West Virginia Offices of the Insurance Commissioner

West Virginia Offices of the Insurance Commissioner Annuity Election Form

Complete this form in its entirety. West Virginia Code §33-3-15 states that a life insurer shall provide notice of its annuity consideration election within ninety days after it enters the State. No life insurer may change its election without the consent of the Commissioner.

Mail to: WV Offices of the Insurance Commissioner Attn: Tax Audit Section P.O. Box 50542 Charleston, WV 25305-0542

Company Name: NAIC Number:

Address:

Contact Person: Title:

Election: Front-End ► Annuity considerations or funds deposited for future purchase of an annuity.

Back-End ► Annuity considerations collected and received by the insurer but are not considered as an annuity consideration until application to purchase an annuity. Pursuant to W. Va. Code §33-3-15, these are the total gross amounts accumulated and any earnings credited to the money accumulated since inception of the contracts.

State of County of

I, being duly sworn according to law, say that I am authorized Name of Officer (Print or type) to represent and further depose Company Name and say that the facts contained in this petition, including any sheets attached hereto, are true and complete.

Signature of Officer Title

Sworn to and subscribed before me this day of ,

My commission expires day of ,

(SEAL) Notary Public

IC-AnnuityElection August, 2009