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Liberty National Life Insurance Company

ADMINISTRATIVE GUIDELINESFOR THE

FLEXIBLE PREMIUM ANNUITYPLAN CODE E91

For Internal Use Only

LNL1011 1010LFPAE91-AG

Table of Contents

The Flexible Premium Annuity issued by Liberty National Life Insurance Company is not a product or deposit of, nor guaranteed by, any financial institution. It is not insured by the FDIC or any other federal agency. Early withdrawals or surrenders may be subject to taxes and/or tax penalties and withdrawal charges. Remember to have your clients consult their tax or financial advisor on details concerning tax or accounting consequences.

3700 S. Stonebridge Drive., McKinney, Texas 75070www.libnat.com

Mailing Funds and Applications 1Policy Issue 1Types of Funds 1Documents Required 2Interest Rates 2Request Forms 2Annual Report 2Exhibits:

A Flexible Premium Annuity Application (LANN-AP) 3B Flexible Premium Annuity Certificate of Receipt (LFPA802-CR) 7C Qualified Funds Identification Worksheet (LSA QFW) 8D Transfer/Section 1035 Exchange Form (F5535) 9E Interest Rate Chart 10F Annuity Systematic Withdrawal Request (LSA ASW) 11G Authorization Agreement for Direct Deposit (LSA DD) 12H Deposit Confirmation Advice/Letter (F7202) 13I Beneficiary Designation Form (LSA BD) 14J Your Guide to Your Liberty National IRA (LSA DF) 15K Minimum Distribution Withdrawal Request (LSA AMD) 16L State Replacement Form (R-3573) 17M Annuity Withdrawal or Surrender Request (LSA SR) 18N Annuity Request Form (LSA PR) 19O Withdrawal Charge Waiver Request (LSA WR) 20P Additional Premium Receipt (LSA APR) 21

Liberty National Administrative GuidelinesThe following pages cover Liberty National’s administrative procedures for the Flexible Premium Annuity. Included are general guidelines, document requirements, interest rate information, request forms and exhibits.

Mailing Funds and Applications

All funds and applications for regular mail are sent directly to:

Liberty National Life Insurance Company Attn: New Business P.O. Box 8080 McKinney, TX 75070

OR express mail to:

Liberty National Life Insurance Company Attn: New Business 3700 S. Stonebridge Drive McKinney, TX 75070

For customer service assistance call Liberty National: (800) 585-9739

Policy Issue

New Business GuidelinesEntering Applicant Data: Use Blue or Black ink pen — do not use a pencil, graphite pen, erasable ink pen or other colored ink pen.

When filling in the fields, print one character per box and stay inside the lines. Align text to the left. It is not necessary to enter periods(.) after abbreviations in the data fields. Example: SR, JR, or APT.

When there are choices to be made with circles, or bubbles, fill in the area inside the bubble. Example: Yes ● No . Do not mark the bubbles with “✗” or “✓.”

Align numeric dollar amounts to the right; never enter a comma in an amount field.

Special symbols, such as “#” to represent apartment or suite number, are acceptable.

Do not mark over, staple through, or cover the corner registration marks or the PASSform ID code.

You must use an original form; Photocopies are not acceptable. Not applicable on EApp.

As there may be large sums of money involved, it is imperative that the legibly completed application and the gross premium by check be mailed to the Home Office without delay. The application, check, and transmittal should be mailed to the Liberty National address above.

Minimum initial deposit is $2,000. Maximum deposit is 20,000 per year, per annuitant. Maximum premium amount accepted without prior Home Office approval is $1,000,000 over life of policy or amount permitted by the Internal Revenue Code. If premium is in excess of this amount, call the Home Office for approval. Policies will generally be mailed within five working days after receipt of application, funds, and certificate of receipt (Exhibit B) in the Home Office.

Make certain all Social Security numbers are listed.

Automatic Payment Plan (Bank Draft Premiums)Bank Draft is available for scheduled, pre-determined amounts with a signed Automatic Payment Authorization. The Automatic Payment Authorization is included on page 3 of application LANN-AP. Minimum bank draft amount is $50.

Types of Funds

Liberty National will accept funds in the form of:1. Nonqualified: Funds from a CD, Money Market, Savings Account, etc. to a

Liberty National nonqualified annuity.

2. Contributory IRA: Funds from a CD, Money Market, Savings Account, etc. to a Liberty National IRA.

3. IRA Transfer: Tax-free transfer of IRA funds directly from the previous IRA trustee/custodian to a Liberty National IRA.

4. IRA Rollover: Tax-free transfer of qualified funds (that is not an IRA Transfer) to a Liberty National IRA. The qualified funds can come from two sources:(1) Previous IRA — customer receives the funds. These funds must

be rolled over to a new IRA within 60 days of receipt to qualify for tax-free treatment.

(2) Previous Qualified Plan (TSA, KEOGH; employer pension, profit-sharing, stock bonus, or 401(k) plan) — if the customer receives an eligible rollover distribution, the customer can roll over all or part of it into an IRA. If the eligible rollover distribution is paid directly to the customer, the payer must withhold 20% of it. However, the customer can avoid withholding by choosing the Direct Rollover option. Under the Direct Rollover option, the payer transfers the eligible rollover distribution directly to an IRA. A Direct Rollover is a tax-free transfer of funds.

5. 1035 Exchange: Tax-free transfer of nonqualified funds directly from one insurance company to a Liberty National nonqualified annuity.

Page 1

Documents Required

Nonqualified: ▲ Flexible Premium Annuity Application (Exhibit A) ▲ Certificate of Receipt (Exhibit B)

Contributory IRA: ▲ Flexible Premium Annuity Application (Exhibit A) ▲ Certificate of Receipt (Exhibit B) ▲ Qualified Funds Identification Worksheet LSA QFW (Exhibit C) ▲ Provide “Your Guide to Your Liberty National IRA” (LSA DF PC E91)

to applicant (Exhibit J)

IRA Transfer or Rollover: ▲ Flexible Premium Annuity Application (Exhibit A) ▲ Certificate of Receipt (Exhibit B) ▲ Qualified Funds Identification Worksheet LSA QFW (Exhibit C) ▲ For transfers from an Annuity/IRA with another insurance

company, you will need to turn in the original policy to Liberty National.

▲ State Replacement Form (if applicable) (Exhibit L) ▲ Provide “Your Guide to Your Liberty National IRA” (LSA DFPC E90)

to applicant (Exhibit J) ▲ Transfer/Section 1035 Form F5535 (Exhibit D)

1035 Exchange: ▲ Flexible Premium Annuity Application (Exhibit A) ▲ Certificate of Receipt (Exhibit B) ▲ Transfer/Section 1035 Exchange Agreement F5535 (Exhibit D) ▲ State Replacement Form (if applicable) (Exhibit L) ▲ Turn in original Policy or Notice of Lost Policy to Liberty National

Interest Rates

The Flexible Premium Annuity has a guaranteed interest rate of 3%. The additional interest rates declared when the initial premium is received will be guaranteed for that premium for two years. Thereafter, new additional interest rates will be declared not more than once in a 12-month period.

Request Forms

▲ Annuity Systematic Withdrawal Request LSA ASW (Exhibit F) ▲ Individual Retirement Annuity Minimum Distribution Withdrawal

Request LSA AMD (Exhibit K) ▲ Annuity Withdrawal or Surrender Request* LSA SR (Exhibit M)

* A form is not required for these services; a letter signed by the owner will also be accepted.

▲ Annuity Request Form LSA PR (Exhibit N) ▲ Withdrawal Charge Waiver Request LSA WR (Exhibit O) ▲ Additional Premium Receipt LSA APR (Exhibit P) ▲ Authorization Agreement for Direct Deposit LSA DD (Exhibit G)

Annual Report

Each year, the policyholder will receive an Annual Report. The Annual Report is an itemized summary which rolls forward the annuity balance from the beginning of the policy year to the end of the policy year. The statement will include deposits, withdrawals, interest credited, renewal rate which will be credited to the annuity, etc.

Page 2

A Flexible Premium Annuity Application (LANN-AP)

1 Always put relationship of beneficiaries to the annuitant on the application. If known, put the Social Security number(s) of the beneficiary(ies) also. If more room is needed than is available on the application to clearly designate beneficiaries of the policy, both primary and contingent, use the Beneficiaries Designation form LSA BD shown as Exhibit I. Or, you may attach a separate piece of paper providing such information, making sure the owner of the contract signs and dates this additional page.

2 A Joint Owner is not allowed on Qualified Funds.

Joint Owner's Last Name

ANNUITANT

Annuitant Telephone No.

- -

Plan Code Home Office Use Only

Pg 1

Annuitant's First Name

M.I.

StreetAddress

City State

Zip Code Social Security Number - -

- -Date of Birth

(mm-dd-yyyy)Age LastBirthday

Owner's First Name M.I. Relationship to Annuitant

StreetAddress

City State Zip Code

Joint Owner's First Name M.I. Relationship to Annuitant

StreetAddress

City State Zip Code

Owner's Last Name

JOINT OWNER

OWNER (if different from Annuitant)

(if different from Annuitant)

Taxpayer ID/ Social Security #

Age LastBirthday

Date of Birth (mm-dd-yyyy)

- -

Date of Birth (mm-dd-yyyy)

- -Age LastBirthday

Taxpayer ID/ Social Security #

LANN-AP

Beneficiary Name Relationship to Annuitant

Social Security Number - -

Annuitant's Last Name

SexMale

Female

SexMale

Female

Male

FemaleSex

APPLICATION FOR DEFERRED ANNUITY * LIBERTY NATIONAL LIFE INSURANCE COMPANY

ADMINISTRATIVE OFFICE: P.O. BOX 8080 * MCKINNEY, TX 75070-8080

(Application Continued)Initials of

Annuitant

26008

J O H N

9 7 2 5 6 7 1 2 3 4 E 9 1

D O ER

1 2 3 M A I N S TA N Y T O W N7 5 0 7 0

T X

4 60 8 2 6 1 9 6 2

J A N E D O E W I F E6 7 8 91 2 3 4 5

1

2

J R D

Page 3

Exhibit


PREMIUM

NTEREST

(The policy anniversary following Annuitant's age 100 (age 81 for single premiumdeferred annuity) unless otherwise indicated.))

1st year interest rate on initial premium . %

REPLACEMENT

Do you have any existing life insurance policies or annuity contracts?If "Yes", Replacement Notice must be completed.

Will the annuity applied for replace any existing life insurance or annuity?If "Yes", explain:

Yes No

Yes No

Premium Mode

Single Premium

Annual

Semi-Annual

Quarterly

Monthly

Payment Method Bank Draft Direct

Draft Day (01 to 28)

TYPE OF ANNUITY

Qualified (not applicable to single premium deferred annuity)

Amount of Modal Premium

$ , .

Amount Paid with Application

$ , .

Pg 2

Expected Maturity Date

- -

E-mail Address

Annuitant Joint OwnerOwner

Non-Qualified

LANN-AP

Amount

$ , .

Contribution Year

Amount

$ , .

Contribution Year



Initials ofAnnuitant (Application Continued)

IRA

IRA Rollover

IRA Transfer

_________________

Non-Qualified

26008

3 Annuitization payment option begins.

4 Select the type of funds. This is required for issuing the annuity contract. Nonqualified and Qualified funds cannot be combined in one contract. Separate applications will be required.

5 The most current new money interest rate is published on UAOnline. This amount includes first year bonus rate and current interest rate.

6 Replacement Notice forms and requirements vary by state. Many states require the Replacement Notice form if the applicant has existing policies or contracts even if there is no intention of replacing. Refer to the chart on the next page for state specific form numbers and requirements. Download from www.libnat.com, 'Agent Services'.

3

4

J R D

0 55 0 0 0

0 00 0 020 1 0 2 2 0 6 3

0 00 0 01

0 00 0 01

0 04

2 0 0 8

2 0 0 9

5

6

Page 4

Exhibit


Replacement Notice Forms

StateIf Applicant has existing life insurance or Annuity

complete

If Applicant is replacing existing life insurance or

Annuity completeState

If Applicant has existing life insurance or Annuity

complete

If Applicant is replacing existing life insurance or

Annuity completeAL R-3573 MO R-1460-4AK Not Required MT R-3573AR R-1460-8 NC R-3573AZ R-3573 ND Not RequiredCA R-3573 NE R-3573CO R-3573 NH R-3573CT Not Required NJ N/A, Product Not ApprovedDC Not Required NM R-3573DE R-3575J NV R-3629AFL R-1460-6 OH R-3573GA R-1460-7 OK R-3576HI R-3573 OR R-3573IA R-3573 PA R-3573-PID R-3575A RI R-3573IL N/A, Product Not Approved SC R-2504-1IN R-3575B SD R-3575FKS R-3575C TN R-1460-2KY R-3573 TX R-3573LA R-3573 UT R-3573MA R-3687 VT R-3573MD R-3573 VA N/A, Product Not ApprovedME R-3573 WA R-3685MI R-3575D WV R-3573MN R-3575H WI R-3575GMS R-3573 WY R-3575E

Page 5

Exhibit


The Applicant agrees: (1) All statements and answers contained herein are full, complete and true to the best of my knowledge and belief. (2) This annuity contract is effectiveon the policy date unless: (a) the Annuitant is not living on the policy date; (b) the check for the initial premium is not honored; or (c) the Owner exercised the contractual right torequest a premium refund. (3) If the annuity contract is not effective on the policy date, the Company's sole obligation will be to refund all premiums received. (4) No agent canmake or change any provisions in the policy, waive any of the Company's rights or bind the Company. (5) Any policy issued on the basis of this application will be considereddelivered in and subject to, the laws of the jurisdiction in which the application was signed. Under penalties of perjury, I certify (1) that the number shown on this form is mycorrect Social Security /Taxpayer ID# and (2) THAT SUBJECT TO A BACKUP WITHHOLDING ORDER UNDER SECTION 3406(a)(1)(C) OF THE INTERNALREVENUE CODE. I understand that the annuity policy will not be federally insured.

MAKE CHECK PAYABLE TO: LIBERTY NATIONAL LIFE INSURANCE COMPANY.

The contract applied for shall take effect on the later of the date the application is approved by the Company at its Home Office, or the date the first stipulated payment is received,in full, at the Home Office of the Company.

I AM I AM NOT

Agent's Signature Agent No.

Agent: To the best of your knowledge, will this policy replace or change any existing life insurance or annuity?To the best of your knowledge, does the Annuitant have any existing life insurance or annuity contracts?

If "Yes" to either question, comply with applicable replacement regulation or rule and furnish Company name.

____________________________________________________________________________________

Yes No

Mail Policy to: Policy Owner Agent Financial Institution

Pg 3

Print Agent Last Name

Yes No

SignedSignature of Owner (if other than Annuitant)

LANN-AP

City State

Date Application Signed(mm/dd/yyyy) - -

SignedSignature of Annuitant



Initials ofAnnuitant

"Automatic" Payment Plan / Bank DraftDoes Not Apply to Single Premium

Please TAPE personalized VOIDED CHECK here.DO NOT STAPLE

"AUTOMATIC" PAYMENT PLAN / BANK DRAFT AUTHORIZATION: I authorize you to pay and charge to my account, checks or electronic debits drawn on myaccount by and payable to the order of Liberty National Life Insurance Company. This authorization is to remain in effect until revoked by me. All premiums andnon-insurance charges may be automatically withdrawn from my account on MONTHLY mode, unless a different mode has been selected on the application.

Account Holder's Signature (as it appears on financial institution records)

26008

7 Mark the appropriate answer to the question regarding backup withholding.

8 Joint Owner signature is required if applicable.

9 Required for proper processing of commissions.

7

8

J R D

0 1 0 2 2 0 0 9

S A L E S U A 1 1 1 1Sales Specialist 9

Page 6

Exhibit

B Flexible Premium Annuity Certificate of Receipt (LFPA802-CR)

LFPA802-CR LNL0767 0309

3700 S. Stonebridge drive • PoSt office box 8080 • Mckinney, texaS 75070-8080

LFPA802CertiFiCAte oF reCeiPt

FLexibLe PRemium ANNuity

Please review the following highlights of your annuity application and check the features and benefits for your understanding and satisfaction. Remember: This certificate is not the annuity contract but only a summary of the features. Only the annuity contract contains governing contractual provisions. Please read your contract carefully.

1. my Liberty National contract includes a base interest rate of _______% on my initial deposit for the first two years.

2. Additionally, my initial deposit will receive a bonus interest rate of _______% for the first year only.

3. the surrender period for the contract is seven (7) years. the surrender charges are: 8%, 8%, 7%, 6%, 5%, 4%, 3%. However, interest earnings may be withdrawn in full without surrender charge.

the interest earnings left in the contract are tax-deferred; withdrawals of earnings prior to age 59 1/2 are taxable and may be subject to penalty tax.

4. i may make additions to my annuity. the minimum addition to my annuity is $50.

5. the guaranteed minimum interest rate on my annuity is 3%.

6. if applicable, i am executing a 1035(a) tax-free exchange or tax-free transfer from an existing annuity or other contract to an annuity issued by Liberty National Life insurance Company, and i understand that the interest rate will be the rate in effect today for 60 days; otherwise it will be the rate in effect when the funds are received by Liberty National Life insurance Company.

7. i may make a partial or complete withdrawal under the nursing Home Waiver (where state approved) without incurring withdrawal charges if the annuitant or annuitant’s spouse:

a. is confined in a hospital or nursing home for a total of at least 30 days within a 35-day period, or has been discharged from such confinement within the previous 60 days; or

b. is enrolled in a hospice care program or has been discharged from such within the previous 60 days.

8. My principal (less withdrawals) is 100% guaranteed by Liberty national Life insurance company, a legal reserve life insurance company.

• it is not insured by the fdic or any other federal agency,

• nor is it a deposit, obligation or guarantee of any financial institution.

• i understand annuities may be subject to investment risk and possible loss of principal.

• a death benefit is available that is equal to the cash value of the policy.

9. i have included a check made payable to Liberty National Life insurance Company for the purchase amount of $___________.

Need more information? Call Liberty National Life Insurance Company at 800-585-9739.

Page 1 – Home Office Copy

____________________________________________________Annuitant/Owner Signature Date

____________________________________________________Joint Owner Signature Date

____________________________________________________Agent Signature Date

Page 7

Exhibit

C Qualified Funds Identification Worksheet (LSA QFW)


QUALIFIED FUNDSIDENTIFICATION WORKSHEET

LSA QFW LNL0969 0509

to be completed whenever the annuity is to be used to fund an ira

Agent: __________________________________________ Branch: __________________________

Annuitant/Owner Name: ___________________________ Contract Number: __________________

Is this a CONTRIBUTORY IRA? ❑ YES ❑ NO

If YES, indicate amount and tax year assignment for the contribution(s)

Amount $ ______________________ Tax Year ___________________

Amount $ ______________________ Tax Year ___________________

Is this an IRA ROLLOVER? ❑ YES ❑ NO

If YES, provide name of fund source ______________________________________________________

If YES, indicate type of rollover funds:

❑ IRA ❑ 401K ❑ TSA ❑ KEOGH ❑ SEP

Is this an IRA TRANSFER? ❑ YES ❑ NO

If YES, provide name of previous IRA trustee/custodian _______________________________________


________________________________ _______________________________ ___________________AnnuitAnt/owner SignAture AnnuitAnt/owner printed nAme dAte

________________________________ _______________________________ ___________________Agent SignAture Agent printed nAme dAte

The Qualified Funds Identification Worksheet is required for tax reporting purposes when annuities are used to fund an IRA. It must be completed at the time of sale and sent to Liberty National, along with the annuity application. The annuity application will not be processed, nor commissions paid, until this form is received by Liberty National.

Contributory IRAThese questions are important because amounts in a “contributory IRA” cannot be rolled over to a qualified employer plan (e.g., a SEP, Keogh, or 401(k) plan). Only new contributions can go towards a contributory IRA.

Contributions made from Jan. 1 through Apr. 15, can be either for the prior calendar year, or for the current calendar year. Therefore, it is important that the tax year for the contribution be indicated.

IRA TransferThese questions are important because direct transfers from one IRA trustee to another IRA trustee are not subject to certain dollar amount and frequency limitations that are imposed if the transfers qualify as rollovers. In addition, the direct transfer from the original IRA to another IRA avoids a 20% income tax withholding requirement otherwise required on the IRA distribution.

A check for an IRA “transfer” cannot come from the individual establishing the IRA; the funds can only come from the prior trustee / custodian. Funds transferred by check should be made payable to the new trustee / custodian “for the benefit of” the customer.

IRA RolloverThese questions are important if the source of the rollover funds is from a qualified retirement plan (TSA; Keogh; SEP; Employer Pension, profit-sharing, stock bonus, or 401(k) plan) because such funds (if kept segregated from new contributions) can be rolled over again at a later time to the same type of qualified plan. Funds from contributory IRA’s can never be rolled over into qualified plans.

Contrary to an IRA “transfer”, a check for an IRA “rollover” will come from the individual establishing the IRA. Funds transferred by check should be made payable to the new trustee/custodian “for the benefit of” the customer.

Nondirect transfers must be completed within 60 days from the time the funds are distributed from the old IRA in order to qualify as a tax-free rollover. Nondirect transfers are subject to 20% withholding by the previous trustee / custodian. Only one nondirect rollover per year is allowed for each IRA.

Page 8

Exhibit

D Transfer/Section 1035 Exchange Form (F5535)

Use for Nonqualified exchanges from Life Insurance, Annuity, and / or Endowment contracts to the Liberty National Annuity contract.

1035 Exchanges permit the policyowner to avoid current taxation on the gain of a terminated policy or to carry a loss forward to the new policy. Remember, a 1035 Exchange is a replacement, and you must follow the replacement procedures in your state. The replacement forms for your state, if any, must be submitted along with the rest of the new business forms.

MULTIPLE FUNDS Per IRS regulations, 1035 Exchanges must be processed to a new contract, thus funds received from a 1035 Exchange cannot be applied to an existing contract.

When multiple 1035 Exchanges are being processed to one contract, the contract will be issued with the effective date being the received date of the last 1035 Exchange funds. Funds received prior to issue, whether they be from one of the multiple 1035 Exchanges or additional deposits by the annuitant will be entered on the pending contract with the contract being issued for the total of all deposits once the final 1035 funds are received. Deposits made prior to issue will receive interest from the date they are actually received.

The deposit advice sent to the annuitant two weeks after issue should reflect the total amount received with a breakdown of the deposits by effective date.

Any of the 1035 Exchanges with lock-in will receive a lock-in interest rate as requested as long as the funds are received within the 60 days allowed. Additional funds deposited by the annuitant prior to issue will receive the current interest rate in effect at the time of receipt.

1. EXISTING CONTRACT / POLICY INFORMATION

Name of Distributing Plan / Company Contract / Policy Number Being Exchanged / Transferred

MAILING ADDRESS of Current Company City State Zip

Phone Number of Current Company

Annuitant Name (Please Print) Annuitant/Owner Social Security Number

Owner Name (Please Print) Owner Social Security Number

Joint Owner Name – if Applicable (Please Print) Joint Owner Social Security Number – if Applicable

Owner Address City State Zip

PLEASE SELECT A or B BELOW (Select One)

A. ❑ FULL 1035 EXCHANGEI hereby make a complete and absolute assignment and transfer all rights, titles, and interests of every nature and character in and to the above contract to the Company in an exchange intended to qualify under Section 1035 of the Internal Revenue Code.Upon receipt, the Company is directed to surrender all of my contract, as indicated above, and apply the value to the product for which I have submitted an application. I understand that by executing this assignment, I irrevocably waive all rights, claims and demand under the above contract. I acknowledge that the Company is furnishing this form and participating in this transaction as an accommodation to me and that the Company assumes no responsibility or liability for my tax treatment under Section 1035 of the Internal Revenue Code or otherwise.

B. ❑ QUALIFIED ACCOUNT TRANSFER (Certain restrictions may apply) From: ❑ IRA ❑ Simple IRA ❑ Roth IRA ❑ Qualified Retirement Plan ❑ 403(b)/TSA Plan ❑ SEP IRA To: ❑ Traditional IRA

I wish to liquidate and transfer the ❑ entire value or ❑ partial value (in the amount of) $__________ or ________% of my present qualified account to the contract/policy I have established through Liberty National Life Insurance Company.If this is a transfer into an existing contract, please provide the existing Contract Number ________________________________. Without this contract number, the transfer must be made into a new contract.This is a transfer and my Required Minimum Distribution (RMD) for this tax year:❑ Has already been distributed to me from the contract/account listed above or from another source.❑ Has not been distributed to me. Please calculate my RMD and distribute only that amount to me.

Prior year’s ending balance as of December 31st (12/31): $______________ Base my RMD on (select one): ❑ Uniform Lifetime Table Calculation; or ❑ Joint Last Survivor

(available only if your spouse is the sole primary beneficiary of your contract and is more than ten (10) years younger than you).

Spouse Name: _____________________________________________________ Spouse Date of Birth: __________________


TRANSFER / 1035 EXCHANGE FORM

F5535 LNL1057 0309Page 1 of 2 – Incomplete without all pages

IMPORTANT PROCESSING INFORMATION: Liberty National begins follow-up calls to the prior carrier to confirm receipt of the request, and to insure that the request will quickly be initiated by the prior carrier. If any additional information is required, the agent is notified.

Note: The policy being replaced must be submitted with the assignment form. Otherwise, if the policy is lost, check the appropriate box on the 1035 Exchange Form.

Page 9

Exhibit

E Interest Rate Chart

EXAMPLE AT 3.00% YIELD — 31 DAY MONTH:

Net Premium

× Accumulation FACTOR

Value

VALUE

− Net Premium

Monthly Interest (30 Days)

$20,000

× 1.002513627

$20,050.28

$20,050.28

− $20,000.00

$50.28

Annual Yield

Nominal Rate

Number Of Days In Interest Accumulation Period

Interest Income Projection Factor

3.00% 2.96% 28 1.002270097

3.00% 2.96% 30 1.002432444

3.00% 2.96% 31 1.002513627

Page 10

Exhibit

F Annuity Systematic Withdrawal Request (LSA ASW)

This form is used to elect a systematic withdrawal option. The W-4P and W-9 forms are included on the form. The “first payment date” must be on the 1st or 15th of the month. Indicate the specific date on the space provided. This form should be used for “Systematic Withdrawals” ONLY. (Do not use this form for a Minimum Distribution Request. Use form #LSA AMD for Minimum Distribution Requests).

Fill in “requested dollar amount” only if a specific amount is requested. If you are requesting interest only or Life Expectancy withdrawal options, indicate such by marking the correct box and leave the “requested dollar amount” option blank. Liberty National will calculate the correct amount.

Please do your own calculations on a separate piece of paper. Indicating a dollar amount when requesting options other than “specific dollar amount” can cause confusion regarding your objective and thereby detain the processing of your request while Liberty National calls to confirm your intent.

If this contract has joint owners, both the owner and joint owner should sign.

Liberty National Life Insurance CompanyAnnuity Systematic Withdrawal Request

Annuity Contract Number ___________________ Contract Owner _________________________________

I, the undersigned contract owner request a systematic withdrawal as indicated below.

❑ Requested Amount $ _____________________❑ Life Expectancy Withdrawal: The sum of each payment will be automatically recalculated each year based on IRS Life Expectancy Tables for my attained age. ❑ Interest Only Withdrawal: The interest will be automatically withdrawn each pay period, provided the interest calculated is $100 or greater.

Mode of Payment ❑ Monthly ❑ Quarterly ❑ Semi-Annually ❑ Annually

This request will be in effect until the funds are exhausted or I notify Liberty National Life Insurance Company otherwise. Start Date _________________ (1st or 15th of the month - specify starting month)

Withdrawing funds will reduce the contract's declared annual yield.

Payment Method Requested:

❑ Direct Deposit — Proceeds to be posted to your bank within three business days (attach completed Authorization Agreement For Direct Deposit) ❑ Check — Mailed to address of record and should arrive within two weeks

Failure to complete the following may result in the delay of processing your request.

❑ I DO NOT want to have Federal Income Tax withheld.❑ I DO want to have Federal Income Tax withheld from the taxable portion of my distribution at a rate of 10%. Please note that the tax is deducted from the amount requested.

• Notice to residents of CA, IA, KS, ME, MA, OR and VT: State Income Tax will be withheld if Federal Withholding is elected unless you check off the following State Withholding Box. ❑ I do not want State Income Tax withheld.• Notice to CT, MT, NM, and NJ residents: State Income Tax is voluntary. Please specify an even $ amount not less than $10. $ _________________

Payer's Request for Taxpayer Identification Number and Certification

Social Security Number ________ / ________ / ________ Employer I.D. Number ________ / _______________

Certification — Under penalties of perjury, I certify that the number shown on this form is my correct Taxpayer Identification Number and that I am not subject to backup withholding because I have not been notified by the Internal Revenue Service 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.

OHIO INSURANCE FRAUD WARNING: 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.

Please notify us immediately of any changes to the above information.

______________________________________________ ____________________________ ______________ Signature Telephone Number Date

______________________________________________ ____________________________________________ Address Joint Owner

______________________________________________ City State ZIP

LSA ASW LNL0967 12-08Page 1 - Home Office Copy

Page 11

Exhibit

G Authorization Agreement for Direct Deposit (LSA DD)

This form is used to initiate Direct Deposit (Electronic Funds Transfer) of annuity withdrawals. Be sure to attach a voided check to this form.

Page 12

Exhibit

H Deposit Confirmation Advice/Letter (F7202)

This is a client letter to confirm receiving / processing of an annuity deposit. Perforated deposit advice is included below the letter for making additional deposit.

This stub is for your records.

Policy Number

Amount of Deposit $ ____________

Date _________________________

Please write your policy number on your check or money order.

For proper credit, detach and return large portion with deposit in the enclosed envelope.

Deposit Advice Please return this advice with your next deposit.

Check here if a new address and make corrections below as necessary. THANK YOU.

F7202

Liberty National Life Insurance Company

Attn: Annuity DepartmentP.O. Box 8080

McKinney, TX 75070-8080

LNL0982 0910

Page 13

Exhibit

I Beneficiary Designation Form (LSA BD)

BENEFICIARY DESIGNATIONS

POLICY NUMBER___________________________

PRIMARY

_________________________________________________________________________________NAME BIRTHDATE RELATIONSHIP




CONTINGENT





Datedat_____________________________this _________ dayof____________ ________. CITY

Witness________________________________Owner__________________________________

Witness________________________________JointOwner _____________________________

3700SOuTHSTONEBRIDgEDRIvE•POSTOffICEBOx8080•MckINNEY,TExAS75070-8080

LSABD LNL09751208

Use this form in the event the number of beneficiaries exceeds the amount of space provided on the application.

Page 14

Exhibit

J Your Guide to Your Liberty National IRA (LSA DF)

Your Guide to Your LibertY NatioNaL ira

PLAN CODE: E91

3700 S. StoNebridGe drive • PoSt office box 8080 • MckiNNeY, texaS 75070-8080

LSA DF PC E91 LNL1050 0309

Every client who is establishing an IRA with Liberty National must be given this form. (Cover only shown here.)

Page 15

Exhibit

K Minimum Distribution Withdrawal Request (LSA AMD)

Liberty National Life Insurance CompanyIndividual Retirement Annuity Minimum Distribution Withdrawal Request

Annuity Contract Number ___________________ Contract Owner _________________________________

I, the undersigned contract owner request a minimum distribution withdrawal as indicated below.

❑ Requested Amount $_____________________❑ Single Life Expectancy Calculation: The sum of each payment will be automatically recalculated each year based on IRS Life Expectancy Tables for my attained age. ❑ Joint Life Expectancy Calculation: The sum of each payment will be automatically recalculated each year based on IRS life expectancy tables for my attained age and the attained age of my beneficiary whose date of birth is: ______________________________.

This request will be in effect until the funds are exhausted or I notify Liberty National Life Insurance Company otherwise.Mode of Payment ❑ Monthly ❑ Quarterly ❑ Semi-Annually ❑ Annually

Start Date _________________ (1st or 15th of the month - specify starting month)

Withdrawing funds will reduce the contract's declared annual yield.

Payment Method Requested:

❑ Company Check ❑ Direct Deposit (attach completed Authorization Agreement For Direct Deposit)

Please provide your account value as of 12/31 of the previous year, if your Liberty National annuity was not in effect at that time. $__________________

Failure to complete the following may result in the delay of processing your request.

❑ I DO NOT want to have Federal Income Tax withheld.❑ I DO want to have Federal Income Tax withheld from the taxable portion of my distribution at a rate of 10%. Please note that the tax is deducted from the amount requested.

• Notice to residents of CA, IA, KS, ME, MA, OR and VT: State Income Tax will be withheld if Federal Withholding is elected unless you check off the following State Withholding Box. ❑ I do not want State Income Tax withheld.• Notice to CT, MT, NM, and NJ residents: State Income Tax is voluntary. Please specify an even $ amount not less than $10. $_________________

Payer's Request for Taxpayer Identification Number and Certification

Social Security Number ________ / ________ / ________ Employer I.D. Number ________ / _______________

Certification — Under penalties of perjury, I certify that the number shown on this form is my correct Taxpayer Identification Number and that I am not subject to backup withholding because I have not been notified by the Internal Revenue Service 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.

Please notify us immediately of any changes to the above information.

______________________________________________ ____________________________ _______________ Signature Telephone Number Date

______________________________________________ ____________________________________________ Address Witness

______________________________________________ City State Zip

LSA AMD LNL0968 1208


Page 1 - Home Office Copy

This form should be used for initiating minimum distributions ONLY. If the customer desires to take a sum of income in excess of and in addition to their minimum distribution, that additional amount should be requested on form LSA ASW - ANNUITY SYSTEMATIC WITHDRAWAL REQUEST.

Do not calculate on this sheet. If there is any discrepancy from Liberty National’s calculation and a figure written on this form, it will result in a customer service issue to determine if minimum distribution or the exact amount the Representative calculated is desired, thereby creating a delay in processing the request.

Important: Only minimum distributions pertaining to Liberty National contracts may be taken free of surrender charges. Commission chargebacks will apply on minimum distributions taken in the first year. (Refer to your Marketplace Bulletin for further details.)

Page 16

Exhibit

L State Replacement Form (R-3573)

R-3573, Ed. 1-02 LNL0565 0309

This document must be signed by the applicant and the agent, if there is one and a copy left with the applicant.

You are contemplating the purchase of a life insurance policy or annuity contract. In some cases this purchase may involve discontinuing or changing an existing policy or contract. If so, a replacement is occurring. Financed purchases are also considered replacements.

A replacement occurs when a new policy or contract is purchased and, in connection with the sale, you discontinue making premium payments on the existing policy or contract, or an existing policy or contract is surrendered, forfeited, assigned to the replacing insurer, or otherwise terminated or used in a financed purchase.

A financed purchase occurs when the purchase of a new life insurance policy involves the use of funds obtained by the withdrawal or surrender of or by borrowing some or all of the policy values, including accumulated dividends, of an existing policy to pay all or part of any premium or payment due on the new policy. A financed purchase is a replacement.

You should carefully consider whether a replacement is in your best interests. You will pay acquisition costs and there may be surrender costs deducted from your policy or contract. You may be able to make changes to your existing policy or contract to meet your insurance needs at less cost. A financed purchase will reduce the value of your existing policy and may reduce the amount paid upon the death of the insured.

We want you to understand the effects of replacements before you make your purchase decision and ask that you answer the following questions and consider the questions on the back of this form.

Are you considering discontinuing making premium payments, surrendering, forfeiting, assigning to the insurer, or otherwise terminating your existing policy or contract? ❑ Yes ❑ NoAre you considering using funds from your existing policies or contracts to pay premiums due on the new policy or contract? ❑ Yes ❑ No

If you answered "yes" to either of the above questions, list each existing policy or contract you are contemplating replacing (include the name of the insurer, the insured or annuitant, and the policy or contract number if available) and whether each policy or contract will be replaced or used as a source of financing:

Insurer Name Contract or Policy Number Insured or Annuitant Replaced (R) or Financing (F)

Make sure you know the facts. Contact your existing company or its agent for information about the old policy or contract. If you request one, an in force illustration, policy summary or available disclosure documents must be sent to you by the existing insurer. Ask for and retain all sales material used by the agent in the sales presentation. Be sure that you are making an informed decision.

Upon Issuance of your new policy or contract, the policy or contract may be returned within 30 days from the date of delivery. You will receive a refund of your premiums paid. Note that this return period may be longer than what is reflected in your policy or contract.

The existing policy or contract is being replaced because:

The agent, by signing below, attests to the fact that the agent only used company approved sales materials and that copies of all sales materials were left with the applicant. The agent and the applicant further certify that the responses herein are, to the best of my knowledge, accurate:

Annuitant/Owner Signature Annuitant/Owner Printed Name Date

Agent Signature Agent Printed Name Date

I do not want this notice read aloud to me. ______________________ (Applicants must initial only if they do not want the notice read aloud.)

1.

2.

(Continue on Reverse Side)

3700 S. SToNebRIdge dRIve • PoST oFFICe box 8080 • MCkINNey, TexAS 75070-8080

IMPORTANT NOTICE: REPLACEMENT OF LIFE INSURANCE OR ANNUITIES


This is a state specific form which is used by the Representative to do a 1035 Exchange, rollover or transfer for which he / she is replacing an existing insurance policy. Send this form in with the completed application.

Be sure to specify state when ordering supplies of these forms.

Page 17

Exhibit

M Annuity Withdrawal or Surrender Request (LSA SR)

ANNUITY NUMBER Liberty NatioNaL Life iNSUraNCe CoMPaNyaNNUity WitHDraWaL or SUrreNDer reQUeSt

ANNUITANT SOCIAL SECURITY NUMBER

OWNER (If different from Annuitant) SOCIAL SECURITY NUMBER

OWNER'S ADDRESS CITY STATE ZIP CODE

MAIL CHECK TO ❏ Annuitant ❏ Owner ❏ Direct Deposit (form attached) ❏ New Carrier

a FULL CASH SURRENDER APPLICATION (Contract Required)

I hereby surrender the above annuity for cancellation in accordance with its provisions, and request payment to me of the full value (less any indebtedness to the Company) as of the date to which premiums are now paid.It is understood and agreed that all liability of Liberty National Life Insurance Company arising out of or under said annuity shall terminate and cease upon acceptance of this request by said Company.

b PARTIAL CASH SURRENDER APPLICATION

As owner of the above annuity, I hereby request a partial surrender of $ ____________ thereunder pursuant to the terms of the annuity. I understand that this partial surrender will reduce the Accumulated Value of this annuity by the amount requested plus any applicable surrender charges.

IMPORTANT TAX INFORMATION 1. The withdrawal that you have requested from this annuity may be subject in whole or in part to Federal Income Tax and may be

subject to an additional tax penalty. Tax penalties may occur when withdrawals are made prior to age 59 1/2 other than in the event of disability. You should consult you tax advisor for details.

2. You will receive a statement early next year which sets forth the taxable portion of your withdrawal which must be reported on your income tax return.

3. We are required by law to withhold Federal Income tax from your withdrawal unless you tell us not to withhold. 4. You are responsible for the payment of income tax and for filing any estimated income tax forms that may be required in the event

tax is not withheld. You may also incur penalties if your withholding and estimated tax payments are insufficient. 5. If withholding is applied to your withdrawal, tax will be withheld on the amount includable in your income subject to Federal

income tax. 6. You may elect not to have withholding apply to your withdrawal, otherwise withholding will be made. I certify that said annuity is not assigned, pledged or hypothecated to anyone and there are no bankruptcy or insolvent proceedings pending against me in any court, and that no Federal tax lien has been filed against the annuity or the person having the right to the proceeds.

I hereby make the following elections:❏ OPTION A (Full Cash Settlement) ❏ OPTION B (Partial Cash Surrender)❏ I do NOT want to have Federal Income Tax withheld from any withdrawal. ❏ I DO want to have Federal Income Tax withheld from any withdrawal.

This application has been executed at (City)

State of , this day of (Month), (Year)

✓ Joint Owner (if applicable)

✓ Signature of Owner


LSA SR LNL0971 1208

Use this form whenever a customer needs to make: • afullcashsurrender(thecontractmustbe

returned with the form) • apartialcashsurrender(specifyamount)

Be sure to mark the appropriate place to mail the check (TOP section) and select the option (A) at the bottom. If this contract has joint owners, both the owner and joint owner should sign above “Signature of Owner” and “Joint Owner.”

Page 18

Exhibit

N Annuity Request Form (LSA PR)

This form is used to delay the annuity maturity date or request an annuity payout option.

2. Request Information On Other Payment Option(s)

Check one or more of the options that you are considering and fill in the information needed for the calculations of each option.

____ LIfe IncOme - Monthly payments of a guaranteed period of 5, 10, 15 or 20 years, as selected, and life thereafter. No payment will become due after death, except payment for any remaining guaranteed period. I would like payments over 5, 10, 15, or 20 years. (Circle # of years you select.)

____ fIXeD AmOUnT - Monthly payment of a fixed amount, but not less than 7% of the proceeds nor more than 15% of the proceeds each year, until the proceeds are fully paid. I would like the monthly payment to be $ _________________.

____ fIXeD PeRIOD - Monthly payment of a fixed period of not less than 10 years and not more than 30 years. I would like the fixed period to be ________________ years.

____ JOInT LIfe IncOme cOnTInUInG TO SURVIVOR - Monthly payments of an income during the joint lifetime of two annuitants and to the survivor during the survivor's remaining lifetime. The Name of the Joint Annuitant is ____________________________________________________________________________ , the Date of Birth of the Joint Annuitant is _____________________ , and the Sex of the Joint Annuitant is __________.

Request payout information of the Option(s) as indicated above. Upon receipt of this information, I will choose the option I desire.

Date

Name of Annuitant ________________________ Contract No: ___________________

Social Security# ____________________________

PLeASe cOmPLeTe OnLY One Of THe TWO SecTIOnS BeLOW

ANNUITY REQUEST FORM

1. Delay maturity Date

As the owner of this Annuity contract, I wish to delay the maturity date until _____________________________

____________________________ ________________________________________________________Today's Date Signature of Owner

Signature of Owner

LSA PR LNL0972 1208

Date

Page 19

Exhibit

O Withdrawal Charge Waiver Request (LSA WR)

Not Available in CA, MA, PA, or SD.

This form is used to initiate the contract withdrawal provision in regard to nursing home, hospital stay and hospice care.

A completed Annuity Withdrawal or Surrender Request Form (LSA SR) is also required.

Nursing Home, Hospital Stay, Hospice Care Withdrawal Charge Waiver Request

(where state approved)

3700 South Stonebridge drive • PoSt office box 8080 • Mckinney, texaS 75070-8080

in accordance with the contract provision, i request that the withdrawal charge be waived on the attached surrender/withdrawal request as:

❒ i am currently confined in a hospital or nursing home and have been confined for a combined stay of at least 30 days within a 35-day period.

Nursing Home means: any state licensed facility that is operated primarily for non-medical maintenance and care of the elderly.

❒ Within the last 60 days, i was discharged from a confinement in a hospital or nursing home which involved a combined stay of at least 30 days within a 35 day period.

Hospital means: any state licensed medical care facility which provides skilled nursing and physician care.

❒ i am currently enrolled in a hospice care Program.

❒ i was discharged from a hospice care Program within the last 60 days.Hospice Care Program means: a coordinated program of medical and other health services provided by a duly licensed hospice.

___________________________ __________ ___________________________ __________ annuitant/annuitant’s Spouse Signature date attending Physician’s Signature date

facility name ________________________________ telephone no. ______________________

note: confinement period in the hospital or nursing home or the enrollment in a hospice care program must have totally occurred after the annuity policy was issued.

LSa Wr LnL0973 1208

Page 20

Exhibit

P Additional Premium Receipt (LSA APR)


ADDITIONAL PREMIUM RECEIPT

Please apply these funds to my existing Flexible Premium Annuity.

Annuitant Name: ___________________________ Owner Name: __________________________________________

Annuity # _________________________________ Additional Amount: $ ____________________(minimum $50.00)

Is this an IRA annuity? ❑ Yes ❑ No If yes, additional amount is for tax year ____________________(If no tax year is specified, funds will be applied for current tax year.)

Received by: _________________________________________________ Date: ______________________________ Authorized Signature

LSA APR

Page 1 - home office copy

LNL0974 1208


ADDITIONAL PREMIUM RECEIPT

Please apply these funds to my existing Flexible Premium Annuity.

Annuitant Name: ___________________________ Owner Name: __________________________________________

Annuity # _________________________________ Additional Amount: $ ____________________(minimum $50.00)

Is this an IRA annuity? ❑ Yes ❑ No If yes, additional amount is for tax year ____________________(If no tax year is specified, funds will be applied for current tax year.)

Received by: _________________________________________________ Date: ______________________________ Authorized Signature

LSA APR

Page 1 - home office copy

LNL0974 1208

This form should be used when additional funds are received on an existing contract.

Page 21

Exhibit

Liberty National Life Insurance Company ADMINISTRATIVE ...unitedamerican.com/Compliance/Compliance...

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