Fill - Free fillable FIT Horizon Income Rev 06/20 PDF form

FIT Horizon Income

Rev 06/20

1) Leave all pages marked “This copy to be left with applicant”, with the client.

2) After reviewing the disclosure(s) with the client, send the signed specification page marked “Submit with

Annuity Application” along with the completed and signed application package.

• Email: imaging@nationallife.com (preferred method)

• Fax: 214-638-9371

• Mail: National Life Group, 1 National Life Drive, Montpelier, VT 05604

Send the application to us by any method below:

Please allow a minimum of 2 business days to be able to view the status of this application on the National Life

Group website www.nationallife.com

3) Continue to submit other required new business forms for your transaction type.

New business application/disclosure

• Ensure you have the correct version of the application and it's completed in full

Transfer/Exchange/Rollover

• If transfer company requires wet signatures then please mail the entire application package with all

applicable signatures (TPA, client etc). Do not send multiple versions of the same transfer paperwork.

Suitability

• Applies if any of the below scenarios is applicable:

• Applicant > 64 years of age

• A Transfer/Rollover/Exchange is involved

• Line of business is Non-Qualified or IRA (Excludes SIMPLE or SEP IRAs)

Replacement

• Applies if money originated from a life insurance or annuity policy

• Name of Life Insurance Company is required for all Replacements

State Specific Forms

With National Life Group, submissions are as easy as 1, 2, 3:

For use in: AL, AK, AR, AZ, CO, DC, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, ME, MD, MI,

MN, MO, MS, MT, NC, NE, NV, NH, NM, OH, OK, RI, SC, TN, TX, UT, VA, WA, WV, WI.

National Life Group

is a trade name of National Life Insurance Company, Montpelier, VT, Life Insurance Company of

the Southwest (LSW), Addison, TX and their affiliates. Each company of National Life Group is solely responsible for its

own financial condition and contractual obligations. LSW is not an authorized insurer in New York and does not conduct

insurance business in New York.

Life Insurance Company of the Southwest

Form No. 12282 Cat. No. 105455; LR 13075

NOTE: This product cannot be used for inherited/beneficiary accounts of any qualification

Form No. 12238

Page 1 of 3

Cat. No. 105223

LR 12528

Rev. 0420

Single Premium Indexed Annuity

Policy Disclosure

This Disclosure reviews important points to consider before you¹ purchase a Single Premium Indexed Annuity. Please refer to the Product

Specification page at the end of this Disclosure for specific details regarding benefits, charges, limitations, and additional features of the annuity.

The Single Premium Indexed Annuity is a tax deferred² annuity, which means all amounts in the annuity accumulate with federal and state

income tax deferred until withdrawn or received as income. You can use the annuity to save for retirement and to receive retirement income for

life. It is not meant to be used to meet short-term financial goals.

Section I - The Annuity Policy

How will the value of my annuity grow?

Your annuity's Accumulation Value will grow by any credited interest. The Accumulation Value equals your premium paid (net of any applicable

state taxes), plus credited interest, minus any withdrawals taken, minus any rider charges.

How is interest calculated and credited?

Each Crediting Strategy will use one of the following methods for determining credited interest: Annual Point to Point with a Cap, Annual Point

to Point with a Participation Rate, Monthly Sum Cap, or Declared Interest.

Annual Point to Point with a Cap - Credits interest after the completion of each Policy Year³, based in part on changes of an underlying index.

The credited rate equals the Annual Index Change, subject to a maximum called the Cap and a minimum of 0%. The Annual Index Change is

the change in the index value at the beginning of the Policy Year to the index value at the end of the Policy Year. We set the Cap in advance for

each Policy Year. The Cap will be no less than 0.25%.

Annual Point to Point with a Participation Rate - Credits interest after the completion of each Policy Year, based in part on changes of an

underlying index. The credited rate equals the Annual Index Change multiplied by the Participation Rate, the result being subject to a minimum

of 0%. The Annual Index Change is the change in the index value at the beginning of the Policy Year to the index value at the end of the Policy

Year. We set the Participation Rate in advance for each Policy Year. The Participation Rate will be no less than 5%.

Monthly Sum Cap - Credits interest after the completion of each Policy Year, based in part on changes of an underlying index. The credited rate

equals the sum of the 12 Monthly Index Changes, the result being subject to a minimum of 0%. The Monthly Index Change for each Policy

Month³ is the change in the index value at the beginning of the Policy Month to the index value at the end of the Policy Month, subject to a

maximum called the Monthly Cap. We set the Monthly Cap in advance for each Policy Year. The Monthly Cap will be no less than 0.25%.

Declared Interest - Credits interest daily at an annual effective rate we set in advance for each Policy Year. The rate will be no less than 0.10%.

The following table provides examples of how to determine the credited rate in various hypothetical situations for the Annual Point to Point with

a Cap:

Step 3: The interest rate credited is 4.50%.

Step 2: The result is limited to no less than 0.00%.

Step 1: Multiply the Participation Rate (which had been declared

at the beginning of the Policy Year) by the Annual Index Change.

30% x 15.00% = 4.50%

Example

Participation

Rate

Hypothetical

Annual

Index

Change

Multiplied

Result

Annual

Minimum

0.00%

Credited

Rate

4.50%

0.00%

0.60%

4.50%

-4.50%

0.60%

1 30% 15.00%

3 30% -15.00%

2 30% 2.00%

In the first example, the credited rate is determined as follows:

The following table provides examples of how to determine the credited rate in various hypothetical situations for the Annual Point to Point with

a Participation Rate:

In the first example, the credited rate is determined as follows:

Step 1: Compare the Annual Index Change to the Cap of 3.00%

(which had been declared at the beginning of the Policy Year) and

limit to no less than 0.00%. The Cap is smaller, since 15.00% is

greater than the Cap of 3.00%.

Step 2: The credited rate is limited to the Cap of 3.00%.

Step 3: The credited rate is 3.00%.

Example

Hypothetical

Annual

Index

Change

15.00%

-15.00%

2.00%

Annual

Cap

Annual

Minimum

0.00%3.00%

Credited

Rate

3.00%

0.00%

2.00%

What is the framework for crediting interest?

You may allocate your Accumulation Value to Interest Accounts that use any combination of the Crediting Strategies shown on the Specification

Page in whole percentages. We maintain each Interest Account separately.

National Life Group® is a trade name representing various affiliates, which offer a variety of financial service products.

P: 800-732-8939 │ F: 214-638-9162 │ Imaging@NationalLife.com │www.NationalLife.com

Centralized Mailing Address: One National Life Drive, Montpelier, VT 05604-5555

Home Office: 15455 Dallas Parkway, Suite 800, Addison, TX 75001

Leave with Applicant

The following table provides examples of how to determine the credited rate in two hypothetical situations for the Monthly Sum Cap:

Hypothetical

Example 1 Example 2

Policy

Month

Monthly

Index Change

Before Cap

Hypothetical

Cap of

1.00%

Hypothetical

Cap of

1.50%

1 3.00% 1.00% 1.50%

2 1.00% 1.00% 1.00%

3 5.00% 1.00% 1.50%

4 -5.00% -5.00% -5.00%

5 3.00% 1.00% 1.50%

6 6.00% 1.00% 1.50%

7 4.00% 1.00% 1.50%

8 -1.00% -1.00% -1.00%

9 2.00% 1.00% 1.50%

10 1.00% 1.00% 1.00%

11 -3.00% -3.00% -3.00%

12 0.00% 0.00% 0.00%

Sum -1.00% 2.00%

Annual Minimum 0.00% 0.00%

Credited Rate 0.00% 2.00%

Step 4: The result is limited to no less than 0%.

Step 2: At the end of the Policy Year the Monthly Index Changes

are summed.

Step 1: Each month the Monthly Index Change is measured subject

to a maximum monthly cap.

In both examples the credited rate is determined as follows:

What happens if I take out some or all of the money from my annuity?

All withdrawals from the annuity may be subject to a Withdrawal Charge. After the first Policy Year, you may withdraw up to 10% of the

Accumulation Value (“Free Withdrawal Amount”) in any one year, without incurring a Withdrawal Charge. Withdrawal Charges are a percentage of

the amount withdrawn in excess of this “Free Withdrawal Amount” see product specification page for details on Withdrawal Charges. The

minimum partial withdrawal you may request is $500, and your Accumulation Value must be no less than $5,000 after the withdrawal. Note: All

withdrawals are subject to the qualified plan's eligibility requirements, if applicable.

Nursing Care Rider

If approved in your state the Policy will be issued with the Nursing Care Rider. If you become confined to a qualified nursing care facility for 60

consecutive day you may be eligible to make a withdrawal from your Policy without application of Withdrawal Charges. Rider benefits are based

upon your issue age:

•

75 or under at issue, you may withdraw a cumulative amount of $250,000 from all policies issued by us without application of Withdrawal

Charges

• 76 and older at issue, you may take a one-time withdrawal of up to 25% of the Accumulation Value without application of Withdrawal Charges

Section II - Access to Value

You may make a total or partial withdrawal, or you may request that your annuity be converted to periodic income. These benefits will be based

on the Accumulation Value, Cash Value and/or Policy Value of your annuity. The Accumulation Value is previously described. The Cash Value of

your annuity is equal to the larger of the Accumulation Value less applicable Withdrawal Charges or the Policy Value. The Policy Value equals a

percentage of the single premium less withdrawals taken, accumulated daily at an annual effective interest rate of no less than 1%. The

percentage of single premium will be no less than 87.5%.

The Accumulation Value of your policy is accessible to meet your needs. You may take a full or partial withdrawal, fulfill a Required Minimum

Distribution requirement, receive annuitized payments or receive policy loans (loans only available on 403(b) or 457(b) policies when approved by

plan and available by law). All withdrawals are subject to federal income tax, state income tax and may be subject to Withdrawal Charges.

Transfers between and among Interest Accounts that use different Crediting Strategies may be made only at the end of the Policy Year after any

interest is credited and only after our receipt of your written request for the transfer at least 15 days prior to the transfer.

How do I transfer amounts in my annuity among Interest Accounts?

Terminal Illness Rider

If approved in your state the Policy will be issued with the Terminal Illness Rider. If after the first Policy Year you are diagnosed terminally ill within

12 months you may withdraw a cumulative amount of $250,000 from all policies issued by us without application of Withdrawal Charges once we

have verified the diagnosis with your physician.

Leave with Applicant

Page 2 of 3

Form No. 12238

Rev. 0420

What happens after I die?

If you die before we start to pay you periodic income, a death benefit will be paid to your beneficiary either as one payment or as a series of

payments over time. If you are the Annuitant, the death benefit is the greater of the Accumulation Value or the Policy Value. If you are the Owner

but not the Annuitant, the death benefit is the Cash Value. If your death occurs after periodic income payments have begun, any payments which

remain to be paid will be paid to your beneficiary.

Can I take a loan from my annuity

If you purchase the annuity as part of a 403(b) or 457(b) plan and your employer's plan permits loans, you may request a loan while pledging your

annuity as collateral, which means that any death benefit or full withdrawal amount will be reduced by any outstanding loan balance. The loan

interest rate charged is a variable loan interest rate based on Moody's Corporate Bond Yield Average. The amount available to be borrowed is

limited by law, plan guidelines and company rules. For more information, please see the loan rider in your policy.

Leave with Applicant

Page 3 of 3

Form No. 12238

Rev. 0420

How do I get income (payouts) from my annuity

You may convert your annuity to income, receiving monthly payments for ten years and then for as long as you are alive. We will calculate the

income using the Cash Value. If you do so after the number of Policy Years specified in your policy, any applicable Withdrawal Charges will be

waived.

Do I pay any fees or charges?

The annuity has no fees or expenses charged against your Accumulation Value. Some states charge a premium tax on annuities, in addition to

any applicable state income tax. If we must pay this tax, we will deduct it from your premium, from your policy's values or from policy benefits as is

appropriate (see "How are state premium taxes assessed?" below). Charges may apply for certain riders.

Section III - Fees, Expenses & Other Charges

How will payouts and withdrawals from my annuity be taxed?

When you receive income or make a withdrawal, you pay ordinary income taxes on the taxable value. If you make a withdrawal before age 59½,

you may be subject to a 10% federal income tax penalty unless you qualify under any exceptions provided by law.

How are state premium taxes assessed?

As of the date of publication of this document, states assessing premium taxes and the method of handling are shown below. We will apply state

premium taxes in accordance with the state law at the time of premium receipt, withdrawal, or annuitization. Please note that any state may

institute a premium tax that may be applicable to policies after issue, whether or not the policy was issued prior to the existence of the premium

tax.

Residents of Maine: The State of Maine imposes a state premium tax of 2% of all premiums paid to non-qualified annuities. We deduct 2% from

your premium and pay this to the state. We apply the remaining 98% of the premium to the Accumulation Value. Since the Cash Value may

depend on the Accumulation Value, the Cash Value may be reduced as a result of the state premium tax.

Residents of South Dakota and Wyoming: The State of South Dakota imposes a state premium tax of 1.25% and the State of Wyoming imposes

a state premium tax of 1% of all premiums paid to non-qualified annuities. We deduct this amount from your premium and pay this to the state.

We apply the remaining amount of the premium to the Accumulation Value. Since the Cash Value may depend on the Accumulation Value, the

Cash Value may be reduced as a result of the state premium tax.

Residents of California: The State of California imposes a 0.50% state premium tax in the case of qualified annuities and a 2.35% state premium

tax in the case of non-qualified annuities. This tax is assessed on Withdrawal Charges in the case of a withdrawal. It is assessed on amounts

withdrawn to provide a periodic income. We deduct the amount of the tax from the amount withdrawn and pay this to the state. We then provide

or apply the remaining amount as is appropriate at that time.

Residents of Nevada and West Virginia: The State of Nevada imposes a state premium tax of 3.5% in the case of non-qualified annuities while

the State of West Virginia imposes a state premium tax of 1% in the case of both qualified and non-qualified annuities. This tax is assessed on

amounts withdrawn to provide a periodic income. We deduct the amount of the tax from the amount withdrawn and pay this to the state. We then

apply the remaining amount as is appropriate at that time.

Section IV - Taxes

You should consult your own tax advisor for tax advice.

What should I know about Life Insurance Company of the Southwest?

Life Insurance Company of the Southwest is a life insurance company that specializes in annuity and life insurance products. Our goal is to provide

products that benefit policyholders regardless of market conditions. We were incorporated in 1955 under the laws of Texas as a legal reserve

insurance company and are licensed in 49 states and the District of Columbia. We are a member of National Life Group, which is a diversified

family of financial services companies that has successfully forged a strong identity as a product innovator offering personalized service.

Companies in the National Life Group offer a comprehensive portfolio of life insurance, annuity and investment products to help individuals,

families and businesses pursue their financial goals.

Acknowledgement and Understanding

Please do not rely on any statement about the annuity that is not consistent with what is described in this Disclosure or in any other material written

by us and provided to you. In case of any ambiguity, conflict or question regarding interpretation of this Disclosure or any other published materials

or statements, the provisions of the Policy form prevail. Please consult your annuity Policy form for further details.

When we use the words, “you” and “your” in this Disclosure, we mean the applicant of the annuity. “We”, “us” and “our” mean Life Insurance Company of the

Southwest.

Annuities owned by certain trusts or corporate entities may not enjoy the tax deferral feature. Buying an annuity within a tax-deferred retirement plan does not

provide tax benefits beyond what are provided by these qualified arrangements. If considering an annuity within a retirement plan, base your decision on the

annuity's other features and benefits as well as its risks and costs, not on its tax benefits.

Policy Years are yearly periods which start on the issue date and on the same month and day each year thereafter. Policy Months are monthly periods which

start on the issue date and on the same day of each month thereafter.

Loans may not be available in all states. All 403(b) and 457(b) annuities must be associated with an employer plan. Hardship withdrawals and loans are also

subject to any restrictions listed in your employer's plan documents. Loans are not available on Roth 403(b) or Roth 457(b).

Benefits at annuitization could be reduced if a misstatement of age or gender has occurred.

Form No. 12250 Page 1 of 5

Cat. No. 105224

LR 13049

Rev. 0420

Product Specification Page

FIT Horizon Income and

Guaranteed Lifetime Income Rider

National Life Group® is a trade name representing various affiliates, which offer a variety of financial service products.

P: 800-732-8939 │ F: 214-638-9162 │ Imaging@NationalLife.com │www.NationalLife.com

Centralized Mailing Address: One National Life Drive, Montpelier, VT 05604-5555

Home Office: 15455 Dallas Parkway, Suite 800, Addison, TX 75001

Leave with Applicant

FIT Horizon Income is Policy Form Series 20710(0320), or state variation thereof.

The Guaranteed Lifetime Income Rider is Rider Form Series 20712(0320), or state variation thereof.

• S&P 500

Index Annual Point to Point

• S&P 500

Index Monthly Sum Cap

• Global Balanced Index Annual Point to Point

• US Fundamental Balanced Index Annual Point to Point

• Declared Interest

Available Crediting Strategies for Interest Accounts:

• If the MVA Factor is greater than or equal to one, then the MVA Amount

is determined by multiplying the amount withdrawn in excess of any Free

Withdrawal Amount times the result of subtracting one from the MVA

Factor. The withdrawal is then adjusted upward by the MVA Amount.

• If the MVA Factor is less than one, then the MVA Amount is determined by multiplying the amount withdrawn in excess of any Free

Withdrawal Amount times the result of subtracting the MVA Factor from one. The withdrawal is then adjusted downward by the MVA

Amount.

• the Accumulation Value minus the Policy Value minus any Recapture Amount and Withdrawal Charge applicable upon withdrawal of the

entire Accumulation Value; times

• the amount withdrawn in excess of any Free Withdrawal Amount; divided by

• the Accumulation Value minus any Free Withdrawal Amount

The MVA Amount will never be greater than the MVA Limit. Within that bound:

The MVA Limit at the time of the calculation of the MVA Amount equals:

However, the MVA limit can be no less than zero.

Market Value Adjustment (MVA)

Immediate Interest Credit

A Market Value Adjustment is an upward or downward adjustment that may

be applied to amounts withdrawn within the first ten Policy Years. The MVA

applies to amounts withdrawn in excess of any Free Withdrawal Amount, even

if the applicable Withdrawal Charge Percentage is zero. The MVA does not

apply to any death benefit.

( )

1 + i

1 + j

n/12

, where

The MVA Factor is calculated using the following formula:

i is the weekly-average 10-year U.S. Treasury Constant

Maturity rate two weeks prior to the policy issue date.

j is the weekly-average 10-year U.S. Treasury Constant

Maturity rate two weeks prior to the calculation of the

MVA.

n is 120 minus the number of completed months since

the issue date.

• Rate Booster S&P 500

Index Annual Point to Point

• Rate Booster S&P 500

Index Monthly Sum Cap

• Rate Booster Global Balanced Index Annual Point to Point

• Rate Booster US Fundamental Balanced Index Annual Point to Point

If you choose the Split Bonus GLIR, an Immediate Interest Credit equal to 5% of

the net single premium is credited to the Accumulation Value at policy issue. If a

withdrawal is made from the policy in excess of the Free Withdrawal Amount, an

Immediate Interest Credit Recapture will apply during the first eight Policy Years.

If you choose the Max Bonus GLIR, there is no Immediate Interest Credit.

Guaranteed Lifetime Income Rider Request and Understanding

I understand that the Activation Bonus, Immediate Interest Credit (if any), Guaranteed Withdrawal Percentages and Rider Charge Rates will be

those in effect on the date the annuity is issued.

GLIR Rider Charge - 1% of Accumulation Value for all Policy Years

Accumulation Value allocated to a Crediting Strategy with the Rate Booster will be assessed an annual charge at the beginning of each Policy

Year equal to 1% of the Accumulation Value allocated to that Crediting Strategy. Crediting Strategies with the Rate Booster will have participation

rates or caps that are higher than standard Crediting Strategies.

Product Issuance Guidelines

• Issue age limits for this annuity are owner/annuitant age 35-75

• Minimum Premium: $50,000

• Maximum premium: Issue ages 35-70 - $1,000,000; 71-75 - $750,000

• Maximum premium limits are per life and are subject to change

• Policy will be issued on the 7th, 14th, 21st, or 28th day of the month following or coincident with the date the single premium is paid

• This annuity is designed for people who are seeking a policy to provide lifetime income.

Immediate Interest Credit Recapture Schedule

Policy Year 1 2 3 4 5 6 7 8 9+

Recapture % 2090 80 70 60 50 40 30 0

Withdrawal Charge %

Policy Year 1 2 3 4 5 6 7 8 9 10+

Standard 18.25 8 7 6 5 4 3 2 0

"Standard & Poor's

", "S&P

", "S&P 500

", "Standard & Poor's 500", and "500" are trademarks of The McGraw-Hill Companies, Inc. and have been

licensed for use by Life Insurance Company of the Southwest. The product is not sponsored, endorsed, sold or promoted by Standard & Poor's and

Standard & Poor's makes no representation regarding the advisability of purchasing the product.

The Global Balanced SG Index (the “Index”) is the exclusive property of SG Americas Securities, LLC (SG Americas Securities, LLC, together with

its affiliates, “SG”). SG has contracted with [S&P Opco, LLC (a subsidiary of S&P Dow Jones Indices LLC] (“S&P”) to maintain and calculate the

Index. “SG Americas Securities, LLC”, “SGAS”, “Société Générale”, “SG”, “Société Générale Indices”, “SGI”, and “Global Balanced SG

Index” (collectively, the “SG Marks”) are trademarks or service marks of SG. SG has licensed use of the SG Marks to Life Insurance Company of

the Southwest (“LICS”) for use in a fixed indexed annuity offered by LICS (the “Fixed Indexed Annuity”). SG's sole contractual relationship with

LICS is to license the Index and the SG Marks to LICS. None of SG, S&P, or other third party licensor (collectively, the “Index Parties”) to SG is

acting, or has been authorized to act, as an agent of LICS or has in any way sponsored, promoted, solicited, negotiated, endorsed, offered, sold,

issued, supported, structured or priced any Fixed Indexed Annuity or provided investment advice to LICS.

No Index Party has passed on the legality or suitability of, or the accuracy or adequacy of the descriptions and disclosures relating to, the Fixed

Indexed Annuity, including those disclosures with respect to the Index. The Index Parties make no representation whatsoever, whether express or

implied, as to the advisability of purchasing, selling or holding any product linked to the Index, including the Fixed Indexed Annuity, or the ability of

the Index to meet its stated objectives, including meeting its target volatility. The Index Parties have no obligation to, and will not, take the needs of

LICS or any annuitant into consideration in determining, composing or calculating the Index. The selection of the Index as a crediting option under a

Fixed Indexed Annuity does not obligate LICS or SG to invest annuity payments in the components of the Index.

THE INDEX PARTIES MAKE NO REPRESENTATION OR WARRANTY WHATSOEVER, WHETHER EXPRESS OR IMPLIED, AND HEREBY

EXPRESSLY DISCLAIM ALL WARRANTIES (INCLUDING, WITHOUT LIMITATION, THOSE OF MERCHANTABILITY OR FITNESS FOR A

PARTICULAR PURPOSE OR USE), WITH RESPECT TO THE INDEX OR ANY DATA INCLUDED THEREIN OR RELATING THERETO, AND IN

PARTICULAR DISCLAIM ANY GUARANTEE OR WARRANTY EITHER AS TO THE QUALITY, ACCURACY, TIMELINESS AND/OR

COMPLETENESS OF THE INDEX OR ANY DATA INCLUDED THEREIN, THE RESULTS OBTAINED FROM THE USE OF THE INDEX AND/OR

THE CALCULATION OR COMPOSITION OF THE INDEX, OR CALCULATIONS MADE WITH RESPECT TO ANY FIXED INDEXED ANNUITY AT

ANY PARTICULAR TIME ON ANY PARTICULAR DATE OR OTHERWISE. THE INDEX PARTIES SHALL NOT BE LIABLE (WHETHER IN

NEGLIGENCE OR OTHERWISE) TO ANY PERSON FOR ANY ERROR OR OMISSION IN THE INDEX OR IN THE CALCULATION OF THE

INDEX, AND THE INDEX PARTIES ARE UNDER NO OBLIGATION TO ADVISE ANY PERSON OF ANY ERROR THEREIN, OR FOR ANY

INTERRUPTION IN THE CALCULATION OF THE INDEX. NO INDEX PARTY SHALL HAVE ANY LIABILITY TO ANY PARTY FOR ANY ACT OR

FAILURE TO ACT BY THE INDEX PARTIES IN CONNECTION WITH THE DETERMINATION, ADJUSTMENT OR MAINTENANCE OF THE

INDEX. WITHOUT LIMITING THE FOREGOING, IN NO EVENT SHALL AN INDEX PARTY HAVE ANY LIABILITY FOR ANY DIRECT DAMAGES,

LOST PROFITS OR SPECIAL, INCIDENTAL, PUNITIVE, INDIRECT OR CONSEQUENTIAL DAMAGES, EVEN IF NOTIFIED OF THE

POSSIBILITY OF SUCH DAMAGES.

No Index Party is a fiduciary or agent of any purchaser, seller or holder of a Fixed Indexed Annuity. None of SG, S&P, or any third party licensor

shall have any liability with respect to the Fixed Indexed Annuity in which an interest crediting option is based is on the Index, nor for any loss

relating to the Fixed Indexed Annuity, whether arising directly or indirectly from the use of the Index, its methodology, any SG Mark or otherwise.

Obligations to make payments under the Fixed Indexed Annuities are solely the obligation of LICS.

In calculating the performance of the Index, SG deducts a maintenance fee of 0.50% per annum on the level of the Index, and fixed transaction and

replication costs, each calculated and deducted on a daily basis. The transaction and replication costs cover, among other things, rebalancing and

replication costs. The total amount of transaction and replication costs is not predictable and will depend on a number of factors, including the

leverage of the Index, which may be as high as 200%, the performance of the indexes underlying the Index, market conditions and the changes in

the market states, among other factors. The transaction and replication costs, which are increased by the Index's leverage, and the maintenance

fee will reduce the potential positive change in the Index and increase the potential negative change in the Index. While the volatility control applied

by the Index may result in less fluctuation in rates of return as compared to indices without volatility controls, it may also reduce the overall rate of

return as compared to products not subject to volatility controls.

The PIMCO US Fundamental Balanced Index (the “Index”) is a trademark of Pacific Investment Management Company LLC (“PIMCO”) and has

been licensed for use for certain purposes by National Life Insurance Company (the “Company”) with respect to this annuity (“the Product”). 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,

appropriateness or needs, as applicable, of the Company, the Product, or any Product owners. The Product is not sold, sponsored, endorsed or

promoted by PIMCO or any other party involved in, or related to, making or compiling the Index. It is not possible to directly invest in 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 Product owner, the Company, or any member of the public regarding the advisability of purchasing annuities generally or the Product

particularly, the legality of the Product under applicable federal or state securities, state insurance and any tax laws, the ability of the Product 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 the Company, the Product, Product owners, or any other person or entity.

PIMCO does not provide investment advice to the Company with respect to the Product, to the Product, or to Product 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

the Company with respect to the Product. Neither PIMCO nor any other party involved in, or related to, making or compiling the Index makes any

representation regarding the Index, Index information, performance, annuities generally or the Product particularly. 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 Product.

The Index is comprised of a number of constituents, some of which are owned by entities other than PIMCO. The Index relies on a variety of

publically available data and information and licensable equity and fixed income sub-indices. All disclaimers referenced in herein relative to PIMCO

also apply separately to those entities that are owners of the constituents of the PIMCO Index and to the Index Calculation Agent.

Leave with Applicant

Page 2 of 5

Form No. 12250

Rev. 0420

Leave with Applicant

Page 3 of 5

Form No. 12250

Rev. 0420

Guaranteed* Lifetime Income Rider (GLIR)

Your policy will be issued with your choice of Max Bonus GLIR or Split Bonus GLIR (each is described below). You must indicate your choice on

the application. Your selection cannot be changed after policy issue. Under either GLIR, you may receive specified withdrawal payments from the

annuity that extend for your lifetime, even if the withdrawal payments completely deplete the Accumulation Value. Without the GLIR, the annuity

terminates when the Accumulation Value reduces to zero.

Withdrawal Benefits under the GLIR

The Accumulation Period is the period of time before the date you elect in writing to exercise withdrawals under the GLIR. These withdrawals are

referred to as Guaranteed Withdrawal Payments. The Withdrawal Period begins on the date of the first installment of the Guaranteed Withdrawal

Payment. You can begin taking Guaranteed Withdrawal Payments when you have attained the minimum required age, the annuity has been

inforce for at least one year, and when all loans, if any, have been repaid.

The initial Guaranteed Withdrawal Payment is determined at the time of the first payment and equals the Accumulation Value multiplied by the

applicable Activation Bonus then multiplied by the applicable Guaranteed Withdrawal Percentage. The Activation Bonus is based on how many

years the policy has been inforce and whether you choose Max Bonus GLIR or Split Bonus GLIR. The Guaranteed Withdrawal Percentage is

determined by your age on the date the Withdrawal Period begins. The Guaranteed Withdrawal Payment is the maximum annual withdrawal

benefit provided by the GLIR. You can request that the Guaranteed Withdrawal Payment be paid in monthly, quarterly, semi-annual, or annual

installments. All withdrawals, whether elected under the GLIR or the terms of the annuity itself, reduce the values of the annuity.

GLIR Bonus Options

Note: The Activation Bonus only applies in the calculation of lifetime income, it does not increase your Accumulation Value.

Max Bonus GLIR

Split Bonus GLIR

2-5

Policy Year Income Elected

105%

Activation Bonus

6-10

150%

16-20

175%21+

130%

11-15

115%

2-5

125%

11-15

145%

21+ 200%

16-20

170%

6-10

Activation Bonus

115%

Policy Year Income Elected

Activation Bonus

1. Immediate Interest Credit of 5% added to the Accumulation Value at issue.

2. Activation Bonus

($200,000 x 170%) x 4.5% = $15,300 for life assuming no Excess Withdrawals

Assume Max Bonus GLIR was elected at issue. Hypothetically at age 65, the Guaranteed Withdrawal Percentage is 4.5%, the Accumulation

Value is $200,000, and the Policy is in the 16th year with a 170% Activation Bonus.

Example of Guaranteed Withdrawal Payment Calculation

• Single Life Level,

• Single Life Increasing,

• Joint Life Level, and

• Joint Life Increasing.

The Guaranteed Withdrawal Percentage depends on the payment option you select. The available payment options are:

Guaranteed Withdrawal Percentage Determination

For Single Life options, the Guaranteed Withdrawal Percentage depends on your age on the date we make the first payment. For Joint Life

options, the Guaranteed Withdrawal Percentage depends on the age of the younger of you and your spouse on the date we make the first

payment. For Increasing options, the Guaranteed Withdrawal Payment will increase by 2.5% at the beginning of each Policy Year after the GLIR

has been in the Withdrawal Period for one year. Guaranteed Withdrawal Payments under the increasing options will cease to increase once the

Accumulation Value is zero or the Income Doubler is activated.

The payments cannot be elected until after the one-year waiting period and until you are at least age 55 or both you and your spouse are at least

age 55 for the Joint Life options.

* Guarantees are dependent on the claims paying ability of the issuing company.

Leave with Applicant

Page 4 of 5

Form No. 12250

Rev. 0420

The table above shows the Guaranteed Withdrawal Percentages for the Single Life Level option. To determine the Guaranteed Withdrawal

Percentages for other payment options, do the following:

Attained

Age

Guaranteed

Withdrawal

Guaranteed

Withdrawal

Attained

Age

5.90%

6.00%

6.10%

6.20%

6.30%

6.40%

6.50%

Attained

Age

Guaranteed

Withdrawal

85+

5.10%

5.20%

5.30%

5.40%

5.50%

5.60%

5.70%

5.80%

Attained

Age

Guaranteed

Withdrawal

4.30%

4.40%

4.50%

4.60%

4.70%

4.80%

4.90%

5.00%

3.00%

3.20%

3.40%

3.60%

3.80%

4.00%

4.10%

4.20%

• Single Life Increasing: subtract 1.0%

• Joint Life Level: subtract 0.5%

• Joint Life Increasing: subtract 1.5%

If the Annuitant is permanently unable to perform two of six activities of daily living (ADLs) without substantial assistance, the Guaranteed

Withdrawal Payment may be doubled for a period of up to five years. The ADLs are bathing, dressing, transferring, toileting, continence,

and eating. The following additional requirements must be met to claim this benefit:

Income Doubler (Not available in all states)

• the Annuitant must reside in the United States,

• the Policy must be inforce at least two years,

• the Accumulation Value must be greater than zero,

• No Excess Withdrawals have been taken in the current Policy Year, and

• the Guaranteed Withdrawal Payment must not be based on a Joint Life Option.

If the Income Doubler is initiated at the time of GLIR activation, the Guaranteed Withdrawal Payment will be twice as much as would otherwise

be calculated. If the Income Doubler is claimed after GLIR activation, the Guaranteed Withdrawal Payment will be doubled at that time. After

the Income Doubler is activated, the Guaranteed Withdrawal Payment will be reduced by 50% upon the earlier of depletion of the Accumulation

Value or five years from activation of the Income Doubler.

Effects of Withdrawals on GLIR Benefits

During the Accumulation Period, all withdrawals decrease the Accumulation Value thus reducing the future initial Guaranteed Withdrawal Payment.

During the Withdrawal Period, all withdrawals are first applied against the Guaranteed Withdrawal Payment. If you request a withdrawal during a

Policy Year that exceeds the Guaranteed Withdrawal Payment, the excess amount is termed an Excess Withdrawal and will cause a proportional

reduction in the Guaranteed Withdrawal Payment in future Policy Years. For example, if you started taking a maximum Guaranteed Withdrawal

Payment of $1,500 and, three years later, you requested an additional $12,000 withdrawal from the annuity, your Guaranteed Withdrawal Payment

would be reduced

• If the Accumulation Value before the Excess Withdrawal of the additional $12,000 was, say, $120,000, the Excess Withdrawal would represent

10% of the Accumulation Value. The future Guaranteed Withdrawal Payment would be reduced by 10%, to $1,350. You would continue to

receive $1,350 annually for life, assuming no future Excess Withdrawals.

• If the Accumulation Value before the Excess Withdrawal of the additional $12,000 was, say, $24,000, the Excess Withdrawal would represent

50% of the Accumulation Value. The future Guaranteed Withdrawal Payment would be reduced by 50%, to $750. You would continue to receive

$750 annually for life, assuming no future Excess Withdrawals.

• If the Accumulation Value before the Excess Withdrawal of the additional $12,000 was exactly $12,000, the Excess Withdrawal would represent

100% of the Accumulation Value. The future Guaranteed Withdrawal Payment would be reduced by 100%, and the Guaranteed Withdrawal

Payments and the annuity itself would both terminate.

In these examples, in the year of the Excess Withdrawal, your total withdrawal benefits are $13,500.

A Rider Charge is deducted from the Accumulation Value at the end of each Policy Year. The Rider Charge equals 1% times the Accumulation

Value.

Cancellation

You may terminate the GLIR (and any future charges) after the tenth Policy Year by giving us written notice at least thirty (30) days prior to the date

on which the termination is to take effect.

1. Rates shown are effective as of the date of publication and are subject to change.

2. The examples above are hypothetical in nature and are not intended to indicate actual performance or results of the policy. They ignore state

premium taxes that may affect the benefit in CA, ME, NV, SD, WV and WY.

3. Product not available in all states.

Cost of the GLIR

FIT Horizon Income is Policy Form Series 20710(0320), or state variation thereof.

The Guaranteed Lifetime Income Rider is Rider Form Series 20712(0320), or state variation thereof.

• S&P 500

Index Annual Point to Point

• S&P 500

Index Monthly Sum Cap

• Global Balanced Index Annual Point to Point

• US Fundamental Balanced Index Annual Point to Point

• Declared Interest

Available Crediting Strategies for Interest Accounts:

• If the MVA Factor is greater than or equal to one, then the MVA Amount

is determined by multiplying the amount withdrawn in excess of any Free

Withdrawal Amount times the result of subtracting one from the MVA

Factor. The withdrawal is then adjusted upward by the MVA Amount.

• If the MVA Factor is less than one, then the MVA Amount is determined by multiplying the amount withdrawn in excess of any Free

Withdrawal Amount times the result of subtracting the MVA Factor from one. The withdrawal is then adjusted downward by the MVA

Amount.

• the Accumulation Value minus the Policy Value minus any Recapture Amount and Withdrawal Charge applicable upon withdrawal of the

entire Accumulation Value; times

• the amount withdrawn in excess of any Free Withdrawal Amount; divided by

• the Accumulation Value minus any Free Withdrawal Amount

The MVA Amount will never be greater than the MVA Limit. Within that bound:

The MVA Limit at the time of the calculation of the MVA Amount equals:

However, the MVA limit can be no less than zero.

Market Value Adjustment (MVA)

Immediate Interest Credit

A Market Value Adjustment is an upward or downward adjustment that may

be applied to amounts withdrawn within the first ten Policy Years. The MVA

applies to amounts withdrawn in excess of any Free Withdrawal Amount, even

if the applicable Withdrawal Charge Percentage is zero. The MVA does not

apply to any death benefit.

( )

1 + i

1 + j

n/12

, where

The MVA Factor is calculated using the following formula:

i is the weekly-average 10-year U.S. Treasury Constant

Maturity rate two weeks prior to the policy issue date.

j is the weekly-average 10-year U.S. Treasury Constant

Maturity rate two weeks prior to the calculation of the

MVA.

n is 120 minus the number of completed months since

the issue date.

• Rate Booster S&P 500

Index Annual Point to Point

• Rate Booster S&P 500

Index Monthly Sum Cap

• Rate Booster Global Balanced Index Annual Point to Point

• Rate Booster US Fundamental Balanced Index Annual Point to Point

If you choose the Split Bonus GLIR, an Immediate Interest Credit equal to 5% of

the net single premium is credited to the Accumulation Value at policy issue. If a

withdrawal is made from the policy in excess of the Free Withdrawal Amount, an

Immediate Interest Credit Recapture will apply during the first eight Policy Years.

If you choose the Max Bonus GLIR, there is no Immediate Interest Credit.

Guaranteed Lifetime Income Rider Request and Understanding

I understand that the Activation Bonus, Immediate Interest Credit (if any), Guaranteed Withdrawal Percentages and Rider Charge Rates will be

those in effect on the date the annuity is issued.

GLIR Rider Charge - 1% of Accumulation Value for all Policy Years

Accumulation Value allocated to a Crediting Strategy with the Rate Booster will be assessed an annual charge at the beginning of each Policy

Year equal to 1% of the Accumulation Value allocated to that Crediting Strategy. Crediting Strategies with the Rate Booster will have participation

rates or caps that are higher than standard Crediting Strategies.

Product Issuance Guidelines

• Issue age limits for this annuity are owner/annuitant age 35-75

• Minimum Premium: $50,000

• Maximum premium: Issue ages 35-70 - $1,000,000; 71-75 - $750,000

• Maximum premium limits are per life and are subject to change

• Policy will be issued on the 7th, 14th, 21st, or 28th day of the month following or coincident with the date the single premium is paid

• This annuity is designed for people who are seeking a policy to provide lifetime income.

Immediate Interest Credit Recapture Schedule

Policy Year 1 2 3 4 5 6 7 8 9+

Recapture % 2090 80 70 60 50 40 30 0

Withdrawal Charge %

Policy Year 1 2 3 4 5 6 7 8 9 10+

Standard 18.25 8 7 6 5 4 3 2 0

Date

Agent SignaturePrint Agent Name Agent Number Date

Print Applicant Name

Applicant Signature

My signature as Applicant acknowledges that I have read and the agent has explained the contents of each of the Disclosure pages above. I

understand that I am applying for an annuity that may credit interest based on a formula that considers the change in the value of an

external index. I understand that the values of my Policy will not participate directly in any equity market. I understand that I am

applying for an annuity that has a Market Value Adjustment (MVA) and that certain withdrawals I take from the annuity may be reduced

as a result of the MVA. I understand that the Guaranteed Lifetime Income Rider will be issued with my Policy. I understand this original

Disclosure will be enclosed with my application and a copy of it will be sent with my Policy.

Sign and Submit with Application

Page 5 of 5

Form No. 12250

Rev. 0420

Owner's Name (First, Middle, Last) or Employer/Plan Name

Section 3 - Beneficiary (For Joint Owners, If an Owner dies the surviving Owner is the sole beneficiary. For qualified policies see the plan documents.)

Primary Beneficiary's Name (First, Middle, Last) Relation to Owner

SSN/TIN Country of Citizenship Relation to OwnerU.S. Citizen

Y N

DOB (mm/dd/yyyy) Alien Registration #

M F

Gender

E-Mail AddressHome Address (Street - No PO Boxes, City, State, Zip)

Phone Number

Section 2 - Annuitant/Participant (if different than Owner)

Annuitant's Name (First, Middle, Last)

SSN/TIN DOB (mm/dd/yyyy) Country of CitizenshipU.S. Citizen

Y N

Alien Registration #

ICC13-11374(0913)

Page 1 of 2

Cat. No. 105243

Section 1 - Owner

Phone Number

National Life Group® is a trade name of National Life Insurance Company, Montpelier, VT, Life Insurance Company of

the Southwest (LSW), Addison, TX and their affiliates. Each company of National Life Group is solely responsible for its

own financial condition and contractual obligations. LSW is not an authorized insurer in New York and does not conduct

insurance business in New York.

P: 800-732-8939 │ F: 214-638-9162 │ Imaging@NationalLife.com │www.NationalLife.com

Centralized Mailing Address: One National Life Drive, Montpelier, VT 05604-5555

Gender

M F

Country of Citizenship

SSN/TIN Share (%)

Contingent Beneficiary's Name (First, Middle, Last) Relation to Owner SSN/TIN Share (%)

Primary Beneficiary's Name (First, Middle, Last) Relation to Owner SSN/TIN Share (%)

Joint Owner's Name (First, Middle, Last) (If applicable, for NQ only)

Relation to OwnerDOB (mm/dd/yyyy)

DOB (mm/dd/yyyy)

Gender

M F

U.S. Citizen

Y N

SSN/TIN

E-Mail AddressHome Address (Street - No PO Boxes, City, State, Zip)

The selected Insurer above is hereafter known as "the Company"

If more space is needed, attach Supplemental Information ICC13-20140(1113)

Alien Registration #

Section 4 - Plan Qualification

Section 5 - Premium Payment

Single Premium:

(Approx)

Transfer/Exchange/Direct Rollover $ Check $

Max Bonus Split Bonus

Section 6 - Available Rider(s) (Guaranteed Lifetime Income Rider is required. One of the following must be selected.)

Other (specify)Roth 457(b)403(b) ROTH 403(b) 457(b) Pension/Profit Sharing

SIMPLE IRA Other (specify)Non-QualifiedROTH IRAIRA4a.

4b.

Employer/District: School/Campus Name:

FIT Horizon Income Single Premium Indexed

Individual Deferred Annuity Application

Section 7 - Premium Allocation (Whole percentages only, must total 100%. Rate Booster strategies have a 1% annual charge.)

(017) Rate Booster S&P 500 Point-to-Point

(020) Rate Booster Global Balanced Point-to-Point

(022) Rate Booster US Fundamental Balanced Point-to-Point

(018) Rate Booster S&P 500 Monthly Sum

(003) S&P 500 Point-to-Point

(011) S&P 500 Monthly Sum

(019) Global Balanced Point-to-Point

(021) US Fundamental Balanced Point-to-Point

(007) Declared Interest

Signature of Primary Agent Agent E-Mail

PercentAgent No.Phone NumberOther Agent Name (print)

Other Agent Name (print) Phone Number Agent No. Percent

Signature of Owner Signature of Annuitant/Participant

ICC13-11374(0913)

Page 2 of 2

Section 8 - Replacement

Section 9 - For Home Office Endorsement Only

Do you have an existing life insurance or annuity policy with us or any other company?

Regardless of the answers to the above questions, please refer to “2630-Required States Forms” to determine the additional form(s) that may be

required.

Will the proposed contract replace or change any existing annuity contract or life insurance policy?

(If answered "Yes" in a NAIC state, a completed and signed NAIC Form A (8027) is required.)

(If answered "Yes", list the insurance company name(s) and policy or contract number(s) below. A state specific replacement form may also be required.)

Yes No

Company Name

Contract/Policy No.Company Name

Contract/Policy No.

Section 10 - Notices/Acknowledgments

Section 11 - Agent Section

Section 12 - Commission (Please Note: If an Option is not selected, standard commissions will apply.)

Notice: Any person who knowingly presents a false statement in an application for insurance may be guilty of criminal offense and subject to penalties

under state law.

Signed Date (mm/dd/yyyy)

Signed at City and State

Is a replacement involved in this transaction?

Yes No

Primary Agent Name (print) Phone Number Agent No. Percent

Acknowledgments: The Annuitant and the Owner, if other than the Annuitant; (1) represents, to the best of their knowledge and belief, that all statements

and answers contained herein are full, complete and true as written and are correctly recorded; and, (2) expressly agrees as follows: 1. This application and

the answers and agreements contained herein shall be the basis of, a part of the consideration for, and a part of the annuity hereby applied for. 2. The

payment of premium is consideration to the Company for the granting of an annuity and upon payment becomes the property of the Company. 3. I authorize

my employer, if applicable, to withhold the premium to purchase the annuity for which I have applied. I authorize the Company to accept premiums on my

behalf. 4. If applicable, I hereby request and authorize the Company to draw upon the Financial Institution listed in Section 5c provided there are sufficient

funds in said account. This authorization shall remain in effect until revoked in writing by me, and received by the Company. I agree that the Company shall

be fully protected in honoring the information in Section 5c and that if the information is rejected by said Financial Institution, whether with or without cause

and whether intentionally or inadvertently, the Company will be under no liability whatsoever even though such rejection results in forfeiture of insurance

coverage. 5. The annuity is effective on the date the premium is received by the Company at its Office. The single premium deferred annuities shall take

effect on the 7th, 14th, 21st or 28th of the month following or coincident with the date the premium is received by the Company in its Office. 6. The

Company is authorized to amend this application by appropriate notation in Section 9 “For Home Office Endorsement Only” to correct errors or omissions.

The acceptance of any annuity issued from this application is acceptance and ratification of the beneficiary designation, if any, in such annuity and of any

amendments contemplated above except that no change shall be made in the plan of annuity or benefits without the written acceptance of the Owner. 7. If

applicable, the undersigned Annuitant hereby adopts, subscribes and agrees to the terms of his/her Employer’s plan, as now in effect or hereafter modified,

and further agrees to be bound by all actions taken by the representatives thereof pursuant to and in accordance with said plan.

I have received a copy of all sales material including electronically presented material and understand that the results shown, other than the guaranteed

minimum values, are not guarantees, promises or warranties. I have received a copy of the Privacy Notice.

I certify that only sales material approved by the Company was used and that originals or copies of all sales material used were left with the

applicant. I have not made statements that differ from this material nor have I made any promises about the expected future values of this policy.

DateCapacity (i.e. Trustee, Guardian of a Minor, etc.)

Other Required Signatures (i.e. Joint Owner, Guardian, etc.)

Agency Name

Trail Commission Option AStandard Commission

Trail Commission Option CTrail Commission Option B

c. Do you anticipate surrendering this annuity before the withdrawal charge period is over?

Yes Nod. Do you anticipate taking withdrawals in excess of the Guarantee Lifetime Income payments? (If not applicable, answer 'No'.)

a. Do you anticipate taking withdrawals (excluding loans) from your annuity during the first policy year other than a required minimum

distribution (RMD)?

b. Do you anticipate taking withdrawals (excluding loans) of more than 10% of the account value in any year after the first policy year,

during the withdrawal charge period?

Yes No

Traditional Fixed and Fixed Indexed Annuity Suitability Form

Section I (This section can NOT be declined)

• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

Section II (If SPIA, go to Section III)

If any of the questions below are answered 'Yes', then this form is required. All sections are required to be completed in full.

Is this transaction a transfer, rollover, replacement or exchange? Yes No

Is this a new non-qualified contract?

Yes No

Is this applicant/owner 65 or older? Yes No

INCOMPLETE FORMS WILL DELAY PROCESSING

Name (First, Middle, Last): DOB (mm/dd/yyyy):

10068(0819)

Cat. No. 101168

Page 1 of 3

LR10628(0112)

National Life Group® is a trade name of National Life Insurance Company, Montpelier, VT, Life Insurance Company of the

Southwest (LSW), Addison, TX and their affiliates. Each company of the National Life Group is solely responsible for its own

financial condition and contractual obligations. LSW is not an authorized insurer in New York and does not conduct insurance

business in New York.

P: 800-228-4579 │ F: 214-638-9162 │ Imaging@NationalLife.com │www.NationalLife.com

Centralized Mailing Address: One National Life Drive, Montpelier, VT 05604

12. What is your risk tolerance for this product?

11. For CA residents only: Do you intend to apply for means-tested government benefits, such as Medi-Cal or veterans' benefits?

Yes No

a. Are you willing to accept non-guaranteed elements in the policy, including variability in premium, cash value, death benefit, or fees?

Yes No

b. What is the duration of existing liabilities and obligations?

9. For NY residents only:

Aggressive

Moderate

Conservative

13. Time Horizon:

New Policy

Existing Policy (Please provide policy number)

4. Annual Household Income: $

1. What is your household liquid net worth? (Penalty free amounts. Include this proposed transaction, if liquid. Exclude home & auto.) $

10. For VT residents only: What is your monthly long term care cost? $

7. Do you anticipate material changes in your household annual income, financial situation and needs, existing assets, liquidity needs, or liquid net worth?

Yes No

If 'Yes', please explain:

6. Annual Tax Bracket:

Under 15% 15% - 28% > 28%

Retired (Former occupation is required):2. Current Occupation: or

5. Annual Household Expenses: $

Bank Products (CDs/Cash): $

Please provide the liquid assets available in:

Securities (Stocks/Bonds/Mutual Funds): $ Life Insurance (cash value) or Annuities: $

Product Applying For: Yes NoRequesting GLIR?

3. Anticipated Retirement Age (from full-time employment): Self Spouse

8. Age starting Social Security Income Self Spouse

Yes NoIs this an existing contract with $10,000 or more being added?

10068(0819) Page 2 of 3

Please submit a recent policy statement copy.

2. Company Name

1. Product Type (Life or Annuity)

3. Dollar Amount

4. Product Name

8. Lifetime Withdrawal Benefit

NoYes

9. Other Riders

10. Rider Fees

11. Years Owned

12. Guaranteed Interest Rate (Required for Fixed & Indexed)

13. Current Fixed Rate (Required for Fixed & Indexed)

14. Participation Rate / Cap (Required for Indexed)

15. Death Benefit (Required for Life Insurance Only) $$$

NoYes

5. Type of Annuity (Fixed / Indexed / Variable / 2 Tier)

6. Type of Life (UL / WL / IUL / VUL)

7. Surrender Charge (Dollar amount)

Replacement #1 Replacement #3Replacement #2

$$$

$ %

19c. This grid must be completed if Life Insurance, Fixed or Indexed Annuity, or Variable Annuity is being replaced.

Section IV

19a. What is the source of premiums for purchasing this annuity? Answer all that apply:

Savings/Checking/CD Reverse Mortgage/Home Equity LoanState Teachers Retirement

Replacement or surrender of life insurance or annuity policy. If so, complete the grid below.

Other: (Do not include tax qualification such as 401(k) or Beneficiary IRA)

Salary (question 19b not required)

Surrender of Mutual Funds, Stocks, Bonds or other Securities within the last 6 months.

If any withdrawal charges were assessed, please specify:

19b. What line of business is this money coming from?

IRA 403b 401k Non-Qualified Beneficiary IRA Other:457(b) Pension Plan

Protection of Premium Paid

Enhanced Death Benefit Feature

Estate Planning

Access to more product options

Potential for more growth opportunity

Control of Assets

Tax Deferral

Immediate Income

Future Income: Starting Age

17. What are your objectives for this purchase?

18. Please provide any additional information specific to this transaction you would like us to take into consideration.

Yes No

14a. Excluding this proposed transaction, have you had a prior annuity exchange?

b. If 'Yes', did it occur within the last 36 months (60 months if CA or MN resident)?

Yes No

16. Which of the following financial, insurance and investment products have you owned and/or currently own?

(Check all that apply)

None Mutual FundsStocks/Bonds (corporate, municipal, etc.)AnnuitiesLife Insurance Other:

Section III

15. Do you have existing life insurance policies or annuity contracts sold by this producer?

Yes No

I recommended this annuity purchase or exchange because I believe it is suitable and in the best interest based upon the information given to me by

the Owner/Applicant. I have reviewed with the Owner/Applicant various favorable and unfavorable features of the annuity (such as potential surrender

periods and charges, potential charges for riders, etc.), and the customer has signed the Disclosure Form (if applicable). If this is a replacement, I have

discussed with the applicant any potential withdrawal/surrender charges, etc., which may be incurred on surrender of the policy, as well as any fees,

charges or withdrawal/surrender period, etc., associated with the new policy.

Agent's Signature

Date

I agree to maintain and make available upon request to the insurer or insurance commissioner, records of the information collected and other information

used as the basis for this recommendation for at least 10 years after the insurer completed the recommended transaction. Any reproduction of the actual

document may be used to maintain these records.

I certify that if this sale is made on or after June 9, 2017 (and/or if I recommended to my customer that additional funds be deposited to their contract)

and the transaction is subject to the Department of Labor Fiduciary Rule, I have relied upon an applicable Prohibited Transaction Exemption (“PTE”),

such as PTE 84-24 or The Best Interest Contract Exemption.

Did you provide investment advice or analysis and recommend the liquidation of a securities product (Variable Annuities, Mutual Funds, etc.)

to purchase this annuity?

(Other than providing assistance with suitability and transfer forms.)

Yes No

If 'Yes', are you FINRA/SEC licensed?

Yes No

Section VI

I acknowledge that it may be a regulatory violation to recommend the sale of a security without appropriate registration. I certify that I am in compliance

with applicable law.

10068(0819) Page 3 of 3

If 'Yes', what Broker Dealer/Investment Advisor are you associated with?

Section V

I have reviewed the Disclosure Form attached to the policy application (if applicable), and provided the information on this form, or I have reviewed the

information contained on it, and confirm that it is complete and accurate. I recognize that the insurer may review my transaction, but I have made my

own determination that this policy and any riders are suitable and in my best interest.

Date Annuitant's Signature (If different from Owner)

Owner/Applicant’s Signature Date

Joint Owner's Signature Date

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