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[SBL LOGO]
SECURITY BENEFIT LIFE
INSURANCE COMPANY ("SBL")
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Member of The Security 700 SW Harrison St.
Benefit Group of Companies Topeka, Kansas 66636-0001
VARIABLE ANNUITY
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1. TYPE OF ANNUITY CONTRACT
[_] Non Qualified [_] 408A ROTH IRA
[_] 403(b) TSA
[_] 408 IRA CONTRIBUTION YEAR __________
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2. ANNUITANT
________________________________________________________________________________
First MI Last
________________________________________________________________________________
Street Address APT
________________________________________________________________________________
City State Zip
___________________________ ___________________________
Date of Birth SSN
________________________________________________________________________________
Telephone E-mail
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3. OWNER (APPLICANT)
________________________________________________________________________________
First MI Last
________________________________________________________________________________
Street Address APT
________________________________________________________________________________
City State Zip
___________________________ ___________________________
Date of Birth SSN
________________________________________________________________________________
Telephone E-mail
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4. JOINT OWNER
________________________________________________________________________________
First MI Last
________________________________________________________________________________
Street Address APT
________________________________________________________________________________
City State Zip
___________________________ ___________________________
Date of Birth SSN
________________________________________________________________________________
Telephone E-mail
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5. PRIMARY BENEFICIARY(IES)
Name DOB Relationship to Owner %
1. ___________________________________________________________________________
2. ___________________________________________________________________________
3. ___________________________________________________________________________
4. ___________________________________________________________________________
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6. CONTINGENT BENEFICIARY(IES)
Name DOB Relationship to Owner %
1. ___________________________________________________________________________
2. ___________________________________________________________________________
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7. ALLOCATION OF PURCHASE PAYMENTS
Small Cap Growth _____%
Small Cap Value _____%
Technology _____%
International _____%
Global _____%
Mid Cap Growth _____%
Mid Cap Value _____%
Social Awareness _____%
Select 25 _____%
Capital Growth _____%
Enhanced Index _____%
Large Cap Growth _____%
Equity _____%
Main Street Growth and Income(R) _____%
Large Cap Value _____%
Global Total Return _____%
Equity Income _____%
Managed Asset Allocation _____%
Global Strategic Income _____%
High Yield _____%
Diversified Income _____%
Money Market _____%
Fixed Account _____%
100%
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8. BILLING INFORMATION
[_] Salary Savings:
Annualized Contribution $_____________________
Bill Number __________________________________
Employer Name ________________________________________________________
[_] Secur-O-Matic Bank Draft [_] Checking [_] Savings
Payment Amount $_____________________ Draft Day _____________________
Frequency: Monthly [_] Semi-Annual [_]
Quarterly [_] Annual [_]
Bank Name__________________________________________________________________
Bank Address_______________________________________________________________
Account Number_____________________________________________________________
Routing Transit Number_____________________________________________________
I hereby authorize SBL to make withdrawals from my account maintained at
the Bank. I authorize the Bank to charge my account for any withdrawals
made by SBL for this purpose. This authority remains in effect until I
revoke it in writing, and SBL and the Bank actually receive such notice.
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9. REPLACEMENT
Will this proposed contract replace or change any existing annuity or
insurance policy? [_] No [_] Yes If yes, please list company and policy
number ____________________________________________________________________
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10. OPTIONAL RIDERS
INCOME RIDER
[_] Guaranteed Minimum Income Benefit*
[_] 3% [_] 5%
COMBINATION RIDER
[_] Combination Annual Stepped Up and Guaranteed Growth
at 5% Death Benefit*
CREDIT ENHANCEMENT RIDER
[_] 3% [_] 4% [_] 5%
DEATH BENEFIT RIDER
[_] Annual Stepped Up Death Benefit
[_] Guaranteed Growth Death Benefit*
[_] 3% [_] 5% [_] 6% [_] 7%
SURRENDER CHARGE WAIVERS
[_] Nursing Home, Terminal Illness, Disability
*The maximum rate under the riders for Contract Value in the Money Market
or Fixed Account is 4%. If you select a rate of 5%, 6% or 7%, those
Accounts will default to a rate of 4%.
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11. ELECTRONIC TRANSFER PRIVILEGE
[_] If you do not wish to authorize Electronic Transfers, you must check
this box. SBL will make transfers, account changes, and effect various
other transactions based on instructions received via telephone, Internet,
or other available electronic means.
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12. STATEMENT OF UNDERSTANDING
I have been given a current prospectus that describes the contract for
which I am applying and a current prospectus for the funds which underlie
each Subaccount above. If my annuity contract qualifies under section
403(b), I declare that I know: (1) the limits on redemption imposed by
Section 403(b)(11) of the Internal Revenue Code; and (2) the investment
choices available under my employer's Section 403(b) plan to which I may
elect to transfer my account balance. I KNOW THAT ANNUITY PAYMENTS AND
WITHDRAWAL VALUES, IF ANY, WHEN BASED ON THE INVESTMENT EXPERIENCE OF THE
SUBACCOUNTS ARE VARIABLE AND DOLLAR AMOUNTS ARE NOT GUARANTEED. The amount
paid and the application must be acceptable to SBL under its rules and
practices. If they are, the contract applied for will be in effect on the
Contract Date. If they are not, SBL will be liable only for the return of
the amount paid.
[_] Check this box to receive a Statement of Additional Information.
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13. TAX IDENTIFICATION NUMBER 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, or (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
the IRS has notified me that I am no longer subject to backup
withholding.**
THE INTERNAL REVENUE SERVICE DOES NOT REQUIRE YOUR CONSENT TO ANY PROVISION
OF THIS DOCUMENT OTHER THAN THE CERTIFICATIONS REQUIRED TO AVOID BACKUP
WITHHOLDING.
___________________________________________________________________________
SIGNATURE OF OWNER SIGNED AT (CITY-STATE) DATE: MONTH DAY YEAR
________________________
SIGNATURE OF JOINT OWNER
**You must cross out item (2) above if you have been notified by the IRS
that you are currently subject to backup withholding because of
underreporting of interest or dividends on your tax return. For
contributions to an individual retirement arrangement (IRA), and
generally payments other than interest and dividends, you are not
required to sign the certification, but you must provide your correct Tax
Identification Number.
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14. REGISTERED REPRESENTATIVE/DEALER INFORMATION
Representative's Statement - to the best of my knowledge, this application
is not involved in the replacement of any life insurance or annuity
contract, as defined in applicable Insurance Department Regulations, except
as stated in question 9 above. I have complied with the requirements for
disclosure and/or replacement.
___________________________________________________________________________
SIGNATURE OF REPRESENTATIVE PRINT NAME OF REP REP NUMBER
___________________________________________________________________________
PRINT NAME OF BROKER/DEALER TELEPHONE BROKERAGE BROKERAGE
NUMBER ACCOUNT # GROUP #
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For Company Representative's Use Only: Option: [_] A [_] B [_] C [_] D
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[SBL LOGO]
SECURITY BENEFIT LIFE
INSURANCE COMPANY ("SBL")
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VARIABLE ANNUITY APPLICATION
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STATE DISCLOSURES
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ALL JURISDICTIONS EXCEPT AR, AZ, CT, DC, FL, KS, KY, LA, ME, MN, NJ, NM, OH, OK,
PA, TX, VA AND WA.
Any person who, with intent to defraud or knowing that he/she is facilitating
fraud against an insurer, submits an application or files a claim containing a
false or deceptive statement is guilty of insurance fraud.
NEW JERSEY ONLY
Any person who includes any false or misleading information on an application
for an insurance policy is subject to criminal and civil penalties.
OKLAHOMA ONLY
WARNING: Any person who knowingly and with intent to injure, defraud or deceive
any insurer, makes a claim for the proceeds of an insurance policy containing
any false, incomplete or misleading information is guilty of insurance fraud.
WASHINGTON ONLY
Any person who knowingly presents a false or fraudulent claim for the payment of
a loss or knowingly makes a false statement in an application for insurance may
be guilty of a criminal offense under state law.
AR, DC, KY, ME, NM, OH AND PA ONLY
Any person who, knowingly and with intent to defraud any Insurance company or
other person, files an application for insurance or statement of claim
containing 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.
CONNECTICUT AND TEXAS ONLY
Any person who, with intent to defraud or knowing that he/she is facilitating a
fraud against an insurer, submits an application or files a claim containing a
false or deceptive statement is guilty of insurance fraud, as determined by a
court of competent jurisdiction.
LOUISIANA ONLY
Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or knowingly presents false information in an application for
insurance is guilty of a crime and may be subject to fines and confinements in
prison.
ARIZONA, FLORIDA AND MINNESOTA ONLY
Do Not Use this form. Use state specific form.
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V9493 (R10-00)U 15-949300-00
