(LOGO)
Principal Principal Life
Financial Group Insurance Company
Mailing Address: Principal Flexible
Des Moines, IA 50392-1840 Variable Annuity Application
1. Replacement
Do you have any pending or inforce life insurance coverage or annuity contracts?
____ Yes ____No
Will this annuity replace or change any pending or inforce life insurance or
annuity contracts? ____ Yes ____ No
If Yes, give details, listing company name and policy/contract number
_______________________________________________________________________________
If Yes, this is a: __ Section 1035 exchange __Direct Transfer of IRA Proceeds
2. Plan Type
___IRA ____ SEP ____Simple IRA ____Pension Trust ____Tax Year ______
___Rollover IRA ____IRA Transfer ____Non Qualified
___Other___________________
3. Annuitant
Name-First__________ Middle_________ Last___________________ ___Male___Female
Birth Date______________ Social Security/Tax ID Number____________
Phone Number (__)_________
Address-Street_________________________ City_____________State______ Zip_______
4. Owner
Name-First__________ Middle_________ Last___________________ ___Male___Female
Birth Date______________ Social Security/Tax ID Number____________
Phone Number (__)_________
Address-Street_________________________ City_____________State______ Zip_______
Is Owner a:___Corporation ___Trust ___Partnership ___Custodian
Optional
5. Joint Owner/Joint Annuitant
Must be Spouses. Not applicable for qualified contracts.
____ Owner and Annuitant are to be Joint Owners and Joint Annuitants.
Optional
6. Power of Attorney Enclose supporting documents.
____Yes ____No If Yes ___Durable ___Non Durable ___Durable Postponed
Name of Authorized Person given Power of Attorney_______________________________
Phone Number of Authorized Person (____) _______________________________________
7. Owner's Beneficiary(ies)
Primay___________________________ Relationship to Owner ______________________
Contingent ______________________ Relationship to Owner ______________________
8. Annuitant's Beneficiary(ies)
Primary__________________________ Relationship to Annuitant___________________
Contingent_______________________ Relationship to Annuitant___________________
9. Annual Enhanced Death Benefit Option
Annual Enhanced Death Benefit Rider: ____ Yes ____ No
If neither box is marked then the Rider will NOT be added.
10. Purchase Payment Information
___Initial Purchase Payment $____________ Make checks payable to Principal Life
Insurance Company. Minimum payment of $2500 Non-Qualified, $1000 Qualified,
or $100 Pre-authorized Checking Withdrawal or Employer Billing.
___Purchase Payment Credit Rider: ____Yes ____ No
If neither box is marked then the Rider will NOT be added. Fixed Dollar Cost
Averaging (DCA) Accounts are not available if rider is elected.
___Monthly PreAuthorized Withdrawal-First Payment Drawn on (Date)______________
MM/DD/YYYY
(Not available on the 29th, 30th, or 31st of any month)
Transit Routing # ________________ Account #________________________________
___Checking Account ___Savings Account
11. Purchase Payment Allocation Use whole number percentages.
Aggressive Growth ___%
AIM V.I. Growth ___%
AIM V.I. Growth and Income ___%
AIM V.I. Value ___%
Asset Allocation ___%
Balanced ___%
Bond ___%
Capital Value ___%
Fidelity VIP Growth ___%
Fidelity VIP II Contrafund ___%
Fixed Account ___%
Fixed DCA 6 Month* ___%
Fixed DCA 12 Month* ___%
Government Securities ___%
Growth ___%
International ___%
International Emerging Markets ___%
International SmallCap ___%
Janus Aspen Aggressive Growth ___%
LargeCap Growth ___%
LargeCap Growth Equity ___%
LargeCap Stock Index ___%
MicroCap ___%
MidCap ___%
MidCap Growth ___%
MidCap Growth Equity ___%
Money Market ___%
Real Estate ___%
SmallCap ___%
SmallCap Growth ___%
SmallCap Value ___%
Utilities ___%
TOTAL 100%
* Must allocate a minimum of $1000 to a Fixed DCA Account and complete Fixed
DCA Account Allocation section below.
____Fixed DCA Account Allocation Use whole percentages.
Transfer from Fixed DCA 6 Month to: Transfer from Fixed DCA 12 Month to:
1._____________________ ___% 1._____________________ ___%
2._____________________ ___% 2._____________________ ___%
3._____________________ ___% 3._____________________ ___%
4._____________________ ___% 4._____________________ ___%
5._____________________ ___% 5._____________________ ___%
12. Employer Information
Complete this section if Payroll Deduct IRA, SEP, Simple IRA, Pesion Trust
or in connection with a Non-Qualifed Employer Plan.
Name of Company_______________________________Name of Company Contact___________
Address-Street_______________________City____________Zip______Phone Number______
__Employer Billing(List Bill) Annualized Amount: $________
Frequency: __Monthly __Quarterly __Semi-Annually __Annually
13. Rate Lock-In for Fixed Account and/or Fixed DCA Account(s)
Applies only to Initial Purchase Payment. If rate lock-in is selected, the
lock-in will apply to the Fixed Account and any Fixed DCA Accounts.
This rate is guaranteed only if the money is received in our home office within
90 days of the date of this application.
___Lock-in current rate
Fixed Account___%for one year Fixed DCA 6 Month ____% Fixed DCA 12 Month ___%
If the box is not marked, the rate in effect at the time the money is received
will apply
14. Scheduled Transfer (dollar cost averaging)
Transfer Start Date (MM/DD/YYYY) _________________
Must be 30 days after the effective date of the contract. Not available on the
29th, 30th, or 31st day of any month.
Frequency: ___Quarterly ___Semi-Annually ___Annually
Use whole percentages and dollar amounts by the selected Division or Fixed
Account. Not available for Fixed DCA Accounts.
Investment Option Amount Investment Option Percentage
Transferring From Transferring To
1._____________________ $__________ ________________________ _____________%
2._____________________ $__________ ________________________ _____________%
3._____________________ $__________ ________________________ _____________%
4._____________________ $__________ ________________________ _____________%
5._____________________ $__________ ________________________ _____________%
__Check here to elect 2% from Fixed Account and indicate "Investment Option
Transferring To" in the section above. Leae "Amount" transferring from blank.
15. Automatic Portfolio Rebalancing
Automatic Portfolio Rebalancing is NOT available for the Fixed Account and Fixed
DCA Accounts.
A. Frequency: __Quarterly __Semi-Annually __Annually Effective Date_________
(MM/DD/YYYY)
Not available on the 29th, 30th, or 31st of any month. If a date is not
specified, the effective date will be the contract anniversary date.
B. __One Time Rebalancing. Specified Future Date (MM/DD/YYYY) __________________
Rebalance my contract as follows:
__Same as Purchase Payment Allocation (Section 11)
__Rebalance as listed below:
Investment Option Percentage Investment Option Percentage
_____________________ __________% ________________________ _____________%
_____________________ __________% ________________________ _____________%
_____________________ __________% ________________________ _____________%
16. Telephone and Internet Transfer Authorization
I (We) want telephone transaction services as described in the prospectus.
____ Yes ____ No
I (We) want Internet transaction services as described in the prospectus.
____ Yes ____ No
If these boxes are not checked, telephone and Internet services will apply.
Telephone or Internet instructions received from any joint contract owner will
be binding on all owners.
17. Scheduled Partial Surrenders (flexible withdrawal option) Accumulated
contract value must be $5000 to elect FWO.
___Accumulated Interest Only
Fixed Account only, NOT available on Fixed DCA Accounts.
___The minimum required distribution for customers over age 70 1/2.
Base minimum required distribution payments on:
___My life expectancy only.
___The joint life expectancy of me and my spouse.
Spouse's Birth Date______________________________
Spouses's Social Security #______________________
___Specified Amount $_______________
Investment Option Percentage
1._____________________ __________%
2._____________________ __________%
3._____________________ __________%
4._____________________ __________%
Effective Date (MM/DD/YYYY)___________
Must be 30 days after the effective date of the contract. Not available on the
29th, 30th, or 31st day of any month. The check will be mailed from our Annuity
Service Office or funds will be electronically transferred 2 days after the
effective date you specify.
Frequency: ___Monthly ___Quarterly ___Semi-Annually ___Annually
Tax Withholding: ___Yes ___ No
Method of Payment: ___Check ___Direct Deposit:
Transit Routing#_________ Account #___________
__Checking Account __Savings Account
18. Waiver of Surrender Charge Rider
On the contract date, if you or any annuitant are confined in a Health Care
Facilitiy, eligible for Social Security disability payments or diagnosed with a
terminal illness, you will not be able to use that condition to qualify for
benefits under the Waiver of Surrender Charge Rider. This Rider is automatically
added to your Contract where available. There is a one-year waiting period
before the rider is effective and the rider will not be issued for ages 86 and
over.
19. Fraud Notices
Arkansas: Any person who knowingly and with intent to defraud any insurance
company or other person submits a statement of claim or any application form
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. Such actions may be considered
felonies and subject to criminal and civil penalties, including imprisonment and
fines. In New York, civil penalties cannot exceed five thousand dollars and the
state value of the claim for each such violation.
Colorado: 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, fines,
denial of insurance, and civil damages. Any insurance company or agent of an
insurance company who knowingly provides false, incomplete, or misleading facts
or information to a contract owner or claimant for the purpose of defrauding or
attempting to defraud the contract owner or claimant with regard to a settlement
or award payable from insurance proceeds shall be reported to the Colorado
Division of Insurance within the Department of Regulatory Agencies.
District of Columbia/Virginia: WARNING: IT IS A CRIME TO PROVIDE FALSE,
MISLEADING, OR INCOMPLETE INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF
DEFRAUDING THE COMPANY OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT
AND/OR FINES AND DENIAL OF INSURANCE BENEFITS.
Kentucky/Maine: Any person, who knowingly and with intent to defraud any
insurance company or other person, files an application for insurance 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.
Louisiana: 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
confinement in prison.
New Jersey: Any person who includes any false or misleading information on an
application for an insurance policy is subject to criminal and civil penalties.
New Mexico: 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 civil fines
and criminal penalties.
Ohio: Any person who, with intent to defraud or knowing that he 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.
20. Signature and Tax Certification
I have read this application and have had the opportunity to read the prospectus
and agree to all its terms. In addition, I authorize the instructions in this
application. I have been given the opportunity to ask questions regarding this
investment, and they have been answered to my satisfaction. All of the
statements in this application are true and complete to the best of my knowledge
and are the basis of any annuity issued. I certify under penalty of perjury
(Check the appropriate response):
___ That the Social Security number or taxpayer identification number show is
correct and that the IRS has never notified me that I am subject to backup
withholding, or 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.
___ I have not been issued a taxpayer identification number but have applied
for such number, or intend to apply for such number in the near future. I
understand that if I do not provide a correct taxpayer identification
number to Principal Life Insurance Company within 60 days from the date of
this certification, backup withholding as described in the prospectus will
commence.
___ I am subject to backup withholding.
Benefits based on the performance of the separate account are variable and not
guaranteed as to dollar amount.
Proposed Annuitant's Signature Date (MM/DD/YYYY) Signed at City, State
______________________________ _________________ _____________________
Proposed Owner's Signature Date (MM/DD/YYYY) Signed at City, State
(If other than Annuitant)
______________________________ _________________ _____________________
If the Annuitant is also the Joint Owner, the above Proposed Annuitant's
signature also represents his or her signature as Joint Owner.
___ Check here to request a copy of the Statement of Additional Information for
this contract.
Registered Representative's Signature Date MM/DD/YYYY
_______________________________________________________________________________
Print Registered Representative's Name Phone Number
( )
_____________________________________________________________ ________________
Home Office Use Only
Princor Financial Services Corporation
Review (Home Office) Date (MM/DD/YYYY)
_______________________________________________________________________________
(LOGO)
Principal Principal Life
Financial Group Insurance Company
Mailing Address:
Des Moines, IA 50392-1840 Marketer's Report
For Proper Credit This Page Must Be Completed
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Agency Office Name and Office Number Group Office Name and Office Number
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Registered Representative Rep Tax ID Number Rep Detail Code Credit %
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Group Rep Name Group Rep Code
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To be Completed by Selling Firm
(A selling agreement must be in place if not sold through Princor)
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Broker/Dealer's Name
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Broker/Dealer Street Address City State ZIP
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Asset Based Compensation
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If this product is being sold through an outside broker dealer, a separate form
(DD 1372) will need to be completed.
For questions on these commission options, please refer to your commission
schedule.
____Option A ____Option B ____Option C
o Will be reduced for ages 76-85 and / or premiums over $2 million.
o Default option: If no commission option is selected, or if more than one
option is selected, the default commission option shall be Option A.
o Split Commissions: If there are multiple selling representatives, they must
all choose the same commission option.
o Option B and C are not available for Internal 1035 Exchanges or Direct
Transfers when reduced commissions are paid.
Replacement
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ALL QUESTIONS MUST BE ANSWERED BY THE REPRESENTATIVE AND THIS REPORT MUST BE
SIGNED.
1. Do you know, or have reason to believe, that replacement is or may be
involved in this transaction? ____Yes ____No
If "Yes", is this ___Section 1035 Exchange
___or a Direct Transfer of IRA Proceeds? (Please choose only one)
2. Please answer the following question about existing insurance or annuity
contracts, issued or under a binding conditional receipt by this or any
other company. Do you have reason to believe that any such other contract
has been or will be subjected to borrowing, assigned, reduced, modified,
adjusted, lapsed, canceled, exchanged, partial or fully surrendered,
changed to reduced paid-up or extended term, or subject to an automatic
premium loan in connection with the purchase of the insurance or annuity
contract applied for?
____Yes ____No
If "Yes", to either question above, give all details not already provided
on the application, including company name and contract number and what has
been or will be done to the existing contract(s):
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3. Do you certify you have explained to the applicant that discontinuing or
changing the existing policy or annuity contract may involve disadvantages,
including but not limited to surrender charges or tax consequences, and
that a careful comparison of existing benefits should be made before
applying for this contract?
____Yes ____No
____Not applicable because questions 1 and 2 were answered "No".
The answers to each question on the application were recorded exactly as given,
and true to the best of my knowledge.
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Soliciting Representative City State Date MM/DD/YYYY
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(LOGO)
Principal Principal Life
Financial Group Insurance Company
Variable Products
Mailing Address: Broker/Dealer
Des Moines, IA 50392-1840 Account Form
Owner Information
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Primary Owner Name (First, MI, Last) Date of Birth Soc. Sec. No. or Fed. Tax
(MM/DD/YYYY) I.D. No.
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Joint Owner Name (First, MI, Last) Date of Birth Soc. Sec. No. or Fed. Tax
(MM/DD/YYYY) I.D. No.
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Street Address E-Mail Address
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City State Zip Home Phone
( )
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State of Primary Residence Is Registered Representative registered in client's
resident state? ____Yes ____No
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Your Citizenship is: Country
___U.S. ___Resident Alien (1078) ___Non-Resident Alien (W-8)-Indicate
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Retired Name of Employer (If Retired, List Prior Nature of Business
Occupation and Employer)
__Yes __No
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Employer's Street Address Occupation Years with Present Employer
or in Retirement
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City State Zip Business Phone
( )
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Owner(s) Suitability Information (used to help confirm that transactions are
consistent with your goals)
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Primary Investment Objective*
(check only one)
___Variable Life - Death Benefit ___Variable Annuity-Long Term/Retirement
Secondary Investment Objective* Risk Exposure*
(check only one)
___Income ___Long-term growth ___Low ___Moderate ___High
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<TABLE>
<CAPTION>
Marital Years of Number of Fed. Tax Estimated Annual Liquid Net Worth* Other Investments and
Status Investment Dependents Bracket* Income (Do Not Include Primary Savings*
Experience* Residence)
<S> <C> <C> <C> <C>
% $ $ $
</TABLE>
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*Corporate/Trust Applicants must complete for suitability review.
Source of Funds To Be Invested
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___Current Income ___Personal Savings ___CD/Money Market Fund
___Mutual Fund Liquidation* ___Qualified Plan Distribution
___Insurance Proceeds (Surrender/Loan)* ___IRA Rollover*
___Transfer from an Annuity Contract* ___Other
*Please complete the Variable Contract Switch Disclosure below.
Variable Contract Switch Disclosure
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I understand that it is Princor's policy not to recommend one financial product
be replaced with another unless a person's investment or personal objectives can
be served better by such switching/replacing. I understand that I may incur a
front-end sales charge, contingent deferred sales charge, or surrender charges.
I understand I may incur income taxes due to this transaction. If my original
investment was in a family of funds or a variable contract, I realize that I
might be able to exchange to a fund or separate account within the family or
contract without incurring a sales charge. I made my original purchase
approximately______________ year(s) ago.
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I am making this exchange because:
___Lower Cost Structure ___Need for Death Benefit ___Need for Tax-Deferral
___Other_______________________________________________________________________
____(Please initial)
Financial Institution Disclosure
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I understand that the investment product that I have purchased is offered
through a Registered Broker Dealer. My Registered Representative has disclosed
to me, orally and in writing, that the securities products purchased or sold
are:
o Not insured by the Federal Deposit Insurance Corporation [FDIC]
o Not deposits or other obligation of the financial institution and are not
guaranteed by the financial institution; and
o Subject to investment risks, including possible loss of principal invested.
Signature
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Sign below exactly as your name appears on this form. For joint registration,
all owners must sign. Please note that the Customer Agreement contains a
pre-dispute arbitration agreement which is set forth in paragraphs 8 and 9 of
the enclosed Customer agreement. I acknowledge receiving a copy of this
agreement.
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Owner's Signature Date (MM/DD/YYYY)
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Joint Owner's Signature Date (MM/DD/YYYY)
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Registered Representative Registered Representative's RR Detail Code &
Printed Name Signature Percent
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Registered Representative Registered Representative's RR Detail Code &
Printed Name Signature Percent
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Registered Principal's Approval and Acceptance Date of Approval
(MM/DD/YYYY)
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Customer Agreement - This Customer Agreement is between the Account Owner(s)
(referred to as I) and Princor Financial Services Corporation (referred to as
You).
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1. Successors
This agreement and its provisions shall be continuous, and shall be for the
benefit of your present organization, and any successor organization or
assigns, and shall be binding upon me and/or the estate, executors,
administrators and assigns.
2. Age
If an individual, I represent that I am of legal age.
3. Orders and Statements
Reports of the execution of orders and statements of the contract shall be
conclusive if not objected to in writing. The former within two days and
the latter within ten days, after forwarding to me by mail or otherwise.
4. Force Majeure
You shall not be liable for loss or delay caused directly or indirectly by
war, natural disasters, government restrictions, exchange or market rulings
or other conditions beyond your control.
5. Joint Owners
This contract is owned jointly, unless you are notified otherwise and the
required documentation is provided, the contract(s) shall be held jointly
with right of survivorship (payable to either, or the survivor). Each joint
owner irrevocably appoints the other as attorney-in-fact to take all action
on their behalf and to represent them in all respects in connection with
this Agreement. You shall be fully protected in acting but shall not be
required to act upon the instructions of either joint owner. Each shall be
liable, jointly and individually, for any amounts due to you pursuant to
this Agreement, whether incurred by either or both.
6. Address
Communications may be sent to me at the address which is on file at your
office, or at such other address as may hereafter be given to you in
writing. All communications so sent, whether by mail, telegraph, messenger
or otherwise, shall be deemed given to me personally, whether actually
received or not.
7. Recording Conversations
I understand and agree that for our mutual protection you may
electronically record any of our telephone conversations.
8. ARBITRATION DISCLOSURES
* ARBITRATION IS FINAL AND BINDING ON THE PARTIES.
* THE PARTIES ARE WAIVING THEIR RIGHT TO SEEK REMEDIES IN COURT,
INCLUDING THE RIGHT TO A JURY TRIAL.
* PRE-ARBITRATION DISCOVERY IS GENERALLY MORE LIMITED THAN AND DIFFERENT
FROM COURT PROCEEDINGS.
* THE ARBITRATORS' AWARD IS NOT REQUIRED TO INCLUDE FACTUAL FINDINGS OR
LEGAL REASONING AND ANY PARTY'S RIGHT OR APPEAL OR TO SEEK
MODIFICATION OF RULINGS BY THE ARBITRATORS IS STRICTLY LIMITED.
* THE PANEL OF ARBITRATORS WILL TYPICALLY INCLUDE A MINORITY OF
ARBITRATORS WHO WERE OR ARE AFFILIATED WITH THE SECURITIES INDUSTRY.
9. AGREEMENT TO ARBITRATE CONTROVERSIES
IT IS AGREED THAT ANY CONTROVERSY BETWEEN US ARISING OUT OF YOUR BUSINESS
OR THIS AGREEMENT, SHALL BE SUBMITTED TO ARBITRATION CONDUCTED BEFORE THE
NATIONAL ASSOCIATION OF SECURITIES DEALERS INC. AND IN ACCORDANCE WITH ITS
RULES. ARBITRATION MUST BE COMMENCED BY SERVICE UPON THE OTHER PARTY OF A
WRITTEN DEMAND FOR ARBITRATION OR A WRITTEN NOTICE OF INTENTION TO
ARBITRATE.
NO PERSON SHALL BRING A PUTATIVE OR CERTIFIED CLASS ACTION TO ARBITRATION,
NOR SEEK TO ENFORCE ANY PRE-DISPUTE ARBITRATION AGREEMENT AGAINST ANY
PERSON WHO HAS INITIATED IN COURT A PUTATIVE CLASS ACTION OR WHO IS A
MEMBER OF A PUTATIVE CLASS ACTION WHO HAS NOT OPTED OUT OF THE CLASS WITH
RESPECT TO ANY CLAIM ENCOMPASSED BY THE PUTATIVE CLASS ACTION UNTIL; (I)
THE CLASS CERTIFICATION IS DENIED; (II) THE CLASS ACTION IS DECERTIFIED; OR
(III) THE CUSTOMER IS EXCLUDED FROM THE CLASS BY THE COURT. SUCH
FORBEARANCE TO ENFORCE AN AGREEMENT TO ARBITRATE SHALL NOT CONSTITUTE A
WAIVER OF ANY RIGHTS UNDER THIS AGREEMENT EXCEPT TO THE EXTENT STATED
HEREIN.
Securities are offered through Princor Financial Services Corporation,
a company of the Principal Financial Group,
711 High Street, Des Moines, Iowa 50392.
Princor Financial Services Corporation member SIPC. 800-247-4123
Understanding Your Principal Variable Annuity
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You have purchased a FLEXIBLE VARIABLE ANNUITY. Annuities are designed as
long-term retirement savings vehicles for individuals allowing for tax-deferred
build up of the earnings. If you are purchasing this variable annuity to fund a
tax qualified retirement plan, you should be aware that this tax deferral
feature is available with any investment vehicle and is not unique to a variable
annuity.
There are many benefits to a variable annuity that may mean a higher cost
compared to other types of investments. These benefits include protection for
your beneficiaries (through a guaranteed death benefit), access to a fixed
account, and the ability to choose among multiple investment advisors. In
addition, you can select a retirement income option that best fits your needs. A
retirement income option unique to annuities is one that provides an income you
can't outlive.
During the accumulation phase, purchase payments you contribute may be allocated
to a fixed interest account and to several separate account divisions. The
separate account divisions fluctuate in value and with them, you bear the
investment risk, including the possible loss of principal. Investment results
depend on the performance of the separate account divisions within the annuity.
Therefore, the accumulated value of this product may be worth more or less than
your original cost.
The product does offer certain guaranteed features that depend on the claims
paying ability of Principal Life Insurance Company. However, annuity contracts
are not insured by the FDIC or any other federal agency. Annuities are not
deposits or other obligations of a bank and are not guaranteed by any bank.
Separate Account Divisions - You have the ability to choose from a variety of
separate account divisions. Each division has a separate objective and invests
in shares of an underlying mutual fund. However, you are not purchasing a mutual
fund. Your prospectus contains a complete list of separate account divisions and
the expenses associated with them.
Fixed Account
Initial Interest Rate - The initial ___________% (if applicable) and
is guaranteed for one year. Any interest rate is subsequent purchase
payments receive the interest rate in effect on the date received in
the home office. The interest rate assigned to a purchase payment is
guaranteed until the next contract anniversary.
Renewal Interest Rate - On each anniversary date, a renewal interest
rate is determined for the entire fixed account accumulated value.
This renewal rate is guaranteed until the next contract anniversary.
The renewal interest rate set on each contract anniversary and the
interest rates credited to new premiums paid between anniversary dates
will differ, and may be higher or lower than the interest rate paid on
the initial premium.
The Company determines all interest rates at its sole discretion.
Interest rates set may depend on many factors, including current and
prior investment conditions, the financial experience and objectives
of the company, and other circumstances. Interest rates credited will
change over time but are guaranteed not to be less than 3.00%.
Fixed DCA Accounts
Fixed DCA 6 Month - The initial interest _____________% and is
guaranteed for six months. Any subsequent purchase rate is payments
receive the interest rate in effect on the date received in the home
office for the remainder of the six month period.
Fixed DCA 12 Month - The initial interest __________% and is
guaranteed for twelve months. Any subsequent purchase rate is payments
receive the interest rate in effect on the date received in the home
office for the remainder of the twelve month period.
Annual Fee - The lesser of $30 or 2% of your contract year-end accumulated value
will be deducted from your accumulated value. This fee is currently waived if
you own or jointly own Principal Variable Annuity Contracts with combined
accumulated value of $30,000 or more.
Surrender Charges - There is a surrender charge scale on your contract of
6,6,6,5,4,3,2,0 (based on contract years) and surrender charges will apply to
any surrenders in excess of your free surrender privilege (see prospectus for
details). There are no surrender charges for amounts used to purchase a benefit
option or amounts paid out at death.
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Withdrawals made prior to age 59 1/2 may incur a 10% IRS penalty.
Other Expenses - A mortality and expense risk charge and, in certain
circumstances, a Transaction Fee and state premium taxes are deducted under the
contract (see prospectus for details). The Company has also reserved the right
to assess a daily Administrative Expense Charge.
There are also deductions from and expenses paid out of the assets of the Mutual
Funds which are described in the Mutual Funds' prospectus.
Annual Enhanced Death Benefit - This rider is optional. If elected, the annual
cost is .20 percent (state variation may apply). The charge is deducted from
your contract's division value at the end of each calendar quarter (.05 percent
quarterly). This charge will not be added to the Mortality and Expense Risks
charge on your contract. You may terminate the rider at any time. Once
terminated, the rider cannot be reinstated.
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Signature of Owner City State Date MM/DD/YYYY
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Signature of Joint Owner City State Date MM/DD/YYYY
(NA for NJ, NY or PA)
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Signature of Representative City State Date MM/DD/YYYY
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