the actual age on the Payout Start Date reduced by one year for each six full years between January 1, 1983 and the Payout Start Date. Income payments for ages and guaranteed payment periods not shown below will be determined on a basis consistent with that used to determine those that are shown. The Income Payment Tables are based on 3.0% interest and the 1983a Annuity Mortality Tables.
INCOME PLAN 1 - LIFE INCOME WITH GUARANTEED PAYMENTS FOR 120 MONTHS
Monthly Income Payment for each $1,000 Applied to this Income Plan

	
	
	Annuitant's                  Annuitant's                  Annuitant's 
Age         Male   Female    Age         Male   Female    Age         Male   Female 
- ----------- -----  ------    ----------- -----  ------    ----------- -----  ------ 
    35      $3.43  $3.25        49       $4.15  $3.82        63       $5.52  $4.97 
    36       3.47   3.28        50        4.22   3.88        64        5.66   5.09 
    37       3.51   3.31        51        4.29   3.94        65        5.80   5.22 
    38       3.55   3.34        52        4.37   4.01        66        5.95   5.35 
    39       3.60   3.38        53        4.45   4.07        67        6.11   5.49 
    40       3.64   3.41        54        4.53   4.14        68        6.27   5.64 
    41       3.69   3.45        55        4.62   4.22        69        6.44   5.80 
    42       3.74   3.49        56        4.71   4.29        70        6.61   5.96 
    43       3.79   3.53        57        4.81   4.38        71        6.78   6.13 
    44       3.84   3.58        58        4.92   4.46        72        6.96   6.31 
    45       3.90   3.62        59        5.02   4.55        73        7.13   6.50 
    46       3.96   3.67        60        5.14   4.65        74        7.31   6.69 
    47       4.02   3.72        61        5.26   4.75        75        7.49   6.88 
    48       4.08   3.77        62        5.39   4.86

INCOME PLAN 2 - JOINT AND SURVIVOR LIFE INCOME WITH GUARANTEED
PAYMENTS FOR 120 MONTHS
Monthly Income Payment for each $1,000 Applied to this Income Plan

	
	
	Female Annuitant's Age 
   Male 
Annuitant's    35      40      45      50      55      60      65      70      75 
   Age 
-----------  -----   -----   -----   -----   -----   -----   -----   -----   ----- 
   35        $3.09   $3.16   $3.23   $3.28   $3.32   $3.36   $3.39   $3.40   $3.42 
   40         3.13    3.22    3.31    3.39    3.46    3.51    3.56    3.59    3.61 
   45         3.17    3.28    3.39    3.50    3.60    3.69    3.76    3.81    3.85 
   50         3.19    3.32    3.45    3.60    3.74    3.87    3.98    4.07    4.14 
   55         3.21    3.35    3.51    3.68    3.87    4.06    4.23    4.37    4.48 
   60         3.23    3.37    3.55    3.75    3.98    4.23    4.47    4.70    4.88 
   65         3.24    3.39    3.57    3.80    4.07    4.37    4.71    5.04    5.34 
   70         3.24    3.40    3.59    3.83    4.13    4.48    4.90    5.36    5.81 
   75         3.25    3.41    3.61    3.86    4.17    4.56    5.04    5.61    6.22

INCOME PLAN 3 - GUARANTEED NUMBER OF PAYMENTS

	
	
	Monthly Income Payment for each 
Specified Period             $1,000 Applied to this Income Plan 
----------------             ----------------------------------- 
    10 Years                    $9.61 
    11 Years                     8.86 
    12 Years                     8.24 
    13 Years                     7.71 
    14 Years                     7.26 
    15 Years                     6.87 
    16 Years                     6.53 
    17 Years                     6.23 
    18 Years                     5.96 
    19 Years                     5.73 
    20 Years                     5.51

Page 13

GENERAL PROVISIONS
THE ENTIRE CONTRACT. The entire contract consists of this Contract, any attached application, an any attached endorsements.
All statements made in written applications are representations and not warranties. No statement will be used by us in defense of a claim or to void the Contract unless it is included in a written application.
Only our officers may change the Contract or waive a right or requirement. No other individual may do this.
We may not modify this Contract without your consent, except to make it comply with any changes in the Internal Revenue Code or as required by any other applicable law.
INCONTESTABILITY. We will not contest the validity of this Contract after the issue date.
MISSTATEMENT OF AGE OR SEX. If any age or sex has been misstated, we will pay the amounts which would have been paid at the correct age and sex.
If we find the misstatement of age or sex after the income payments begin, we will:
- pay all amounts underpaid including interest; or
- stop payments until the total payments are equal to the corrected amount.
For purposes of the Misstatement of Age or Sex provision, interest will be calculated at an effective annual rate of 6%.
ANNUAL STATEMENT. At least once a year, prior to the Payout Start Date, we will send you a statement containing Contract Value information. We will provide you with Contract Value information at any time upon request. The information presented will comply with any applicable law.
SETTLEMENTS. We may require that this Contract be returned to us prior to any settlement. We must receive due proof of death of the owner or annuitant prior to settlement of a death claim. Due proof of death is one of the following:
- a certified copy of a death contract; or
- a certified copy of a decree of a court of competent jurisdiction as to a finding of death; or
- any other proof acceptable to us.
Any full withdrawal or death benefit under this Contract will not be less than the minimum benefits required by any statute of the state in which the Contract is delivered.
DEFERMENT OF PAYMENTS. We will pay any amounts due from the Variable Account under this Contract within seven days, unless:
- the New York Stock Exchange is closed for other than usual weekends or holidays, or trading on such Exchange is restricted;
- an emergency exists as defined by the Securities and Exchange Commission; or
- the Securities and Exchange Commission permits delay for the protection of Contract holders.
We reserve the right to postpone payments or transfers from the Dollar Cost Averaging Fixed Account and Guaranteed Maturity Fixed Account for up to six months. If we elect to postpone payments or transfers from the Dollar Cost Averaging Fixed Account or Guaranteed Maturity Fixed Account for 30 days or more, we will pay interest as required by applicable law. Any interest would be payable from the date the payment or transfer request is received by us to the date the payment or transfer is made.
VARIABLE ACCOUNT MODIFICATIONS. We reserve the right, subject to applicable law, to make additions to, deletions from, or substitutions for the mutual fund shares underlying the Sub-accounts of the Variable Account. We will not substitute any shares attributable to your interest in a Sub-account of the Variable Account without notice to you and prior approval of the Securities and Exchange Commission, to the extent
Page 14

required by the Investment Company Act of 1940.
We reserve the right to establish additional Sub-accounts of the Variable Account, each of which would invest in shares of another mutual fund. You may then instruct us to allocate purchase payments or transfers to such Sub-accounts, subject to any terms set by us or the mutual fund. We reserve the right to limit the availability of funds for this Contract.
In the event of any such substitution or change, we may by endorsement, make such changes as may be necessary or appropriate to reflect such substitution or change.
If we deem it to be in the best interests of persons having voting rights under the contracts, the Variable Account may be operated as a management company under the Investment Company Act of 1940 or it may be deregistered under such Act in the event such registration is no longer required.
Page 15

	
	
	GLENBROOK LIFE AND ANNUITY COMPANY 
GLENBROOK                                                                                       P.O. BOX 94042 
  LIFE AND ANNUITY                                                                              PALATINE, IL 60094-4042 
 
 
                                 APPLICATION FOR FLEXIBLE PREMIUM DEFERRED VARIABLE ANNUITY 
- ---------------------------------------------------------------------------------------------------------------------------------- 
OWNERS 
 
Name                                   Soc. Sec. No.                                               Birth Date    /  / 
     -------------------------------                 -------------------------------------                    ---------- 
Address                                City                                                        State            Zip 
       -----------------------------                 -------------------------------------                -----         ---------- 
         / / Male  / / Female          Relationship to Owner 
                                                              -------------------------------------------------------------------- 
 
Name                                   Soc. Sec. No.                                               Birth Date    /  / 
     -------------------------------                 -------------------------------------                    ---------- 
Address                                City                                                        State            Zip 
       -----------------------------                 -------------------------------------                -----         ---------- 
         / / Male  / / Female          Relationship to Owner 
                                                              -------------------------------------------------------------------- 
- ---------------------------------------------------------------------------------------------------------------------------------- 
ANNUITANT (Leave blank if Annuitant same as sole Owner.) 
 
Name                                   Soc. Sec. No.                                               Birth Date    /  / 
     -------------------------------                 -------------------------------------                    ---------- 
Address                                City                                                        State            Zip 
       -----------------------------                 -------------------------------------                -----         ---------- 
         / / Male  / / Female          Relationship to Owner 
                                                              -------------------------------------------------------------------- 
- ---------------------------------------------------------------------------------------------------------------------------------- 
BENEFICIARY 
 
Primary                                Relationship to Owner 
       -----------------------------                          -------------------------------------------------------------------- 
 
Contingent                             Relationship to Owner 
          --------------------------                          -------------------------------------------------------------------- 
- ---------------------------------------------------------------------------------------------------------------------------------- 
INVESTMENT ALTERNATIVE ALLOCATION--$ OR % 
 
INITIAL PURCHASE PAYMENT $                                                     ENHANCED DEATH BENEFIT    / / Yes   / / No 
                           -------------------------------------- 
 
      DEAN WITTER                                     DREYFUS                                      FIDELITY 
 
      VIS Dividend Growth                             VIF Growth & Income                          VIP II Contrafund 
- -----                                           -----                                        ----- 
 
      VIS Dividend Growth                             VIF Money Market                             VIP Growth 
- -----                                           -----                                        ----- 
 
      VIS Quality Income Plus                         VIF Small Company Stock                      VIP High Income 
- -----                                           -----                                        ----- 
 
      VIS Utilities                                   Socially Responsible Growth Fund 
- -----                                           ----- 
 
      MFS                                             TWENTIETH CENTURY                            OTHER 
      Emerging Growth Series                          TCI Balanced 
- -----                                           -----                                                     ------------------------- 
 
      Limited Maturity Series                         TCI International 
- -----                                           -----                                                     ------------------------- 
 
 
                                               GUARANTEED MATURITY FUND ACCOUNT 
 
      for 1 year              for 3 years                   for 5 years                   for 7 years                  for 10 years 
- -----                   -----                         -----                         -----                        ----- 
- ---------------------------------------------------------------------------------------------------------------------------------- 
TAX QUALIFIED PLAN   / / Yes     / / No 
 
/ / IRA ROLLOVER     / / IRA TRANSFER       / / IRA/YEAR OF CONTRIBUTION           / / OTHER 
                                                                         -----               ------------------------------------- 
- ---------------------------------------------------------------------------------------------------------------------------------- 
SPECIAL INSTRUCTIONS                                                 REPLACEMENT 
                                                                     WILL THE ANNUITY APPLIED FOR REPLACE ANY EXISTING INSURANCE 
                                                                     OR ANNUITY    / / Yes    / / No 
 
                                                                     COMPANY                         POLICY NO. 
 
                                                                     ------------------------------  ----------------------------- 
- ---------------------------------------------------------------------------------------------------------------------------------- 
If this application is declined, Glenbrook Life and Annuity Company will have no liability except to return the purchase payments. 
 
I UNDERSTAND THAT ANY DISTRIBUTION FROM A GUARANTEED MATURITY FIXED ACCOUNT PRIOR TO THE END OF A RATE GUARANTEE PERIOD MAYBE 
SUBJECT TO A MARKET VALUE ADJUSTMENT.  I UNDERSTAND THAT CONTRACT VALUES AND INCOME PAYMENTS BASED ON THE INVESTMENT EXPERIENCE 
OF A VARIABLE ACCOUNT ARE VARIABLE AND ARE NOT GUARANTEED AS TO DOLLAR AMOUNT.  I RECEIVED THE CURRENT PROSPECTUSES FOR THIS 
VARIABLE ANNUITY.  FOR APPLICANTS IN NEW JERSEY:  ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION 
FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.  FOR APPLICANTS IN KENTUCKY, OHIO AND PENNSYLVANIA:  ANY 
PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR 
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 SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL 
PENALTIES. 
 
I HAVE READ THE ABOVE STATEMENTS.  I REPRESENT THAT THEY ARE COMPLETE AND TRUE TO THE BEST OF MY KNOWLEDGE OR BELIEF. 
 
Signed at                                                                                             Date 
                          -----------------------------------------------------------------------                 ---------------- 
                      City                                              State 
 
                                                                                                      Phone No(s) 
Signature(s) of Owner(s)                                                                              Of Owner(s) 
                          -----------------------------------------------------------------------                 ---------------- 
- ---------------------------------------------------------------------------------------------------------------------------------- 
AGENT USE ONLY  Do you have any reason to believe that the Contract applied for is to replace or change any existing annuity or 
                Life Insurance?   / / Yes     / / No 
 
 
Agent's Signature                                                    Agent/Branch No. 
                  ----------------------------------------------                     --------------------------------------------- 
 
Agent's Signature 
                  ----------------------------------------------

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