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APPLICATIONSINGLE PREMIUM DEFERRED ANNUITY (SPDA)
A. PRODUCT SELECTION
Preserve
ProOption
6-Year 7-Year 8-Year 9-Year3-Year 4-Year 5-Year 10-Year
5-Year 7-Year 10-Year
Product Choices
B. ANNUITANT
Annuitant Information Joint Annuitant Information (Not available
for Qualified Plans)
1. COMPLETE NAME (FIRST/MIDDLE/LAST)
2. RESIDENTIAL ADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE
8. COMPLETE NAME (FIRST/MIDDLE/LAST)
9. RESIDENTIAL ADDRESS (NO P.O. BOX)
3. SOCIAL SECURITY #
CITY STATE ZIP CODE
10. SOCIAL SECURITY #
5. DATE OF BIRTH 6. AGE 7. PHONE NUMBER 12. DATE OF BIRTH 13.
AGE 14. PHONE NUMBER
MALE FEMALE4. SEX
C. OWNER
Owner Information(Complete only if Owner is different from
Annuitant) (If trust, include full trust document)
Joint Annuitant Information (Not available for Qualified
Plans)
1. COMPLETE NAME (FIRST/MIDDLE/LAST)
2. RESIDENTIAL ADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE
8. COMPLETE NAME (FIRST/MIDDLE/LAST)
9. RESIDENTIAL ADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE
MALE FEMALE 11.SEX
5. DATE OF BIRTH ORTRUST
6. AGE 7. PHONE NUMBER
MALE FEMALE4. SEX
NON-NATURAL OWNER
3. SOCIAL SECURITY # ORTIN
11.
12.DATE OF BIRTH 13. AGE 14. PHONE NUMBER
MALE FEMALESEX10. SOCIAL SECURITY #
401 PENNSYLVANIA PARKWAY, SUITE 300, INDIANAPOLIS, IN 46280 800
767 7749 PAGE 1 OF 4GLA-MYGA-GEN 06/2013
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D. SPECIAL REQUESTS
APPLICATIONSINGLE PREMIUM DEFERRED ANNUITY (SPDA)
E. TAX QUALIFICATION
Non-Qualified Roth IRATraditional IRA
Roth IRA Conversion SEP IRA (include IRS Form 5305)
Inherited Beneficiary IRA
Plan Type (check one) Please complete if applicable
If Traditional IRA Contribution-Tax Year _________
If Roth IRA Contribution-Tax Year______________
If Roth IRA-Inception Date___________________
F. PREMIUM AMOUNT
AmountSource
Check with Application
Estimated 1035 Exchange Amount
Estimated Qualified Transfer/ Rollover Amount
Estimated Non-Qualified Transfer/ Rollover Amount
(i.e. liquidation of mutual fund, money market)
$
$
$
$
G. BENEFICIARIES
Relationship to OwnerPrimary Beneficiary Full NameDate of Birth
Social Security Numberor TIN Percentage
Relationship to OwnerContingent Beneficiary Full Name Date of
BirthSocial Security Numberor TIN Percentage
401 PENNSYLVANIA PARKWAY, SUITE 300, INDIANAPOLIS, IN 46280 800
767 7749 PAGE 2 OF 4
Please check here if you are attaching additional Beneficiary
information
GLA-MYGA-GEN 06/2013
(Please list any special requests below)
(If Spousal Joint Ownership, 'surviving spouse' is normally
listed as primary beneficiary)
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APPLICATIONSINGLE PREMIUM DEFERRED ANNUITY (SPDA)
H. EXISTING COVERAGES/REPLACEMENTPlease answer the following
questions
I. OWNER AND ANNUITANT SIGNATURE(S)
a. Do you have any other life insurance policies or annuity
contracts?
b. Is the Contract applied for replacing or likely to replace
any existing life insurance or annuitycontracts?
If “Yes,” and required by your state, complete the necessary
Replacement Notice.
If “Yes,” and required by YOUR state, complete the necessary
Replacement Notice.
I acknowledge and understand that most annuities purchased with
Qualified Funds are subject to the Required Minimum Distribution
(”RMD”) Rules. If I am currently subject to RMDs or taking RMDs, I
understand that the RMDs must be withdrawn before transferring
funds.
I believe this to be a suitable purchase for my financial
status. Any applicable Surrender Charge, Early Withdrawal and
Market Value Adjustment provisions have been explained to me.
I agree to all terms and conditions as shown, and have read and
understand all the statements made above. I agree that this
application will be made part of the annuity Contract, and all
statements made in this application are true, to the best of my
knowledge and belief. I understand that amounts payable under the
Contract may be subject to a Market Value Adjustment.
Yes
Yes No
No
401 PENNSYLVANIA PARKWAY, SUITE 300, INDIANAPOLIS, IN 46280 800
767 7749 PAGE 3 OF 4GLA-MYGA-GEN 06/2013
Signed at: City, State, Zip Date
Signature of Owner Date
Signature of Annuitant Date
Signature of Joint Owner Date
Signature of Joint Annuitant Date
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J. AGENT SIGNATURE(S)
1. Will this plan replace any existing life insurance or
annuity?
If "Yes,” please explain:
_________________________________________________________________________
For any replacement, indicate the type of coverage proposed to
be replaced:
2. Advertising materials:
• I certify that I used only insurer-approved sales material
with this Application and that an original or a copy of allsales
material was left with the Proposed Owner.
• I certify that a printed copy of any electronically presented
sales material was/will be presented to the ProposedOwner no later
than the date the Contract is delivered.
3. I certify that this Application is in accordance with the
Guggenheim Life and Annuity Company’s Business Guidelineswith
respect to the acceptability of replacements.
4. By signing below, I hereby certify, to the best of my
knowledge and belief, that all information in thisapplication is
true. I also certify that I have explained any applicable Surrender
Charges, Early WithdrawalMarket Value Adjustments provisions
contained in this Contract, and I certify that this annuity is
suitable forthe Applicant, based upon the Applicant's
disclosure.
Yes No
Fraud Notice: Any person, who knowingly and with intent to
defraud any insurance company or other person, files anapplication
for insurance or statement of claim containing any materially false
information or conceals for the purpose of misleading, information
concerning any fact material thereto commits a fraudulent insurance
act, which is a crime and subjects such person to criminal and
civil penalties.
If you haven't received your agent number please indicate
"PENDING"
401 PENNSYLVANIA PARKWAY, SUITE 300, INDIANAPOLIS, IN 46280 800
767 7749 PAGE 4 OF 4
APPLICATIONSINGLE PREMIUM DEFERRED ANNUITY (SPDA)
Signature of Agent Date
Signature of Agent (If Joint Case) Date
GLA-MYGA-GEN 06/2013
Agent Number Split %
Producer Name Email Address
Office Phone Number
Agent Number Split %
Producer Name Email Address
Office Phone Number
Term Life Whole Life Variable Life Fixed Annuity Variable
Annuity Other: _______________
1 COMPLETE NAME FIRSTMIDDLELAST: 8 COMPLETE NAME
FIRSTMIDDLELAST: 2 RESIDENTIAL ADDRESS NO PO BOX: 9 RESIDENTIAL
ADDRESS NO PO BOX: CITY: STATE: ZIP CODE: CITY_2: STATE_2: ZIP
CODE_2: 3 SOCIAL SECURITY: 10 SOCIAL SECURITY: 6 AGE: 7 PHONE
NUMBER: 13 AGE: 14 PHONE NUMBER: 1 COMPLETE NAME FIRSTMIDDLELAST_2:
8 COMPLETE NAME FIRSTMIDDLELAST_2: 2 RESIDENTIAL ADDRESS NO PO
BOX_2: 9 RESIDENTIAL ADDRESS NO PO BOX_2: CITY_3: STATE_3: ZIP
CODE_3: CITY_4: STATE_4: ZIP CODE_4: 3 SOCIAL SECURITY OR TIN: 3
SOCIAL SECURITY OR TIN_2: 6 AGE_2: 7 PHONE NUMBER_2: 6 AGE_3: 7
PHONE NUMBER_3: fill_2: fill_3: fill_4: fill_5: undefined_2: Agent
Number: Check Box191: OffCheck Box192: OffCheck Box193: OffCheck
Box194: OffCheck Box195: OffCheck Box196: OffCheck Box197: OffCheck
Box198: OffCheck Box199: OffCheck Box200: OffCheck Box201:
OffText10: Check Box13: OffCheck Box14: OffCheck Box15: OffCheck
Box16: OffCheck Box17: OffCheck Box18: OffText19: Text20: Text21:
Text22: Text24: Text25: Text26: Text27: Text29: Text30: Text31:
Text32: Text34: Text35: Text36: Text37: Text39: Text40: Text41:
Text42: Text44: Text45: Text46: Text47: Text49: Text50: Text51:
Check Box52: OffCheck Box53: OffCheck Box54: OffCheck Box55:
OffCheck Box56: OffCheck Box59: OffCheck Box60: OffCheck Box61:
OffCheck Box62: OffCheck Box63: OffCheck Box64: OffText65: Text66:
Text67: Text68: Text69: Text70: Text71: Text72: Text73: Text74:
Text1: Check Box2: OffCheck Box3: OffDOB1: DOB2: DOB3 or TRUST:
DOB4 or TRUST: DOB6: DOB7: DOB8: DOB9: DOB10: DOB11: SIGNED DATE:
Check Box1: OffCheck Box4: OffCheck Box5: OffCheck Box6: OffCheck
Box7: OffCheck Box8: OffCheck Box9: OffCheck Box10: OffCheck Box11:
Off
