Fill - Free fillable Immediate Annuity Application PDF form

8513 (09/06) 1 of 4 (04/09) Policy: SPIA

Immediate Annuity Application

1 Purchase

G Tailored Income Annuity

G Other _____________________________________________________________________________________________

2 Owner(s)

PRIMARY/TRUST/BUSINESS ENTITY NAME SSN (or TIN) BIRTH/TRUST DATE

TRUSTEE/BUSINESS REPRESENTATIVE NAME(S)

GENDER

G Female G Male G Not Applicable

PHONE

ADDRESS CITY STATE ZIP CODE

JOINT/CONTINGENT NAME SSN (or TIN) BIRTH DATE

GENDER

G Female G Male

PHONE

ADDRESS CITY STATE ZIP CODE

3 Annuitant(s) (Complete only if Annuitant(s) is not Owner(s).)

PRIMARY NAME SSN (or TIN) BIRTH DATE

GENDER

G Female G Male

PHONE

ADDRESS CITY STATE ZIP CODE

JOINT/CONTINGENT NAME SSN (or TIN) BIRTH DATE

GENDER

G Female G Male

PHONE

ADDRESS CITY STATE ZIP CODE

4 Beneﬁ ciary Designation (To designate multiple primary and/or contingent beneﬁ ciaries, instead attach form 6304.)

PRIMARY NAME SSN (or TIN) BIRTH/TRUST DATE

ADDRESS CITY STATE ZIP CODE

CONTINGENT NAME SSN (or TIN) BIRTH/TRUST DATE

ADDRESS CITY STATE ZIP CODE

5 Annuity Purpose

G Non-Qualiﬁ ed

G IRA G Traditional G Roth G SEP

G 403(b) TSA G Non-ERISA G ERISA with contributions from: G Participant G Employer

G Qualiﬁ ed Pension: ________ (Attach form 5835.) G Deﬁ ned Beneﬁ t G Deﬁ ned Contribution

PLAN YEAR

Standard Insurance Company

Individual Annuities 800.247.6888 Tel 800.378.4570 Fax

1100 SW Sixth Avenue Portland OR 97204-1093 www.standard.com

8513 (09/06) 2 of 4 (04/09) Policy: SPIA

Notices and Disclosures

Contract Return; Information Request

The owner(s) may return the contract for any reason within thirty (30) days after it is received. If the contract is returned, The

Standard will: (a) cancel the contract from the beginning; and (b) promptly refund any premium paid by the owner(s), less

any prior partial withdrawals. Upon the written request of the owner(s), The Standard will provide factual information about

the contract’s beneﬁ ts and provisions within a reasonable time.

Applies if the annuity is purchased through a bank or credit union.

The annuity is not a deposit. The annuity is not guaranteed by any bank or credit union. The annuity is not insured by the

FDIC or by any other governmental agency. The purchase of an annuity is not a provision or condition of any bank or credit

union activity. Some annuities are subject to investment risk and they may go down in value.

State Fraud Notices

AR, KY, LA, ME, NM, OH, OK, PA and TN Residents: Any person who knowingly and with intent to defraud any insurance

company or other person ﬁ les 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.

CO Residents: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance

company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, ﬁ nes,

denial of insurance and civil damages. Any insurance company or agent of any insurance company who knowingly provides

false, incomplete, or misleading information to a policyholder or claimant for the purpose of defrauding or attempting to

defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported

to the Colorado Division Of Insurance of Regulatory Services.

DC Residents:

Any person who knowingly presents a false or fraudulent claim for payment of a loss or beneﬁ t or knowingly presents

false information in an application for insurance is guilty of a crime and may be subject to ﬁ nes and conﬁ nement in prison.

FL Residents: Any person who knowingly and with intent to injure, defraud, or deceive any insurer ﬁ les a statement of claim or

an application containing any materially false, incomplete, or misleading information is guilty of a felony of the third degree.

MD Residents: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or beneﬁ t or

who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject

to ﬁ nes and conﬁ nement in prison.

NJ Residents: Any person who includes any false or misleading information on an application for an insurance policy is subject

to criminal and civil penalties.

WA Residents: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the

purpose of defrauding the company. Penalties include imprisonment, ﬁ nes and denial of insurance beneﬁ ts.

Privacy Statement

I understand that, in the course of processing my application, Standard Insurance Company may collect personal information

about: (a) me; and (b) others I have identiﬁ ed in this application, e.g. beneﬁ ciaries, policyowners and annuitants. I understand

that the personal information may include information about my: (a) age; (b) occupation; (c) income; (d) ﬁ nances; and

(e) other insurance. Standard Insurance Company may obtain personal information from: (a) this application; (b) other

forms I submit to Standard Insurance Company; (c) an employer; (d) an insurance sales representative; (e) other insurance

companies; (f) Standard Insurance Company’s Web sites; and (g) any other person, organization or institution having records

or knowledge of me that are necessary to process this transaction. In the course of processing this transaction there may

be circumstances in which Standard Insurance Company discloses to other parties the information collected about me. I

authorize Standard Insurance Company to disclose personal information to: (a) an employer (such as name, employment

status and Social Security number); (b) organizations or persons, including insurance sales representatives, that perform

services or functions necessary to process this transaction; and (c) other insurance companies. No other disclosure may be

made without my further authorization except: (a) to the extent necessary for the conduct of Standard Insurance Company’s

business; or (b) as permitted or required by law. I understand that failure to sign the authorization may: (a) impair the ability

to process my application or evaluate my claim for beneﬁ ts; and (b) be the basis for denying my application or my claim for

beneﬁ ts. I understand that this authorization: (a) will automatically expire 24 months following the date of my signature

below; (b) may be revoked by me at any time by sending a written request for revocation to Standard Insurance Company at

the address shown above; and (c) such revocation may be the basis for denying my application or my claim for beneﬁ ts. I also

understand that: (a) I or my authorized representative has the right to request a copy of my authorization and to learn the

nature and substance of any personal information about me in Standard Insurance Company’s ﬁ le; (b) I have the right to ask

Standard Insurance Company to correct or amend such information, if necessary; and (c) Standard Insurance Company will

carefully review my request and, where appropriate, make the necessary change. To obtain further information about these

rights and Standard Insurance Company’s information practices, I have been informed that I may request a copy of Standard

Insurance Company’s Notice of Information Practices by contacting the Annuity Department at the above address.

8513 (09/06) 3 of 4 (04/09) Policy: SPIA

6 Premium

TOTAL AMOUNT AMOUNT ATTACHED ESTIMATED AMOUNT FORTHCOMING

MONEY SOURCE

G New Investment G Rollover (Attach form 12213.) G Transfer (Attach form 12213.) G 1035 Exchange (Attach form 12213.)

7 Income Option Selection (Attach proof of age. Attach a signed copy of the contract illustration.)

G Life Income

G Add Life Income Commutation feature.

G Add Inﬂ ation Protection feature with an increasing beneﬁ t of G 1 G 2 G 3 G 4 G 5 %

G Life Income with Installment Refund

G Add Life Income Commutation feature.

G Life Income with Certain Period

of G 5 G 10 G 15 G 20 G ______ years

G Add Life Income Commutation feature.

G Add Inﬂ ation Protection feature with an increasing beneﬁ t of G 1 G 2 G 3 G 4 G 5 %

G Joint and Survivor Life Income

with survivor payment of G 50% G 66²⁄3% G 75% G 100%

G Joint and Survivor Life Income with Installment Refund

G Joint and Survivor Life Income with Certain Period

of G 5 G 10 G 15 G 20 G ______ years

G Joint and Contingent Survivor Life Income

G Certain Period

of G 5 G 10 G 15 G 20 G ______ years

G Add Inﬂ ation Protection feature with an increasing beneﬁ t of G 1 G 2 G 3 G 4 G 5 %

8 Payments

(Attach form 5031 or IRS forms W-9 and W-4P. Routine payments can be made via direct deposit by attaching form 1142 6.)

DATE OF FIRST PAYMENT MODAL PERIOD

G Monthly G Quarterly G Semiannually G Annually

If no date is indicated or funds are not received by the date requested, the ﬁ rst payment will be made after one completed

modal period (based on the mode selected) after Standard Insurance Company receives the full premium payment.

9 Remarks (For any additional remarks that are attached to this application, be sure to sign and date all papers.)

STANDARD INSURANCE COMPANY HOME OFFICE USE (WV residents must consent in writing to any changes shown in this section.)

8513 (09/06) 4 of 4 (04/09) Policy: SPIA

Declarations and Signatures

10 Owner(s) and Annuitant(s) (For a tax-qualiﬁ ed plan, attach form 13018 for spousal consent, if applicable.)

A G Yes G No The owner(s) has(have) existing life or annuity policies.

(For states using replacement form 10443, attach that form.)

B G Yes G No To the best of my(our) knowledge, the contract applied for will replace an existing life insurance or

annuity contract. In the event of replacement, I(we) understand that the agent must leave the

original or a copy of all written or printed communications used for presentation to me (us).

(If Yes, include a state replacement form where required.)

C G Yes G No I(We): (1) understand and acknowledge that Standard Insurance Company does not offer legal,

ﬁ nancial, tax, investment or estate-planning advice; and (2) have had the opportunity to seek such

advice from the proper sources before purchasing this contract. I(We) have determined that the

purchase of this annuity is suitable given my(our) legal, ﬁ nancial, tax, investment, estate-planning

or other goals or circumstances.

D G Yes G No I(We): (1) have received a copy of the product disclosure; and (2) have signed and attached a copy

of the contract illustration.

I(We) represent that all statements and answers to questions herein are true and complete to the best of my(our) belief

and knowledge. I(We) understand that the application will be attached to and made part of the annuity contract.

____________________________________________________________________________________________ _______________________________ _______________________________

PRIMARY OWNER SIGNATURE DATE SIGNED AT (CITY, STATE)

____________________________________________________________________________________________ _______________________________ _______________________________

JOINT/CONTINGENT OWNER SIGNATURE DATE SIGNED AT (CITY, STATE)

____________________________________________________________________________________________ _______________________________ _______________________________

PRIMARY ANNUITANT SIGNATURE (IF NOT OWNER) DATE SIGNED AT (CITY, STATE)

____________________________________________________________________________________________ _______________________________ _______________________________

JOINT/CONTINGENT ANNUITANT SIGNATURE (IF NOT OWNER) DATE SIGNED AT (CITY, STATE)

11 Insurance Broker

NAME E-MAIL PHONE

BUSINESS OR INSTITUTION NAME

ADDRESS CITY STATE ZIP CODE

LICENSE NUMBER STANDARD INSURANCE COMPANY PRODUCER IDENTIFICATION

I declare that: (a) the application was signed and dated by the owner(s) and by the annuitant(s), if not the owners(s),

after all answers and information were recorded herein; and (b) I have truly and accurately recorded on this form all of

the information provided by the owner(s) and the annuitant(s), if not the owner(s).

A G Yes G No The owner(s) has(have) existing life or annuity policies.

(For states using replacement form 10443, attach that form.)

B G Yes G No To the best of my knowledge, the contract applied for will replace an existing life insurance or

annuity contract.

(If Yes, include a state replacement form where required.)

C G Yes G No I certify that a copy of the product disclosure and a signed contract illustration was presented to

and left with the applicant.

D G Yes G No I certify that (a) the suitability requirements applicable to this annuity have been met; (b) I have

completed the suitability section of the disclosure statement with the applicant(s); (c) a copy of that

form has been left with the applicant(s); and (d) a copy of the form is enclosed with this application.

E G Yes G No I certify that I have veriﬁ ed the identity of each owner and annuitant by reviewing a government-

issued photo identiﬁ cation.

____________________________________________________________________________________________ _______________________________ _______________________________

INSURANCE BROKER SIGNATURE DATE SIGNED AT (CITY, STATE)

13018 (05/06) 1 of 2

Standard Insurance Company

Individual Annuities 800.247.6888 Tel 800.378.4570 Fax

1100 SW Sixth Avenue Portland OR 97204-1093 www.standard.com

Qualiﬁed Joint and Survivor Annuity Notice and Spousal Consent

Qualiﬁed Joint and Survivor Annuity Notice (Applicable only if a plan is subject to ERISA provisions.)

Qualiﬁed Joint and Survivor Annuity

Married Participants

The law requires that beneﬁts from this plan be paid in the form of a Qualiﬁed Joint and Survivor Annuity (“Q JSA”), unless

you elect another beneﬁt option offered by the plan. If you decide to elect a beneﬁt option other than a Q JSA, then your

spouse must consent in writing to your election. Your spouse's signature must be witnessed by a Plan Representative or a

Notary Public. Your election must be made no more than 90 days prior to the date distributions commence (however, at least

seven days must elapse from the time you receive this Q JSA explanation to the time of the distribution). The election (or

spousal consent to the election) may be revoked at any time within those 90 days. If you decide to change the beneﬁt option

before distributions commence, then you must again obtain your spouse's written consent as described above.

For married participants, a Q JSA beneﬁt is a Joint and Survivor Annuity. Monthly payments are made for your life. After

your death, monthly payments, usually of 50 percent of the amount you received, are made to your spouse for life. The total

amount payable as a Q JSA must be the actuarial equivalent of the amount that would be payable to you in a Life annuity.

The monthly payment amount paid during your life will be less than it would be in a Life Annuity based on a single life.

The law also requires that any and all survivor beneﬁts from this plan be paid to your spouse, unless you designate a different

beneﬁciary. If you decide to designate a beneﬁciary other than your spouse, then your spouse must consent in writing to

your beneﬁciary designation. Your spouse's signature must be witnessed by a Plan Representative or a Notary Public.

Unmarried Participants

The law requires that, unless you elect otherwise, beneﬁts from this plan be paid in the form of a Single Life Annuity:

you will receive monthly payments for your life, and then no payments are made after your death. If you decide to elect

another beneﬁt option offered by the plan, your election must be made no more than 90 days prior to the date distributions

commence (however, at least seven days must elapse from the time you receive this Q JSA explanation to the time of the

distribution). You may revoke your election at any time within those 90 days.

If any survivor beneﬁts are payable through the beneﬁt payment option you have chosen, then you may designate a

beneﬁciary to receive those survivor beneﬁts.

13018 (05/06) 2 of 2

1 Spousal Consent (Applicable only if a plan is subject to ERISA provisions.)

I am ❏ Married ❏ Not Married ❏ Married, but cannot locate my spouse

Important: This section must be completed if this 403(b) TSA is subject to the provisions of the Employee Retirement

Income Security Act (ERISA). If you are not sure whether or not this 403(b) TSA plan is administered under ERISA, please

contact one of our annuity specialists at (800) 247-6888. Your spouse must complete this section if your account balance has

ever been greater than $5,000. Your spouse’s signature must be witnessed by an Authorized Plan Representative or a Notary

Public.

SPOUSE NAME

I understand that by signing below I give my consent to this distribution. Furthermore, I acknowledge that this transaction/

policy change may result in the reduction of beneﬁts that might otherwise have become distributable under this plan. I have

read and understand the explanation of the Qualified Joint and Survivor Annuity. If my spouse did not select a QJSA, I consent to

payment in the form selected.

_______________________________________________________________________________________________________________________________ _______________________________

SPOUSE SIGNATURE DATE

WITNESS NAME AND TITLE

_______________________________________________________________________________________________________________________________ _______________________________

WITNESS SIGNATURE DATE

State of ________________________ County of ____________________________

Subscribed and sworn/afﬁrmed before me this __________________ day on

__________________, by ________________________________________________

_____________________________________________________ ______________

Notary Public for ________________ state. My commission expires ____________.

STAMP

AUTHORIZED PLAN REPRESENTATIVE NAME (Required only if there is no spouse signature and the vested account balance was ever more than $5,000.)

I, as authorized plan representative, hereby state that it is established to my satisfaction that spousal consent to the above

choice cannot be obtained because the participant is unmarried, or the participant’s spouse is unavailable for consent, or

because of other legitimate circumstances that prevent obtaining spousal signature.

_______________________________________________________________________________________________________________________________ _______________________________

AUTHORIZED PLAN REPRESENTATIVE SIGNATURE DATE

2 Authorization

I have read and understand the explanation of the Qualiﬁed Joint and Survivor Annuity. As required by regulations, I certify

that at least seven (7) days have elapsed since I received the Q JSA explanation. If I did not select a Q JSA, I elect to waive

payment of my beneﬁts in the form of a Q JSA and to receive payment in the form selected. If I designated a joint annuitant

or beneﬁciary other than my spouse, I elect to waive payment of any survivor beneﬁts to my spouse. I have the right to revoke

either election at any time prior to the date my beneﬁt payments begin. I understand that after payments begin, my election

is irrevocable.

I have completed appropriate sections of this form and represent that all information is true and accurate.

_______________________________________________________________________________________________________________________________ _______________________________

OWNER OR PARTICIPANT SIGNATURE DATE

_______________________________________________________________________________________________________________________________ _______________________________

OWNER SIGNATURE DATE

NOTARY PUBLIC SIGNATURE DATE

5031 (06/06) 1 of 1

Standard Insurance Company

Individual Annuities 800.247.6888 Tel 800.378.4570 Fax

1100 SW Sixth Avenue Portland OR 97204-1093 www.standard.com

Substitute IRS Forms W-4P and W-9

1 Identiﬁcation

TAXPAYER NAME POLICY NUMBER(S)

ADDRESS CITY STATE ZIP CODE

Withholding Certiﬁcate for Pension or Annuity Payments — Substitute IRS Form W-4P

2 Federal Income Tax Withholding

1 Check here if you do not want any Federal income tax withheld from your pension or annuity. ❏

(Do not complete lines 2 or 3).

2 Total number of allowances and marital status you are claiming for withholding from each

periodic pension or annuity payment. (You may also designate an additional dollar amount on line 3.) _______________

❏ Single ❏ Married ❏ Married, but withhold at higher “Single” rate

3 Additional amount, if any, you want withheld from each pension or annuity payment $______________

(Note: For periodic payments, you cannot enter an amount here without entering the number (including zero)

of allowances on line 2.)

3 State Income Tax Withholding

1 State for income tax withholding _______________ ❏ Withhold ❏ Do Not Withhold (unless required)

2 Additional amount, if any, you want withheld from each pension or annuity payment $______________

Request for Taxpayer Identiﬁcation Number and Certiﬁcation — Substitute IRS Form W-9

This form is required. If the form is not on ﬁle, Standard Insurance Company will be required to withhold income taxes according to Internal Revenue

Service guidelines. You (as payee) are required by law to provide Standard Insurance Company (as payor) with your correct taxpayer identiﬁcation number

(generally your Social Security number). Failure to do so may result in a $50 penalty imposed by the Internal Revenue Service. In addition, in the event of

such failure, we are required to withhold from your taxable distribution according to current regulation, regardless of your withholding election above.

4 Taxpayer Identiﬁcation Number (TIN)

TAX IDENTIFICATION NUMBER (E.G. SOCIAL SECURITY NUMBER)

5 Certiﬁcation

Under penalties of perjury, I certify that:

1 The number shown on this form is my correct taxpayer identiﬁcation number (or I am waiting for a number to

be issued to me), and

2 I am not subject to backup withholding because: (a) I am exempt from backup withholding, (b) I have not been

notiﬁed by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure

to report all interest or dividends, or (c) the IRS has notiﬁed me that I am no longer subject to backup

withholding, and

3 I am a U.S. person (including a U.S. resident alien).

Important Note: You must STRIKE OUT the language in section (2) above if you have been notiﬁed by the IRS that you are currently subject to

backup withholding because you have failed to report all interest and dividends on your tax return.

6 Authorization

I have completed appropriate sections of this form and represent that all information is true and accurate. The Internal

Revenue Service does not require your consent to any provision of this document other than the certiﬁcations required to

avoid backup withholding.

_______________________________________________________________________________________________________________________________ _______________________________

TAXPAYER SIGNATURE DATE

ALLOWANCES

AMOUNT

STATE

AMOUNT

SI 15510 1 of 4 (8/13)

Submit original with application. Leave copy with applicant. Keep copy in producer ﬁ le.

Incomplete without all pages and signatures

The purpose of this proﬁ le is to help your insurance broker determine if the annuity product you are purchasing from The

Standard is suitable based on your ﬁ nancial situation and goals. You must complete this proﬁ le in its entirety and submit it

with your application for The Standard to proceed with your purchase.

Full Legal Name Birth Date

Are you actively employed?



Yes



No Anticipated Retirement Age

A. OWNER INFORMATION

Suitability Proﬁ le

Standard Insurance Company

Individual Annuities 800.247.6888 Tel

1100 SW Sixth Avenue Portland OR 97204-1093 www.standard.com

1. Why are you considering purchasing this annuity?

(check all that apply) ................................................................



Immediate Income



Long-Term or Lifetime Income



Tax Deferral



Assets for Beneﬁ ciaries



Estate Planning



Retirement



Safety of Funds



Other

2. What is your ﬁ nancial time horizon for achieving this

annuity’s goals?



Less than one year



1-5 years



6-10 years



Longer than 10 years

3. How long do you plan to keep this annuity? years

4. Which ﬁ nancial products do you own or have you

previously owned? (check all that apply)



Deferred Annuities



Immediate Annuities



Life Insurance



Certiﬁ cates of Deposit



Stocks/Bonds/Mutual Funds



Other

5. What sources of funds will be used for the purchase of this

annuity? (check all that apply)



Other Annuities



Life Insurance



Savings/Checking



Certiﬁ cates of Deposit



Money Market



Stocks/Bonds/Mutual Funds



Loan



IRA or Retirement Plan



Other

6. Is the source of funds a life insurance policy or annuity

contract? ..................................................................................



Yes



If yes:

a. Will you incur a surrender charge by exchanging your

old policy? ...........................................................................



Yes



If so, what is the surrender charge (including, if applicable,

MVA or other adjustments) on each policy being replaced? .... Policy 1: ______% Policy 2: ______%

Policy 3: ______% Policy 4: ______%

b. Will a market value adjustment reduce the value of the

replaced contract? ..............................................................



Yes



c. Will you lose existing beneﬁ ts by surrendering your

existing policy? (check all that apply) .....................................



Yes



Death Beneﬁ t



Living Beneﬁ t



Interest Bonus



Persistency Bonus



Higher Guaranteed Interest Rate



Other

B. FINANCIAL GOALS AND OBJECTIVES

Reset

SI 15510 2 of 4 (8/13)

Submit original with application. Leave copy with applicant. Keep copy in producer ﬁ le.

Incomplete without all pages and signatures

Suitability Proﬁ le

Standard Insurance Company

Individual Annuities 800.247.6888 Tel

1100 SW Sixth Avenue Portland OR 97204-1093 www.standard.com

1. What is your federal income tax bracket? .............................



10%



15%



25%



28%



33%



35%

2. What will be your annual gross income after this

proposed annuity purchase? ................................................ $

3. What are your annual living expenses, including annual

debt payments? .................................................................... $

4. After the purchase of this annuity, will you have sufﬁ cient

income to meet your expenses? ...........................................



Yes



5. Do you anticipate signiﬁ cantly higher expenses during

the proposed annuity surrender period including

medical expenses? ...............................................................



Yes



6. Do you anticipate signiﬁ cantly lower income during the

proposed annuity surrender period?.....................................



Yes



7. What are your total liquid assets before the proposed

annuity purchase? ................................................................ $

Liquid assets may be:

• Savings/Checking/CDs • Stocks/Bonds/Mutual Funds

• Retirement Plan Funds • Life Insurance

• Cash Value of Annuities

8. What percentage of your liquid assets will the proposed

annuity purchase be? (Annuity purchase amount ÷ Line 7) ...... %

9. Do you anticipate changes in your out-of-pocket

medical expenses during the proposed annuity’s

surrender period? .................................................................



Yes



10. Is your income sufﬁ cient to cover future changes in your

household or medical expenses during the proposed

annuity's surrender period? ..................................................



Yes



11. Do you have an emergency fund for unexpected expenses? .....



Yes



12. If you answered yes to questions 5, 6 or 9, or no to

questions 4, 10 or 11, please explain.

C. FINANCIAL INFORMATION

B. FINANCIAL GOALS AND OBJECTIVES (cont.)

d. By proceeding with the proposed exchange or

replacement, will you be subject to increased fees,

investment advisory fees, or charges for riders and

similar product enhancement? .............................................



Yes



e. Have you had another policy exchange or replacement

within the past 36 months? ..................................................



Yes



f. How does this annuity better meet your ﬁ nancial goals?

SI 15510 3 of 4 (8/13)

Submit original with application. Leave copy with applicant. Keep copy in producer ﬁ le.

Incomplete without all pages and signatures

1. Do you anticipate a need to withdraw more than a

penalty-free amount from this annuity during the

surrender period? .................................................................



Yes



2. Do you understand that if you withdraw more than a

penalty-free amount from this annuity during the

surrender period, you will incur a surrender charge? ...........



Yes



3. What distributions do you anticipate from this annuity?

(check all that apply) ...........................................................



Annuitization



Immediate income



Substantially Equal Periodic Payments



Required minimum distributions



Full surrender



Partial withdrawals



Interest-only payments

4. When do you anticipate taking your ﬁ rst distribution from

this annuity? (choose one) .....................................................



1 year



2-5 years



6-7 years



8-10 years



Longer than 10 years

5. Do you understand that you may incur a 10% federal

tax penalty for withdrawals before age 59½? .......................



Yes



6. Does the owner currently reside in a nursing home or

assisted living facility? ..........................................................



Yes



7. Describe your risk tolerance:



Conservative: I want to preserve my initial principal with minimal risk, even if that means the account

does not generate signiﬁ cant income or returns and may not keep pace with inﬂ ation.



Moderate: I am willing to accept some risk to my initial principal and tolerate some volatility to seek

higher returns, and understand I could lose a portion of money invested.



Aggressive: I am willing to accept maximum risk to my initial principal to aggressively seek maximum

returns, and I understand I could lose most, or all, of the money invested.

8. Which of the following best describes your ﬁ nancial experience?



Very experienced: Good understanding of ﬁ nancial products, own a broad range of ﬁ nancial products,

conﬁ dent about ﬁ nancial decisions.



Moderate experience: General understanding of some ﬁ nancial products, own some ﬁ nancial products, willing

to make some ﬁ nancial decisions.



Limited experience: Primary savings in certiﬁ cates of deposit, savings/checking, money market funds;

nervous about ﬁ nancial decisions.

9. What additional information should your insurance producer know before making a ﬁ nal annuity purchase recommendation?

(Examples: expected major life changes, beneﬁ ciary needs, etc.)

D. OTHER CONSIDERATIONS

Suitability Proﬁ le

Standard Insurance Company

Individual Annuities 800.247.6888 Tel

1100 SW Sixth Avenue Portland OR 97204-1093 www.standard.com

SI 15510 4 of 4 (8/13)

Submit original with application. Leave copy with applicant. Keep copy in producer ﬁ le.

Incomplete without all pages and signatures

Suitability Proﬁ le

Standard Insurance Company

Individual Annuities 800.247.6888 Tel

1100 SW Sixth Avenue Portland OR 97204-1093 www.standard.com

Please initial each statement if it is true:

_____ I represent that all statements and information provided herein are true and complete to the best of my belief

and knowledge.

_____ I understand that should I provide incomplete or inaccurate information, I will limit the protection afforded to me

by state law regarding the suitability of this purchase.

_____ I have reviewed the product-speciﬁ c disclosure with my insurance broker, and I understand the costs and

features of the annuity I am purchasing.

_____ I understand and acknowledge that The Standard and its representative do not offer legal, ﬁ nancial, tax,

investment or estate-planning advice and I have had the opportunity to seek such advice from the proper

sources before purchasing this annuity.

_____ I believe that the purchase of this annuity is appropriate to my particular legal, ﬁ nancial, tax, investment, and

estate-planning goals, and other insurance needs.

Owner Signature: Date:

Signed In (city/state):

E. OWNER DECLARATIONS AND ACKNOWLEDGMENT

I have recommended the purchase of this annuity. (If applicable, I have also recommended replacing or exchanging

existing annuities.)

The basis for my recommendation is:

I declare that I have truly and accurately recorded on this form all of the information provided by the Purchaser(s). I

have veriﬁ ed the identity of the Purchaser(s) with government-issued photo identiﬁ cation, and I believe the identity

information provided to me is true and accurate. I have informed the Purchaser(s) of the various features of the

annuity including tax penalties and fees. I believe that the Purchaser(s) will beneﬁ t from the annuity’s features.

Based on the facts disclosed to me by the Purchaser(s), and based on all circumstances known to me at the time the

recommendation was made, I declare that this annuity purchase as a whole is suitable to the insurance needs and

ﬁ nancial objectives of the Purchaser(s).

Insurance Broker Signature: Date:

Insurance License Number:

Standard Insurance Company Producer Identiﬁ cation No:

F. INSURANCE BROKER DECLARATIONS AND ACKNOWLEDGMENT

11426 (09/05) 1 of 1

Standard Insurance Company

Individual Annuities 800.247.6888 Tel 800.378.4570 Fax

1100 SW Sixth Avenue Portland OR 97204-1093 www.standard.com

Request for EFT of Annuity Payout

1 Contract Identiﬁcation

POLICY NUMBER

PAYOR NAME PHONE

ADDRESS CITY STATE ZIP CODE

2 Financial Institution Account

FINANCIAL INSTITUTION NAME FINANCIAL INSTITUTION TYPE

❏ Bank ❏ Credit Union ❏ Savings and Loan

NAME ON ACCOUNT ACCOUNT TYPE

❏ Checking ❏ Savings

Attach Void Check or Account Statement

3 Authorization

I authorize and request that Standard Insurance Company electronically deposit payments into the designated account

shown above. I authorize Standard Insurance Company to: (a) contact my ﬁnancial institution to conﬁrm the information

above; and (b) resolve deposit problems. I understand that deposits will be delayed if I do not provide accurate and complete

information on this form. This authorization will remain in full force and effect until I: (a) revoke it; or (b) it otherwise

ends; as provided for below.

I agree to notify Standard Insurance Company as soon as reasonably possible of any changes to my account. I understand

that if my account is closed or if the account number is changed: (a) this agreement will end; and (b) Standard Insurance

Company will not be liable for any consequences of the failure to transfer to my account. If this agreement ends, I

understand that any remaining payments will be made by check until a new designated account is set up.

I understand that I may continue to receive payment checks through the U.S. mail for one to two more payment cycles, until

all necessary transactions have been completed between: (a) Standard Insurance Company; and (b) my ﬁnancial institution.

I further understand that my deposits may not be posted to my account until the evening of the due date.

I may end this authorization at any time. If I choose to do so, I will contact Standard Insurance Company at the address or

telephone number shown above.

I am attaching: (a) an original void check (if I designated a checking account); or (b) a photocopy of that part of the

statement that veriﬁes my name and account number (if I designated a savings account). I understand that: (a) a photocopy

of a check or a deposit slip is not sufﬁcient; and (b) Standard Insurance Company will make deposits to only one account on

my behalf.

_______________________________________________________________________________________________________________________________ _______________________________

PAYOR SIGNATURE DATE

12213 1 of 2 (4/09)

Request for Rollover, Transfer or Exchange

1 Transferring Institution

COMPANY OR CUSTODIAN PHONE

STREET ADDRESS (NOT A POST OFFICE BOX) CITY STATE ZIP CODE

2 Existing Policy or Account

OWNER(S) OWNER SSNs (or TINs)

ADDRESS CITY STATE ZIP CODE

ANNUITANT(S), INSURED(S) OR PARTICIPANT ANNUITANT, INSURED(S) OR PARTICIPANT SSNs (or TINs)

BENEFICIARY (IF PARTICIPANT IS DECEASED) BENEFICIARY SSN (or TIN)

INVESTMENT VEHICLE

 CD  Life Insurance  Annuity  Custodial Account  Other ___________________

ACCOUNT OR CONTRACT NUMBER(S)

3 Transaction Type (Complete section A or B.)

A Qualiﬁed Funds

(For rollover, transfer or exchange into a 403(b) Tax-Sheltered Annuity, use form 12 213-TSA-A.)

Funds From Funds To

 Traditional IRA

 Inherited IRA

 Roth IRA

 SEP IRA

 403(b) TSA

 Qualiﬁed Pension

or Proﬁt Sharing Plan

 Other: _______________________

Initiated by Participant

 Traditional IRA

 Roth IRA

 SEP IRA

 Qualiﬁed Pension

or Proﬁt Sharing Plan

 Other: __________________________

Initiated by Beneﬁciary

 Inherited IRA (Attach form 13668.)

Standard Insurance Company’s Traditional IRA, Roth IRA, SEP and 403(b) contracts meet the requirements of

Internal Revenue Code § 408(b), 408A, 408(k) and 403(b)(1) respectively.

B Non-Qualiﬁed Funds

Transaction Type:  Direct Transfer

 1035 Exchange

Additional Funds Forthcoming After This Transfer:  No  Yes: $________________

The undersigned owner(s) authorizes the transferring institution to liquidate and transfer the requested amount

or percentage of the owner(s)’s rights, title and interest in the referenced account(s), without exception to Standard

Insurance Company. This assignment is made to facilitate the exchange of all or a portion of the above-referenced

policy for a new policy(ies) with Standard Insurance Company pursuant to Section 1035 of the Internal Revenue

Code. The undersigned owner(s) understands and agrees that Standard Insurance Company is providing this form

and participating in this exchange at the owner(s)’s request. The owner(s) acknowledges that Standard Insurance

Company has not made, and will not make, any representations or warranties regarding the tax effects, if any, of

this assignment, and any resulting taxes will be the sole responsibility of the owner(s). In consideration of Standard

Insurance Company’s willingness to participate in this exchange, the owner(s) accepts all responsibility for the validity

of this assignment and releases Standard Insurance Company from any and all claims or liability resulting from this

exchange. This Absolute Assignment shall be binding on the owner(s) and on the owner(s)’s personal representatives,

heirs, successors and assignees. The owner(s) acknowledges and warrants that no other person has any interest in

this policy, that no proceeding in bankruptcy is pending or has been ﬁled affecting the policy, and that any collateral

assignment of the policy has been properly released by the collateral assignee prior to the execution of this Absolute

Assignment contract’s beneﬁts and provisions within a reasonable time.

Standard Insurance Company

Individual Annuities 800.247.6888 Tel 800.378.4570 Fax

1100 SW Sixth Avenue Portland OR 97204-1093 www.standard.com

12213 2 of 2 (4/09)

4 Lost Policy Statement (Applicable only to a full surrender to effect the rollover, transfer or exchange.)

The undersigned certiﬁes that:

 The policy or contract is attached.

 The policy or contract is lost or has been destroyed. To the best of my knowledge it is not in anyone’s possession.

5 Participant/Beneﬁciary Declaration (

Complete only for rollover of 403(b) Tax-Sheltered Annuity funds.)

The undersigned requestor is a:

 Participant, older than age 59½, severed from employment or with another distributable event.

 The beneﬁciary of a deceased participant of the plan sponsor releasing these funds.

 Neither of the above.

6 Authorization

The undersigned owner(s) or beneﬁciary authorizes the transferring institution to liquidate and transfer

__________ % or $ __________________ as cash from the policy or account to Standard Insurance Company:

 Transfer Immediately (default action if no selection is made)

 Transfer on Maturity or Anniversary Date

 Transfer on _______________________________

I(We) authorize disclosure of information to Standard Insurance Company as necessary to complete the requested transaction.

I(We) understand that the rollover, transfer or exchange will be effective on the date the check(s) is(are) received.

__________________________________________________________________________________ ________________________

OWNER OR BENEFICIARY SIGNATURE DATE

__________________________________________________________________________________ ________________________

OWNER SIGNATURE DATE

__________________________________________________________________________________ ________________________

GUARANTEE SIGNATURE (IF APPLICABLE) DATE

7 Request for Funds Transfer (To be completed only by an authorized Standard Insurance Company home-ofﬁce employee.)

Standard Insurance Company is prepared to accept the assets as indicated in this document and will transfer the assets into a

new or existing policy with Standard Insurance Company.

Standard Insurance Company (TIN #93-0242990) hereby requests that the above-documented surrender or partial

withdrawal be transacted immediately. All proceeds, including any premiums, shall be payable and forwarded to:

Standard Insurance Company

FBO:

Unit 36

P.O. Box 5000

Portland, OR 97208-5000

 Please refer to the Standard Insurance Company annuity contract number: ____________________________ .

 The requested action is a 1035 Exchange, therefore please:

• Provide Cost Basis (see the enclosed Request For Cost Basis And Balance form).

AUTHORIZED STANDARD INSURANCE COMPANY HOME OFFICE EMPLOYEE DATE

OWNER(S), ANNUITANT(S) OR BENEFICIARY NAME

CONTRACT NUMBER

DATE

Michigan Department of Treasury

4924 (Rev. 05-13)

MI W-4P

Withholding Certicate for Michigan Pension or Annuity Payments

INSTRUCTIONS: Use Form MI W-4P to notify pension administrators of the correct amount of Michigan income tax to withhold from

your pension or annuity payment(s). You may also use this form to choose not to have any Michigan income tax withheld from your

payment(s). Military pensions and pensions paid by the Railroad Retirement Board are exempt from tax and withholding.

Entities subject to Michigan taxes that disburse pension or annuity payments are required to collect withholding if the payment is

expected to be taxable unless you opt out using this form (see instructions for line 1). Entities over which Michigan does not have

jurisdiction are not required to withhold Michigan income tax from your pension or annuity payment(s). If your pension administrator does

not withhold, you may need to make estimated income tax payments to avoid owing penalty and interest. For further information, see

General Instructions on page two, the

Michigan Estimated Income Tax for Individuals (MI-1040ES) or consult a tax advisor.

If you have more than one pension administrator, you will need to complete a form for each pension or annuity. If you do not le MI W-4P,

the administrator may withhold even if you will not owe tax on your pension income. See instructions on page two.

GENERAL INFORMATION

Name Social Security Number

Mailing Address (Number, Street, P.O. Box)

City State ZIP Code

Marital Status

Single Married Married (withhold the same as “Single”)

Check only ONE box. For joint lers, the age of the oldest spouse determines the age category.

Check here if your pension or annuity payments are not taxable or you wish to opt out. See lines 7 or 8 for additional voluntary withholding.

NOTE: Opting out may result in a balance due on your MI-1040 as well as penalty and/or interest.

2. Check here if you (or your spouse if older) were born before 1946. See instructions for line 2.

3. Check here if you (or your spouse if older) were born during the period 1946 through 1952 (deduction is $20,000 single/$40,000 joint).

See instructions for line 3.

4. Check here if you were born during the period 1946 through 1952 and your pension or retirement benets were from employment

with a governmental agency that was not covered by the Social Security Act (deduction is $35,000 single/$55,000 joint).

Check here if you (and your spouse) were born after 1952. See instructions for line 5.

Enter number of personal exemptions allowed on your Michigan Income Tax Return (MI-1040). Do not claim

more than your allowable personal exemptions on all MI W-4s (wages) or MI W-4P forms combined.

Additional Voluntary Withholding from Pension or Annuity Payment:

Voluntary percentage amount you want withheld from each pension or annuity payment (if permitted by

your pension administrator). This amount must be a percentage.

Voluntary dollar amount you want withheld from each pension or annuity payment (if permitted by your

pension administrator).

AUTHORIZATION

Signature

Printed or Typed Name and Title Date

Sign and return this completed form to the administrator of your pension or annuity. Keep a copy for your records.

Visit www.michigan.gov/taxes for additional information.

Reset Form

General Instructions

Significant income tax changes took effect in 2012 and going

forward. As a result, your pension payment may be subject to

tax and an underpayment may result if the incorrect amount of

tax is withheld. These changes may result in a balance due if the

incorrect amount is withheld from pension or annuity payment(s).

Caution: Some benefits do not meet the definition of “pension

and retirement benefits” under Michigan’s individual income

tax laws and are not eligible for subtraction on your Michigan

income tax return. Visit www.michigan.gov/taxes for additional

information. For these instructions the words “retirement

benefits” mean pensions, annuities, and other retirement benefits.

Taxpayers born before 1946 may deduct all retirement benefits

paid from public employment and retirement benefits from

private plans up to $48,302 on a single return or $96,605 on a

joint return. Recipients born during the period 1947 through

1952 are eligible to deduct retirement benefits up to $20,000 for

single or married filing separate taxpayers, or $40,000 if married

filing a joint return. For joint filers, the age of the oldest spouse

determines the age category.

For tax year 2013, single recipients born in 1946 or recipients

filing a joint return where the older spouse was born in 1946 are

eligible to deduct $20,000 (or $40,000 if filing a joint return)

against all income, not just retirement benefits. Recipients born

in 1946 may continue to use the MI W-4P so that they have the

appropriate amount withheld from their income.

Recipients born after 1952 may not deduct retirement benefits on

the Michigan Income Tax Return (MI-1040).

Multiple pensions: If you (and your spouse) receive multiple

pension payments, your withholding on those payments may not

cover your entire tax liability. Married couples where each spouse

receives retirement benefits may choose to have withholding

calculated as if each was single on the MI W-4P and select one

personal exemption in order to have sufficient withholding to

cover the tax liability. Taxpayers with multiple pensions may

need to make quarterly estimated payments (MI-1040ES) or

consult a tax advisor to ensure the proper amount is withheld or

paid through estimated payments.

Estimated Payments: There are penalties for not paying enough

state income tax during the year, either through withholding or

estimated tax payments. Taxpayers who choose not to have tax

withheld from their retirement benefits may be required to make

estimated tax payments. Refer to Form MI-1040ES for estimated

tax requirements.

When should I complete this form? Complete Form MI W-4P

and give it to the administrator of your retirement benefits as

soon as possible.

Your tax situation may change from year to year; you may want

to evaluate your withholding each year. You can change the

amount to be withheld by submitting an updated Form MI W-4P

to your pension administrator at any time.

Is every pension administrator required to withhold

Michigan tax? Only companies over which Michigan has taxing

jurisdiction are required to withhold Michigan tax from your

retirement benefits. If your pension administrator does not fall

under Michigan jurisdiction, you may request to have Michigan

tax withheld, but the company is not required to do so. If no taxes

are withheld from your payments, it is likely you will be required

to make estimated payments in place of the withholding. Contact

your pension and/or annuity administrator to verify whether tax

will be withheld from your payments.

Line-by-Line Instructions

Line 1: You may opt out of withholding tax from your

retirement benefits if you believe you will not have a balance

due on your MI-1040. If you (and your spouse) opt to have no

Michigan tax withheld from your retirement benefits by checking

the box on line 1, it may result in a balance due on your MI-1040

as well as penalty and/or interest.

Line 2: If you (or your spouse) were born prior to 1946, all

benefits from public sources are exempt and benefits from

private sources may be subtracted up to $48,302 for a single filer

or married filer filing separately or $96,605 if married filing a

joint return for the 2013 tax year. In addition, benefits that will

be rolled into another qualified plan or IRA will not be taxable

if the amount rolled over is not included in federal adjusted gross

income (AGI). Any private retirement benefits in excess of the

limits above are taxable.

Line 3: If you, or your spouse if your spouse is older than

you, were born in 1946 you may deduct the Michigan standard

deduction equal to $20,000 ($40,000 on a joint return) from your

taxable income instead of retirement benefits. If you (or your

spouse if older) were born during the period 1947 through 1952,

the first $20,000 for single filers or $40,000 for joint filers of all

private and public pension and annuity benefits may be subtracted

from Michigan taxable income. Benefits in excess of these limits

are taxable.

Line 4: If you were born during the period 1947 through 1952

and received retirement benefits from employment with a

governmental agency that was exempt from the Social Security

Act, the first $35,000 for single filers or $55,000 for joint filers of

all retirement benefits may be subtracted from Michigan taxable

income. The Michigan standard deduction for those born in 1946

is also increased by $15,000 if you received retirement benefits

from employment with a governmental entity that was exempt

from the Social Security Act.

Line 5: If you (and your spouse) were born after 1952, all private

and public retirement benefits are fully taxable and may not be

subtracted from Michigan taxable income.

Line 6: Enter personal exemptions you are claiming for

withholding. Do not claim more than your allowable personal

exemptions on all MI W-4s (wages) or MI W-4P forms combined.

Line 7: You may designate additional withholding if you expect

to owe more than the amount withheld. The amount on line 7

must be a percentage. Check with your pension administrator to

see if they permit additional withholding.

Line 8: If allowed by your pension administrator, you may enter

an additional dollar amount to be withheld from each payment.

Failure to have sufcient tax withheld from your

retirement benets may result in a balance due on

your MI-1040 as well as penalty and/or interest.

Form 4924, Page 2

Instructions for Completing MI W-4P,

Withholding Certicate for Michigan Pension or Annuity Payments

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