A Fraternal Benefit Society – Beaver, Pennsylvania 15009-9513 Page 1 of 3

5400 Tuscarawas Road Beaver, PA 15009 Phone: (800) 722-4428 Email: [email protected] INDIVIDUAL DEFERRED ANNUITY APPLICATION (Please print)

Plan: ______Non-Qualified: □ Qualified: □ IRA □ SEP IRA □ TSA □ Keogh □ Roth □ Coverdell □ Other Please note, the appropriate Disclosure Statements must be included with the application

Annuitant: ______Social Security Number: ______Permanent Address: ______City: ______State: ____ Zip: _____ Mailing Address: ______City: ______State: ____ Zip:_____ Phone Number: ______□ Home □Cell Email: ______Date of Birth: ______Age: ______Sex: ____ Marital Status: ______

Owner (if other than Annuitant): ______Social Security Number: ______Permanent Address: ______City: ______State: ____ Zip: _____ Mailing Address: ______City: ______State: ____ Zip:_____ Phone Number: ______□ Home □Cell Email: ______Date of Birth: ______Age: ______Sex: ____ Marital Status: ______Is the Proposed Annuitant a member of the GCU? □ Yes □ No Lodge Number

Primary Beneficiary (Additional Beneficiaries may be provided on separate page with Annuitant/Owner’s Signature and date) Name: ______SSN ______%______Address: ______Relationship: ______Phone Number: ______□ Home □Cell Email: ______Name: ______SSN ______%______Address: ______Relationship: ______Phone Number: ______□ Home □Cell Email: ______Name: ______SSN ______%______Address: ______Relationship: ______Phone Number: ______□ Home □Cell Email: ______Contingent Beneficiary Name: ______SSN ______%______Address: ______Relationship: ______Phone Number: ______□ Home □Cell Email: ______Name: ______SSN ______%______Address: ______Relationship: ______Phone Number: ______□ Home □Cell Email: ______

ICC20 DefAnu-2010 GCU – A Fraternal Benefit Society – Beaver, Pennsylvania 15009-9513 Page 1 of 3

Method of Purchase (Checks should be payable to GCU) Check purchase Amount: $______Rollover (from retirement account): $______Transfer (CD, mutual fund, brokerage acct, money market): $______Replacement (Annuity and/or cash value life insurance): $______Total Estimated Premium: $______

Replacement Questions: 1. Do you currently have existing life insurance or annuity contracts in force or pending with this or any other company?

□ Yes □ No If yes, specify total amount (including pending with other companies): ______

2. Will this replace or change any life insurance or annuity contract in force with this company or any other company? □ Yes □ No 3. Other Annuities in force? □ Yes □ No If Yes, total amount $

4. Will existing value from another life insurance or annuity contract (through loans, surrenders, or otherwise) be used to pay premiums for the policy applied for? □ Yes □ No If Yes to 1, 2, or 3, show name of insurer and contract numbers:

FRAUD WARNING

WARNING: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.

Tax Identification Certification (in lieu of W-9)

Under penalties of perjury, I certify that:  The number shown on this application is my correct taxpayer identification number; and  I am not subject to back-up withholding due to failure to report interest and dividend income; and  I am a U.S. Citizen or other U.S. Persons (as defined in the W-9 instructions). Certification Instructions: You must strike out item 2 above if you have been notified by the IRS that you are currently subject to back-up withholding. Owner’s/ Annuitant’s Statement  I/We declare that all statements in this Application are true to the best of my/our knowledge and belief and agree that this Application shall be a part of the Annuity Contract issued by the Company.  I/We understand that my contract has a free-look period if I am dissatisfied for any reason  I/We believe this product is suitable for my/our financial goals  I understand that the annuity contract will not be issued until all money has been received and total dollar amount meets the minimum premium requirement of the product The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid back-up withholding. GCU IS LICENSED TO DO BUSINESS AS A FRATERNAL BENEFIT SOCIETY. AS SUCH, IT IS NOT INCLUDED IN ANY STATE’S LIFE AND HEALTH GUARANTY ASSOCIATION (OTHERWISE KNOWN AS THE GUARANTY ASSOCIATION). THIS MEANS THAT FRATERNAL BENEFIT SOCIETIES CANNOT BE ASSESSED FOR THE INSOLVENCY OF OTHER LIFE INSURERS OR OTHER FRATERNAL BENEFIT SOCIETIES. BY LAW, A FRATERNAL BENEFIT SOCIETY IS RESPONSIBLE FOR ITS OWN SOLVENCY. IF THERE IS AN IMPAIRMENT OF RESERVES, A CERTIFICATE HOLDER MAY BE ASSESSED A PROPORTIONATE SHARE OF THE IMPAIRMENT. THIS PROCESS IS DESCRIBED IN THE CERTIFICATE ISSUED BY THE SOCIETY.

ICC20 DefAnu-2010 GCU – A Fraternal Benefit Society – Beaver, Pennsylvania 15009-9513 Page 2 of 3 I agree that this Application shall be the basis for and a party of any contract issued. I understand that only an officer of GCU may, in writing: (1) make or modify contracts: or (2) waive any of GCU’s rights or requirements.

Dated at: (City, State) this (Date) Day of (Month) , (Year) Annuitant Signature: Owner Signature

(Parent/Guardian if under 16) (If different from Annuitant)

Agent’s Report 1. To the best of your knowledge, is life insurance or annuity replacement involved in this transaction? □ Yes □ No 2. Did you ask each question exactly as set forth in the application? □ Yes □ No 3. To the best of your knowledge, is the annuity now applied for intended to replace or change any existing insurance with any company? □ Yes □ No

If yes, have you complied with any regulatory requirements regarding replacement? □ Yes □ No 4. I have verified the Proposed Insured’s identity by viewing the individual’s photograph on a driver’s license, passport or other official document. □Yes □ No

Agent Signature: Agent Name (Print):

License No.: GCU Agent No.:

ICC20 DefAnu-2010 GCU – A Fraternal Benefit Society – Beaver, Pennsylvania 15009-9513 Page 3 of 3 ANNUITY DISCLOSURE FLEX FIVE ADVANTAGE DEFERRED FLEXIBLE ANNUITY (ISSUED AGES 0 TO 88)

INTEREST RATE: Your annuity will earn an initial interest rate of ______%apy. This rate is fixed for 1 contract year. Unless surrendered, this contract will continue after the 5 year period at the GCU declared interest rate. SURRENDER CHARGE This annuity contains surrender charges for a period of 5 years for early surren- SCHEDULE: der, withdrawals or termination. Maximum surrender charge is 9%. Year 1 2 3 4 5 % Charge 9% 7% 5% 3% 1% PENALTY FREE WITHDRAWAL—The owner may withdraw up to 10% of the initial deposit in the first year. The amount increases to 20% of the contract value in years 2 through 5, based on the prior anniversary date contract value, without surrender charges. SURRENDER CHARGE LONG TERM CARE—No surrender charges will be imposed on withdrawals EXCLUSIONS: or surrender of this contract upon receipt the owner has become confined to a Long Term Care facility and certified as needing to reside in the facility. TERMINAL ILLNESS—No surrender charges will be imposed on withdrawals or surrender of this contract should the owner become terminally ill as certified by an attending physician. GCU reserves the right to authenticate the physician’s diagnosis. DEATH—No surrender charges will be imposed on death benefits paid under this annuity contract. The above GCU Surrender Charge Exclusions may be modified or withdrawn at any time at the discretion of the GCU Board of Directors. Withdrawals prior to age 59 1/2 may be subject to an IRS early distribution penalty.

______Date Signature Applicant/Annuitant

______Date Signature of Agent

DISC-5YrAdv.2020 Suitability Evaluation Worksheet for Fixed Annuities

The GCU is committed to selling our members the appropriate products to meet their financial needs. These questions are designed to help determine if purchasing a fixed annuity product is suitable for your needs. All questions must be completed and your signature is required on this form.

Product Information:

ANNUITY TYPE: (check one)  Qualified  Non-Qualified

Owner/Applicant Information:  Married  Single  Divorced  Widowed

Owner/Applicant: ______Age: ______DOB: ______Joint Owner Name: ______Age: ______DOB: ______

1. Work Status: Owner:  Retired  Employed  Unemployed  Other Joint Owner:  Retired  Employed  Unemployed  Other

2. Residence: Owner:  Living at Home  Assisted Living  Nursing Home Joint Owner:  Living at Home  Assisted Living  Nursing Home

3. Federal Tax Rate:  0%  10%  12%  22%  24%  32%  35%  37%

4. Do you own any of the products listed below:  Stocks & Bonds  Government Securities  Mutual Funds  Fixed Annuities  Variable Insurance  I have not owned any of the above products  Certificates of Deposit

5. What percentage of your liquid assets would you feel comfortable allocating to the categories below?

Low Risk ____% Moderate Risk ____% High Risk ____% 100% of Total Assets

• Fixed Annuities are generally not considered aggressive growth assets. They are not securities and do not constitute a direct investment in the stock market.

6. Financial/Investment Objectives (please check 1-3 primary reasons)  Tax Deferral  Wealth Accumulation  Immediate Income  Potential for better rate  Death Benefit  Estate Planning  Protection from Market Risk  Qualify for Government Programs  Other ______ Retirement Income (e.g. Medicaid, VA)

Financial Information:

7. Source(s) of Income (All that apply)

 Salary/Wages  Interest Income  Pension/IRA Payments  Trust Income  Social Security  Dividends  Other Annuities  Other ______

Suitability02/06/2019 Suitability Evaluation Worksheet for Fixed Annuities

8. Monthly Income & Expenses

Approximate Monthly Household Approximate Monthly Household Income (net after taxes): $ ______(a) Expenses: $ ______(b)

Monthly Disposable Household Income: $ ______(c) (a) – (b) = (c)

9. Non-Liquid Assets

Value of Home $ ______Mutual Funds/Brokerage Accounts Business Interests $ ______not readily convertible to cash Qualified Plans $ ______without penalty $ ______(if under 59-1/2) Annuities/Insurance cash values subject to surrender penalties $ ______Other ______$ ______

Total Non-Liquid Assets: $ ______

10. Liquid Assets

Cash $ ______Mutual Funds/Brokerage Accounts Short Term CDs $ ______readily convertible to cash Other Real Estate $ ______without penalty $ ______Qualified Plans $ ______Annuities/Insurance cash values (over 59-1/2 and not subject to surrender penalties $ ______no surrender penalties) Other ______$ ______

Total Liquid Assets: $ ______

Total Net Worth: $ ______

11. After purchase of this annuity, do you believe you have enough remaining liquid assets and other sources of income to cover any emergencies or contingencies such as sudden health care needs or increased living expenses?

 Yes  No

12. Do you anticipate any adverse change in assets, living expenses, medical expenses, and/or income during the surrender period of this contract?

 Yes  No

Will there be any surrender charges or penalties to withdraw funds from your current financial product (i.e., the source of funds for this annuity purchase)?  Yes  No

If yes, provide the name of company, product, year of purchase, accumulation value prior to surrender, dollar amount of surrender charge or penalty, and percentage of surrender charge or penalty. If applicable, list MVA amount separately and indicate positive or negative.

Suitability02/06/2019

Suitability Evaluation Worksheet for Fixed Annuities

Company/Product/Year Accumulation Value w/o Surrender Surrender MVA Amt of Purchase Surrender Charges and MVA Charge Amt. ($) Charge Amt. (%) ($) (+/-)

Acknowledgements

• I understand an annuity is a long-term contract that I should not plan to fully surrender before completion of the surrender charge periods. • I understand that my principal may be subject to a surrender charge if I surrender or partially surrender my contract before completion of the surrender charge period. • I understand surrender charges may apply to withdrawals, that may be taxable, and when made before age 59-1/2, may result in tax penalties. • (If replacement) I understand the benefits and costs of this replacement, including but not limited to surrender charges, possible loss of benefits, tax consequences, product features and enhancements, fees, and expenses. My agent has provided a comparison of the benefits and restrictions of both contracts. • I understand that I should contact a tax professional or attorney for any tax or legal advice.

PLEASE REVIEW THE FORM AND SIGN ATTESTING THAT THE INFORMATION IS TRUE AND CORRECT TO THE BEST OF YOUR KNOWLEDGE. THIS FORM SHOULD NOT BE SIGNED IF ANY REQUIRED ITEM IS LEFT BLANK.

______Applicant/Owner’s Signature Date

Agent’s Statement

I believe the purchase of this annuity contract is suitable after reviewing the information provided to me by the applicant/owner. If applicable, I have discussed the advantages and disadvantages of any replacement or exchange of another annuity contract or life policy. I have reasonably informed the applicant/owner of all-important features of the annuity and proposed transaction.

To the best of my knowledge, the questions on this form have been answered truthfully and I have complied with GCU suitability requirements consistent with my contractual obligations.

______Agent Signature Date

Suitability02/06/2019