Variable Annuity Application
Send Application and check to:
Cova Financial Services Life Insurance Company
Policy Service Office: P.O. Box 10366
Des Moines, Iowa 50306-0366
For assistance call: [800 343-8496]
Cova Variable Annuity
ACCOUNT INFORMATION
1. Annuitant
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Name (First) (Middle) (Last)
Address (Street) (City) (State) (Zip)
Social
Security Number -- --
Sex / / M / / F Date of Birth ______/______/______
Phone ( )
2. Owner (Complete only if different than Annuitant)
Correspondence is sent to the Owner.
Name (First) (Middle) (Last)
Address (Street) (City) (State) (Zip)
Social
Security/Tax ID Number -- --
Sex / / M / / F Date of Birth/Trust / /
Phone ( )
3. Joint Owner
Name (First) (Middle) (Last)
Address (Street) (City) (State) (Zip)
Social
Security Number -- --
Sex / / M / / F Date of Birth ______/______/______
Phone ( )
4. Beneficiary
Show full name(s), address(es), relationship to Owner, Social Security
Number(s), and percentage each is to receive. Use the Special Requests section
if additional space is needed. Unless specified otherwise in the Special
Requests section, if Joint Owners are named, upon the death of either Joint
Owner, the surviving Joint Owner will be the primary beneficiary, and the
beneficiaries listed below will be considered contingent beneficiaries. Primary
Name Address Relationship Social Security Number %
Primary Name Address Relationship Social Security Number %
Contingent Name Address Relationship Social Security Number %
Contingent Name Address Relationship Social Security Number %
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5. Plan Type
/ / Non-Qualified
Qualified
/ / 401
/ / 403(b) TSA Rollover*
408 IRA* (check one of the options listed below)
Traditional IRA SEP IRA Roth IRA
/ / Transfer / / Transfer / / Transfer
/ / Rollover / / Rollover / / Rollover
/ /Contribution - Year___ / / Contribution - Year___ / / Contribution-Year____
*The annuitant and owner must be the same person.
6. Purchase Payment
Initial
Purchase
Payment $_____________________________
Make Check Payable to Cova
RIDERS
7. Benefit Riders (subject to state availability and age restrictions )
These riders may only be chosen at time of application. Please note, there are
additional charges for the optional riders. Once elected these options may not
be changed.
1) / / Living Benefit Rider
2) Death Benefit Riders (Check one. If no election is made, the Annual
Step Up option will apply).
/ / Return of Purchase Payments
/ / Annual Step Up
/ / Greater of Annual Step Up and 5% Annual Increase
3) / / Earnings Preservation Benefit Rider
(not available for Qualified Plans)
4) / / Other
COMMUNICATIONS
1. Telephone Transfer
I (We) authorize Cova Financial Services Life Insurance Company (Cova) or any
person authorized by Cova to accept telephone transfer instructions and/or
future payment allocation changes from me (us) and my Registered
Representative/Agent. Telephone transfers will be automatically permitted unless
you check one or both of the boxes below indicating that you do not wish to
authorize telephone transfers. Cova will use reasonable procedures to confirm
that instructions communicated by telephone are genuine. I (We) DO NOT wish to
authorize telephone transfers for the following (check applicable boxes): w
Owner(s) w Registered Representative/Agent
SIGNATURES
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2. Fraud Statement
Notice to Applicant:
For Arkansas, Kentucky, Louisiana, New Mexico, Ohio, Pennsylvania and Washington
D.C. Residents: Any person who knowingly and with intent to defraud any
insurance company or other person files an application or submits a 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.
For Florida Residents: Any person who knowingly and with intent to injure,
defraud, or deceive any insurer files a statement of claim or an application
containing any false, incomplete, or misleading information is guilty of a
felony of the third degree.
For New Jersey Residents: Any person who includes any false or misleading
information on an application for an insurance policy is subject to criminal and
civil penalties.
3. Special Requests
4. Replacements
Does the applicant have any existing policies or contracts? w Yes w No Is this
annuity being purchased to replace any existing insurance and annuity policy(s)?
w Yes w No If "YES", applicable disclosure and replacement forms must be
attached.
5. Acknowledgement and Authorization
I (We) agree that the above information and statements and those made on all
pages of this application are true and correct to the best of my (our) knowledge
and belief and are made as the basis of my (our) application. I (We) acknowledge
receipt of the current prospectus of Cova Variable Annuity Account One. PAYMENTS
AND VALUES PROVIDED BY THE CONTRACT FOR WHICH APPLICATION IS MADE ARE VARIABLE
AND ARE NOT GUARANTEED AS TO DOLLAR AMOUNT.
(Owner Signature & Title, Annuitant unless otherwise noted)
(Joint Owner Signature & Title)
(Signature of Annuitant if other than Owner)
Signed at
(City) (State)
Date
6. Agent's Report
Agent's Signature
Phone
Agent's Name and Number
Name and Address of Firm
State License ID Number (Required for FL)
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Client Account Number
Home Office Program Information:
Select one. Once selected, the option cannot be changed.
Option A ________ Option B ________ Option C ________
